Transcript 2013 CPT Coding Changes

2013 CPT Coding Changes
Julie E Larish, CPC
1
CPT coding and documentation –
Whose job is it?
American Psychiatric Association
• Documentation and coding is part of physician
work
• You are responsible for the clinical work and
equally responsible for the documentation
and coding
• This should not be the job of your staff!
2
Overview of changes implemented in 2013
• Key codes have been deleted, e.g. 90862 Pharmacologic
Management
• Key services have been assigned Established numbers
and/or are described differently, and all Established codes
can be used in all settings
• There are now two codes for an initial evaluation; one with
medical services and one without
• Psychotherapy is no longer distinguished by site of service
• Psychotherapy with E/M is now an E/M code with a
Psychotherapy add-on
• There is a Established crisis psychotherapy code
• Work previously described using the interactive codes is
now done by using an add-on code
3
4
5
6
Timeline
• August 31, 2012
• CPT electronic files released;
changes to CPT codes public
• November 2012
• CMS releases the Final Rule on
the 2013 Physician Fee
Schedule (includes relative
values)
• Established code set goes in to
effect – must bill using
Established CPT codes
• January 1, 2013
7
Pharmacologic Management
Medication Support Service with or
without Psychotherapy
8
Pharmacologic Management
• 90862 has been DELETED
• Psychiatrists should use the appropriate E/M
series code (99xxx) to report this service
• A Established add-on code – 90863 – has been
added to describe pharmacologic
management when performed by a
prescribing psychologist; Physicians should
NEVER use 90863
9
• Psychotherapy with E/M is now reported by
selecting the appropriate E/M service code
(99xxx series) and the appropriate psychotherapy
add-on code
• The E/M code is selected on the basis of the site
of service and the key elements performed
• The psychotherapy add-on code is selected on
the basis of the time spent providing
psychotherapy and does not include any of the
time spent providing E/M services
• If no E/M services are provided, use the
appropriate psychotherapy code (90832, 90834,
90837)
10
Medication Management with or without psychotherapy is now recorded with E/M
codes
New PATIENT in OUTPATIENT SETTING
99201 – New Patient Office Visit – Problem Focused w/
Straightforward decision making (10)
99202 – New Patient Office Visit – Expanded Problem Focused
w/Straightforward decision making (20)
99203 – New Patient Office Visit – Detailed w/Low Complexity
decision making (30)
99204 – New Patient Office Visit – Comprehensive w/Moderate
Complexity decision making (45)
99205 – New Patient Office Visit – Comprehensive w/High
Complexity decision making (60)
11
Established PATIENT in OUTPATIENT SETTING
99211 – Established Patient Office Visit – Problem Focused w/
Straightforward decision making
99212 – Established patient Office Visit – Expanded Problem
Focused w/Straightforward decision making
99213 – Established Patient Office Visit – Detailed w/Low
Complexity decision making
99214 – Established Patient Office Visit – Comprehensive
w/Moderate Complexity decision making
99215 – Established Patient Office Visit – Comprehensive w/High
Complexity decision making
12
PATIENTS in INPATIENT SETTING
99221 – Initial hospital care – Detailed w/ Low decision making
99222 – Initial hospital care – Detailed w/ Moderate decision
making
99223 – Initial hospital care – Detailed w/ High decision making
99231 – Subsequent Hospital Care – Problem focused w/low
complexity
99232 – Subsequent Hospital Care – Expanded problem focused
w/moderate complexity
99233 - Subsequent Hospital Care – Detailed w/high complexity
13
1997 CMS Documentation Guidelines for Evaluation and Management
Services – Abridged & Modified for Psychiatric Services
ELEMENTS NEEDED FOR E/M
DOCUMENTATION
14
99201
Outpt Medication/ New patient/Problem focused
99202
Outpt Medication/ New patient/Expaned problem focused
99203
Outpt Medication/ New patient/Low Complexity
99204
Outpt Medication/ New patient/Moderate Complexity
99205
Outpt Medication/ New patient/High Complexity
99211
Outpt Medication/Established/Problem focused
99212
Outpt Medication/Established/Expaned problem focused
99213
Outpt Medication/Established/Low complexity
99214
Outpt Medication/Established/Moderate complexity
99215
Outpt Medication/Established/High complexity
99221
Inpt
Medication/Initial Day/Low complexity
99222
Inpt
Medication/Initial Day/Moderate complexity
99223
Inpt
Medication/Initial Day/High complexity
99231
Inpt
Medication/Subsequent Day/Low complexity
99232
Inpt
Medication/Subsequent Day/Moderate Complexity
99233
Inpt
Medication/Subsequent Day/High Complexity
M0064
Outpt Medication monitoring
15
99211
99212
Minimal
At Least 1:
Please pull out
this table in
your handouts!
