Psychotherapy coding changes 2017

There were two changes in the psychiatry section of CPT for 2017. The first is the description of psychotherapy codes were revised to remove the words “and/or family.”   In 2016, CPT code 90832 was defined as “Psychotherapy, 30 minutes with patient and/or family member.” In 2017 the definition is “Psychotherapy, 30 minutes with patient.”   Codes 90833, 90834, 90836, 90837, 90838, and 90839 were similarly revised.

The CPT Changes Insider’s View 2017 notes that although another person may be in the room (and they label this person as an “informant”) the individual psychotherapy codes are for individual treatment and the patient must be in the room “for all or a majority of the service.” The therapy focus is on the individual, not the family, even if the family member is present for part of the session and provides information. Therapy focused on the family should be reported with family therapy codes. According to CPT, individual and family therapy may be reported on the same day, although your payer may not follow that coding rule.

Family psychotherapy now has time added to the description.

CPT code 90846 was revised from “Family psychotherapy (without the patient present),” to “Family psychotherapy (without the patient present), 50 minutes.”

CPT code 90847 was revised from “Family psychotherapy (conjoint therapy) (with the patient present),” to “Family psychotherapy (conjoint therapy) (with the patient present), 50 minutes.”

Psychotherapy codes follow the CPT time rule, which is that in order to bill the service, the clinician must meet the mid point of time. In this case, in order to bill either 90846 or 90847, the family therapy must be at least 26 minutes. As always, document time in the medical record when time is a descriptor.

CPT is making a clearer distinction between individual and family therapy.

Additional coding information is at

January 24, 2017 I am giving a webinar “New revenue opportunities for primary care in 2017.” Check back: I’ll post an announcement about registering in late December.


An announcement from Betsy

In about one week I’ll be launching my new website,  Some of you have already heard about this great new resource for coding education and training. And some of you completed a survey for me recently that will help me make CodingIntel even better.

You can see the results of the survey here.

As part of the launch, I’m sending out a series of videos and downloadable resources to give you an idea of what the content on CodingIntel will be like.

You can watch the first video about How Physician Services are Paid here, and download the companion resource here.

I’ll post the next video on Friday.

Medicare will pay for non-face-to-face prolonged services starting January 1, 2017 Codes: 99358 and 99359

Does this sound familiar? Before a visit with a new patient, the physician or non-physician practitioner receives old records. A stack of old records. And, these EHR printouts aren’t always organized in any way and frequently include pages and pages of non-information. (Don’t tell CMS we can’t send these electronically, but instead print the EHR record, mail it and then scan it into the next EHR.) What does the physician or NPP do? Now, spends his or her own time reviewing the records.

Starting January 1, that is a paid service, if it takes 31 minutes or more.

Truly, if the clinician meets half of the threshold time for the prolonged service without face-to-face contact (31 minutes), Medicare will pay. And the best part of this announcement: CMS will pay using CPT codes not HCPCS codes and follow CPT coding rules.

99358 Prolonged evaluation and management service before and/or after direct patient care, first hour

+ 99359 each additional 30 minutes (List separately in addition to code for prolonged services)

CPT Rules:

  • This service may be provided on the same day or on a different day than the face-to-face service.
  • It is for extensive time in addition to seeing the patient, and must relate to a service for a patient where direct face-to-face patient care has occurred or will occur and be part of ongoing patient management.
  • Code 99358 is not an add-on code. That is it can be reported on the day when no other service is provided.
  • Code 99359 is an add-on code to code 99358.
  • The time during the day a non-face-to-face service does not need to be continuous.
  • CPT tells us not to report these services during the same month as complex chronic care management (99487, 99489) or during the service time of transitional care management (99495, 99496).
  • You cannot double count the time for these non-face-to-face prolonged services codes and time spent in certain other activities represented by specific CPT codes. However, the list of CPT codes are mostly those which have a status either non-covered or bundled by Medicare. (Care plan oversight: 99339, 99340, 99374—99380; anticoagulant management: 99363, 99364, medical team conferences: 99366—99368, online medical evaluations: 99444, or other non-face-to-face services that have more specific codes and no upper limit in the CPT codes.

The example given in the CPT book is for extensive record review. However, there could be other coordination services that meet the requirements.

Because Medicare is following CPT rules for these services then the CPT rules related to time is in effect. I always think this is a “through the looking glass rule.” However it is a well-established CPT principle. For a service defined with a time component, the clinician must meet over half of the time stated. In the introduction in your CPT book under the heading time it states “A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed.” In the case of these non-face-to-face prolong surfaces that means that 99358 maybe reported when 31 minutes have been spent. In order to report the add-on code 99359, 76 minutes would need to be spent in the non-face-to-face prelaunch services work. There is no provision or splitting this work over to calendar dates. This time rule does not relate to the stated times for E/M services.

