Using Correct Codes for Psychotherapy
Correct Codes for Psychotherapy
All mental health professionals including psychologists, psychiatrists, nurses, and social workers delivering psychotherapy services use the same applicable CPT codes when billing clients and filing health insurance claims with third-party payers, including Medicare, Medicaid, and private health insurance carriers.
First, behavioral health professionals might bill two types of CPT codes for new patients. These are E/M codes and Psychiatric evaluation codes. Depending on the situation and time involved, it may be appropriate to bill for both codes. A few guidelines include:
- E/M: Use E/M codes when evaluating a new medical issue. To bill for E/M, you must provide three documentation elements – history, examination, and medical decision-making.
- Psychiatric evaluation: Use psychiatric evaluation codes for a diagnostic assessment. You may need to use these codes more than once if more time is needed to complete the initial evaluation.
You are allowed to bill an E/M service with every psychotherapy visit, but it is not required with every encounter. E/M services are only to be billed if there is a separate medical issue that was addressed and documented during the encounter. For example, if you address the side effects of medication during a visit, you might bill for an E/M visit in addition to a psychotherapy session.
However, if a patient has been stable and on the same medication for years and attends a psychotherapy visit, you can only bill for the psychotherapy session. You cannot bill for E/M because there are no medical or medication concerns expressed during the visit. Also, to bill for E/M, your documentation must prove your active management or discussion of a medical or medication problem that is distinct from the psychotherapy service.
Supporting Documentation for E/M Code
The documentation must include the following three sections:
- History: The history section must include the history of present illness (HPI), review of systems (ROS) and past family and social history (PFSH).
- Examination: The examination section includes the type of examination performed based on your judgment, the patient’s history and the nature of the problem. You will need to document one to 14 elements depending on the level of examination.
- Medical decision-making: The medical decision-making section includes the number of diagnoses or treatment options documented during the specific encounter, the complexity of the data reviewed, and the risk of complications.
- Pass the midpoint: You must pass the midpoint to bill for a certain amount of time. For example, the midpoint between 30 minutes and 45 minutes is about 38 minutes. To bill for 45 minutes of psychotherapy, you must pass 38 minutes.
- Keep them separate: The time associated with the E/M service cannot count toward the time of the psychotherapy service. The E/M service must be significant and distinct from the psychotherapy service.
- In short, if you provide psychotherapy with an E/M service, bill the E/M service based on the three major components – history, examination, and medical decision-making – with a psychotherapy code, and document both the E/M work and psychotherapy work separately.
CPT © Copyright 2021 American Medical Association
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