99213
Problem Focused
At Least 1:
99214
Exp Problem Focused
99215
Detailed
At Least 1
At Least 4: or At Least 3:
Comprehensive
At Least 4: or At Least 3:
H
Location
Location
Chronic DX
Location
Chronic DX
Location
Chronic DX
Location
Chronic DX
P
Quality
Quality
Chronic DX
Quality
Chronic DX
Quality
Chronic DX
Quality
Chronic DX
I
Severity
Severity
Chronic CX
Severity
Chronic CX
Severity
Chronic CX
Severity
Chronic CX
Duration
Duration
Duration
Duration
Duration
Timing
Timing
Timing
Timing
Timing
Context
Context
Context
Context
Context
Modifying factors
Modifying factors
Modifying factors
Modifying factors
Modifying factors
Assoc Signs &
Assoc Signs &
Assoc Signs &
Assoc Signs &
Assoc Signs &
Symptoms
Symptoms
Symptoms
Symptoms
Symptoms
Constitutional
Constitutional
Constitutional
O
Eyes/ENT/Mouth
Eyes/ENT/Mouth
Eyes/ENT/Mouth
S
CV
CV
CV
Respiratory
Respiratory
Respiratory
GI
GI
GI
GU
GU
GU
Musculoskeletal
Musculoskeletal
Musculoskeletal
Skin/Breast
Skin/Breast
Skin/Breast
Neuro
Neuro
Neuro
Psych
Psych
Psych
Endocrine
Endocrine
Endocrine
Hem/Lymph
Hem/Lymph
Hem/Lymph
Allergy/Immun
Allergy/Immun
R
No ROS
No ROS
Allergy/Immun
All others negative
P
No PFSH
No PFSH
No PFSH
At least 2 required
All others negative
All 3
F
Past medical
Past medical
S
Family History
Family History
H
Social History
Social History
Constitution
Measurement of any 2 of 7 vital signs
Sitting or standing BP
Supine BP
Pulse Rate & regularity
Height
Respriations
Ttempreture
Weight
General Appearance
Development
Deformaties
Body Habitus
Attention to grooming
Nutrition
Musculoskeletal
Assessment of Muscle Stength & Tone
Flaccid
Cog Wheel
Antalgic
Hip Extensor
Spastic
Spastic
Atxic
Myopathic
Steppage
Festinating
Paraplegic spastic
Stuttering
Helicoped
Quadriceps
Tqabetic
Examination of Gait & Station
Waddling
Psychiatric
Description of Speech
rate
atriculation
volume
cohearence
Spontaneity with notation of abnormalities - eg. perservation, paucity of language
Description of Thought Process
rate of thoughts
abstracct reasoning
Computation
content of thoughts eg. Logical, illogical tangential
Description of Associations
loose
tangential
Hallicinations
homicdal
intact
obessions
preoccupation with violence
circumstantial
Description of Abnormal or Psychotic Thoughts
delusions
Suicidal
Description of Client's Judgement and Insight
Judgement concerning everyday activities and social situations
Insight eg. Concerning psychiratric condition
Complete Mental Status Examination
Orientation to time, place, person
Recent and remote memory
attention span and concentration
language (eg naming objects, repeating phrases
fund of knowledge (eg awareness of current events, past history, vocabulary)
mood and affect (eg depression, anxiety, agitation, hypomania, lability
Medical Decision Making
Complexity
Straight forward
Low Compexity
Moderate Complexity
High Complexity
Diagnosis
2 or more sefl limited or minor problems or 1 stabel