Neither CPT (nor Medicare in their final rule) limits the specialty of physician or NPP who can perform these services. Although CMS discusses it in the section related to improving payment accuracy for primary care, there is no prohibition for other specialties using these codes. These codes could be relevant for any physician or NPP who needs to review extensive records prior to a patient visit when the time reaches the 31 minute threshold.

And of course, document time in the medical record and briefly describe the work that was done.

January 24, 2017 I am giving a webinar “New revenue opportunities for primary care in 2017.” Check back: I’ll post an announcement about registering in late December.




Using time to select an inpatient or observation service

I made a mistake recently when I spoke to a group of hospitalists, and although I’m embarrassed to admit it, admit it I am. I was asked if the time spent coordinating care on the floor out of the patient room could be used when selecting an inpatient service. I incorrectly said that over half of the total time had to be face-to-face with the patient. This was wrong! I confused office/outpatient rules with inpatient rules. I have since gone back to CPT and the CMS manual and to their Medicare Contractor, NGS and corrected it in writing. In case any of you have a similar moment of confusion, here’s what I found, with citations.

Summary: A physician, NP or PA may use time to select an inpatient or observation code when more than half of the total unit time is spent in counseling or coordination of care. Although it could be face-to-face counseling, the coordination of care does not have to be done face-to-face.

What needs to be documented: total time on the unit and that over half was in counseling. “I spent xx minutes on the unit caring for the patient, over half in counseling/ coordination of care.”


From CPT: Unit/floor time (hospital observation services, inpatient hospital care, initial inpatient hospital consultations, nursing facility): For reporting purposes, intraservice time for these services is defined as unit/floor time, which includes the time present on the patient’s hospital unit and at the bedside rendering services for that patient. This includes the time to establish and/or review the patient’s chart, examine the patient, write notes, and communicate with other professionals and the patient’s family.

From the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 C

In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

From NGS: (I have removed the references to office based services)

Time-Based Evaluation and Management Services

The National Government Services Medical Review Department is currently performing service-specific prepayment audits on several families of E&M services as well as prolonged services.

Medical review results indicate that in some cases, when time-based codes are billed, the amount of time involved is missing completely from the documentation. In other cases, the records may specify the amount of time involved but lack documentation detailing what was actually done during that time. The purpose of this article is to assist in improving documentation so that it supports the billed services.

 Time-Based Services

It is essential that the documentation specifically state the amount of time involved in the service. Simply stating, for example, that you had a “lengthy discussion with the patient” is imprecise and subjective.

The preferred practice is to include clock times or start and stop times in your documentation, (e.g., “03/09/2008 3:15–3:55 p.m.”). In certain instances where this is not feasible, such as in inpatient settings where the total time is not continuous, a summary of time, or total time spent is acceptable.

Counseling and/or Coordination of Care

Only when counseling and/or coordination of care constitute more than 50 percent of the floor time, will time be the key or controlling factor in E&M code selection.

Documentation in support of these services should include the following:

  • Total duration of floor time.
  • The duration of counseling or coordination of care and medical decision making.
  • A detailed description of the coordination of care or counseling provided. The documentation needs to provide sufficient information on what was coordinated and what was discussed or advice provided during counseling. Simple references such as “chart reviewed, RN consulted, reviewed Rx, etc.” is not sufficient.

The physician need not complete a history and physical examination in order to select the level of service. Time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

Special thanks to my friend and colleague Shelley Watts, who helped me sort this out.

Codes: 99221–99223, 99231–99233, 99218–99220, 99224–99226, 99234–99236.

Lesion destruction

When reading this article, it would be helpful to have your copy of the CPT book for reference. This article is meant as a companion to the codes listed in the book, and isn’t a replacement for your book or electronic access to CPT codes.

CPT describes destruction as “destruction means the ablation of benign, premalignant or malignant tissues by any method, with or without curettement, including local anesthesia and not usually requiring closure.” The services are now defined by the type of lesion that is destroyed. CPT notes that any method includes laser surgery, electrosurgery, cryosurgery, chemosurgery and surgical curettement. Also, anesthesia for these services provided by the physician/PA/NP who performs them may not be billed separately.

These codes have a ten-day global period and are considered minor procedures.

