Psychiatry Medical Billing and Coding - Key Services to Document
Staying up-to-date with the latest codes is crucial to successfully code for psychiatric services as well as those of all other medical specialties.
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Accurate medical coding services are critical for any medical specialty including psychiatry to ensure correct and timely reimbursement for services provided to patients. Coding errors like upcoding can impact any practice and the consequences can be severe. A 2018 AMA blog had highlighted the case of a psychiatrist who was fined $400,000, and permanently excluded from taking part in Medicare and Medicaid in part due to upcoding error in claim submission. The issue was that he billed for 30- or 60minute face-to-face sessions with patients when, in reality, he was only meeting with patients for 15 minutes each to do medication checks. Medscape’s latest article discusses how to accurately code certain key services that psychiatrists often provides. Psychiatric diagnostic evaluation and re-evaluation Psychological testing and evaluation is done to determine the cause of psychological symptoms and disorders, and to determine the correct diagnosis and follow up with the appropriate course of treatment. This diagnostic evaluation is usually reported with two codes - one with medical services for use by psychiatrists, psychiatric nurse practitioners, and psychiatric physician assistants; and another for an evaluation without medical services for use by social workers, psychologists, and other licensed therapists.  90791 Psychiatric/psychological diagnostic interview without medical services (intake interview)  90792 Psychiatric diagnostic interview (for prescribers / medical services) Medical services may consist of any medical activities such as performing elements of a physical exam or considering writing a prescription or modifying psychiatric treatment based on medical co-morbidities.
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Some key points regarding these codes in CPT book include: These codes may be used instead of seeing the patient if information needs to be obtained from family members, guardians, or others They may be billed more than once if the patient is seen on one day and a family member or other party is interviewed on another day. Here, both evaluations can be reported as if provided to the patient No time limit is instructed about the frequency of reporting the psychiatric diagnostic evaluation For a break in treatment, or if a patient needs a new evaluation after a hospitalization, it may be billed again Do not bill these codes on the same day as psychotherapy in crisis codes Medication management and psychotherapy Both these procedures have to be documented at the same visit. With the deletion of medication management codes, psychiatric practices were recommended to use evaluation and management (E/M) codes. Established patient visit codes are most common (CPT 99201–99215), as medication management is frequently performed in an office or clinic setting. Also, it is performed on patients who are known to the prescribing clinician. Consider using 99212
for
a
stable
patient,
who
just
needs
a
prescription
refill,
and 99214 for a patient with a very complex situation
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Tips include If only medication management is performed, the clinician may select the level of office visit (or other E/M service) based on the key components of history, exam, and medical decision-making, or on time. When both medication management and psychotherapy are provided on the same day, make sure to select an add-on psychotherapy code with the office visit. Psychotherapy code is billed based on the time, while the office visit must be selected based on the level of history, exam, and medical decision-making that is performed.
Crisis Codes Crisis codes are used for emergency sessions with patients who are in high distress and under complex or life-threatening circumstances that demand immediate attention. 90839: Psychotherapy for crisis; first 60 minutes +90840: Each additional 30 minutes These codes describe face-to-face time with the patient and/or family member and can be used in any location when a patient needs an urgent assessment and history during a crisis state, a mental status exam, and an immediate plan for psychotherapeutic intervention. While the code 90839 needs to be used for 30-74 minutes of time, add-on code can be used for additional 30-minute increments. Remember not to report these codes in addition to the psychiatric diagnostic evaluation or psychotherapy or other psychiatric services.
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Blog.therapynotes.com explains that when billing crisis codes, make sure the documentation includes A preliminary assessment of risk, mental status, and medical stability The need for further evaluation or referral to other mental health services (if applicable) Communication with contacts who may have pertinent information for the assessment Substance use (if applicable) Outcome of the session Individual and family therapy Also referred to as counseling or psychotherapy Individual therapy, individual therapy allows the patient to freely provide information with no negative consequence. At the same time, family therapy help aid the person back to recovery. 90846 Family psychotherapy (without the patient present), 50 minutes 90847 Family psychotherapy (conjoint therapy) (with the patient present), 50 minutes Because the code is defined as 50 minutes, over 25 minutes must be spent in order to bill the code. In cases where family members are present in an individual therapy session, the focus of this therapy is on the individual. So, bill the individual psychotherapy codes. Interactive Complexity Add-on Code According to CMS, “Interactive Complexity (90785) is an add-on code specific for psychiatric services and refers to communication difficulties during the psychiatric
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procedure.” This code may be added to the diagnostic psychiatric evaluation (90791, 90792), to psychotherapy services (90833–90838), and to group psychotherapy (90853). Interactive complexity can be reported with psychiatric procedures when at least one of the following communication difficulties is present: The need to manage maladaptive communication related to high anxiety, high reactivity, repeated questions, or disagreement among participants that complicates delivery of care Caregiver emotions/behavior that interfere with implementation of the treatment plan Patient with limited language proficiency Use of play equipment, physical devices, interpreter or translator to overcome significant language barriers As these coding and documentation can be time consuming and labor intensive, psychiatric practices, individual psychiatrists, clinics, community mental health centers and hospitals can rely on professional medical billing companies to prepare their medical claims. Such companies will provide services from experienced coders who are up to date with the latest psychiatry medical coding standards.
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