Tuesday, September 8, 2015

CPT code 90834 ,90832, 90837 - Psychiatric Services Coverage/Reimbursement

Code 90834: Psychotherapy, 45 minutes with patient and/or family member

• Code 90837:
Psychotherapy, 60 minutes with patient and/or family member  In general, providers should select the code that most closely matches the actual time spentperforming psychotherapy. CPT® provides flexibility by identifying time ranges that may be associated with each of the three codes:
• Code 90832 (or + 90833): 16 to 37 minutes,
• Code 90834 (or + 90836): 38 to 52 minutes, or
• Code 90837 (or + 90838): 53 minutes or longer

Do not bill psychotherapy codes for sessions lasting less than 16 minutes.

Psychotherapy codes are no longer dependent on the service location (i.e., office, hospital, residential setting, or other location is not a factor). However, effective January 1, 2014, when E&M services are paid under Medicare’s Partial Hospitalization Program (PHP) and not in the physician office setting, the CPT outpatient visit codes 99201-99215 have been replaced with one Level II HCPCS code - G0463. Further information about this code can be found in the CY 2014 OPPS/ASC final rule that was published in the Federal Register on December 10, 2013.

Example: A geriatric psychiatrist (physician) billed for a level 3 E&M service (99213) and 45 minutes of psychotherapy (90836). The medical record contained one entry for the date of service and, at the top, a notation: “45 minutes”. It did not indicate whether the 45  minutes was spent providing the psychotherapy services or both services. An overpayment for the psychotherapy service and a billing error occur when there is no separate entry for the amount of time spent performing psychotherapy services. 

Psychotherapy Psychiatric Therapeutic Procedures (CPT Codes 90832-90838, 90845-90853, 90865):

A. Codes 90832-90834 represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy

B. Codes 90845-90853 represent psychoanalysis , group psychotherapy, family psychotherapy, and/or interactive group psychotherapy

C. Code 90865 represent narcosynthesis for psychiatric diagnostic and/or therapeutic purposes NOT included in these codes:

• Teaching grooming skills
• Monitoring activities of daily living (ADL)
• Recreational therapy (dance, art, play)
• Social Interaction Codes 90832-90838 Severe and profound intellectual disability (mental retardation, ICD-9 codes 318.1, 318.2, 319) is never covered for psychotherapy services

• In such cases, rehabilitative, E/M codes, or pharmacological management codes should be reported. Patients with dementia represent a very vulnerable population in which co-morbid psychiatric conditions are common. For such a patient to benefit:

• Dementia must be mild

• They retain the capacity to recall the therapeutic encounter from one session, individual or group to another.

• Capacity to meaningfully benefit from psychotherapy must be documented in the medical record Services are not covered when documentation indicates that dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective Codes 90833, 90835, and 90838 MUST be submitted with E/M services by either the MD/DO or NPP Code 90846 is used for family psychotherapy without patient present

Psychotherapy probe review findings

First Coast Service Options Inc. (First Coast) recently conducted post payment provider specific probes reviews in response to data aberrancies identified for Current Procedural Terminology (CPT) code 90834 (psychotherapy, 45 minutes with patient and/or family member). Post payment medical reviews resulted in high error rates. Services were denied because submitted medical records did not meet documentation requirements as outlined in the Psychiatric Diagnostic Evaluation and Psychotherapy Services local coverage determination (LCD) (L33128). Specifically the medical records were missing one or more of the following documentation requirements for each date of service:

•    Documentation of measurable goals on the treatment plan;
•    Detailed summary of the psychotherapy sessions, including descriptive documentation of therapeutic interventions;
•    Degree of patient participation and interaction with the therapist;
•    Reaction of the patient to the therapy sessions;
•    Documented progress toward measurable goals since the last sessions; and changes or lack of changes in the patient’s symptoms or behavior;
•    Documentation of adjustments in the treatment plan that reveal the dynamics of treatment;
•    Treatment plan was not updated and did not support the medical necessity of each psychotherapy session.

