Internal Medicine Coding Alert

As primary care physicians, internists often find themselves in the position of providing counseling to their patients on a number of issues. Discussing treatment options with a patient and their family, helping a patient understand the importance of complying with a recommended diet and exercise program, talking about difficulties they experience complying with the physicians ordersthese are all areas in which internists find themselves spending a lot of time and energy. But, it is not always clear how they should bill for this time.

Many internists wonder if they should bill for counseling using the CPT codes for outpatient psychotherapy (90804-90815).

In a letter to IMCA recently, one internal medicine practice manager asked: Can any physicianinternal medicine, pediatric, or family practiceuse psychiatric codes if providing counseling services?

The answer, according to Brett Baker,, third-party relations specialist for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), is yes, you can use these codes, but, you really may not want to.

Technically, any physician can use any of the codes in CPT, and Medicare does not prohibit any specialty from using any set of the CPT codes, explains Baker. However, it is very likely that a payer, seeing that these codes are billed by a non-psychiatrist, is going to want some extra documentation to ensure that the services provided meet the code definition.

The CPT codes for outpatient psychotherapy specifically state that these codes are for treatment of a psychiatric condition, he continues.

These codes are listed under the CPT heading Psychiatric Therapeutic Procedures. Under this category heading, CPT reads: Psychotherapy is the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the patient and, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.

It would be very rare for an internist to provide this kind of intense mental health treatment, Baker notes.
Most commonly, internists are dealing with psychological, emotional, or practical difficulties a patient is having related to the treatment of a physical illness, he says. They might spend time discussing problems a patient is having with family members that is related to the patients illness, or spend time counseling the patient about avoiding risk factors, or things of that nature.

If this is the case, this time can be billed in one of two ways: using the preventive medicine counseling codes (99401-99412), or, if time spent counseling the patient amounts to more than 50 percent of an office visit encounter, using the regular office/outpatient E/M codes (99201-99215).

Use Preventive Medicine Counseling Codes

According to CPT, these codes are to be used to report services provided to individuals at a separate encounter for the purpose of promoting health and preventing illness or injury. (See box below for codes and definitions.)

These are the codes that should be used if a patient comes into your office specifically for a counseling visitand is not seen for any other medical evaluation or treatment, says Cynthia C. Thompson, CPC, a senior consultant with Gates, Moore and Co., an Atlanta-based medical practice management and reimbursement consulting firm.

Preventive medicine codes are used when the primary care physician is perhaps counseling a patient about options regarding having surgery or not having surgery, or making decisions about their care, she says. In younger patient populations it may be about sexual practices or substance abuse prevention.

Thompson emphasizes that these codes are to be used only if the patient comes in specifically for the counseling and it is not part of another office visit.

CPT says that these codes are not to be used to report counseling and risk-factor reduction interventions provided to patients with symptoms or established illness, she notes. If that is the case, then the counseling will be included in the office visit, and the physician will bill the regular office-visit codes.

Reimbursement Considerations

It should be noted that Medicare and many other health plans do not cover preventive medicine services and will not pay for services billed under 99401-99412, say both Baker and Thompson.

If the patient comes in just for the counseling, then it is correct to bill the preventive counseling codes, advises Thompson. Getting paid is another issue.

Baker agrees, and advises that internists will most likely have to bill the patient directly for these services.

Note: For Medicare patients, this will entail getting the patient to sign a waiver, known as an advance beneficiary notice (ABN), before the counseling treatment is provided.

Use Office/Outpatient Codes

If the counseling takes place as part of an office visit, and it comprises more than 50 percent of the time spent on the encounter, then time can be used as a factor in determining the level of service billed, says Baker.

Counseling and coordination of care is the only situation in which the time spent can be considered a factor in determining the level of service billed, he explains.

For example, if the total time for a patients visit is 40 minutes, and 25 of the 40 minutes were spent counseling the patient, then time would be the controlling factor in choosing the level of E/M service. The coder would use the time guidelines listed under the code in the CPT description. (See definitions of the office/outpatient visit E/M codes listed in the box on this page.) In the above example, the correct E/M level would be 99215; 50% of 40 minutes is 20 minutes and counseling accounted for 25 minutes, hence, more than 50% of the encounter time.

Of course, the physician needs to specifically document the time that was spent on the counseling and what was discussed, says Thompson. I usually recommend to my clients that the physician make a note in the chart, such as writing 20/30 if counseling comprised 20 minutes of a 30 minute patient encounter. Also, they need to document what kind of counseling they are providing, they cant just write counseling in the notes.

Dont Forget the Prolonged Services Codes

If the counseling is delivered as part of an office/outpatient visit, the time spent on counseling is more than 50 percent of the encounter time, and the total time of the visit exceeds the appropriate E/M visit level, then, the internist can bill for the extra time using the prolonged services codes (99354-99355), says Baker. (See description of codes in the box below.)

The code 99354 is for prolonged services with direct (face-to-face) patient contact, first hour, but it can be used beginning at 30 minutes past the time amount allotted for the appropriate patient visit code, Baker says.

Note: For more information on using prolonged services codes, see the article on the cover of the October 1998 issue of IMCA.

The code 99355 should be billed if an additional 30 minutes is spent beyond that time, but that does not equal the time for the higher level E/M visit code.

Use Caution if Choosing Psychotherapy Codes

Though in most cases internists would not be providing services that would be considered psychotherapy under CPTs definition, if they feel they are providing a service that meets the definition they should bill those codes, says Baker. If you furnish psychiatric services that meet the CPT code descriptors, it is still essential that the counseling service provided is properly documented.

Carriers will probably have software edits in place that flag psychiatric codes submitted by non-psychiatrists or non-psychologists. At that point, they would demand documentation of the services provided in order for the claim to be paid, he explains.

Baker also recommends that internal medicine practices contact their local Medicare carrier and their other third-party payers to find out how they handle these situations.

The clinicians also need to be certain that psychotherapy codes are the most appropriate codes to be used in these situations for reasons other than coding complications, adds Thompson.

If you use the psychotherapy codes, most carriers will kick it into mental health, she says. Payers often have stipulations for mental health care provided to their patients that differ from requirements for the rest of their health care, she says. Many health plans dont cover mental health services, or the patient has these services under another carrier, she says. It gets very complicated and often the reimbursement is lower.

In addition, use of a psychiatric CPT code will leave the patient with a mental health history which may or may not be appropriate.

For most internists, it is better to bill for these services as part of the office visit or bill the preventive counseling codes separately, she says.