Psychiatry Coding & Reimbursement Alert

Question: Our psychiatrist recently had a patient’s wife come in during a prescheduled psychotherapy appointment. The patient did not come as he was very sick and was unable to make it. The patient’s wife discussed the patient’s condition and the treatment options and the outcome of treatment. Can this time that our psychiatrist spent discussing the patient’s condition and treatment be reported with 90846 or an individual psychotherapy code or an E/M code?

Maryland Subscriber

Answer: You cannot report any individual psychotherapy code (such as 90832, Psychotherapy, 30 minutes with patient and/or family member; 90834, …45 minutes…; or 90837, …60 minutes…) for the visit. You cannot report any of these codes even though the descriptor to these codes includes the phrase “and/or family member” in it. For you to report one of these individual psychotherapy codes, your psychiatrist should have performed psychotherapy with the main focus being on the “patient” and some peripheral interaction with the patient’s family. In such a situation, you will typically only be adding the time spent with the family to the time spent with the patient to help choose the appropriate psychotherapy code. In this case, the focus of the encounter is on the wife’s questions about the patient’s condition, treatment options, and prognosis, none of which seems to meet the definition of “psychotherapy.”

You can report 90846 (Family psychotherapy [without the patient present]) if and only if your psychiatrist spent the time with the patient’s family discussing family dynamics and how it is affecting the patient’s condition or his treatment or on how family interaction can improve the treatment outcome. Again, in this case, that does not seem to be the focus of the encounter, so be cautious about reporting the session using 90846.

Regarding the use of an E/M code for the visit by the patient’s wife, you should be aware that Medicare and most other payers typically require a face-to-face encounter with the patient for you to report an E/M code attributable to the patient. Since your clinician saw the patient’s wife and not the patient, you probably cannot report an E/M code for the visit.

That said, there are exceptions to almost every rule. Thus, Medicare’s National Coverage Determinations Manual 100-03, chapter 1, section 70.1, states, in part, “In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure background information to assist in diagnosis and treatment planning. When a physician contacts his patient’s relatives or associates for this purpose, expenses of such interviews is properly chargeable as physician’s services to the patient on whose behalf the information was secured.” However, this section goes on to state, “Counseling principally concerned with the effects of the patient’s condition on the individual being interviewed would not be reimbursable as part of the physician’s personal services to the patient.” So, whether the payer in question would cover and pay for the conversation with the wife as a service to the patient would depend on the nature of the conversation and how it is viewed by the payer.

In this situation, physicians will sometimes consider the conversation and counseling as a service provided to the person present (i.e. the wife in this case) rather than “the patient” that is the subject of the conversation. That may be another option if none of the others presented here are acceptable.

Bottom line: Check with your payer before reporting 90846 or any other code for this encounter, and only use 90846 when the physician performs family psychotherapy.