Internal Medicine Coding Alert

Question: What is the proper use of 90862? Is it just for follow-up of already diagnosed psychiatric problems? Can an internist use this code? How should I use it if there is a follow-up for a psychiatric problem and another complaint such as ear pain?

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Answer: CPT makes it clear that a physician does not have to be a psychiatrist to use the psychiatric codes. The introduction to CPT states, "It is important to recognize that the listing of a service or procedure and its code number in a specific section of this book does not restrict its use to a specific specialty group."

Today, internists write many prescriptions for antidepressant drugs. With the new generation of antidepressants, many nonpsychotic depressions are now treated with medication alone, and often exclusively by the patient's internist. In addition to depression, many internists also prescribe medications and manage the milder forms of other common mental disorders such as dementia and anxiety.

Code 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy) is for a psychiatric condition that is treated by medication alone. According to CPT Assistant, 90862 is to be used when "the physician is evaluating how the medication is affecting the patient, determining the proper dosage level and prescribing medication for the period of time before the patient is next seen." Generally, this patient is not receiving other services from the physician at that encounter.

Also, nonphysician practitioners often assist in the treatment of psychiatric patients. Clinical psychologists, social workers, marriage and family counselors, and other licensed mental-health professionals frequently are the primary providers of such psychiatric services as psychotherapy, behavioral therapy, family therapy, marital therapy or group therapy. Although in some states clinical psychologists and clinical nurse specialists are authorized to prescribe psychotropic medications, in many states only a licensed physician is authorized to prescribe and manage these types of medications. Code 90862 is used to report the physician's services in these cases. Note that although psychiatrists often treat patients in conjunction with other mental-health professionals, this type of situation is rare for internists.

Internists managing a psychiatric condition are normally managing other conditions as well. CPT Assistant indicates that if the patient is seen for another complaint, such as ear pain, then only the E/M service is coded. The medication management would be included in the E/M service because it is one of the medical decision-making components.

The RVUs for 90862 are about the same as for 99213 (a level-three office or other outpatient visit), 1.41 versus 1.39, respectively. However, Medicare outpatient psychiatric benefits apply to this code. Under the outpatient psychiatric benefit provision, Medicare pays only 50 percent of the allowable, leaving the patient to pay the other half. You may find that commercial policies also apply their lower psychiatric benefit rate to this code. Because the E/M code and 90862 involve prescription drug management, you may find that the E/M code better describes and provides better reimbursement for the services provided.