CPT Primer for Psychiatrists.pdf

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CPT Primer for Psychiatrists

What is CPT?

Current Procedural Terminology (CPT) was first published by the American Medical

Association (AMA) in 1966. The CPT coding system was created to provide a uniform

language for describing medical and surgical procedures and diagnostic services that

would facilitate more effective communication between clinicians, third-party payers, and

patients. The 2013 CPT Manual is the most recent revision of the 4

edition of the book.

The AMA’s CPT Editorial Panel has the sole authority to revise, update, or modify CPT.

The panel has seventeen members, eleven nominated by the AMA, and one each from

the Blue Cross and Blue Shield Association, the Health Insurance Association of

American, the Centers for Medicare and Medicaid Services (formerly HCFA), the

American Hospital Association, and the Health Care Professionals Advisory Committee,

and one representative from the AMA/Specialty Society RVS Update Committee. In

1990, Tracy Gordy, M.D., became the first psychiatrist to be appointed to the panel. He

retired as chair of the panel in November 2007.

The CPT Editorial Panel is supported by the CPT Advisory Committee, which has

representatives from over 90 specialty societies. The committee’s main role is to advise

the editorial panel on procedural coding and nomenclature that is relevant to each

committee member’s specialty. The committee also serves as a conduit through which

revision to CPT can be proposed by specialty societies, or by individual members of

those specialty societies.

The AMA’s CPT coding system is now used almost universally throughout the United

States. The Transaction Rule of the Health Insurance Portability and Accountability Act

(HIPAA), which went into effect on October 16, 2002, requires the use of CPT codes by

all who are covered by HIPAA. The CPT codes comprise Level I of the HCPCS (Health

Care Financing Administration Common Procedure Coding System) codes used by

Medicare and Medicaid. Every healthcare provider who is paid by insurance companies,

or whose patients are reimbursed by insurance companies, should have a working

knowledge of the CPT system.

How Is the CPT Manual Organized?

The CPT manual is organized to be as user friendly as possible. The following is a quick

survey of its contents.

Introduction

The short introduction contains valuable information for the clinician on how to use the

manual, including:

 A description and explanation of the format of the terminology (This section

describes how some routine procedural terms are not repeated for subsequent

related procedures to conserve entry space.);

 A description of how to request updates of CPT (It is vital that physicians keep the

AMA aware of changes in practice that require coding changes.);

 A discussion of the specific guidelines that precede each of the manual’s six

sections (E/M and the five clinical sections);

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 A discussion of ―add-on codes‖ for additional or supplemental procedures;

 An explanation of code modifiers and how they are to be used;

 A brief discussion of how place of service relates to CPT;

 A discussion of the inclusion of codes for unlisted procedures or services in each

section;

 A note that some CPT codes require interpretation and reporting if they are to be

used;

 A note that special reports may be required to determine the medical appro-

priateness of rare or very new services;

 A discussion of how to identify code changes from year to year;

 A reference to the expanded alphabetical index now included in the Manual;

 A note on how to obtain electronic versions of CPT; and finally

 How references to AMA resources on the CPT codes are noted in the Manual.

Illustrated Anatomical and Procedural Review

This section provides a review of the basics of anatomy and medical vocabulary that are

necessary for accurate coding. Lists of prefixes, suffixes, and roots are given, followed by

22 anatomical illustrations. There is also an index of all the procedural illustrations that

appear throughout the manual, listed by their corresponding codes.

Molecular Pathology

This is a new section in 2013.

Evaluation and Management Codes

Although the rest of the CPT manual is organized according to the numerical order of the

codes, the evaluation and management (E/M) codes, 99xxx, are provided in the first code

section because they are used by physicians in all specialties to report a considerable

number of their services. The E/M codes are preceded by tables that indicate the

required components for the various E/M codes and fairly extensive guidelines that define

the terms used in the code descriptors and provide instructions for selecting the correct

level of E/M service.

Major Clinical Sections

Next come the major clinical sections: Anesthesia, Surgery, Radiology, Pathology and

Laboratory, and Medicine. Each of these sections is preceded by guidelines. The

psychiatry codes, 908xx, are found in the Medicine section. The codes in the Psychiatry

subsection cover most of the services mental health professionals provide to patients in

both inpatient and outpatient settings.

