Billing Guidelines Using the New CPT Codes

How to Bill Using the New CPT Codes

By now I’m sure that you are aware of the changes affecting behavioral health CPT codes which take effect on January 1, 2013. To help you prepare for the transition, I have compiled a reference guide to help you make sense of it all. The new codes are described with their definitions and specific billing pointers are highlighted.

Initial Evaluation (90791)

 An integrated bio-psychosocial assessment including history, mental status and recommendations.

  • Can be used more than once when separate evaluations are conducted with the patient and an informant on different days
  • Cannot be reported on the same day as psychotherapy or crisis psychotherapy
  • Can be used for reassessments when required

Interactive Complexity Add-on Code (+90785)

Interactive complexity refers to specific communication factors that complicate the delivery of a psychiatric procedure.  Common factors include more difficult communications with discordant or emotional family members and engagement of young and verbally underdeveloped or impaired patients.  Typical patients are those who have third parties such as parents, guardians, other family members, interpreters, language translators, agencies, court officers, or schools involved in their psychiatric care.

  • Add-on code is reported in addition to primary code and never alone
  • Reflects increased work intensity of the service, but does not change the time of the service
  • Can be used in addition to initial evaluation or psychotherapy
  • One of the following must exist:Maladaptive communication (e.g., high anxiety, high reactivity, repeated questions or disagreement) among participants that complicates the delivery of care)
    • Emotional or behavioral conditions inhibiting initiation of treatment plan
    • Mandated reporting required (e.g., abuse or neglect)
    • Play equipment, devices, interpreter or translator required due to inadequate language expression or different language between client and provider

Psychotherapy Codes & the CPT Time Rule

Psychotherapy refers to the treatment of mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth or development.

  • A unit of time is attained when the midpoint between two time units is passed
  • The typical time closest to the actual time should be used
  • 16 minute minimum for psychotherapy
  • 30 minutes = 16 – 37 minutes (90832)
  • 45 minutes = 38-52 minutes (90834)
  • 60 minutes = 53+ minutes (90837)

 

 

Family Therapy (90846 & 90847)

These codes have been retained and no changes to their description have been made.

  • 90846 & 90847 are used when the primary focus of treatment is the family or subsystems within a family (e.g., parental couple, or the children) although the service is always for the benefit of the patient
  • This is different from psychotherapy codes with patient or family present where the focus is on the individual with occasional family involvement
  • Use 90847 for couples

Crisis Psychotherapy (90839, +90840)

Crisis psychotherapy is defined as an urgent assessment and history of a crisis state, a mental status exam, and a disposition.

  • Used for patients who present in high distress with complex or life threatening circumstances that require urgent or immediate attention
  • Do not report with initial evaluation (90791)
  • Do not report with standard psychotherapy (90832, 90834, and 90837)
  • Do not report with interactive complexity (+90875)
  • Use 90839 for the first 60 minutes
  • Use add-on code 90840 for each additional 30 minutes (list separately in addition to 90839)
  • Use 90839 for the first 31 to 74 minutes of a crisis session
  • Use 90832 when psychotherapy for crisis is 30 minutes or less
  • Crisis code 90839 can only be reported once per date, but time does not need to be continuous on that date

Final Notes

Make sure you check with each of your payors to determine the reimbursement rates for the new codes. Also, ask how they will handle authorizations which were obtained under the old codes, which carry into the new year. Will they still be honored or is a new authorization needed? If this is unclear, I suggest getting a new authorization to be on the safe side. I also suggest that you ask if there are any authorization requirements for any of the new codes (e.g., 60 minute sessions).

Please keep in mind that some codes may not be covered by some insurance companies. For instance, Medicare will not reimburse for crisis Psychotherapy in 2013. Finally, I want to remind you that evaluation and management (E/M) codes are only billable if you are a psychiatrist, nurse practitioner, or physician assistant. Since psychologists, social workers and other therapists cannot bill for these codes I have excluded them from this article, however the coding algorithm below includes E/M codes.

I hope you find this helpful. Please submit a comment if the information you are getting from your payors may be helpful to the rest of us.

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Resources

Coding Algorithm

AMA Webinar

CPT 2013 Standard Edition

Coding and Payment Guide for Behavioral Health Services 2013

Health Insurance Claim Forms

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Dennis Given, Psy.D.

Licensed psychologist & owner of Psychology Associates of Chester County, Inc.

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14 comments on “Billing Guidelines Using the New CPT Codes

  1. Thanks – very informative!

  2. Thanks for the info..I can hardly wait to see how they cut our income!

  3. Do you have an example fpr the interactive complexity add-on code? When is it appropriate to use this code. If a client has a DSS worker, and there is collaboration? Or if you make a CPS report outsied of the session or in the session? Are these appropriate uses of the code?

  4. Thank you for your time and effort writing and sharing this post.

  5. rachel on said:

    Is 90791 a time-based code? For example, if an initial evaluation takes 3 hours, is it billed as 3 units?

    • I don’t believe there is a time component for the 90791. There also wasn’t one when the initial eval was coded as a 90801, however, I generally do an hour for these. I would use crisis codes 90839 for the first hour and 90840 for each additional 30 minutes. I’m assuming there is a crisis if your initial eval last three hours. In this case you should bill one unit of 90839 (1 hour) and four units of 90840 (additional 2 hours in 30 minute units).

  6. We’re a hospital outpatient program and are having trouble billing 90853 and 90785 to Medicare. Has anyone else had this problem?

  7. Kathleen on said:

    I do monthly billing for a phychiatrist. We just started using the new 2013 codes last month and I am wondering how we break up the old fees into the two new codes?

  8. Pingback: Is Your Practice Ready for ICD-10? | SuccessfulPractice.net

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