Wiki 99214 with 90833. BH visit with psychotherapy. Documentation

[Brenda1973]

Can anyone clarify with me. I code for Behavioral Health . My psychiatrist is performing an E/M of 99214 and 90833 for CBT.
His documentation statement for only the 90833 and not the 99214 looks like the below:

"Assessment and Plan:
Spent 17 minutes doing MI for smoking and CBT for depression."

Is that enough documentation to warrant a 90833?

The last AAPC BH webinar I watched on this stated that one quick statement or sentence was enough documentation to warrant a psychotherapy code WHEN it is paired along with an E/M level. The presenter said that the provider just needed a statement that the (CBT) psychotherapy was done, (reason) for depression and (minutes) the time spent on psychotherapy. The AAPC presenter stated that 90833 didn't need to go into great detail and that one sentence would be sufficient as long as it contained the required documentation. Required documented would be that CBT/psychotherapy was performed , the reason and time spent on psychotherapy. If provider is documenting that he performed this service then we shouldn't question his statement. When I code these I make sure that all of the required documentation is in the note for the E/M level and then the short statement for CBT is accurate.

We do know that the 17 minutes is counted separately from the E/M visit.

We do know that psychotherapy codes of 90832, 90834 and 90836 alone follow different documentation guidelines. Those are full progress notes that my LCSW use.

Can anyone agree with me or send me advice/ documentation? I am just looking to clarify as I have a director questioning this.

 

[georgiarackley]

You are correct to question this. The documentation standard is no different when a physician renders psychotherapy with an E/M and psychotherapy rendered by an LCSW, as you note. That said, because the physician is rendering psychotherapy during an E/M visit, the documentation of the psychotherapy will usually be integrated into the note as that is the clinical flow of the encounter. It typically is found within the HPI or assessment where the psychiatrist will document an expanded discussion that supports the billing of psychotherapy. For example, if they say CBT was done, I would expect to see something more specific such as "discussed patterns of negative thinking, and reviewed weekly journal of thoughts and related feelings. Reinforced daily mindfulness exercises which the patient reports to be helpful." While there is no requirement for a separate and distinct psychotherapy note along with the E/M, I have seen psychiatrists do so which is ideal. If an LCSW billed for psychotherapy and simply said that is was done, the reason why and the total minutes it would not count as billable, correct? This is no different. From a compliance standpoint, I would strongly recommend going back to your psychiatrist and asking him/her to document a bit more content to support the billing of the psychotherapy. I hope this helps.