Category II and III Codes

The Medicine section is followed by a listing of the supplemental Category II and

Category III codes. These codes are generally optional codes used to facilitate data

collection and are never used as substitutes for the standard Category I CPT codes.

Category II codes are used for performance measurement. According to the CPT

Manual, Category II codes are ―intended to facilitate data collection about the quality of

care rendered by coding certain services and test results that support nationally

established performance measures and that have an evidence base as contributing to

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quality patient care.‖ These codes will be used more and more as Medicare attempts to

shift from volume-based payment to quality-based payment.

Category III codes are temporary codes that are used to allow data tracking for emerging

services and procedures.

Appendixes and Index

The last section of the manual includes appendixes and an extensive alphabetical index.

There are 13 appendixes:

1. Appendix A: Modifiers—modifiers are two-digit suffixes that are added to CPT codes

to indicate that the service or procedure has been provided under unusual

circumstances (e.g., –21, which indicates a prolonged E/M service) (See Appendix B

of this book for a list of modifiers.)

2. Appendix B: Summary of Additions, Deletions, and Revisions (of codes in the current

manual)

3. Appendix C: Clinical Examples—provides clinical examples to clarify the use of E/M

codes in various situations

4. Appendix D: Summary of CPT Add-On Codes—codes used to denote procedures

commonly carried out in addition to a primary procedure

5. Appendix E: Summary of CPT Codes Exempt From Modifier –51 (multiple

procedures)

6. Appendix F: Summary of CPT Codes Exempt From Modifier –63 (which denotes a

procedure perfomed on infants)

7. Appendix G: Summary of CPT Codes That Include Moderate (Conscious) Sedation

8. Appendix H: Alphabetic Index of Performance Measures by Clinical Condition or

Topic (a listing of the diseases, clinical conditions, and topics with which the Category

II codes are associated.)

9. Appendix I: Genetic Testing Code Modifiers (used

―to

provide diagnostic granularity of

service to enable providers to submit complete and precise genetic testing information

wihout altering test descriptors.‖)

10. Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves

11. Appendix K: Products pending FDA Approval (vaccine products that have been

assigned a Category I codes in anticipation of their approval)

12. Appendix L: Vascular Families

13. Appendix M: Crosswalk to Deleted CPT Codes (indicating which current codes are to

be used in place of the deleted ones)

The index is preceded by instructions explaining that there are four primary classes of

index entries:

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1. Procedure or Service

2. Organ or Other Anatomic Site

3. Condition

4. Synonyms, Eponyms, and Abbreviations

The instructions also explain the index’s use of modifying terms, code ranges, and space-

saving conventions.

Psychiatry Codes

The codes most frequently used by psychiatrists can be found in the Psychiatry subsection of

the Medicine section of the CPT Manual (codes 90785-90899). For 2013 and beyond there

have been major changes to the Psychiatry codes. A distinction has been made between an

initial evaluation with medical services done by a physician (90792) and an initial evaluation

done by a non-physician (90791). The psychotherapy codes have been simplified: There are

now three timed codes to be used in all settings (90832- 30 minutes; 90834-45 minutes;

90837- 60 minutes) and accompanying add-on codes for psychotherapy (indicated in CPT by

the + symbol in the CPT Manual) that are to be used by psychiatrists when the psychotherapy

is provided in the same encounter as medical evaluation and management (90833 -30

minutes, 90836 - 45 minutes, 90838 – 60 minutes). In lieu of the codes for interactive

psychotherapy, there is now an add-on code for interactive complexity (90785) that may be

used with any code in the Psychiatry section for which it is appropriate. Another change is

that a new code has been added for psychotherapy for a patient in crisis (90839). When a

crisis encounter goes beyond 60 minutes there is an add-on code for each additional 30

minutes (90840). Code 90862 has been eliminated, and psychiatrists will now use the

appropriate evaluation and management (E/M) code when they do pharmacologic

management for a patient. (A new code, add-on code 90863, has been created for medication

management when done with psychotherapy by the psychologists in New Mexico and

Louisiana who are permitted to prescribe, but this code is not to be used by psychiatrists or

other medical mental health providers). All of these changes are discussed in detail below.

