Psychiatry Coding & Reimbursement Alert

Take care to check documentation for psychotherapy during the same session.

When your psychiatrist sees a new patient, referred or otherwise, he will undertake an initial interview that assesses the patient's condition. Our advice that follows will help you know when to use initial interview CPT® codes and to discern them from psychotherapy codes.

Here is a coding scenario that you will most likely encounter in your practice:

A patient gets referred from the emergency department of the hospital for evaluation and treatment from your psychiatrist. The patient had complaints of severe headache and hearing voices. The emergency department physician completed an examination of the vital signs, neurological system, heart, abdomen and lungs, along with conducting an electrocardiogram. With no significant findings, he refers the patient to your psychiatrist for examination, evaluation and to assess if the patient needs psychotherapy.

What to report: The emergency department generally does not use psychiatry interview and examination codes (e.g., 90801, Psychiatric diagnostic interview examination), although there is no place of restriction for the use of the code. You're more likely to see an E/M code such as 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components...) for the services rendered by the ED physician.

When the patient first presents to your psychiatrist, your psychiatrist will undertake an initial evaluation of the patient. This initial interview examination will include a complete mental status examination, complete evaluation of the patient's history, a review of systems, as well as discussions with family members and ordering diagnostic tests with interpretations. A complete mental status examination will include your psychiatrist assessing the patient's:

• recent and remote memory,
• concentration and attention span,
• mood and affect (e.g., depression, anxiety, agitation, hypomania, lability)
• orientation to time, place and person,
• fund of knowledge (e.g., awareness of current events, past history, vocabulary) and
• language(e.g., naming objects, repeating phrases)

The psychiatrist does this by asking appropriate questions and through examinations. You should report the services rendered by your psychiatrist with 90801.

Use 90802 for Initial Interview With Children

When your psychiatrist performs an initial interview examination for a child with whom he faces communication difficulties and uses interactive equipment for examination, evaluation and assessment, you will need to report the services rendered by your psychiatrist with 90802 (Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication).

The use of 90802 is typically meant for children with whom your psychiatrist has communication difficulties. However, you can also use the same CPT® code for adults when these patients suffer from mental deficits that have compromised their abilities to communicate verbally. "90802 can also be used for adults who have otherwise lost either the communication skills to explain their symptoms and response to treatment, or the necessary skills to understand the psychiatrist if he or she uses ordinary adult language to communicate," adds Kent J. Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. "You can turn to the same initial interview code if your psychiatrist uses the help of an interpreter, as is the case when your psychiatrist has to evaluate a deaf person or in the case of a person who requires a foreign language interpreter."

Turn to 90801 for Significant Status Changes

Although 90801 is your first choice when your psychiatrist conducts an initial interview and examination, you can use the same code if your physician notes significant changes in the status of the patient. For instance, you can also use 90801 if there has been a long gap in treatment or if the patient is not taking his medications regularly, resulting in changes to the initial recorded mental status.

Example: A patient who was previously being treated for depression by his family physician is referred to your psychiatrist for evaluation and treatment. The family physician notes a status change from mild depression to severe depression with increased frequency of episodes and sends all the relevant documentation of the patient for your psychiatrist's reference. Your psychiatrist undertakes a thorough review of the patient's previous history, mental status, review of systems and has a discussion with the patient's family.

You report this interview and examination with 90801, because even though the patient has a previous psychiatric history, he has a current change in mental status that needs evaluation by your psychiatrist.

Don't Report 90801, 90802 With Other Psychotherapy Codes

If your psychiatrist, during the initial interview and examination, decides to perform behavioral psychotherapy for the patient, you cannot report 90801 with other psychotherapy codes (90804, Individual psychotherapy, insight oriented, behavior modifying and/or supportive...-90829, Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication...). Under the National Correct Coding Initiative, 90801 and 90802 are column 2 codes for the psychotherapy codes and cannot be reported separately under any circumstances.

In such a scenario, you can report psychotherapy codes that include evaluation and management services to report the examination and evaluation that your psychiatrist performed. So, depending on the facility in which your psychiatrist saw the patient, the time spent for psychotherapy and the type of psychotherapy (behavioral or interactive), you can use appropriate psychotherapy with evaluation and management codes.

Example: Your psychiatrist provided evaluation and management services (such as a physical examination, drug monitoring, and assessment of other co-morbid conditions) along with behavioral psychotherapy to a patient suffering from depression in his office for a period of 55 minutes face-to-face, of which 30 minutes were spent on the psychotherapy.

You can code 90807-22 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services) for the visit. Code 90807 is chosen because your psychiatrist provided both behavioral psychotherapy and E/M services in the office setting and the amount of time exceeds that for 90807 but is less than that listed for the next level of codes (i.e., 90808 and 90809 at 75-80 minutes). The face-to-face time includes both the amount of time spent on providing psychotherapy and the amount of time spent performing evaluation and management services during the visit. Because the total time in this example (i.e. 55 minutes) exceeds the typical time listed in CPT, you may indicate that circumstance by appending modifier 22 (Increased Procedural Services) to code 90807.