Let’s start with skin tags. There are two codes for the destruction of skin tags. 11200 is used for removal of skin tags up to and including 15 lesions, with an add-on code 11201 for each additional 10 lesions or part thereof. The method of the destruction doesn’t affect the code selection. If 1 to 15 skin tags are removed, report 11200 with one unit. If 16 to 25 skin tags are removed report 11200 with one unit and 11201 with one unit –not an additional unit for each skin tag. The CPT code description says each additional 10 lesions, not each additional lesion. That is why the add-on code is reported only once. Use ICD-10 code L91.8 for skin tags. Before you remove skin tags, warn the patient that the insurance company may consider it cosmetic, and may not pay for the service based on medical necessity.

The destruction of premalignant lesions, i.e, actinic keratoses are reported with codes 17000, 17003, and 17004. 17000 is reported for the destruction of a single lesion. Each additional lesion is reported with an add-on code 17003. If four AKs are are destroyed, Report 17000 one unit and report 17003 three units. Use 17003 for the second through the 14th lesion. If 15 lesions are destroyed, use code 17004 with one unit. The ICD-10 code for actinic keratosis is L57.0.

17110 is the code to use for destroying benign lesions such as warts or seborrheic keratoses. The definition of the code specifically states to use this for benign lesions other than skin tags or cutaneous vascular proliferative lesions. Code 17110 is reported once if 1 to 14 lesions are destroyed. If 15 or more lesions are destroyed, use 17111. For common warts, use B07.8, other viral warts. There are two codes in the category L82 for SKs.

In the editorial comments under the heading “destruction” and before code 17000 there is an instruction on reporting destruction of lesions in specific anatomic sites. Specifically, CPT instructs us to use other codes for lesions destruction of the mouth, eyelid, conjunctiva, penis, anus, vulva and vagina.


46900—46917—Anus Code selection varies by method, and if simple or extensive


54050—54057—Penis Code selection varies by method, and if simple or extensive


56501—Vulva Code selection depends on simple or extensive


57061—Vagina Code selection depends on simple or extensive




If a physician destroys a lesion on the mouth, eyelid, or conjunctiva, use a code from the organ system to which they relate. Those codes are listed above. For destruction of the lesion of the anus or the penis the codes are defined as simple or extensive. If the destruction is simple, the method of the destruction determines the code. For lesions of the vulva or vagina, code selection depends on whether the destruction is simple or extensive.

There is also a series of codes for destruction of malignant lesions using any method. These codes are defined by location and the lesion diameter. There is one set of codes for trunk arms and legs (17260—17266). There is a second set of codes for lesions on the scalp, back, hands, feet and genitalia (17270—17276). And there is a third set of codes for lesions on the face, ears, eyelids, nose, lips, and mucous membranes (17280—17286). For these codes we are measuring the diameter of the lesion to select the code, after determining the correct code set by body area. The distinctions are.5 cm or less, .6 cm to 1 cm, 1.1 to 2 cm, 2.1 to 3 cm, 3.1 to 4 cm, or a lesion diameter of over 4 cm.

End confusion about modifier -57 (and get paid for initial evaluations)

Recently I completed an audit for a general surgery practice. Included in the audit were two services for an initial hospital visit on the day of an emergency surgery. Both of these were reported with modifier -25 on the evaluation and management (E/M) service and both were denied by the payer. The practice did not appeal the denials.

Experienced coders are shaking their heads as they read this. They know that the (E/M) service should have been reported with modifier-57 not modifier -25. Why? Modifier-25 is used on an E/M services on the same day as a minor surgical procedure to indicate that the E/M service was separate and distinct from the minor procedure. A minor procedure is defined by Medicare––and this is accepted by all commercial payers—as a procedure with 0 or 10 global days. The global days are found in the Medicare Physician Fee Schedule and available in many coding programs. A major procedure is a procedure with 90 global days. An initial evaluation prior to a major surgical procedure is always payable. When this initial evaluation results in the decision for surgery on that calendar day on the next calendar day, append modifier -57 to the E/M service.

Key points to remember:

  • Use modifier -25 on an E/M service provided on the same day as a minor procedure. Remember, the NCCI edits require that the E/M is separate and distinct, that the physician or NPP needed to evaluate a condition prior to the decision to perform the procedure. Payment for the decision to perform the procedure is included in the payment for the procedure. For example, if an evaluation for bleeding and anemia results in the decision for an endoscopy. Report both the E/M and the endoscopy.
  • Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery.
  • Appeal denials up to the Medical Director of the plan. A surgeon should always be paid for the E/M prior to an urgent/emergency surgery.
  • Do not append modifier -57 on the E/M for the decision for surgery if the surgery is scheduled later than the day after the E/M service.