Interactive Complexity Add-On

90785 Interactive Complexity -- This add-on code may be used with any of the codes in

the Psychiatry section when the encounter is made more complex by the need to involve

others than the patient. It will most frequently be used in the treatment of children. When

this add-on is used, documentation must explain what exactly the interactive complexity

was (i.e., the need for play equipment with a younger child; the need to manage parents’

anxiety; the involvement of parents with discordant points of view).

What is an add-on code? An add-on code is a code that can only be

used in conjunction with another code and is indicated by the plus

symbol (+) in the CPT manual. While basic CPT codes are valued to

account for pre- and post-time, add-on codes are only valued based

on intra-service time since the pre- and post-time is accounted for in

the basic code. In the new Psychiatry codes there are three different

types of add-on codes: 1.) Timed add-on codes to be used to indicate

psychotherapy when it is done with along with medical evaluation and

management; 2.) A code to be used when psychotherapy is done that

involves interactive complexity (e.g., psychotherapy provided to

children or geriatric patients who have difficulty communicating without

assistance); and 3.) A code to be used with the crisis therapy code

for each 30 minutes beyond the first hour.

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Psychiatric Diagnostic Evaluation Codes





90791Psychiatric Diagnostic Evaluation – This code is used for an initial diagnostic

interview exam that does not include any medical services. In all likelihood this code will not

be used by psychiatrists. It includes a chief complaint, history of present illness, family and

psychosocial history, and complete mental status examination. In the past most insurers

would reimburse for one 90791 (then a 90801) per episode of illness. The guidelines now

allow for billing this on subsequent days when there is medical necessity for an extended

evaluation (i.e., when an evaluation of a child that requires that both the child and the

parents be seen together and independently). Medicare will pay for only one 90791 per

year for institutionalized patients unless medical necessity can be established for others.

90792Psychiatric Diagnostic Evaluation with Medical Services– This code is used for

an initial diagnostic interview exam for an adult or adolescent patient that includes medical

services. It includes a chief complaint, history of present illness, review of pertinent systems,

family and psychosocial history, and complete mental status examination, as well as any

medical work such as the ordering and medical interpretation of laboratory or other diagnostic

studies or the prescribing of medications. In the past most insurers would reimburse for one

90792 (then a 90801) per episode of illness. The guidelines now allow for billing this on

subsequent days when there is medical necessity for an extended evaluation (i.e., when an

evaluation of a child that requires that both the child and the parents be seen together and

independently).

Medicare will pay for only one 90792 per year for institutionalized patients unless medical

necessity can be established for others. Medicare permits the use of this code or the

appropriate level of the E/M codes (see below) to denote the initial evaluation or first-day

services for hospitalized patients. Medicare also allows for the use of 90792 if there has been

an absence of service for a three-year period.

For 2013, it is important to note that both codes 90791 and 90802 are not subject to the

outpatient mental health services limitation under Medicare that will be eliminated in 2014.

They have always been reimbursed at 80% like all other medical codes.

Psychiatric Therapeutic Procedure Codes





There are now three basic timed individual psychotherapy codes, which are to be used in all

settings and add-on codes to be used when psychotherapy is done along with medical

evaluation and management and/or when psychotherapy is provided for a patient when there

is interactive complexity. Note that the descriptors for the psychotherapy codes now list the

time as the time spent ―with patient and/or family member,‖ rather than ―face- to-face with the

patient‖ as for the previous psychotherapy codes.



+90785, the system complexity add-on code, may be used with these codes



90785, the system complexity add-on code, may be used with all of these codes

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Another difference is the way time is now defined by CPT. The CPT manual has

standards in place that are to be used when selecting codes that have a time attached to

them, except when rules are stipulated within the codes themselves. The bullets below

will provide you with the basics for coding for psychiatric services.

 Time is only the time spent face-to-face with the patient and/or family member.

 When codes have sequential typical times attached to them, as with the basic

psychotherapy codes, the code that is closest to the typical time should be

selected.

 A unit of time is attained when the mid-point is passed. (For example, if you see a

patient for more than 15 minutes you may code using 90832, the 30-minute code;

and if you see a patient for 35 minutes, you would also use 90832. However, if

you see the patient for 38 to 52 minutes, you would use 90834, the 45-minute

code; and for 53 minutes or more you would use 90837, the 60-minute code).

90832 Individual Psychotherapy, 30 minutes with patient and/or family member

90833 Individual Psychotherapy, 30 minutes with patient and/or family member

when performed with an evaluation and management service (list separately in

addition to the code for the primary procedure.)

