Tell me something I don’t know: confusion in reporting Psychiatry services

CMS recently released a MedLearn Matters article about coding for psychotherapy and evaluation and management (E/M) services on the same day. This article reported that the comprehensive error rate testing contractor (CERT) had found a high error rate when E/M services and psychotherapy are reported together. Tell me something I don’t know.

 In 2012 physicians, nurse practitioners, physician assistants and clinical nurse specialists working in psychiatry reported medication management with code 90862. That code was deleted in 2013. Medical practitioners working in psychiatry who performed medication management were instructed to report the service with E/M codes. If psychotherapy was provided there were new add-on codes for psychotherapy reported with medical evaluation services. The CPT book instructed clinicians not to use the time spent for the E/M service to determine the level of service for psychotherapy. While psychotherapy codes are time-based codes, E/M services may be reported either based on time (unless provided on the same day as psychotherapy) or based on the three key components of history, exam, and medical decision-making. It was all very confusing to medical clinicians working at psychiatry.

 The MedLearn Matters article tries to clarify this. “The main error that CERT has identified with the revised psychiatry and psychotherapy codes is not clearly documenting the amount of time spent only on psychotherapy services. The correct E&M code selection must be based on the elements of the history and exam and medical decision making required by the complexity/intensity of the patient’s condition. The psychotherapy code is chosen on the basis of the time spent providing psychotherapy.” That is, select the E/M service based on the history, exam, and medical decision-making documented and add a note “After the E/M service, I spent XX minutes in psychotherapy with the patient.” Describe the psychotherapy.   The article further stated that it needed to be clear that the time spent in psychotherapy did not include the time of the E/M service.“Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.”

Clinicians tell me that this is a false delineation, and that there is no easy way to mark when the E/M service stopped and the psychotherapy started. But, these are the coding rules that we have in 2014. What is a medical clinician working in psychiatry to do?

Providing medication management or medical evaluation only: if this is the only service provided a clinician may use time or the three key components to select the code. If psychotherapy is not done on the same day, and the visit is dominated by counseling, a clinician may use time to select the code. The CPT describes counseling as dominating the visit when over 50% of the time of the total visit time is composed of discussion of the diagnosis, prognosis, risks and benefits, importance of compliance, and patient or family education. In that case, document the total time and that more than 50% of the time was spent in counseling. “I spent 20 minutes with the patient over half of the discussing the side effects of medication and the other issues above.”

Only psychotherapy is provided: if only psychotherapy is provided and there is no medical E/M, use the psychotherapy standalone codes based on time. These codes are hurt 90832, 90834, and 90837. Document time in the record and describe the psychotherapy that was performed.

When both an E/M services (such as medication management) and psychotherapy are provided on the same calendar date: in this case report both an E/M service and an add on psychotherapy code. Select the level of service based on the history, exam and medical decision making. Then, document the time spent in psychotherapy not including in it the time it took to provide the E/M service.. I suggest documenting the patient’s subjective report, the mental status exam and the assessment in the plan. Then note “after the E/M service was performed I also provided XX minutes of psychotherapy.” Describe the nature of the psychotherapy. Do not document the total time of the visit because that includes both the E/M service and the psychotherapy.

Although most clinicians don’t want to read the CPT book, the section about psychiatry codes includes important editorial comments and instructions for use of the codes. Because there was such a major change in 2013, and Medicare has identified a high error rate for these services it is important for someone in the office to review this section of the book. It will only take 15 or 20 minutes to read through the editorial comments in the psychiatry section and the reward will be an increased understanding and higher coding accuracy.

 

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