1 self limited problem (eg., medication side effect chronic illness or acute uncomplicated illness (eg
exacerbation anxiety)
1 or more chronic illness with mild exacerbation, progression or side
1 or more chronic illnesses with severe exacerbation, progression, or side
effects of tx, or 2 or more stable chronic illnesses or undiagnosed new effect of tx (eg. Schizophrenia) or acute chronic illness with threat to life
problem with uncertain prognosis
(eg. Suicidal or homicidal ideation
Lab requiring venipuncture
EEG
Data
Urinalysis
Psychological testing
Skull film
Neurospsycholocial testing
Lumbar puncture
Suicide risk assessment
Management
Options
Reassurance
Avg Time
5 minutes
10 minutes
Psychotherapy
Environmental intervention (eg, Prescription drug management, open-door
agency, school, vocational placement) Referra; for seclusion, ETC, Inpatient, Outpatient routine,
consultation
no comorbid medical conditions
15 minutes
25 minutes
Drug therapy requiring intensive moitoring (eg, taperin diazepam for
patient in withdrawal), closed-door seclusion, Suicide observation, ECT:
patient has comorbid medical condition (eg, cardiovascular disease)
Reapid intramuscular neuroleptic administraton, Pharmacolgic restraint
(eg, droperidol)
40 minutes
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History
• Problem focused – chief complaint, brief history of
present illness or problem
• Expanded problem focused – Chief complaint, brief
history of present illness, problem pertinent system
review
• Detailed – Chief complaint, extended history of
problem, problem pertinent system review extended to
include a review of a limited number of additional
systems, pertinent past, family and/or social history
directly related to client’s problems
• Comprehensive - Chief complaint, extended history of
problem, review of systems that is directly related to
the problem(s) identified in the history of the present
illness plus a review of all additional body systems,
completed past, family and social history
17
History requirements
99211
99212
99213
Minimal
Problem Focused
Exp Problem Focused
At Least 1:
H
Location
P
Quality
I
Severity
At Least 1:
Location Chronic
DX
Quality
Chronic
DX
Severity Chronic
CX
99214
99215
Detailed
Comprehensive
At Least 4: or At Least
At Least 1
3:
At Least 4: or At Least 3:
Location Chronic
Location Chronic
Location Chronic DX
DX
DX
Quality
Chronic
Quality
Chronic DX
DX
Quality
Chronic DX
Severity Chronic
Severity Chronic
Severity Chronic CX
CX
CX
Duration
Duration
Duration
Duration
Duration
Timing
Timing
Timing
Timing
Timing
Context
Modifying
factors
Context
Context
Context
Context
Modifying factors
Modifying factors
Modifying factors
Modifying factors
Assoc Signs &
Assoc Signs &
Assoc Signs &
Assoc Signs &
Assoc Signs &
Symptoms
Symptoms
Symptoms
Symptoms
Symptoms
18
Review of Systems
• A ROS is an inventory of body systems obtained
through a series of questions seeking to identify
signs and/or symptoms which the patient may be
experiencing.