90834 Individual Psychotherapy, 45 minutes with patient and/or family member

90836 Individual Psychotherapy, 45 minutes with patient and/or family member

when performed with an evaluation and management service (list separately in

addition to the code for the primary procedure.)

90837 Individual Psychotherapy, 60 minutes with patient and/or family member

90838 Individual Psychotherapy, 60 minutes with patient and/or family member

when performed with an evaluation and management service (list separately in

addition to the code for the primary procedure.)

Other Psychotherapy Codes





90845Psychoanalysis – Psychoanalysis is performed by therapists who are trained

and credentialed to practice it. Psychoanalysis is reported on a per-session basis and is

reimbursed by most insurance programs. The issue of medical necessity has resulted in

challenges to reimbursement for psychoanalysis by managed care companies. Note that

90845 is not a time-based code.

90846Family Psychotherapy (Without the Patient Present) – This code is used

when the psychiatrist provides therapy for the family of a patient without the patient being

present. Under Medicare rules, 90846 is only covered if the therapy is clearly directed

toward the treatment of the patient, rather than to treating family members who may have

issues because of the patient’s illness. While most insurance companies will reimburse

for this code, problems may occur because the service is not face-to-face with the

patient.

90847Family Psychotherapy (Conjoint Psychotherapy) (With Patient Present) –

This code is used when the therapy includes the patient and family members. It is



90785, the system complexity add-on code, may be used with all of these codes

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covered by most insurance plans, and is challenged less often than 90846 because the

patient is present. It should also be used for couples therapy.

90849Multiple-Family Group Psychotherapy – This code is used when the

psychiatrist provides psychotherapy to a group of adult or adolescent patients and their

family members. The usual treatment strategy is to modify family behavior and attitudes.

The service is covered by most insurance plans.

90853Group Psychotherapy (Other Than of a Multiple-Family Group) – This code

relies on the use of interactions of group members to examine the pathology of each

individual within the group. In addition, the dynamics of the entire group are noted and

used to modify behaviors and attitudes of the patient members. The size of the group

may vary depending on the therapeutic goals of the group and/or the type of therapeutic

interactions used by the therapist. The code is used to report per-session services for

each group member. Most insurance plans cover this procedure.

Codes for Other Psychiatric Services or Procedures 

90865Narcosynthesis for Psychiatric Diagnostic and Therapeutic Purposes (e.g.

sodium amobarbital (Amytal) interview) – This procedure involves the administration,

usually through slow intravenous infusion, of a barbiturate or a benzodiazepine in order to

suppress inhibitions, allowing the patient to reveal and discuss material that cannot be

verbalized without the disinhibiting effect of the medication. This code is reimbursed by

most insurers.

90867Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) initial

treatment, including cortical mapping, motor threshold determination, delivery and

management

90868Subsequent TMS Delivery and Management, per session

90869Subsequent TMS Motor Threshold Re-Determination with Delivery and

Management

90870Electroconvulsive Therapy (Includes Necessary Monitoring); Single seizure –

This code is for electroconvulsive therapy (ECT), which involves the application of electric

current to the patient’s brain for the purposes of producing a seizure or series of seizures

to alleviate mental symptoms. ECT is used primarily for the treatment of depression that

does not respond to medication. The code includes the time the physician takes to

monitor the patient during the convulsive phase and during the recovery phase. When

the psychiatrist also administers the anesthesia for ECT, the anesthesia service should

be reported separately, using an anesthesia code. ECT is covered by most insurance

plans.

90875Individual Psychophysiological Therapy Incorporating Biofeedback

Training by any Modality (face-to-face with the patient), With Psychotherapy (e.g.,

insight-oriented, behavior modifying, or supportive psychotherapy); approximately 20-30

minutes and,

90876approximately 45-50 minutes

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These two procedures incorporate biofeedback and psychotherapy (insight oriented,

behavior modifying, or supportive) as combined modalities conducted face-to-face with

the patient. They are distinct from biofeedback codes 90901 and 90911, which do not

incorporate psychotherapy and do not require face-to-face time. Medicare will not

reimburse for either of these codes.

90880Hypnotherapy – Hypnosis is the procedure of inducing a passive state in which

the patient demonstrates increased amenability and responsiveness to suggestions and

commands, provided they do not conflict seriously with the patient’s conscious or

unconscious wishes. Hypnotherapy may be used for either diagnostic or treatment

purposes. This procedure is covered by most insurance plans.

