Psychiatry Coding & Reimbursement Alert

Question: A patient recently saw our psychiatrist for his scheduled psychotherapy session. During the visit, our clinician reviewed his medication and discussed the effects and adverse effects and made some adjustments to the dosage. He then proceeded with his psychotherapy session. Ten minutes into the session, the patient turned reticent and our clinician was forced into terminating the session. The total duration of the session was 25 minutes. Should I report only 90832, or should I report an E/M code with +90833?

Michigan Subscriber

Answer: You are incorrect in both the choices that you have suggested for reporting the session. In the scenario that you have elaborated, your clinician only spent ten minutes performing psychotherapy. As per CPT® time rules for psychotherapy codes, your clinician will need to spend a minimum of 16 minutes for you to report either 90832 (Psychotherapy, 30 minutes with patient and/or family member) or +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 only ten minutes was spent in psychotherapy, it does not satisfy the time limitation for reporting a psychotherapy service. So, you cannot report either of these codes for this session.

Also, it is wrong for you to look at the duration of the entire session to see if you can report a psychotherapy code for the visit. Since the time spent in pharmacological management is part of evaluation and management of the patient, you cannot add this time to the psychotherapy code and report 90832. If you do this, not only will this be denied, you might even be opening your doors to an audit.

So, in this case, you can only report the pharmacological management of the patient. Depending on the level of complexity of the service, you will have to report only an appropriate E/M code for the visit.