One of the biggest problems providers have with the new psychotherapy code changes is time. The codes are now for only 30-, 45-, or 60-minute sessions – and more on those numbers later. The 70- and 80-minute session codes are gone.
“It’s part of a push toward shorter-term interventions,” said Nina Marshall, MSW, director of public policy for the National Council for Behavioral Health. For providers who use the evaluation and management (E/M) codes instead of psychotherapy codes, there is increased documentation time, she says.“All in all, we’re seeing reimbursement going down – that’s what we’ve been hearing from our members,” Marshall tells Behavioral Healthcare.
E/M codes take longer to select because of all of the different factors that go into choosing a code, says Marshall.
Just because a patient has a more severe diagnosis doesn’t necessarily mean you can bill a higher-level E/M or a longer psychotherapy session, she adds. “A more severe diagnosis could work for a higher level code, but it depends on what takes place in that session,” she says. The E/M code depends on medical decision-making, history, and more, she says. It’s not just time-based. “People are used to using just one code for a medication-management visit, but that’s not how it works anymore,” she says. “You have to be thinking about the jigsaw puzzle.”
Likewise, having a dual diagnosis doesn’t automatically rate a higher level E/M. “You might have two chronic conditions but still have a lower level E/M,” says Marshall. “It’s everything taken together.” Suicidal ideation, for example, constitutes a higher risk – one of the elements of determining the E/M level – but other parts of the visit may be lower level.
There’s another issue: the E/M codes are for use by medical staff: physicians, psychiatric nurse practitioners, nurse practitioners, and physician assistants, says Marshall. They cannot be used by psychologists or social workers.
Medicaid, the primary payer for mental health services, uses CPT, but also uses state-based codes. This varies from state to state; some states only use HCPCS codes, instead of CPT codes, for psychotherapy, says Marshall. In general, there are more state-based codes for addiction treatment services, with mental health services tending to use the CPT codes. HCPCS codes allow for day treatment services and intensive outpatient services, while CPT codes allow for medication management and psychotherapy.
Providers are expected to need help with coding and billing, especially as the claims process becomes standardized under health care reform. The National Council offers training, as does NIATx/SAAS on the addiction side.
There are two sets of guidelines for the E/M codes – 1997 and 1995. Psychiatrists, because they are medically based, use the 1997 guidelines, because they can be used in single-system reviews – in other words, the entire body doesn’t need to be evaluated. With the 1997 guidelines, the examination, history, and medical decision making can all be focused on the psychiatric component, says Marshall.
Finally, it’s important to note that counseling – in E/M verbiage – doesn’t mean the same thing as counseling in a psychotherapist’s language. You can use time under one condition when determining an E/M level – if most of the visit time is spent on counseling. “Time spent on this kind of counseling is not psychotherapy,” says Marshall. “It is a discussion with a patient and/or family concerning the recommended studies, risks and benefits, instructions for treatment,” she says. “It is nothing like psychotherapy. Psychotherapy is the treatment of a mental illness in which the physician attempts to alleviate emotional disturbances.”
Note: It’s a truism among coders that “if it wasn’t documented, it wasn’t done.” Documentation for psychotherapy can be much more time-consuming that documentation for medical visits, but it’s essential to getting paid. Documentation for psychotherapy should include the focus of the session, the type of modality (CBT, etc.), said Marshall.
There are still ways of capturing time spent, says Marshall. “It is still possible to bill for 90 or 120 minute sessions,” she said. “The challenge is that not all payers are using these codes.” You would need to use prolonged services codes, she says, to bill for longer sessions.
“But payers expect people to use 30- or 45- minute sessions which cuts you off at 52 minutes,” she says. “This puts people who do longer sessions in a bind.”
And here’s the bottom line – the 60 minute code is supposed to be 53 minutes up to 89 minutes. That means you can’t use prolonged services codes until you get to 89 minutes.