90882Environmental Intervention for Medical Management Purposes on a

Psychiatric Patient’s Behalf With Agencies, Employers, or Institutions – The

activities covered by this code include physician visits to a work site to improve work

conditions for a particular patient, visits to community-based organizations on behalf of a

chronically mentally ill patient to discuss a change in living conditions, or accompaniment

of a patient with a phobia in order to help desensitize the patient to a stimulus. Other

activities include coordination of services with agencies, employers, or institutions. This

service is covered by some insurance plans, but because some of the activities are not

face-to-face, the clinician should check with carriers about their willingness to reimburse

for this code.

90885Psychiatric Evaluation of Hospital Records, Other Psychiatric Reports,

Psychometric and/or Projective Tests, and Other Accumulated Data for Medical

Diagnostic Purposes – Although this would seem to be a very useful code, because

reviewing data is not a face-to-face service with the patient, Medicare will not reimburse

for this code and some commercial carriers have followed suit. Medicare considers the

review of data to be part of the pre-/postwork associated with any face-to-face service.

90887Interpretation or Explanation of Results of Psychiatric, Other Medical

Examinations and Procedures, or Other Accumulated Data to Family or Other

Responsible Persons, or Advising Them How to Assist Patient – Medicare will not

reimburse for this service because it is not done face-to-face with the patient, and

clinicians should verify coverage by other insurers to ensure reimbursement. It is

appropriate to use an E/M code in the hospital where floor time is expressed in

coordination of care with the time documented.

90889Preparation of Report of Patient’s Psychiatric Status, History, Treatment, or

Progress (Other Than for Legal or Consultative Purposes) for Other Physicians,

Agencies, or Insurance Carriers – Psychiatrists are often called upon to prepare

reports about the patient for many participants in the healthcare system. This code would

be best used to denote this service. However, because this is not a service provided

face-to-face with a patient, Medicare will not reimburse for this code either, and clinicians

should verify coverage by other insurers.

90899Unlisted Psychiatric Service or Procedure – This code is used for services not

specifically defined under another code. It might also be used for procedures that require

some degree of explanation or justification. If the code is used under these

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circumstances, a brief, jargon-free note explaining the use of the code to the insurance

carrier might be helpful in obtaining reimbursement. If it is used for a service that is not

provided face-to-face with a patient, the psychiatrist should check with the patient’s

insurer regarding reimbursement.

95970, 95974, 95975Neurostimulators, Analysis–Programming – These codes have

been approved for vagus nerve stimulation (VNS) therapy for treatment-resistant

depression. Clinicians performing VNS therapy should use the appropriate code from the

95970, 95974, and 95975 series of codes found in the neurology subsection of the CPT

manual. Medicare will not reimburse for these codes.

M0064Brief Office Visit for the Sole Purpose of Monitoring or Changing Drug

Prescriptions Used in the Treatment of Mental Psychoneurotic and Personality

Disorders – M0064 is not, in fact, a CPT code. It is a HCPCS Level II code (CPT codes

are HCPCS Level I), part of the HCPCS system used by Medicare and Medicaid. M0064

should only be used for the briefest medication check with stable patients.

Evaluation and Management Codes

With the elimination of code 90862 and the addition of the add-on codes for

psychotherapy when done with evaluation and management (E/M), psychiatrists will be

using far more E/M codes than they have in the past. Previously, many psychiatrists just

used the E/M codes for their inpatient and nursing facility encounters, but now they will

be used for outpatient care as well.

The evaluation and management codes were introduced in 1992 to cover a broad range

of services for patients, in both inpatient and outpatient settings. E/M code descriptors

provide explicit criteria for selecting codes, and the clinical vignettes given in Appendix C

of the CPT Manual provide examples of situations that fulfill these criteria.

Evaluation and management codes cover a family of general medical services provided in

various settings, i.e., office, hospital, nursing home, emergency department, etc. While

E/M codes are frequently used for hospital inpatient services, inpatient and outpatient

consultations, and nursing facility services; they are less frequently used in psychiatry for

office and other outpatient services, emergency department services, and domiciliary,

rest home services. It is extremely important to read the guidelines to the Evaluation

and Management section of the CPT Manual because they explain how to choose the

appropriate level of service when using E/M codes.

