Psychiatry Coding & Reimbursement Alert

Read our experts’ opinions on deciphering these scenarios.

Did you take the quiz on page 25? Compare your results to these solutions.

Scenario 1: Same Day Psychotherapy with Group Psychotherapy

What to report: In this case scenario, you will need to report 90853 (Group psychotherapy [other than of a multiple-family group]) for the group psychotherapy and 90832 (Psychotherapy, 30 minutes with patient and/or family member) for the individual psychotherapy with the modifier 59 (Distinct procedural service) or modifier XE (Separate encounter) appended to 90832.

If you encounter a scenario where your clinician performs individual psychotherapy and group therapy on the same calendar date of service, you will need to check on Correct Coding Initiative (CCI) edits as you will face edits when trying to report 90853 and the individual psychotherapy code together.

However, the modifier indicator to the above mentioned edit is ‘1,’ which means you can overcome the edits with a modifier. For services prior to October 1, 2014, the group psychotherapy code was in the column 2 of the edits which meant that you had to report 90853 with the modifier appended to it. But, for services after Oct.1, 2014, the edits were reversed. So, you will now need to append the modifier to the individual psychotherapy code.

Scenario 2: Group Psychotherapy Coupled With Interactive Complexity

What to report: In the scenario described, you will report 90853x10 and report +90785 (Interactive complexity [List separately in addition to the code for primary procedure]) x6.

When reporting group psychotherapy code, 90853, you report one unit of the code for each participating member in the group and not claim 90853 once for the entire group. As ten members were present in the scenario described, you will have to report ten units of 90853 (i.e. one for each patient) when reporting the services of your psychiatrist for the group psychotherapy.

Since your clinician encountered communication difficulties with six of the ten patients, you will have to report the add-on code +90785 to inform the payer about the interactive complexity and to get reimbursed for the extra time and effort that your clinician had to put in to treat these six patients.

Like the group psychotherapy code, you will have to report the interactive complexity add-on code for each of the members with whom your clinician had difficulty communicating. As your psychiatrist had to use play equipment with six of the members of the group, you should report +90785 for each of these six patients.

Scenario 3: Group Psychotherapy With Separate Family Session

What to report: In the instance elaborated, you will report 90853x4 for the group psychotherapy with the four patients and report the multiple family therapy code, 90849 (Multiple-family group psychotherapy) x4 with the modifier 59 appended to it.

You will have to report 90849 for the session held by your psychiatrist for the family members of the patients. You cannot report 90853 for this session as this CPT® code is reported only when members of an active treatment group are part of a group psychotherapy session.

Even though 12 family members of the patients took part in the family group therapy session, you still cannot count all the 12 people in the group and report 12 units of 90849. You will report this code once for each family group present and not for each family member. Since the 12 family members were part of the family of four patients, you will only report 90849x4. “This is another key distinction between 90853 and 90849,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Code 90853 is reported once per patient; code 90849 is reported once per family group.” 

As according to CCI edits, 90849 is a column 2 code for 90853 with the modifier indicator ‘1,’ you will have to report 90849 with a suitable modifier in order to get compensated for both 90853 and 90849. The modifier that you will use with 90849 is 59 or XE.

Scenario 4: Group Psychotherapy in a Partial Hospitalization Setting

What to report: In the example described, you will report you will report G0410 (Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes) x4 and G0411 (Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes) x3.

You cannot report 90853 for group psychotherapy sessions provided to Medicare patients in a partial hospitalization program setting. For Medicare patients in partial hospitalization program settings, you will have to use either G0410 or G0411. You use these two codes based on whether or not your clinician had communication difficulties with the patient. “Unlike +90785, G0411 is not an add-on code,” Moore points out. “So, for each Medicare patient in the group you will have to choose whether to report G0410 or G0411, rather than adding G0411 to G0410 for the three involving interactive complexity.” 

Since in the scenario illustrated, your psychiatrist encountered interactive complexities with three of the seven patients in the group session, you will report G0411 for each of these three patients in the group. For the rest of the group, you will report one unit of G0410 for each of the patients. Since there were four such patients, you will report G0410x4.

“If these had not been Medicare patients and the payer preferred CPT® codes to HCPCS codes, then you likely would have reported the situation using 90853 for each patient and +90785 for each of the three patients requiring interactive complexity,” Moore observes. 

Coding tip: You should provide adequate documentation that all the guidelines that satisfy reporting the procedure codes were followed. You should use place of service as 52 (Psychiatric facility-partial hospitalization) for a partial hospitalization program setting.