Psychiatry Coding & Reimbursement Alert

Hint: Check when to overlook CCI edits for better reimbursement.

When your clinician performs psychotherapy for crisis, you will need to understand CPT^® time rules to claim appropriate compensation for your clinician’s efforts while knowing what other psychiatry codes you are and are not allowed to report on the same calendar date of service.

Bust these four common myths that will help you perfect your crisis management reporting and help you understand better the rules for reporting the crisis management codes, 90839 (Psychotherapy for crisis; first 60 minutes) and the add-on code, +90840 (…each additional 30 minutes [List separately in addition to code for primary service]).

Myth 1: 90839 Can be Reported More Than Once on one Calendar Date

Reality: You should only use the psychotherapy for crisis CPT^® code 90839 only once per calendar date of service for a given patient, regardless of the number of sessions (on that particular calendar date) in which your clinician performed the crisis management.

“The CPT^® guidelines are explicit on this point,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “CPT^® states code 90839 ‘should be used only once per date even if the time spent by the physician or other health care professional is not continuous on that date’,” adds Moore.

When reporting 90839 and the add-on code +90840, you will need to follow CPT^® time rules to help in your code selection based on time spent. Even though the descriptor to 90839 mentions the time component as “first 60 minutes,” you report 90839 for the time spent in crisis management for a minimum duration of 30 minutes and maximum up to 74 minutes of service.

Likewise, even though the add-on code +90840 mentions the time component as “each additional 30 minutes,” you use one unit of +90840 when time spent on the crisis management extends for 15 minutes beyond the first hour (or a total of 75 minutes).

According to the time rules, you report 90839 for the first 30-74 minutes of service and report 90839 with one unit of +90840 for crisis management between 75 minutes to 104 minutes.

If the crisis management occurred in more than one session on the same calendar date of service, you will still continue to report only one unit of 90839. Since the face-to-face time performing crisis management need not be continuous, you just have to add up the total time spent on the same day of service and report 90839 for the first 30-74 minutes and then calculate the appropriate number of add-on units of +90840 for each additional 30 minutes spent face-to-face with the patient.

Myth 2: Crisis Management Can be Reported With Psychodiagnostic Evaluation

Reality: If a situation arises where your clinician is performing an initial psychodiagnostic evaluation of the patient and the patient turns aggressive or suicidal and needs emergency crisis management, you cannot report 90839 with 90791 (Psychiatric diagnostic evaluation)or 90792 (…with medical services).

“This is another point on which the CPT^® guidelines are explicit,” Moore says. “CPT^® states, ‘Do not report [90839, +90840] with 90791 or 90792’.”

When you look at Correct Coding Initiative (CCI) edits for bundling between 90839 and psychodiagnostic codes, 90791 or 90792, you will find that 90839 is bundled into the evaluation codes with the modifier indicator ‘0.’ So, you cannot overcome this bundling edit by using any modifier to either of the codes. If you try reporting 90839 with 90791 or 90792, only the evaluation code will be paid,and payment for 90839 will be denied.

So, if you encounter a situation wherein your clinician has to perform crisis management on the same calendar date on which an initial psychodiagnostic evaluation is being performed, you will need to check if all the components of the evaluation were completed. If so, you will only report 90791 or 90792 (as appropriate) and not report 90839.

On the other hand, if all the components of the evaluation were not completed because your clinician had to perform the crisis management, you will have to look at reporting 90839 and the appropriate number of units of +90840 for the crisis management rather than reporting 90791 or 90792.

Myth 3: Non-crisis Psychotherapy Codes Always Override Crisis Psychotherapy Codes

Reality: Again, as in the situation with psychiatric diagnostic evaluation codes, if you encounter a situation wherein your clinician had to perform crisis management during a psychotherapy session, you cannot report both 90839 and the non-crisis psychotherapy codes (90832-+90838) on the same calendar date of service.

“From a CPT^® perspective, 90839-+90840 and 90832-+90838 both represent psychotherapy. Thus, CPT^® requires you to use one set of codes or the other to report the psychotherapy provided to a given patient on a given date,” says Moore.

According to CCI edits, you will face bundling if you try reporting 90839 with any of the other psychotherapy codes. The edits bundle 90839 into the psychotherapy code with the modifier indicator ‘0,’ thus allowing you only to report the psychotherapy code and not the crisis management code. So, if you report both the codes together, you will only be paid for the psychotherapy code and not for 90839.

Here again, you will need to look at whether or not the time threshold for the crisis psychotherapy was met. If this was met, you can look at only reporting the crisis management codes, 90839 and the appropriate units of +90840, instead of looking only at CCI edits and reporting the appropriate time-based psychotherapy code.

Reimbursement tip: Medicare assigns 3.72 non-facility relative value units (RVUs) to 90839, which, multiplied by the current $35.9335 conversion factor, leads to $133.67 in reimbursement. In comparison, a 60-minute psychotherapy session that you will report with 90837 (Psychotherapy, 60 minutes with patient and/or family member) carries a total of 3.56 RVUs ($127.92). So, if the time threshold and other conditions for reporting crisis psychotherapy are met, you can report 90839, which will better compensate the clinician for the time and effort spent with the patient.

Note: If the clinician does not meet the time threshold of 30 minutes of face-to-face crisis management needed to report 90839, you can count the time spent on crisis psychotherapy as part of the total time spent on psychotherapy. Then choose the appropriate non-crisis psychotherapy code.

Myth 4: Use +90785 for Communication Issues during Crisis Management

Reality: In most situations where your clinician performs a crisis management, you will see that your clinician had trouble with communication with the patient. But, you should not reach out to the interactive complexity add-on code, +90785 (Interactive complexity [List separately in addition to the code for primary procedure]) whenever you see such a situation.

The reason codes 90839 and +90840 are excluded from the use of this add-on code is because psychotherapy for crisis inherently involves specific communication factors that complicate the delivery of a psychiatric procedure, which is what the code for interactive complexity is otherwise intended to capture. For instance, according to CPT^®, one of the reasons to report interactive complexity is the need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) that complicates delivery of care. This need is almost always present in psychotherapy for crisis. Since interactive complexity is inherent in the use of the psychotherapy for crisis codes, you should not bill +90785 in addition to 90839 and +90840. A parenthetical notation following code +90785 in CPT^® explicitly states, “Do not report 90785 in conjunction with 90839, 90840, or in conjunction with E/M services when no psychotherapy service is also reported.”

Also, since crisis management codes are time-based codes, reporting the appropriate units of codes 90839 and +90840 captures any extra time necessitated by interactive complexity without the need to report +90785. So, even though your clinician had to spend extra time face-to-face with the patient overcoming the communication issues, he will receive appropriate compensation for the additional time spent, because you will report crisis management codes on the basis of time.