Level of Service

The level of service for an E/M code encompasses the skill, effort, time, responsibility,

and medical knowledge necessary to evaluate, diagnose, and treat medical conditions.

There are seven components that are used to define E/M levels of service:

 history,

 examination,

 medical decision making,

 counseling,

 coordination of care,

 nature of presenting problem, and

 time.

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The three key components used in selecting the level of service within each category or

subcategory of E/M service are:

 the extent of the history

 the extent of the examination

 the complexity of medical decision making involved

The clinician’s ability to determine the appropriate level of service being provided to the

patient within each category or subcategory of evaluation and management services is

dependent on a thorough understanding of the Definition of Terms (found in the

Evaluation and Management Services Guidelines that precede the listing of the E/M

codes in the CPT Manual) and the Instructions for Selecting a Level of E/M Service (also

in the Guidelines). The brief synopsis that follows is not an adequate substitute for a

careful review of these sections of the CPT Manual.

There are three to five levels of service for each category or subcategory of E/M services.

Each level of service represents the total work (skill, time, effort, medical knowledge, risk)

expended by the clinician during an incident of service. For example, outpatient E/M

codes are divided by new patient and established patient, with five levels of service for

new patient care (99201-99205) and five for established patient care (99211-99215).

Each of the levels is based on the depth of history and examination and complexity of the

decision making involved, and the descriptors for the codes provide a typical time for the

code as well.

Consultations are divided into office or other outpatient consultations, initial inpatient

consultations. There are five levels of service for office consultations (99241-99245), and

initial inpatient consultations (99251-99255). Consultations are provided at the request of

another healthcare provider to whom a written report must be given. The CPT Editorial

Panel voted to delete the follow-up inpatient consultations and the confirmatory

consultations. The appropriate E/M service code (i.e., Established patient, office or other

outpatient service) should be used based on the setting and type of service. Clinicians

should become thoroughly familiar with the descriptors and codes within each family of

services as well as with the guidelines that spell out the methodology for selecting the

level of service provided. Medicare no longer pays for the consultation codes and some

commercial insurers have eliminated them as well.

History

There are four levels of history in the E/M codes: problem focused, expanded problem

focused, detailed, and comprehensive. The more detailed the history, the greater the

work effort.

Examination

The same four categories define the examination: problem focused, expanded problem

focused, detailed, and comprehensive. The more extensive the examination, the greater

the work effort. For psychiatry, a complete mental state examination (single system

examination) qualifies as a comprehensive examination.

Decision Making

There are four levels of medical decision making presented in the E/M codes: 1.

Straightforward; 2. Low complexity; 3. Moderate complexity; and 4. High complexity. The

more complex the medical decision making, the greater the work effort.

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The complexity of the medical decision making depends on: the number of diagnoses or

management options; the amount and/or complexity of data to be reviewed; and the risk

of complications and/or morbidity or mortality.

For example, the lowest level of service for Office or Other Outpatient Consultations

(99241) requires:

 a problem focused history;

 a problem focused examination; and

 straightforward medical decision making

Average time: 15 minutes

While the highest level of service for Office or Other Outpatient Consultations (99245)

requires:

 a comprehensive history;

 a comprehensive examination; and

 medical decision making of high complexity

Average time: 80 minutes

The clinician selects 99241 or 99245 (or any of the levels in between, 99242, 99243,

99244) on the basis of the work performed (i.e., extent of history and examination,

complexity of medical decision making). The average times given for each code are

guidelines for the clinician and are not a requirement when using the key components

(history, examination, and medical decision making) in selecting the level of service.

Time and Level of Service

Time (as a component in selecting the level of service) has two definitions in the E/M

guidelines. The clinician must review these definitions (see CPT 2010, E/M Services

Guidelines) in order to fully understand the rationale for the two definitions.

For office and other outpatient visits and office consultations, intraservice time is defined

as the face-to-face time spent providing services to the patient and/or family members.

Time spent pre- and post-service (time that is not face-to-face) is not included in the

average times listed for office and outpatient consultation services. The work associated

with the pre- and post-encounter time has been calculated into the total work that forms

the basis for how each code is reimbursed, and, therefore, the average face-to-face times

listed with each E/M code are considered fair proxy for the total work effort.

