Psychiatry Coding & Reimbursement Alert

Question: Our psychiatrist conducted a follow-up evaluation for a patient admitted to our inpatient psychiatric center after a suicide attempt. She has a past history of bipolar disorder and borderline personality disorder and is currently using heroin and oxycontin. The treatment plan includes opiate detox protocol, group and recreational therapy, and daily med management. What should we report for this?

Kentucky Subscriber

Answer: It depends on whether or not the psychiatrist also provided psychotherapy as part of the encounter. If so, then based on the medication and treatment information you provide, you could report 90817 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services), provided the documentation indicates the face-to-face time spent. If there was no psychotherapy involved, then consider using a subsequent hospital care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient...) to report the follow-up inpatient E/M service that was provided.