Psychiatry Coding & Reimbursement Alert

Question: Our psychiatrist typically sees patients for mental health conditions such as depression, bipolar disorder in remission, and panic disorders. Sometimes, these patients come to our office for prescriptions and follow-up care planning for stable conditions that are more appropriately coded with an E/M code than psychotherapy.

The psychiatrist typically spends 30-45 minutes and bills either 99214 (Office or other outpatient visit for the evaluation and management of an established patient; ... Physicians typically spend 25 minutes face-to-face with the patient and/or family).or 99215 (Office or other outpatient visit for the evaluation and management of an established patient; ... Physicians typically spend 40 minutes face-to-face with the patient and/or family) plus 99354 (Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) and the appropriate ICD-9 codes.

My question is should we continue to report the psychiatrist's services this way? And does Medicare pay less for an E/M code with a psychiatric diagnosis code?

Missouri Subscriber

Answer: If a psychiatrist provides and documents the key components of an E/M service, then it is entirely appropriate for him or her to report that with the corresponding E/M code. Typically, the level of service will depend on the level of history, exam, and medical decision making involved. However, if counseling or coordination of care dominate the encounter (i.e. consume more than 50 percent) of the face-to-face time in the office/outpatient setting), then it is acceptable to choose the level of service based on the total time spent with the patient. As suggested by your question, a 30-45 minute encounter approximates the typical time of a 99214 or 99215.

The prolonged services codes, including 99354, require at least 30 minutes of prolonged service beyond the usual service. As noted, the typical time for 99214 is 25 minutes, so to report 99354 in addition to 99214 the psychiatrist would need to spend at least 55 minutes face-to-face with the patient. For 99215, with a typical time of 40 minutes, the psychiatrist would need to spend at least 70 minutes face-to-face with the patient. Given the encounters you described are only 30-45 minutes, it would not be appropriate to report 99354 with either 99214 or 99215 for such encounters.

An E/M code with a psychiatric diagnosis (290-319) code may be subject to Medicare's mental health outpatient treatment limitation. That limitation effectively changes the usual 80 percent/20 percent (Medicare/beneficiary) responsibility to a 60 percent/40 percent split in 2012. The total amount allowed to the practice is unaffected.

Resource: For more information on Medicare's outpatient mental health treatment limitation, you may read section 210 of chapter 12 of the Medicare claims processing manual online at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf