E/M Coding Remains Tricky in 2018 for Psychiatry Services

Extensive changes to CPT coding in recent years have dramatically altered how psychiatrists bill for services, highlighting the importance of understanding E/M codes for both inpatient and outpatient care.

Coding for evaluation and management services and psychotherapy has always been tricky, but changes introduced for CPT in 2018 may have you in a fright. Don’t worry! In her training session, “E&M Coding for Psychiatry Services,” medical coding expert Letitia Patterson walks you through the essentials: documentation requirements, general behavioral health intervention codes, and the keys to knowing who can (and can’t) use E/M codes with psychiatry services.

Plus, read on to sort out the new codes, cut through CPT coding confusion, overcome common coding pitfalls, and get a firm handle on imminent changes.

Don’t Let New E/M Codes Make You Nervous

In 2017, Medicare agreed to cover codes 99378 and 99359, while HCPCS codes G0502, G0503, G0504 and G0507 were added, according to CMS FAQs.

But further changes go into effect on January 1, 2018, when G0502, G0503 and G0504 will be replaced by new CPT codes 99492, 99493 and 99494 for Psychiatric Collaborative Care Management Services. In addition, 99483 and 99482 will be introduced.

Here are the basics of how the five new E/M psychiatric codes break down:

• 99483: Typically a 50-minute assessment of and care planning for a patient with cognitive impairment
• 99484: Care management services for behavioral health conditions, involving at least 20 minutes of clinical staff time per calendar month
• 99492: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities
• 99493: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities
• 99494: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities (this must be listed separately in addition to code for primary procedure)

Key: CMS’s collaborative care model is designed to promote behavioral health integration and enhance typical primary care by adding two key services: care management support for patients receiving behavioral health treatment and regular psychiatric inter-specialty consultation to the primary care team, particularly, notes Patterson, regarding patients whose conditions are not improving.

Billing All Together Now!

Mental health coders will recognize some of the other CPT coding issues and pitfalls from years past.

For instance, what services can be billed together? Psychotherapy and E/M can be billed together (+90833, +90836 and +90838) but may not be billed with prolonged services. In order to be billed together, the psychotherapy and E/M services provided must be separate and easily recognized as significant. To code properly, the level and type, not time, of E/M service must be determined first.

An important exception to services billed together would be psychotherapy for crisis: Time-based codes +90839 and +90840 may not be billed together with diagnostic evaluation codes 90791, 90792, 90832-90838, or 90785.

More About Diagnostic Evaluation Codes 90791-2

Generally speaking, the documentation required for psychiatric diagnostic evaluation with medical services includes the details of the onset of the illness. However, if for instance a patient is being seen for a new episode or illness, the service can be used again, Patterson explains.

Key: The difference between 90791 and 90792 is the use of medical services. Both codes cover evaluation of a patient’s ability and capacity to respond to treatment—but only 90792 includes medical services.

How to use: Proper use of these codes, according to Patterson, requires: a complete medical and psychiatric history along with a mental status exam, establishment of an initial diagnosis, and evaluation of the patient’s ability and capacity to respond to treatment. Information may be obtained not just from the patient but also from other physicians, healthcare providers, and/or the family if the patient is unable to provide a complete history, she notes.

Important: Do not report 90791 on the same day as an E/M code. Neither 90791 nor 90792 can be billed on the same day as psychotherapy. You may bill 90791 on more than one day if doing so is considered medically necessary (more on that below). Also, you may report 90792 with add-on code 90785 for interactive complexity.

Documentation tips:

• Include a patient history along with the mental status report and any provider recommendations.
• Include any communication with family members and others, along with any diagnostic test orders or review of those tests.
• If it is medically necessary to bill a code more than once, include a statement to that effect. For example, you might bill more than once if a child is involved and seeing both the child and the parent—whether together or independently—is necessary, Patterson explains.
• The key to billing for 90792 is to document any additional physical exam elements pertinent to the care of the patient on that day—including any resulting recommendations, prescription drug management, and lab or test orders.

The bottom line is that you want to paint a full story for the patient on that day—including the reason for any assessment (or reassessment) to establish medical necessity, Patterson affirms.

Keep Calm with the Crisis Codes

Because using psychotherapy-for-crisis codes can also be a bit tricky, here are a few handy tips to guide you.

Two basic requirements:

• The visit must be face to face and the provider has to give full attention to the patient. Telephone calls do not count towards this code.
• No other services can go on during the time period of using psychotherapy for crisis; this is a key part of why you can’t use them with the codes above.

Remember also to use the code that closely matches the time spent with the patient; for example, if 37 to 70 minutes was spent, use code 90839 (60 minutes spent with the patient), and use 90840 to bill for additional 30 minutes past the initial hour.

Get the Right Tools: Knowing what to bill together can be tricky, and sometimes an extra visual guide can help. In her webinar, Patterson provides you with an invaluable algorithm to know when you can—and can’t—bill codes together. This is a huge time saver!

Time Is Ticking

Another pitfall involves when time is a factor in selecting the right code. Per current coding guidelines, time is a factor for psychotherapy (90832, 90834 and 90837), psychotherapy for crisis (90839 and 90840) as well as psychotherapy paired with E/M services (90833, 90836 and 90838).

Time also factors into prolonged psychotherapy (90+ minutes), which covers outpatient codes 99354 and 99355, and inpatient codes 99356 and 99357.

However, family psychotherapy (90846, 90847 and 90849), which is considered medically necessary treatment of the family unit when maladaptive behaviors of family members are exacerbating the patient’s illness in the treatment process, is based on who is present during services provided instead of the time spent with the patient.

And group psychotherapy (90853), in which personal and group dynamics are discussed, allowing emotional catharsis, instruction, insight and support, is not time-based.

For any doubts about services provided, time spent, location of patient (hospital, hospice, home, etc.) or their status as outpatient or inpatient, coders should immediately clarify with psychiatrists.

Keeping Up with the Changes

Although it may appear daunting to keep up with what’s new, it’s important to remember: ensure the psychiatrist documented medical services performed as thoroughly as possible. For any doubts, refer to the latest CPT guidebook issued by the AMA. And keep track of changes carriers may make to which codes they will accept, and be aware that each carrier may have a different interpretation of how such codes are to be selected, advises the AAPC.

Behavioral health specialists can ensure they understand current and upcoming CPT coding changes and remain compliant by joining medical coding expert Letitia Patterson, who provides a thorough overview of current clarifications and descriptors to CPT codes, as well as the latest HCPCS codes in the collaborative care model for behavioral health, in her talk on “E&M Coding for Psychiatry Services” for ProfEdOnDemand. Ideal for psychiatrists, coders and compliance specialists alike, Letitia’s webinar will guide you through key concerns such as how to be thorough in documentation, who can and can’t use E/M codes, and how to bill for multiple services performed on the same day.