Psychiatry Coding & Reimbursement Alert

Hint: Check CCI when reporting family therapy with individual therapy.

As you get ready to ring in the New Year, you should be aware of some changes that are going to modify the way you report psychotherapy services. You might end up raising red flags if you aren’t aware and make these changes to your psychotherapy reporting.

Case Scenario #1: Your psychiatrist reviews a 45-year-old male patient with complaints of depression. The patient has been regularly attending weekly sessions of individual psychotherapy and is also on medications to treat the symptoms.

During the scheduled session, your clinician spent ten minutes with the patient performing pharmacological management. He assessed the medication that the patient had been taking and discussed the effects and checked if the patient was experiencing any adverse effects. He then spent 15 minutes with the patient performing the individual psychotherapy. He spent the next ten minutes with the patient’s wife and son counseling the family. The patient was in the room during the session.

Case Scenario #2: Your psychiatrist reviews a 19-year-old female patient whom your clinician has diagnosed with anorexia nervosa. The patient has been under your psychiatrist’s care for the past three months now. He has been conducting regular sessions of behavioral psychotherapy to help the patient overcome the condition.

During the scheduled session, your clinician spent 30 minutes performing the individual psychotherapy. He then spent ten minutes with the family members that included the patient’s parents and her brother. The patient was present in the room during the session.

Case Scenario #3: Your psychiatrist sees a 23-year-old male patient whom your clinician has previously diagnosed with generalized anxiety disorder. The patient has been scheduled for his first psychotherapy session.

During the scheduled session, your clinician first sees the patient and performs the individual psychotherapy. Since it is the first session, your clinician spends an hour with the patient. He then sees the patient’s parents and his sister for another 30 minutes counseling them. The patient was present in the room during the session.

So, how do you report these three case scenarios that include individual psychotherapy and family therapy, and how will your coding change when your clinician performs these three services in 2017?

Stop Combining Family Counseling with Individual Psychotherapy

As we reported in an earlier issue of the Psychiatry Coding Alert, CPT^® 2017 has introduced changes that will alter the way you report individual psychotherapy. The new change that has been introduced removes the phrase, “and/ or family member” from all the individual psychotherapy codes (90832-90838). “For psychotherapy services, the 2017 coding manual explains that a code’s stated time for sessions applies to face-to-face time with a patient who is present for all or most of their session,” says Melody Lidmila, CPC, CEC, Coding specialist at the University of Colorado Health, in Loveland, CO.

“The guidelines preceding the psychotherapy codes in CPT^® state that codes 90832, 90833, 90834, 90836, 90837, and 90838 ‘describe psychotherapy for the individual patient, although times are for face-to-face services with patient and may include informant(s)’,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “The implication is that these services may still involve informants, such as family members, but it is the time spent face-to-face with the patient that drives code choice.”

So, now you will no longer be adding up the time spent in performing individual psychotherapy and the time spent counseling the patient’s family members. Since the time spent counseling family members now cannot be reported with the individual psychotherapy codes, you will only calculate the time spent with the patient and report the appropriate psychotherapy codes based on that time and based on whether or not your clinician performed an evaluation and management service.

Report Family Therapy Separately When Appropriate

As CPT^® 2017 has now further separated out family psychotherapy from individual psychotherapy, you will now have to report time spent counseling family members only with family therapy codes 90846 (Family psychotherapy [without the patient present], 50 minutes) and 90847 (Family psychotherapy [conjoint psychotherapy] [with patient present], 50 minutes), depending on whether or not the patient was present in the room during the session. However, you should note that CPT^® 2017 has introduced some changes to family therapy codes also.

According to the newly introduced changes, you now have a time descriptor to both the family therapy codes. Previously, there was not time descriptor for either code. The new time descriptor reads “50 minutes.” Even though the time descriptor specifies 50 minutes, you can report family therapy codes if your clinician spends a minimum duration of 26 minutes performing the service.

“This minimum is consistent with CPT^® conventions that state a unit of time is attained when the midpoint is passed,” Moore says.