– A problem pertinent ROS inquires about the system
directly related to the problem identified
– An extended ROS inquires about the system directly
related to the problem(s) identified in the HPI and a
limited number of additional systems
– A complete ROS inquires about the system(s) directly
related to the problems identified in the HPI plus ALL
addition body systems
19
R
99211
99212
99213
99214
99215
Minimal
Problem Focused
Exp Problem Focused
Detailed
Comprehensive
No ROS
No ROS
Constitutional
Constitutional
Constitutional
O
Eyes/ENT/Mouth
Eyes/ENT/Mouth
Eyes/ENT/Mouth
S
CV
CV
CV
Respiratory
Respiratory
Respiratory
GI
GI
GI
GU
GU
GU
Musculoskeletal
Musculoskeletal
Musculoskeletal
Skin/Breast
Skin/Breast
Skin/Breast
Neuro
Neuro
Neuro
Psych
Psych
Psych
Endocrine
Endocrine
Endocrine
Hem/Lymph
Hem/Lymph
Hem/Lymph
Allergy/Immun
Allergy/Immun
Allergy/Immun
All others negative
All others negative
20
PFSH
• Past – the patient’s past experiences with illnesses, operations,
injuries and treatments
• Family – a review of medical events in the patient’s family, including
diseases which may be hereditary or place the patient at
risk
• Social – an age appropriate review of past and current activities
P
99211
99212
99213
99214
99215
Minimal
Problem Focused
Exp Problem Focused
Detailed
Comprehensive
No PFSH
No PFSH
No PFSH
At least 2 required
All 3
F
Past medical
Past medical
S
Family History
Family History
H
Social History
Social History
21
Examination
• Problem focused – A limited examination of the
affected area or system
• Expanded problem focused – A limited
examination of the affected system and other
symptomatic or related system(s)
• Detailed – An extended examination of the
affected system and other symptomatic or
related system(s)
• Comprehensive – A general multisystem exam or
completed examination of a single organ system.
22
When doing an examination – NEVER
document
“ABNORMAL”
Without elaboration of the finding!
23
Exam For MD’s in General Health Services
Constitution
Any three vital signs
General Appearance
Eyes
Conjunctivae & lids
Pupils & Irises
Optic discs
ENT
External ears & nose
EACs &TMs
Hearing
Nasal mucosa, septum & turbinates
Lips, teeth, & gums
Oropharynx
Neck
Neck
Thyroid
Respiratory
Respiratory effort
Percussion
Palpation
Auscultation
Cardio/Vascular
Palpation of heart
Auscultation
Carotids
Abdominal aorta
Femoral
Pedal Pulses
Extremities for edema &/or variocosities
Chest
Inspection of breasts
Palpation of breast & axillae
GI (abdomen)
Masses, tenderness
Liver & Spleen
Hernia
Occult test
Anus, perineum & rectum
Genitourinary
MALE
Scrotal contents
Penis
Prostate gland
FEMALE
External genitalia
Urethra
Bladder
Cervis
Groin
Other
Adnexa/parametria
Lymph (nodes in two or more areas)
Neck
Axillae
Muscular
Gait & Station
Digits & nails
1) Head, neck
2) spine, ribs & pelvis
5) Right lower extremity
6) left lower extremity, with exam including:
ROM
Stability
Joint(s), bones(s), muscles of at least one area:
3) right upper extremity
4) Left upper extremity
inspection&/or palpation
Strength & tone
Skin
Inspection of skin & subcutaneous tissue
Palpation of skin & subcutaeous tissue
Neurology
Cranial nerves
Sensation
Psychiatric
Judgement & insight
Reflexes
Orientation
time/place/person
Memory
Mood & affect
24
Exam for Psychiatric Services
Constitution
Musculoskeletal
Measurement of any 3 of 7 vital signs:
Sitting or standing BP Respiration
Weight
Supine BP
Tempreture
Pulse rate and rgularity Height
General Appearance
Development
Deformities
Nutrition
Attention to Grooming
Body Habitus
Assessment of muscle strength and tone
Cog Wheel
Spastic
Examination of Gait and Statiion
Antalgic
hip extnsor
spastic
ataxic
myopathic
steppage
festinating
paraplegic spastic
stuttering
helicopod
quadriceps
tabetic
waddling
Flaccid
Problem focused – 1-5 elements in red
Expanded problem focused – 6 or more
elements in red
Detailed - 9 or more elements in red
Comprehensive – all elements in red
Psychiatric
Description of Speech
rate
articulation
volume
coherence
spontaneity with notation of abnormalities - eg.
perservation paucity of language
Description of Thought Processes
rate of thoughts
abstract reasoning
computation
content of thoughts eg. Logical, illogical, tangential
Description of Associations
loose
tangential
intact
circumstantial
Description of Abnormal or Psychotic Thoughts
hallucinations
homicidal
delusions
suicidal
obsessions
preoccupation with violence
Description of Client's Judgement and Insight
judgement concerning everyday activities & social
situations
insight eg. Concerning psychiatric condition
Complete Mental Status Examination
orientation to time, place, person
recent and remote memory
attention span and concentration
Language (eg naming objects, repeating phrases)
fund of knowledge (eg, awareness of current events, past
history, vocabulary)
mood and affect (eg, depresion, anxiety, agitation,
hypomania, lability)
25
CMS and APA recognize single organ system examinations. If you
complete other areas of the body during your examination of the
client, your findings must be documented appropriately.
* the constitutional measurements may be completed and
documented by ancillary personnel.
Level of Exam Perform and Document:
Problem Focused - One to five elements identified in red.
Expanded Problem Focused - At least six elements identified in
red.
Detailed - At least nine elements identified by a bullet.
Comprehensive - Perform all elements identified in red;
document every element in each box
26
99211
99212
99213
99214
99215
Minimal
Problem Focused
Exp Problem Focused
Detailed
Comprehensive
Constitution
Measurement of any 2 of 7 vital signs
Sitting or standing BP
Supine BP
Pulse Rate & regularity
Height
Respriations
Ttempreture
Weight
General Appearance
Development
Deformaties
Body Habitus
Attention to grooming
Musculoskeletal
Nutrition
Assessment of Muscle Stength & Tone
Flaccid
Cog Wheel
Spastic
Examination of Gait & Station
Antalgic
Hip Extensor
Spastic
Atxic
Myopathic
Steppage
Festinating
Paraplegic spastic
Stuttering
Helicoped
Quadriceps
Tqabetic
Waddling
Psychiatric
Description of Speech
rate
atriculation
volume
cohearence
Spontaneity with notation of abnormalities - eg. perservation, paucity of language
Description of Thought Process
rate of thoughts
abstracct reasoning
Computation
content of thoughts eg. Logical, illogical tangential
Description of Associations
loose
tangential
Hallicinations
homicdal
obessions
preoccupation with violence
intact
circumstantial
Description of Abnormal or Psychotic Thoughts
delusions
Suicidal
Description of Client's Judgement and Insight
Judgement concerning everyday activities and social situations
Insight eg. Concerning psychiratric condition
Complete Mental Status Examination
Orientation to time, place, person
Recent and remote memory
attention span and concentration
language (eg naming objects, repeating phrases
fund of knowledge (eg awareness of current events, past history, vocabulary)
mood and affect (eg depression, anxiety, agitation, hypomania, lability
Medical Decision Making
27
Complexity of Medical Decision Making
• The levels of E/M services recognize four types of medical decision
making
–
–
–
–
Straightforward
Low complexity
Moderate complexity
High complexity
• Medical decision making refers to the complexity of establishing a
diagnosis and/or selecting a management option as measured by:
– The number of possible diagnoses and/or the number of management
options that must be considered
– The amount and/or complexity of medical records, diagnostic tests,
and other information that must be obtained, reviewed and analyzed
– The risk of significant complications, morbidity, and/or mortality, as
well as co-morbidities, associated with the client’s presenting
problem(s), the diagnostic procedure(s) and/or the possible
management options.
28
• For each encounter, an assessment, clinical impression, or diagnosis should be
documented. It may be explicitly stated or implied in documented decisions regarding
management plans and/or further evaluation.
• For a presenting problem with an established diagnosis the record should reflect
whether the problem is: a) improved, well controlled, resolving or resolved; or, b)
inadequately controlled, worsening, or failing to change as expected
• For a presenting problem without an established diagnosis, the assessment or
clinical impression may be stated in the form of differential diagnoses or as a
"possible", "probable", or "rule out" (R/O) diagnosis.
• The initiation of, or changes in, treatment should be documented. Treatment
includes a wide range of management options including patient instructions, nursing
instructions, therapies, and medications.
• If referrals are made, consultations requested or advice sought, the record should
indicate to whom or where the referral or consultation is made or from whom the
advice is requested
29
Amount and/or Complexity of Data to be Reviewed
•
•
•
•
•
•
If a diagnostic service (test or procedure) is ordered, planned, scheduled, or
performed at the time of the E/M encounter, the type of service, eg, lab or x-ray,
should be documented.
