Psychiatry Coding & Reimbursement Alert

Weigh services provided for improved coding accuracy.

When your psychiatrist reviews the effects of drugs prescribed, you may be challenged by a thorny decision: whether to report 90862 or an E/M code for the encounter. Read on to know when a psychiatric med management code fits best and when it's better to apply an E/M code instead.

If the physician prescribes a drug for any mental health disorder and performs very minimal psychotherapy and no other services are provided, you would report the visit with 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy). You can also apply this code when your psychiatrist asks the patient to come back for another visit at a later date to review the effects of the medication.

During the encounter, your physician might evaluate the effects the medication is having on the patient and may also undertake necessary dosage adjustments for the period till the patient is asked to come back for a follow-up visit.

For example, a child who is taking medication to treat attention deficit hyperactivity disorder may present for medication management. During the encounter, the psychiatrist provides a brief interval history and mental status exam with a focus on the patient's response to the medication and any side effects, says Kent J. Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. Regulation of the medication, as needed, is also provided, he adds.

For instance, "our documentation includes (but is not limited to) current medications/ compliance, side effects, MSE, assessment, follow up, diagnosis and treatment including prescription along with risks and benefits," shares Lauren Dixon, office coordinator, WMHS Behavioral Health Services, in Cumberland, MD.

Careful: Note that most states do not provide authorization to clinical psychologists and other licensed mental health care professionals to prescribe psychotropic medications. So, 90862 would typically be reported when psychotropic drugs such as antidepressants, anti-anxiety drugs, and antipsychotic drugs, are prescribed by a psychiatrist or a licensed physician for use by a patient for the treatment of a relevant psychiatric or other mental health condition.

Time factor: Unlike psychiatry CPT® codes 90804 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility...)-90829 (Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting...), 90862 isn't time based. Typically, the services your psychiatrist will provide while performing pharmacological management of patients will not last beyond 25 minutes.

"In our outpatient psychiatry practice, we use the 90862 for medication management approximately 90 percent of the time," offers Dixon. "It allows us 10-20 minute visits."

Minimal Psychotherapy? How to Determine

You shouldn't report 90862 if the patient received more than minimal psychotherapy or any other services during the visit, so knowing what "minimal psychotherapy" entails can help you appropriately report this code.

Minimal psychotherapy would be brief, supportive therapy to help patients cope with stresses. "This psychotherapy is distinguished from that included in codes 90804 through 90829 by both its length and its nature," explains Moore. "As the word "minimal" implies, the psychotherapy involved in 90862 is very brief and not the focus of the encounter. By comparison, the psychotherapy involved in 90804-90829 is much longer (approximately 20-30 minutes, at a minimum)," he adds. "Also, the nature of psychotherapy in 90862 is supportive, whereas the psychotherapy included in 90804-90829 is intended to be more definitively therapeutic."

So, for example, if a bipolar patient on medication presents for medication management and the psychiatrist spends 5-10 minutes of the encounter encouraging them to take their medication and pursue the treatment options prescribed at a previous visit, that is most likely the kind of minimal psychotherapy envisioned in 90862. By comparison, if the same patient presents for 20-30 minutes of more definitive therapeutic communication intended to, among other things, alleviate the patient's emotional disturbances, then a code such as 90804 would be in order.

No psychotherapy: If the psychiatrist sees a patient for medication management and documents a mental status exam and interval history but doesn't provide psychotherapy, you can still report 90862, according to CPT® Assistant (March 2010). "There is no requirement for any psychotherapy to occur when performing this procedure," CPT Assistant says. "The code descriptor states that code 90862 is for pharmacologic management 'with no more than minimal psychotherapy.' This is done to distinguish it from a psychotherapy session in which evaluation and management services are provided."

Psychotherapy only: If the primary service is psychotherapy "rather than medication management," the appropriate code describing psychotherapy with medical evaluation and management services should be used, instead of code 90862," CPT® Assistant clarifies.

Reach for E/M Codes for More Extensive Management

If your psychiatrist conducts a more extensive medical evaluation and management (E/M) of the patient that includes diagnostic evaluation along with pharmacological management of the patient, then you cannot bill 90862 separately or with any other E/M codes or psychiatric CPT® codes such as 90804-90829.

So if other medical E/M services are provided to the patient, then you should use the most appropriate E/M (e.g. 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components...) code, and 90862 should not be billed on the same calendar date of service.

For example, if the bipolar patient described above presents with complaints of significant side effects that he believes are the result of medication prescribed by the psychiatrist, the physician may do significantly more evaluation and management of the patient than would normally be associated with 90862 to determine if the signs and symptoms are, in fact, medication related or have another cause.

In this case, the history, exam, and medical decision making provided by the psychiatrist may necessitate the use of an E/M code, rather than 90862. If the psychiatrist also provides substantial psychotherapy with the E/M services, then it may be apt to report an appropriate code that encompasses both services, such as 90805 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services).

Payment advantage: The total RVUs for 90862 (approx. $58.54; 1.72 total RVUs) are less than the RVUs of an E/M code such as 99213 (approx. $70.46; 2.07 total RVUs) or 99214 (approx. $104.16; 3.06 total RVUs). Thus, billing an E/M instead if the encounter supports this level of service could earn you more revenue for med management services.

Switch to M Codes for Minimal Pharma Management

When a follow-up visit is totally restricted to monitoring or changing medication that is prescribed in the treatment of mental, psychoneurotic, and personality disorders, then you would report the visit using HCPCS code M0064 (Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders). Note that this code can also be reported if your psychiatrist is using the visit to change the medication to another medication and no other services were performed during the visit.

M0064 would be reported only when monitoring or changing a drug prescribed is the purpose of the visit. "Unlike 90862, this code does not include even minimal medical psychotherapy, and unlike an E/M service, M0064 involves no evaluation or management of the patient beyond monitoring or changing the patient's medication," says Moore. Unlike most other services provided in support of mental health treatment, M0064 is not subject to Medicare's outpatient mental health treatment limitation; for more information on that limitation, please see section 210 of chapter 12 of the Medicare Claims Processing Manual, online at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

As the RVUs for M0064 indicate (approx, $49.35; 1.45 total RVUs), the reimbursement is a little bit more than what is assigned for E/M services code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components... Physicians typically spend 10 minutes face-to-face with the patient and/or family) which are (approx. $42.55; 1.25 total RVUs).