So, when your clinician performs individual psychotherapy and family therapy, you will still have to continue counting time spent as you did in the past. However, you will have to segregate the time spent in performing the two services as you will need to report the services separately. You can report time spent counseling family members separately with either 90846 or 90847 if and only if your clinician spent a minimum of 26 minutes or more performing this service.

Continue Reporting Prolonged Services with Psychotherapy Codes

You report 90837 (Psychotherapy, 60 minutes with patient) when your clinician spends 53 or more minutes performing individual psychotherapy and no E/M service was performed during the visit. If your clinician spends 90 minutes or more performing the individual psychotherapy, you can report an appropriate prolonged service code based on the location where your clinician performed the service. “Only one psychotherapy code is allowed with prolonged services,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, PA.

“Prolonged services can be reported with 90837,” says Rebecca Yowell, deputy director for reimbursement policy at the American Psychiatric Association. “You can not bill prolonged services with the add-on code 90838 (the psychotherapy code you use when you also do an E/M service).” You cannot report the prolonged service code if you are reporting the psychotherapy with a same visit evaluation and management code. “Prolonged services codes cannot be reported with CPT^® +90838,” Falbo adds.

Since there are no changes to the way you report prolonged care codes with psychotherapy codes, you will continue to report prolonged services codes with the psychotherapy code, 90837. “For psychotherapy visits lasting 90 minutes or longer, the appropriate prolonged service code (99354-99357) should be used,” Lidmila says.

The only change that you will need to bear in mind is to know that the entire time component for calculating 90837 and the appropriate prolonged services code should be satisfied by the time component of the individual psychotherapy only. So, your clinician should spend a minimum of 90 minutes performing individual psychotherapy for you to report 90837 and an appropriate prolonged services code.

“This is because the prolonged services code requires a minimum of 30 minutes beyond the typical time of the base code in order to report it. Prolonged service of less than 30 minutes is not separately reportable, per CPT^®,” Moore adds.

Apply This Knowledge to the Case Scenarios

Case Scenario #1: In case scenario #1, your psychiatrist performed the scheduled individual psychotherapy session only for duration of 15 minutes and the family therapy for ten minutes. If the service was done prior to Jan.1, 2017, you could report +90833 (Psychotherapy, 30 minutes with patient when performed with an evaluation and management service [List separately in addition to the code for primary procedure]) for the session, because at that point, the descriptor included “and/or family member” and the total duration of the session including individual and family members is 25 minutes.

However, if the service was done after Jan.1, 2017, you need to factor in only the time spent in individual psychotherapy. According to CPT^® time rules for individual psychotherapy, you can report +90833 if and only if your clinician spent a minimum of 16 minutes performing the psychotherapy session. Since the time spent by your clinician falls short of this, you cannot report +90833 for the session. As your clinician also performed the pharmacological management, you should only report the most appropriate E/M code for the visit.

Case Scenario #2: In case scenario #2, your psychiatrist performed 30 minutes of individual psychotherapy and ten minutes of family counseling. Prior to Jan.1, 2017, you could have reported 90834 for this service as the total time spent amounts to 40 minutes with patient and/or family members, which satisfies the time requirement of 38 to 52 minutes for reporting this code.

If the service is done after Jan.1, you will report 90832, as the individual psychotherapy was done only for 30 minutes, which is the typical time component for 90832 and less than the minimum time requiredto report 90834. You cannot report 90847 for the visit as your clinician did not perform the family counseling for 26 minutes or more.

Case Scenario #3: In case scenario #3, your psychiatrist performed 60 minutes of individual psychotherapy and 30 minutes of family therapy. If you were reporting this service before Jan 1st, and the focus of the time spent with the family was on the individual (rather than family dynamics) you could have reported 90837 and +99354 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure]…) for the visit, since the session lasted for 90 minutes and thus satisfies the time requirement for reporting prolonged services code.

For this service beyond Jan 1, 2017, you would only be reporting 90837 for the individual psychotherapy. You cannot report the prolonged service code factoring in the time spent in family therapy. Instead, since the family therapy meets the time requirement of 26 minutes, you can report 90847 for the family therapy. Append modifier 59 (Distinct procedural service) to 90837 to report both the services together, since CCI edits otherwise bundle 90837 into 90847 when reported on the same date for the same patient.