The review of lab, radiology and/or other diagnostic tests should be documented.
A simple notation such as "WBC elevated" or "chest x-ray unremarkable" is
acceptable. Alternatively, the review may be documented by initialing and dating
the report containing the test results.
A decision to obtain old records or decision to obtain additional history from the
family, caretaker or other source to supplement that obtained from the patient
should be documented.
Relevant findings from the review of old records, and/or the receipt of additional
history from the family, caretaker or other source to supplement that obtained
from the patient should be documented. If there is no relevant information
beyond that already obtained, that fact should be documented. A notation of “Old
records reviewed” or “additional history obtained from family” without
elaboration is insufficient.
The results of discussion of laboratory, radiology or other diagnostic tests with the
physician who performed or interpreted the study should be documented.
The direct visualization and independent interpretation of an image, tracing or
specimen previously or subsequently interpreted by another physician should be
documented.
30
31
FOR CALIFORNIA ONLY:
How to handle an E/M (Medication Management)
when psychotherapy is also involved
Even though the E/M services are not based on time,
THE TIME SPENT FACE TO FACE WITH THE CLIENT MUST BE
DOCUMENTED FOR TOTAL TIME TO BE REPORTED TO MEDI-CAL in
addition to the psychotherapy time and documentation and travel
time!
Medi-cal billing = E/M time + Psychotherapy time + Documentation
and travel time
The psychotherapy add-on code is selected on the basis of the time
spent providing psychotherapy and does not include any of the time
spent providing E/M services
32
• Psychotherapy with E/M vs E/M with psychotherapy
2012
2013
Appropriate 99xxx series code plus one of the following:
•
90805, 90817
•
90807, 90819
90836, Psychotherapy 45 minutes when performed
with an E/M
•
90809, 90821
90838, Psychotherapy 60 minutes when performed
with an E/M
90833, Psychotherapy, 30 minutes when performed
with an E/M
33
The psychotherapy add-on code can be billed
with the following E/M codes:
• Outpatient, New Patient
99201 – 99205
• Outpatient, established patient:
99211 – 99215
• Subsequent hospital care
99231 – 99233
34
Psychotherapy
2012
• 90804, 90816
2013
90832, Psychotherapy, 30 minutes
• 90806, 90818
90834, Psychotherapy, 45 minutes
• 90808, 90821
90837, Psychotherapy, 60 minutes
35
Important concepts – CPT time rule
CPT Time Rule
• “A unit of time is attained when the mid-point is
passed”
• “When codes are ranked in sequential typical
times and the actual time is between two typical
times, the code with the typical time closest to
the actual time is used.”
• As an example, codes of 30, 45, and 60 minutes
are billed at 16-37 mins, 38-52 mins, and 53-67
mins.
(CPT 2013, p xii)
36
Important concepts – Add-on code
Add-on Code
• It is a code(s) that describes work that is
performed in addition to the primary service
• It is never reported alone
• Examples include Psychotherapy, Interactive
Complexity and Crisis Services
• You cannot bill 90833, 90836 or 90838
without an E/M service! Use 90832, 90834 or
90837 if no E/M service was performed!
37
Documenting E/M w/Psychotherapy
(and interactive complexity)
• You DO NOT have to write separate notes for the
combination of E/M, Psychotherapy and
interactive complexity!
• You DO have to list each code in your
documentation and time spent on each code.
**remember to include documentation and
travel time.
• You DO have to include all requirements for each
code in your documentation
• You DO have to include any interactive complexity
38
Additional Documentation
Requirements for E/M w/psychotherapy
• In addition to all the requirements for E/M
services, you must also include the following
for psychotherapy:
– Review of counseling/therapy given
– Changes to treatment plan or plan of care
– Other resources used
– Type of interactive complexity
39
EVERY NOTE WRITTEN IN A CHART
MUST INCLUDE
• DATE OF SERVICE
• DATE DOCUMENTATION WRITTEN
• SIGNATURE OF PROVIDER OF
SERVICE
40
INTERACTIVE COMPLEXITY
90785
Use when one of the following communication factors is present during the
visit:
• The need to manage maladaptive communication (related to, e.g., high
anxiety, high reactivity, repeated questions, or disagreement) among
participants that complicates delivery of care.
