Psychiatry Coding & Reimbursement Alert

Hint: Add minutes spent on services to family too.

To accurately report the CPT^® 2013 add-on codes for psychotherapy, namely +90833, +90836 and +90838, you’ll need to concentrate on the time your psychiatrist spent on psychotherapy along with choosing an appropriate code for the E/M or medication management service provided.

Apply CPT® Time Rules For Choosing Appropriate Add-on Code

Based on time spent by your clinician in providing psychotherapy, you’ll report one of the following new add-on codes when a simultaneous E/M service or medication management service is provided:

• +90833 – Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service [List separately in addition to the code for primary procedure]
• +90836 – Psychotherapy, 45 minutes…
• +90838 –Psychotherapy, 60 minutes…

Although these add-on codes that you will report for the psychotherapy part of the session describe specific time spent during the session, you’ll have to use the CPT^® time rules to determine exactly which of the three codes you’ll use to report a session.

Applying CPT^® time rules, you’ll report +90833 for a psychotherapy session that lasts between 16 minutes to 37 minutes, +90836 for a session that lasts between 38 minutes to 52 minutes and +90838 for a session that is more than 53 minutes.

Caveat: When a psychotherapy session where no E/M service is provided lasts for more than 90 minutes, you can use prolonged services codes (99354-99357) as an add-on code to 90837 (Psychotherapy, 60 minutes with patient and/or family member). However, if such a scenario were to happen in a session where in your clinician provides E/M services and conducts a prolonged psychotherapy session, you cannot use the prolonged services codes along with the +90838.  The Correct Coding Initiative (CCI) edits indicate that prolonged services codes are column two codes for +90838 with the modifier indicator ‘0,’ which tells you that you cannot use these codes together under any circumstances.

Observe That Location Matters for E/M

Unlike old codes for psychotherapy, you do not have different codes when psychotherapy services are provided in different locations (such as outpatient, office, or inpatient). The new add-on codes are the same, regardless of the location in which these services are provided.

However, when reporting psychotherapy with E/M services, you’ll still have to look at the location in which the services were provided, as the code you will choose for the E/M service provided is still dependent on the location, such as office, inpatient, etc.

Reminder: Just as the new add-on codes for psychotherapy are not location specific, they also remain the same, regardless of whether or not an interactive element was present. To capture the interactive complexity of the service, you’ll need to report the add-on code +90785 (Interactive complexity [List separately in addition to the code for primary procedure]).

Keep Track of Time for Different Services Provided

When reporting psychotherapy services along with an E/M service, you’ll need to check documentation to see the time spent for each service. You’ll need to note that the time spent on the E/M service cannot be counted in choosing the appropriate psychotherapy services code. So, when selecting the code for the psychotherapy service, you’ll only count the minutes spent on the psychotherapy aspect of the service, not the E/M or medication management aspects.

Best bet: When choosing the E/M services code, select the code based on the level of the history, exam, and medical decision making involved. Selecting the E/M code solely on the basis of time is justified only when counseling and/or coordination of care dominates the encounter.

“In a situation where an E/M service is provided in conjunction with psychotherapy, which itself is chosen on the basis of time and principally involves counseling the patient, it may be difficult to establish that counseling and/or coordination of care separate from that involved in the psychotherapy dominated the E/M service enough to justify also coding the E/M service based on time,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Know When to Select E/M Service for Medication Management

Although 2013 saw the implementation of a new code for medication management, namely +90863 (Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services [List separately in addition to the code for primary procedure]), you’ll have to exercise restraint in the use of this code.

You’ll choose this code for any pharmacological management service only if the service is provided by a prescribing psychologist or other non-medical practitioner who is licensed by his or her state to prescribe but is not qualified to bill evaluation and management services.

In such a scenario, you’ll use +90863 as an add-on code to the psychotherapy services codes, 90832, 90834 or 90837 (psychotherapy codes that you’ll choose depending on time spent).

If your clinician is allowed to bill out E/M services, you’ll have to choose the most appropriate E/M code depending on the complexity of the service for any medication management that he provides. For same session psychotherapy services, you’ll choose the add-on codes for psychotherapy depending on the time spent on psychotherapy.

Example: Your psychiatrist reviews a 60-year-old male patient for complaints of depression. The patient has been under your psychiatrist’s care for the past four months now. He has been conducting regular sessions of psychotherapy to help the patient overcome the depression. Your psychiatrist has also prescribed anti-depressant medication for the patient.

After the psychotherapy session in his office, your psychiatrist reviews the effects of the patient’s medication, including any adverse effects. Taking into account the improvements to the patient’s progress and any adverse effects, your psychiatrist makes some adjustments to the dosage.

The entire session lasts for 55 minutes, with your psychiatrist spending about 10 minutes on pharmacological management. Since your psychiatrist spent 45 minutes on psychotherapy of the patient, you’ll report +90836 for the psychotherapy and report the medication management with an appropriate level of E/M service, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components…).

Check When to Use Add-on Psychotherapy Codes in Lieu of Family Codes

Since the add-on codes for psychotherapy involve psychotherapy with the patient and/or family member, you’ll have to discern when to use these codes and when to use the family therapy codes, 90846 (Family psychotherapy [without the patient present]) and 90847 (Family psychotherapy [conjoint psychotherapy] [with patient present]).

If the session was focused on the patient with peripheral involvement of the family, you’ll have to include time spent with family members into the time spent on the psychotherapy session for the patient to zero in on the right add-on code.

Watch this: If the session was primarily focused on counseling the family members of the patient and providing them information about how their interaction with the patient will benefit his/ her treatment, you’ll have to use the family psychotherapy session codes, 90846 or 90847, as appropriate. “From a CPT^® perspective, during family psychotherapy, the psychiatrist includes the family in the treatment process, and the family dynamics related to the patient are the main focus. The emphasis during the sessions is still on the patient’s care. However, the therapy is aimed at the environment in which the patient lives or will live and the family interactions in that environment,” notes Moore.

Family psychotherapy coding may be separately reported for each patient in the family, but it should not be reported for each family member. Also, note that these codes are not time-based; they should only be reported once per session. “The patient’s absence (90846) or presence (90847) helps determine which of the two codes to report,” points out Moore.

Do this: There are no Correct Coding Initiative (CCI) edits for the add-on psychotherapy codes and family therapy codes, 90846 and 90847. So, you can report the add-on codes along with family therapy codes if both the services were provided in the same session.