The documentation for psychotherapy services should include on a periodic basis the patient’s capacity to participate and benefit from psychotherapy. Such periodic documentation should include the estimated duration of treatment in terms of number of sessions required and the target symptoms, measurable and objective goals of therapy related to changes in behavior, thought processes and/or medications, methods of monitoring outcome, and why the chosen therapy is an appropriate modality either in lieu of or in addition to another form of psychiatric treatment. For an acute problem, there should be documentation that the treatment is expected to improve the mental health status or function of the patient. For chronic problems, there must be documentation indicating that stabilization of mental health status or function is expected. Documentation will reflect adjustments in the treatment plan that reveals the dynamics of treatment.

It is expected that the treatment plan for a patient receiving outpatient psychotherapy (i.e., measurable and objective treatment goals, descriptive documentation of therapeutic intervention, frequency of sessions, and estimated duration of treatment) will be updated on a periodic basis, generally at least every three months.

The medical record documentation maintained by the provider must indicate the medical necessity of each psychotherapy session and include the following:

•    The presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms
•    sufficient to alter baseline functioning; and
•    A detailed summary of the session, including descriptive documentation of therapeutic interventions such as examples of attempted behavior modification, supportive interaction, and discussion of reality; and
•    The degree of patient participation and interaction with the therapist, the reaction of the patient to the therapy session, documentation toward goal oriented outcomes and the changes or lack of changes in patient symptoms and/or behavior as a result of the therapy session.
The rationale for any departure from the plan or extension of therapy should be documented in the medical record. The therapist must document patient/therapist interaction in addition to an assessment of the patient’s problem(s).

First Coast recommends providers be familiar with medical necessity indications and documentation requirements for psychotherapy services as indicated in the Psychiatric Diagnostic Evaluation and Psychotherapy Services LCD.

Psychotherapy (CPT Codes 90832-90838)

Psychotherapy is the treatment of mental illness and behavior disturbances, in which the provider establishes a professional contact with the patient and through therapeutic communication and techniques, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, facilitate coping mechanisms and/or encourage personality growth and development.

Insight oriented, behavior modifying, and/or supportive psychotherapy refers to the development of insight or affective understanding, the use of behavior modification techniques, the use of supportive interactions, and the use of cognitive discussion of reality, or any combination of the above to provide therapeutic change.

Psychotherapy will be considered medically necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning. Psychotherapy services must be performed by a person licensed by the state where practicing, and whose training and scope of practice allow that person to perform such services.

Psychotherapy must be provided as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnoses. Some patients receive psychotherapy alone, and others receive psychotherapy along withmedical evaluation and management services. These services involve a variety of responsibilities unique to the medical management of psychiatric patients such as medical diagnostic evaluation (i.e. evaluation of co-morbid medical conditions, drug interactions, and physical examinations), drug management when indicated, physician orders, interpretation of laboratory or other diagnostic studies and observations. The patient should be amenable to allowing insight-oriented therapy such as behavioral modification techniques, interpersonal psychotherapy techniques, supportive therapy, and cognitive/behavioral techniques to be effective.

Psychotherapy services are not considered to be medically reasonable and necessary when they are rendered to a patient who has a medical/neurological condition such as dementia, delirium or other psychiatric conditions, which have produced a severe enough cognitive deficit to prevent effective communication with interaction of sufficient quality to allow insightoriented therapy (i.e. behavioral modification techniques, interpersonal psychotherapy techniques, supportive therapy or cognitive/behavioral techniques). In these cases, evaluation and management or pharmacological codes should be used. Psychotherapy services are not considered to be medically reasonable and necessary when they primarily include the teaching of grooming skills, monitoring activities of daily living, recreational therapy (dance, art play), or social interaction. Psychotherapy times are for face-to-face services with the patient. The patient must be present for all or some of the service.

In reporting, choose the code closest to the actual time (i.e., 16-37 minutes for 90832 and 90833, 38-52 minutes for 90834 and 90836, and 53 or more minutes for 90837 and 90838). Do not report psychotherapy of less than 16 minutes duration. Some psychiatric patients receive a medical evaluation and management service on the same day as a psychotherapy service by the same physician or other qualified health care professional. These services to be medically necessary should be significantly different and separately identifiable

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