Wiki E/M Code with 90833

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KMilsap

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Looking for clarification on billing an add-on psychotherapy code with E/M for med management. Right now, our docs are reporting total visit time, as well as time doing psychotherapy. So for example, he may document that he spent a total of 22 minutes with the patient, with 16 minutes of that doing psychotherapy. My understanding is that anything done to get the E/M level cannot be used towards the psychotherapy time, which leaves us with 6 minutes that was spent doing med management. Because so little time was spent doing the med management, I would code this as a 99211 with 90833 as an add-on.

The provider now has me second-guessing myself. He stated that he should still get the 99213 for the content of his medication management, as well as the 90833 for the psychotherapy, and that time should not play a factor into deciding the E/M level. Side note, the documentation is VERY minimal. A few sentences: Mood is good. Anxiety is low. Sleep is ok. No stressors. Then his normal ROS & Exam, which again is very minimal.

Do I bill the E/M based on content, or based on the time left after subtracting the time spent on psychotherapy?

Also, I'm the only BH coder at our facility, and don't have many resources to bounce questions off of. Would anyone be willing to be available for questions as they arise?

Thank you all so much!
 
I would bill the E&M service based on content and the 16 minutes documented as therapy for the add-on code. According to guidelines the time documented for the E&M service is not considered for the add-on code. According to the APA using time for code selection for an E&M service in behavioral health is discouraged since the overlap with therapy is not always easy to distinguish and the term counseling (as in coordination of care/counseling) that is done must be medical counseling such as prescription options and not psychotherapy in order to be considered for code selection based on time. The term counseling in the code description can lead to confusion. A lot of education has been done with providers at my facility in this regard.

As a sole coder like you, I found the Optum Behavioral Health Services coding and payment guide as well as the APA website helpful in resolving questions.
 
Thank you for your guidance! While that does clarify things for me a bit more, I still cannot wrap my head around billing a 99213, and 90833 when he says he spent a total of 20 minutes with the patient, 19 of which was psychotherapy (which he has done quite a bit). I have the 2016 Optum Psych book that I refer to, and will definitely look into the APA website as well. Thank you!
 
When both E/M and therapy are provided, it is better not to mention total time. It would be much better for the provider to only mention the therapy time only, ie: 16 minutes spent in psychotherapy. The note must provide content for the E/M outside of the therapy note. Our providers have no problems documenting their E/M and adding a paragraph with the separate therapy note, which is where they document the therapy time.
 
The office visit code should be determined based on the extent of 2 out of 3 components: History, Exam, and Medical Decision Making. Many times even with minimal documentation the 99213 level can be achieved. I do agree that it is counterproductive in this case to document the total time of the visit. I would instruct the practitioner to document time only for the psychotherapy portion and grade the office visit according to the 3 components.
 
Time Documented

I am receiving a rejection from an auto carrier because our time for therapy is documented as follows: Time spent with patient and family member on psychotherapy services 38 to 52 minutes.
They insist that the provider must document a start and stop time for therapy and are refusing future payment without it.

Has anyone else run into this? As far as I can tell, start/stop time is not a requirement for documentation. Our EMR allows start and stop for whole visit, not therapy alone.

Thanks!!!
 
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