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More on coding: Add-on psychotherapy codes require added documentation

April 30, 2013
by Alison Knopf, Contributing Writer
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Mental health providers are still coming to terms with the loss of their beloved “med-check” code – 90862. But then, coders should really never have used it only for med-checks anyway, says Quinten A. Buechner, president and CEO of ProActive Consultants (Cumberland, Wis.). Buechner, who specializes in psychological and Evaluation and Management (E/M) coding, admits that this is a complex issue because what mental health providers really want to do is bill for psychotherapy based on time. But E/M codes can’t be billed based on time if the add-on psychotherapy code is based on time, he says, quoting from the CPT book – the “bible” of coding.

Although E/M codes – the ones used by physicians for “office visits” – can be billed by time if more than half of the session time is spent on counseling, the E/M time cannot be used for psychotherapy. This is complicated, and even top coders aren’t sure why CPT made the changes. We discussed the “time” issue already, but this bears repeating, because as 2013 goes on, more and more mental health clinicians want to simply use E/M codes. It’s not allowed under CPT coding rules: time cannot be used to determine the E/M level as long as psychotherapy and an E/M are being done. But this doesn’t mean you have to choose between the E/M and psychotherapy codes. In some cases, you can bill both – if you provide a medical service (the E/M) and the psychotherapy.

If you are a physician billing the E/M (psychologists do not bill E/Ms) and performing psychotherapy, you must determine the E/M level based on the levels of history, examination, and medical decision-making. For documentation, use one section of the note for the E/M – and label it E/M – and use the other section for a therapy note. Simply talking about medications is not enough to justify billing an E/M, Buechner stresses.

Likewise, psychiatrists can’t just document the time spent counseling – they have to document something about what went into the session.

He has told his clients to document one section of the note for the E/M – and label it as such – or to have two notes, an E/M note and a psychotherapy note. “Too many consultants told psychiatrists that just talking about meds was enough,” he says. Since many mental health professionals don’t do their own coding, but send it out to consultants, it’s important to be very clear, in documentation. It’s also important to be clear because someday, your notes are going to be audited – by Medicare, or by a commercial payer – and if the documentation doesn’t support what you billed, you will have to give back money.

The dreaded audit

Coders who bill for psychiatrists know coding, and dread the reviews and audits from insurance companies. As one put it recently, auditors have different opinions – one might say you have to repay the money, and another might say everything is separate and you can bill both the E/M and the psychotherapy.

If all you do is the med-check, you can only bill the lowest-level E/M, 99211 for an established patient. That code brings in under $20 from most health plans. Few clinicians simply do a med check, however – they also do some counseling. A slightly higher involvement may involve 99212 and, for example, 90833, from the series of codes used when psychotherapy is performed with an E/M. For the 99212, the documentation would refer to the psychiatric condition, the medication, and a brief report updating the patient’s status.

Beware “double-dipping”: The criteria that need to be met for psychotherapy are different than those that need to be met for the E/M. Any time – or documentation of work – spent on therapy cannot be used toward the E/M, and any time – or documentation of work – spent on the E/M can’t be used toward the psychotherapy.

 

Figure: E/M codes and add-on psychotherapy codes add up to more money, but documentation must be right

If you bill an E/M and a psychotherapy code, make sure you document each separately in your notes. The add-on codes are based on time.

Code

Time

Add-on to E/M code?

90832: 

16-37 minutes

 

90833: 

16-37 minutes 

Yes

90834: 

38-52 minutes

 

90836: 

38-52 minutes 

Yes

90837: 

53-plus minutes

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