For inpatient hospital care, hospital consultations, and nursing facility care intraservice

time is defined as unit floor time. Unit floor time includes all work the clinician performs

on behalf of the patient while present on the unit or at the bedside. This work includes

direct patient contact, review of chart, writing orders, reviewing test results, writing

progress notes, meeting with the treatment team, telephone calls, and meeting with the

family. Pre- and post-time work such as reviewing patient records in another part of the

hospital has been included in the calculation of total work as described above in the

definition of face-to-face time.

There is one final and important twist in using time in the selection of the level of service.

When counseling and/or coordination of care (see Physicians Current Procedural

Terminology 2013 , page 10) accounts for more than 50 percent of the patient and/or

family encounter unit/floor time, then time becomes the key factor in selecting level of

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service. The clinician makes the selection by matching the time of the encounter (face-

to-face or unit/floor) to the average time listed for the appropriate E/M service. In this

instance there is no consideration of the extent of the history, the exam, the medical

decision making required, or the nature of the presenting problem; time is the sole

determinant.

Counseling is defined as a discussion with the patient and/or family concerning one or

more of the following: diagnostic results, prognosis, risks and benefits of treatment,

instructions for management, compliance issues, risk factor reduction, patient and family

education. Coordination of care entails discussions about the patient’s care with other

providers or agencies. These two services are considered contributory factors and

although important to E/M service, are not required to be provided at every encounter.

The following are examples of counseling and coordination of care. A clinician spends 35

minutes on the hospital floor (third hospital day for patient) and over 50 percent of that

time was spent in counseling and/or coordination of care. The correct code is 99233

(subsequent hospital care), average time 35 minutes. In this case, history, examination,

and medical decision making are no longer the factors that determine the selection of the

level of service. Instead, the clinician documents the extent of the

counseling/coordination of care in the daily progress note.

A patient returns to a psychiatrist’s office for a medication check. The encounter takes a

total of 25 minutes, during which time more than 12.5 minutes is spent explaining to the

patient about how a newly prescribed medication works, how to establish a routine so

that no doses will be missed, and the possible side-effects of the medication and what to

do if they occur. The appropriate E/M code would be 99214 (office or outpatient service

for an established patient), based on the 25-minute time rather than on a detailed history

and examination and moderately complex medical decision making that would be

required to use this code if counseling and coordination had not taken up more than 50

percent of the time.

Use of Modifiers

Modifiers are two-digit suffixes (e.g., –22, Unusual Procedure Services) that are added to

procedural codes to indicate the service or procedure has been provided under unusual

circumstances. The modifiers most likely to be used by psychiatrists are:

–22 Unusual Procedure Services

This modifier is used when the work associated with the service provided is greater

than that usually required for the listed code.

–25 Significant, Separately Identifiable Evaluation and Management Service by

the Same Physician on the Same Day of the Procedure or Other Service

This modifier is used to indicate that on the day a procedure or service identified by a

CPT code was performed, the patient’s condition required a significant, separately

identifiable E/M service above and beyond the other service provided or beyond the

usual pre- and postoperative care associated with the procedure performed.

–26 Professional Component

This modifier is used for procedures that are a combination of a physician component

and a technical component. When the physician component is reported separately,

this modifier is added to the usual procedure.

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–52 Reduced Services

This modifier is used to report a service that is reduced in time.

The following is an example of how to use modifiers:

The therapy session requires extension from 50 minutes to 65 minutes because of the

emergence of important material just before the session was scheduled to end. The

session would be coded 90806-22 and a short explanatory note should be appended to

the insurance form, explaining the use of the code.

Documentation

Documentation is an extremely complex issue, an issue we can only touch on here. For

example, there may be special documentation requirements for Medicare found in the

local Medicare contractor’s Local Coverage Determination (LCD) policies; or when

psychiatrists use E/M codes for treating Medicare patients, the HCFA (CMS)

documentation guidelines should be used (but the clinician must decide whether to use

the 1995 or 1997 guidelines—see below); and commercial insurers may have their own

requirements.

Although accurate documentation of services and procedures is vital for good medicine,

documentation has become an increasingly troublesome practical issue for clinicians. It

is especially problematic for psychiatrists because of confidentiality issues and the

amount of clinical information produced during psychotherapy sessions. Also,

documentation for psychotherapy codes is one issue, while documentation for E/M codes

is another.

