Psychiatry Coding & Reimbursement Alert

Question: Our psychiatrist recently saw an established patient with history of depression. He discussed medication with the patient and spent about 10 minutes for this part of the service. He then discussed some behavioral changes and made some suggestions. He spent another 10 minutes for this part of the service. Can I report an add-on psychotherapy code and E/M code for the encounter?

Delaware Subscriber

Answer: You cannot report any psychotherapy code for the behavioral changes that your clinician discussed with the patient. The time rules for psychotherapy state that your clinician will have to spend a minimum of 16 minutes in performing a psychotherapy service for you to report either 90832 (Psychotherapy, 30 minutes with patient and/or family member) or the add-on code +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]).

Since your clinician did not spend the required minimum of 16 minutes performing psychotherapy, you cannot report a psychotherapy code for that part of the service. So, you will only have to report an appropriate E/M code for the medication management and counseling that your clinician performed.