General Coding Guidelines for Psychiatry and Psychology Services
Coding Guidelines for Psychiatry and Psychology Services
Psychiatry and Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases. References to providers include physicians and nonphysicians, such as clinical psychologists, independent psychologists, nurse practitioners, clinical nurse specialists, and physician assistances when the services performed are within the scope of their state license and clinical practice/education. Let’s discuss general coding guidelines for psychiatry and psychology services in this article.
Individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy. Psychiatric service CPT codes should not be used when other CPT codes such as an evaluation and management (E/M) service or pharmacological codes are more appropriate.
Interactive Complexity (90785) is an add-on code specific for psychiatric services and refers to communication difficulties during the psychiatric procedure. Add-on codes may only be reported in conjunction with other codes, never alone.
The specific communication difficulties are present with patients who typically:
- Have other individuals legally responsible for their care, such as minors or adults with guardians, or
- Request others to be involved in their care during the visit, such as adults accompanied by one or more participating family members or interpreter or language translator, or
- Require the involvement of other third parties, such as child welfare agencies, parole or probation officers, or schools.
Interactive complexity may be reported with psychiatric procedures when at least one of the following communication difficulties is present:
- The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicate the delivery of care.
- Caregiver emotions/behavior that interferes with the implementation of the treatment plan.
- Evidence/disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with a report to the state agency) with the initiation of discussion of the sentinel event and/or report with the patient and other visit participants.
- Use of play equipment, physical devices, interpreter or translator to overcome significant language barriers.
Do not report the CPT add-on code for Interactive Complexity code in conjunction with Psychotherapy for crisis codes or in conjunction with E/M services when no psychotherapy service is also reported.
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