• 2. Caregiver emotions or behaviors that interfere with implementation of
the treatment plan.
• 3. Evidence or disclosure of a sentinel event and mandated report to a
third party (e.g., abuse or neglect with report to state agency) with
initiation of discussion of the sentinel event and/or report with patient
and other visit participants.
• 4. Use of play equipment, physical devices, interpreter or translator to
overcome barriers to diagnostic or therapeutic interaction with a patient
who is not fluent in the same language or who has not developed or lost
expressive or receptive language skills to use or understand typical
language.
41
DO NOT USE 90785 IF:
• Psychotherapy for crisis (90839, 90840)
• E/M alone, i.e., E/M service not reported in
conjunction with a psychotherapy add-on service
• Family psychotherapy (90846, 90847, 90849)
TYPICAL CLIENTS
• 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
• Require the involvement of other third parties, such as child welfare
agencies, parole or probation officers, or schools.
42
Important concepts – Interactive Complexity
• “Interactive” in previous codes was limited in use
to times when physical aids, translators,
interpreters, and play therapy was used
• “Interactive Complexity” extends the use to
include other factors that complicate the delivery
of a service to a patient. These include:
– Arguing or emotional family members in a session
that interfere with providing the service
– Third party involvement with the patient, including
parents, guardians, courts, schools
– Need for mandatory reporting of a sentinel event
43
Add-on code 90785 to be reported with:
• Diagnostic Evaluations (90791-90992)
• Psychotherapy (90833-90838)
• E/M codes (99201-99255; 9930499377;99341-99350)
• Group Psychotherapy (90853)
• Time spent on Interactive Complexity service
is to be reflected in time of psychotherapy
code reported
• Interactive Complexity service is not a factor
for selecting E/M code except as it affects key
components
44
45
46
PSYCHOTHERAPY WITHOUT
E/M SERVICES
47
48
90832
Both
16-37 minutes of psychotherapy
90834
Both
38-52 minutes of psychotherapy
90837
Both
53 + minutes of psychotherapy
90832 90785 Both
16-37 minutes of psychotherapy
Interactive Complexity
90834 90785 Both
38-52 minutes of psychotherapy
Interactive Complexity
90837 90785 Both
53 + minutes of psychotherapy
Interactive Complexity
90839
Outpt Crisis first 60 minutes
90840
Outpt Crisis each additional 30 miutes
E/M coding can be used if a medical service was also
conducted.
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Individual Psychotherapy used in both Outpatient and
Inpatient Settings:
- Individual Psychotherapy - Individual
psychotherapy, insight oriented, behavior modifying
and/or supportive, 16-37 minutes face-to-face with the
patient
• 90832
• 90834 – Individual Psychotherapy - Individual
psychotherapy, insight oriented, behavior modifying
and/or supportive, 38-52 minutes face-to-face with the
patient
• 90837 – Individual Psychotherapy - Individual
psychotherapy, insight oriented, behavior modifying
and/or supportive, 53 + minutes face-to-face with the
patient
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CHARTING REQUIREMENTS
90832 90834 90837
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Name of Client
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Procedure Code
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Diagnosis Code/Complaints/Emotional Symptoms
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Face-to-face time
16-37 38-52 53+
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Date of service
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History
History of Present Illness
PFSH (Past, Family, Social)
Historical Response to Treatment
Client Appearance
Environmental Attributes
Level of Cognitive Capacity
Disposition/Tendencies
Medical Evaluations/Impressions
Medical Examination/ROS
Medical Tests Review
Progress/Response to Treatment
Interactive activities
Goal/Milestones Met
Interventions required
Review of Counseling/therapy given
Plan of Care/Changes to Plan of Care
Other resources of information
Medications
Effects of Medications
Side-effects experienced
Medication Education Administered
Referrals
Date Documentation Written
Signature of Provider of Service
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Prescribing Psychologists
If medication review and prescription
management happens during a psychotherapy
session, 90863 would be added in addition to
• 90832
• 90834
• 90837
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53
•
90839 Psychotherapy for crisis; first 60 minutes
• +90840 Each additional 30 minutes
Example: 120 min of crisis therapy reported:
90839 x 1
90840 x 2
• Less than 30 minutes reported with codes 90832 or
90833 (psychotherapy 30 min)
• Used to report total duration of face-to-face time with the
patient and/or family providing psychotherapy for crisis
• Time does not have to be continuous
• Provider must devote full attention to patient and
cannot provide services to other patients during time
period.
