Psychiatry Coding & Reimbursement Alert

Question: A patient with major depression saw our psychologist for 60 minutes to assess her coping skills. The psychologist documented her treatment plan as including calming exercises and meditation. How should we report this encounter?

Wisconsin Subscriber

Answer: For the encounter you describe above, you would 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) and would append modifier 22 (Increased procedural services) to indicate that the time involved was longer than the typical time associated with the service. For the diagnosis code, you would report either ICD-9 code 296.20 (Major depressive disorder, single episode; unspecified degree) or 296.30 (Major depressive affective disorder, recurrent episode; unspecified degree) for the major depression.

If the psychologist does not specify whether this is a single or recurrent episode, then use 296.20, since it may be used for either a single or unspecified episode. In either case, the fifth digit allows you to describe the current status of the depression (e.g. mild, moderate, severe, etc.), if specified.