By Alison Knopf
When mental health providers bill insurance companies, they use codes — Current Procedural Terminology or CPT codes — to designate the therapeutic or treatment procedures that they have performed. A huge revamp of the CPT code set for 2013 means that, in many cases, providers will for the first time have to learn completely new codes.
The new CPT codes are published by the American Medical Association, which, along with specialty societies, conducted a comprehensive review to come up with new codes that are designed to reflect current practice. Active participants in the process of changing the psychotherapy codes included the American Psychiatric Association, the American Psychiatric Nurses Association, the American Psychological Association, and the American Academy of Child and Adolescent Psychiatry. The changes took effect with services provided Jan. 1. The new CPT billing codes take their place alongside another recently revised set of codes — the diagnostic codes in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
In 2013, for the first time in more than 20 years, the CPT codes used to bill for psychotherapy services have been completely revamped. These codes are used by psychiatrists, psychologists, and other qualified health care providers, but now these providers will be using, in many cases, the same codes used by primary care and other physicians. All of the old psychotherapy codes have been deleted (see Figure 1-click photo gallery), and new codes have been added. In the meantime, the world of Evaluation and Management (E/M) services has been opened up to mental health providers.
Why does coding matter? Because it’s the way you get paid for a service. And it must be accurately documented: a truism of coding is that “if it wasn’t documented, it wasn’t done.” You can get audited, and if your documentation doesn’t justify the codes you have billed, not only may you have to refund the money and pay a fine, but if Medicare or Medicaid is involved, you could face a federal fraud charge and prison time. Private payers also have many avenues of recourse against you, not the least of which is kicking you off their panels.
Goodbye to 90862 “med-checks”
We asked Quinten A. Buechner, President and CEO of ProActive Consultants, a Cumberland, Wisconsin-based coding consultant specializing in psychology and E/M coding, to reflect on the changes.
One of the most important CPT coding changes involves the pharmacologic management code, which should now be reported using Evaluation and Management (E/M) codes. Previously, the CPT code for pharmacologic management (90862) was used to bill for assessing medications, but that code has been deleted and replaced by an E/M code, which is chosen based on E/M selection code criteria.
Thus, there’s a new and somewhat more complicated process involved in coding what had been considered a simple “med-check” before. The bottom line: If you do perform a simple med-check, you might only be able to bill one of the lowest E/M levels, whereas if the history, examination, and medical decision-making add up to a higher level, you can document it and bill it. In working with this and other new codes, watch out for “documentation creep” – ensure that the E/M codes are medically necessary to prevent denials, audits, and the potential for allegations of fraud should a pattern of such billing be discovered by audit.
The deletion of 90862 was long overdue, said Buechner. “Documentation for the code was almost universally poor, every payer did their own thing in terms of requirements, and many physicians used psychotherapy with the E/M but did little to no standard E/M documentation,” he said. The code description was also misleading. “So the code was tossed out and the providers were told to use E/Ms.”
There were many problems as well of physicians saying they should be paid like physicians, but not required to perform “physiology-based medicine” since they are only performing psychotherapy or med-checks. These physicians brought the new requirement to use E/M codes on themselves, said Buechner. “They were using the codes but documenting in the 1980s style of charging level 4 E/Ms with not much more than saying, ‘Stable, stay on meds.’” The message in the new CPT is: “Use E/Ms like the other docs do and do it right!” said Buechner. This brought med-checks into the line with the rest of the world, he said.
If pharmacologic management – including prescription and review of medication – is performed with a psychotherapy service, and you do not bill an E/M, instead, you would bill new add-on code 90863 in conjunction with new psychotherapy code 90832, 90834, or 90837 depending on time. If you bill an E/M and psychotherapy, you would use the appropriate E/M for pharmacologic management and the appropriate psychotherapy code.
Everyone who can use an E/M code must do so. This group includes people licensed to practice medicine – physicians, physician assistants, certified nurse practitioners – but generally not psychologists or other Ph.D.s. Some states do license Ph.D.- and PsyD.-level providers who take extra training and education, said Buechner.