Psychiatry Coding & Reimbursement Alert

Hint: Use G codes for Medicare patients in partial hospitalization programs.

When your clinician handles group psychotherapy sessions, you will need to know criteria for coverage, what other codes you can and cannot report for the same session, and the appropriate modifiers to use to unbundle some codes that face edits.

Be Aware of Documentation Guidelines for 90853

When your psychiatrist or psychologist performs group psychotherapy for patients, you’ll have to report the session with 90853 (Group psychotherapy [other than of a multiple-family group]). You should report one unit of the code for each patient that was part of the group. Although it is typical for a group therapy session to have about eight to ten patients, the maximum number of patients that is permissible to participate in a group therapy session is 12.

The documentation should include details about why and how this group psychotherapy is beneficial and medically necessary for the patient’s treatment. To establish the medical necessity of the session, the documentation should include the diagnosis for which the patient is being treated. The documentation should also include how much time was spent on each session and the number of sessions your clinician intends to perform for the patients.

You should remember that if you are making claims with 90853 at frequent intervals, you might be inviting a review from Medicare to see if the services performed by your clinical psychologist are medically reasonable or not.

Reminder: Group therapy doesn’t include socialization, music therapy, recreational activities, art classes, excursions, sensory stimulation, eating together, cognitive stimulation, and motion therapy, as this does not satisfy the guidelines for group therapy. You cannot claim these services with 90853. Self help groups or support groups without a qualified professional are also not billable with 90853.

Example: Your psychiatrist conducts group psychotherapy for seven patients suffering from depression. Your clinician plans a total of six sessions with each session planned for a total of 45 minutes. For each session, since there are seven patients participating in the group, you’ll have to report 90853 for each of the seven patients. Since 90853 is not a time based code, you do not have to worry about the time spent on the individual patient but should document the total time spent for the group psychotherapy session.

Append Add-on Code for Interactive Complexity

When your clinician conducts group psychotherapy sessions and there are communication factors that complicate the provision of the service, you can get compensated for the additional time and effort that your clinician spent on the patient(s). For this, you will have to report the add-on code +90785 (Interactive complexity [List separately in addition to the code for primary procedure]) along with the group psychotherapy code.

“Per CPT®, common communication factors that represent interactive complexity include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.“Typical patients are those who have third parties involved in their psychiatric care,” adds Moore.

Since the group psychotherapy code is reported for each individual patient in the group, you have to report +90785 for the interactive complexity encountered for each patient that needed the extra time and effort to be spent by your clinician.

Example: Your psychiatrist performs group therapy for a group of ten adolescent patients. Since he encountered communication difficulties with six of the ten patients, he used play equipment to communicate with them.

What to report: Since the use of “play equipment” needs extra time and effort and satisfies the CPT® guidelines for the use of +90785, you can report the group psychotherapy sessions for these six children with interactive complexity using 90853 and +90785. For each of the other four patients who did not need the use of play equipment, you just report 90853.

In addition to situations that involve the use of play equipment or other physical devices, psychiatric procedures may be reported “with interactive complexity” when at least one of the following is present, according to CPT® guidelines:

1. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.
2. Caregiver emotions or behavior that interferes with the caregiver’s understanding and ability to assist in the implementation of the treatment plan.
3. Evidence or disclosure of a sentinel event and mandated report to third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with
patient and other visit participants.
4. Use of interpreter or translator to communicate with the patient to overcome barriers to therapeutic or diagnostic interaction between the physician or other qualified health care professional and a patient who:

• Is not fluent in the same language as the physician or other qualified health care professional, or
• Has not developed, or has lost, either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the physician or other qualified health care professional if he/she were to use typical language for communication.

Caveat: As per guidelines laid down by CMS, you cannot use +90785 solely for any translation or interpretation services that your clinician might use during the delivery of a psychiatric service, as it amounts to higher beneficiary payments and copayments on the basis of ethnicity or disability that could implicate Title VI of the Civil Rights Act of 1964 or section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act respectively.

Know if You Can Report Same Day Individual and Group Psychotherapy

According to Correct Coding Initiative (CCI) edits, individual psychotherapy codes (90832-90837) and group psychotherapy code (90853) are bundled together with the modifier indicator ‘1,’ which means you can report these two services together if a modifier is appended.

So, even though these codes face edits, you can unbundle the codes by using an appropriate modifier such as 59 (Distinct procedural service). “The modifier is appended to the group psychotherapy code, because it is the Column 2 code in each edit pair and is the code that will be denied if unmodified in this situation,” points out Moore.

Example: If a patient sees your psychiatrist for individual psychotherapy for 30 minutes and on the same date of service participates in a group psychotherapy session, you report 90832 (Psychotherapy, 30 minutes with patient and/or family member) for the individual psychotherapy and report 90853-59 for the group psychotherapy.

Discern When to Report E/M Services With 90853

Before reporting an E/M service encounter on the same date of service as group psychotherapy, you will need to pay heed to CCI edits that bundle these codes with the modifier indicator ‘1.’ However, as the indicator is ‘1,’ you can unbundle the codes if a separate and significant E/M encounter was performed on the same day.

To unbundle the codes and report them together on the same date of service, you will have to append a modifier to the E/M service code. “Specifically, you will have to use the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to get it paid in addition to 90853 provided to the same patient on the same date, since the E/M code is the Column 2 code in these edit pairs” notes Moore.

Example: Your psychiatrist reviews antidepressant medication prescribed for a patient prior to his group psychotherapy session. Your clinician reviews the medication history, effects, and adverse effects of the medication and performs some adjustments to the dosage prescribed. The patient then participates in the group psychotherapy session. You report 90853 for the group psychotherapy and report 99212-25 for the pharmacological management.

Substitute 90853 With G Codes For These Medicare Patients

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 appropriate G codes instead.

You should note that the G codes used to report group psychotherapy are time-based and distinguished by the absence or presences of interactive complexity. So, the two codes that you will use for reporting group psychotherapy for a Medicare patient in a partial hospitalization program include:

• G0410 (Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes)
  
• G0411 (Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes)
  

Reminder: 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.