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Psychotherapy for Crisis Services
Presenting problem typically life-threatening or complex and
requires immediate attention to a patient in high distress
•
Codes include:
• Urgent
assessment and history of crisis state
• Mental status exam
• Disposition
Treatment includes:
• Psychotherapy
• Mobilization of resources to diffuse crisis and restore safety
• Implementation of psychotherapeutic interventions to
minimize potential for psychological trauma
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Codes for crisis services cannot be reported in
combination with:
90791, 90792 (diagnostic services)
• 90832-90838 (psychotherapy)
• 90785 (interactive complexity
•
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Psychiatric diagnostic evaluation - Overview
• A distinction has been made between diagnostic
evaluations without medical services and evaluations
with medical services
• Interactive services are captured using an add-on code
• These codes can be used in any setting
• These codes can be used more than once in those
instances where the patient and other informants are
included in the evaluation
• These codes can be used for reassessments
• Psychiatrists and other medical providers have the
option of using 90792 – Psychiatric Evaluation with
Medical Management (Assessment with Med
Management)
57
Assessments (initial psychiatric
diagnostic procedures)
Two new codes distinguish between an initial
evaluation with medical services provided by a
physician (90792) and an initial evaluation
provided by a non-physician (90791)
Initial Evaluation 90791 includes the following:
• Assessment including history, mental status and
recommendations
• May include communication with family, others,
and review and ordering of diagnostic studies
58
Initial Evaluation 90792 with medical services and
provided by a physician includes those services in
(90791) AND:
• Medical assessment beyond mental status as
appropriate
• May include communication with family,
others, prescription medications, and review
and ordering of laboratory or other diagnostic
studies
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• Psychiatric Diagnostic Codes can be reported
once per day.
• Cannot be reported with an E/M code on same
day by same provider.
• Cannot be reported with psychotherapy
service code on same day.
• May be reported more than once for a patient
when separate diagnostic evaluations are
conducted with the patient and other collaterals
such as family members, guardians, and
significant others.
• Providers must use the patient’s name for
services reported under these codes.
60
Codes that Remain the Same
•
90846 - Family psychotherapy (without the patient present) – (collateral services), which
mean sessions with significant persons in the life of the patient, necessary to serve the
mental health needs of the patient. Could be only one person in this setting as the “family”.
•
90847 - Family psychotherapy (conjoint psychotherapy) (with patient present) (Collateral
Service) Could be only one person in this setting as the “family”.
•
90849 – Multiple-Family Group Psychotherapy - Insight Oriented, Behavior Modifying
and /or Supportive. CPT code 90849 is used when there are multiple family groups and
similar dynamics for clients are being treated. This code is frequently used in hospitals and
drug treatment centers where psychotherapy with several different families takes place over
their issues surrounding hospitalization of the client or the client’s abuse of substances.
Clients may or may not be present, but eh focus must include the clients’ problems, not just
the family members’ problems. The therapist would drop an encounter document for each
client represented in the group.
•
90853 - Group psychotherapy (other than of a multiple-family group) Group Therapy,
which means services designed to provide a goal directed, face–to–face therapeutic
intervention with the patient and one or more other patients who are treated at the
same time, and which focuses on the mental health needs of the patients
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• All DMH coding structures remain the same.
• There will need to be extensive adjustments in
systems and the clinical medical record to
accommodate the federal changes
• THERE WILL BE NOT DELAYS IN
IMPLEMENTATION BY THE FEDERAL
GOVERNMENT!
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QUESTIONS?
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