Psychiatry Coding & Reimbursement Alert

Question: Our clinical psychologist recently saw a patient requiring prolonged counseling for duration of 130 minutes. Since there is no psychotherapy code that covers such a prolonged period of time, he is of the opinion that we have to bill 90808 and use the prolonged services code 99354 to cover the additional time. Please tell me if this is right or is there some other way of doing this so that the entire duration of the psychotherapy session is paid for.

Minnesota Subscriber

Answer: You cannot bill a prolonged services code (99354-99357) with psychotherapy codes that do not also include medical evaluation and management services. The parenthetical following the descriptor for prolonged service code 99354 clearly specifies that this code can only be used along with an appropriate evaluation and management services code or codes 90809 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services) or 90815 (Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately75 to 80 minutes face-to-face with the patient; with medical evaluation and management services).

Also, as per Correct Coding Initiative (CCI) Edits, prolonged services code 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]) is a column 2 code for psychotherapy codes with the modifier '0' that indicates that these two codes are mutually exclusive codes and cannot be reported together under any circumstances. Interestingly, CCI also makes 99354 a column 2 code for both 90809 and 90815 with the modifier '0,' even though CPT® explicitly permits these code combinations.

So if you try billing 90808 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient) along with 99354, your claim for the prolonged services will likely be denied, especially if the payer is using the CCI edits.

It is best that you check with the insurance company to see if you can bill the additional time using some other convention. For instance, a payer may allow you to report 90806 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient) with 90808 to capture the extra time. Alternatively, a payer may suggest that you report 90808 with modifier 22 (Increased procedural services) appended. Per CPT®, "When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code." CPT® lists increased time as one reason modifier 22 might be used. CPT® does prohibit use of modifier 22 with evaluation and management services, but code 90808 is not an E/M service.

In any case, along with the claim, send in the documentation that specifies the need for the additional time for counseling for the patient, explaining in detail the medical necessity of it. However, it is most likely that your claim for the additional time will be denied. For instance, unless the payer specifies otherwise, CCI edits generally prohibit two psychotherapy codes being claimed for the same patient on the same date of service. So it is probable that you will only be paid for the time specified for 90808.