In 1995 the Health Care Financing Administration published documentation guidelines for

evaluation and management services. In 1997 revised E/M documentation guidelines

were issued. Currently, physicians can choose to base their documentation on either

the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services.

Following either set will fulfill documentation requirements to the satisfaction of the

Medicare program, and should be acceptable to private insurers as well. Generally,

psychiatrists will want to use the 1997 guidelines, which allow for a single-system

psychiatric exam.

The Health Insurance Portability and Accountability Act (HIPAA), which was approved in

December 2000 and became effective in April 2001, has very specific requirements for

the privacy of patient records, and has very clear ramifications for the documentation of

psychotherapy. HIPAA distinguishes between psychotherapy notes (notes a therapist

may keep about the patient’s personal life as distinguished from the patient’s medical

history and treatment) and the medical record, and holds these personal notes to a

higher level of confidentiality. Since 2003, when all physicians were expected to be in

compliance with HIPAA, the standard of practice is that psychotherapy notes be kept so

that they can be easily separated from the rest of a patient record.

Reimbursement Issues

It is very important for the clinician to understand that just because a code exists for a

service in the CPT Manual, this does not guarantee that an insurance carrier or third-

party payer will reimburse for that code. For example, Medicare will not pay for code

90882, Environmental Intervention, nor will it pay for certain codes done on the same day

as others. You need to be aware of these exceptions. Clinicians may also find their

contracts with managed care organizations specify certain codes that are not

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reimbursable, or that patients’ insurance policies specify certain services that are not

covered. It is essential to find out about any of these issues before treatment begins.

RBRVS and Medicare Reimbursement Policies

Because Medicare’s Resource-Based Relative Value Scale (RBRVS) system for the

payment of clinicians has become the basis of fee schedules, even for commercial

carriers, a discussion of coding issues associated with Medicare reimbursement is useful

even for those psychiatrists who do not treat Medicare beneficiaries.

Since 1992, the Medicare program has reimbursed physician services based on the

Resource-Based Relative Value Scale (RBRVS). RBRVS is a system that allows the

mathematical calculation of Relative Value Units (RVUs) for every CPT code. The cost of

providing each service described in CPT is divided into three components: physician

work, practice expense, and professional liability insurance. RVUs are assigned to each

component, then added together and multiplied by a conversion factor that is determined

annually by CMS and voted on by Congress. The resulting figure is the Medicare fee for

each service. Medicare fees vary slightly throughout the country due to adjustments for

geographical differences in resource costs. For instance, the fees in New York are

higher than those in Mississippi.

Medicare generally excludes from payment all non-face-to-face services such as

telephone calls, environmental interventions, record reviews, and case management,

although there may be some variation in local payment policies.

The way to avoid delay of payment or audits because of disputes over use of codes that

you’re not absolutely certain about is to prospectively negotiate with insurers about the

use of any codes that are not unquestionably standard.

Conclusions

Careful, correct coding is vital to the practicing psychiatrist. Take it seriously. Not only

will correct coding help achieve prompt and appropriate payment for treatment, it will also

provide protection from charges of fraud and abuse. Accurate documentation of the

services you have provided, and coded for, is the most certain means of protection

against allegations of abusive or fraudulent billing. Accurate documentation is also

extremely helpful in defending against malpractice allegations. You need to stay current

on coding issues.

 Buy and read the AMA’s annually published CPT Manual

 Stay in touch with your District Branch and the APA’s Office of Healthcare

Systems and Financing about coding and billing issues.

 Psychiatrists who provide services under Medicare must educate themselves on

policies specific to Medicare. You must be sure to read any correspondence sent

to you by your Medicare contractor.

You should code and bill for all services rendered regardless of local or national payer

policies – the developing database may help change payment policies that negatively

affect reimbursement of mental health services.

It is important that you not try to game the reimbursement system by manipulating codes

inappropriately. Medicare/Medicaid fraud, and insurance fraud in general, is a serious

priority of the Justice Department.

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Office of Healthcare Systems & Financing

800 343 4671 ● [email protected]

Note: Although psychiatrists are likely to use only the codes within the Psychiatry and

E/M sections of the CPT Manual to cover the services they provide, the Manual clearly

states in its introduction: “Any procedure or service in any section of this book may

be used to designate the services rendered by any qualified physician.”