Coding and Compliance Training
Psychiatrists
Objectives
 Remember the principles of compliance
and their importance to your practice
 Review teaching physician rules
 Assure knowledge to appropriately
document and bill in Psychiatry
School of Medicine Compliance 843-8638
Compliance is important to reimbursement
Providing good care while billing accurately
and confidently requires:
 Providing medically necessary services
 Meeting documentation requirements
 Understanding appropriate billing
Understanding and applying coding and compliance
conventions improves reimbursement and the quality of
the medical record documentation.
School of Medicine Compliance 843-8638
Compliance is important to reimbursement
Good documentation and billing practices make for good
patient care.
Who’s Looking:
 Recovery Audit Contractors (RACS)—Medicare, Medicaid and
commercial insurers pay third party contractors to recoup
inappropriately documented or billed services
 Office of Inspector General (OIG), Health & Human Services—
works with the Department of Justice to investigate suspected
abuse or fraudulent claims
 Routine error rate testing and auditing programs
School of Medicine Compliance 843-8638
Types of Psychiatric Services
 Psychiatric diagnostic evaluation
 Evaluation and Management services (E&Ms)
 Psychotherapy
– Individual
– For crisis
– Group settings
 Procedures/other
School of Medicine Compliance 843-8638
Psychiatric Diagnostic Evaluation with Medical Services
CPT Code 90792
Must include documentation of:
 History
 Mental status
 Indicated physical exam elements
 Recommendations
Also includes, as appropriate:
 Communicating with family or other sources
 Ordering and/or reviewing of diagnostic studies
School of Medicine Compliance 843-8638
Psychiatric Diagnostic Evaluation-CPT Code 90792
 90792 is a comprehensive service used once per evaluation
(even if two sessions are required)
 If reported more than once per episode of illness,
documentation is required to establish medical necessity.
 May not be reported on the same day as an E&M service or
psychotherapy
 In certain, rare circumstances family members, guardians, or
significant others may be seen in lieu of the patient.
School of Medicine Compliance 843-8638
For Interactive Complexity—add code 90785
 Reports additional work due to specific communication factors that
complicate the delivery of a psychiatric procedure
 Interactive complexity
factors are typically present with patients who:
 have individuals legally responsible for their care such as minors or adults
with guardians
 request others to be involved in their care during the visit or
 require the involvement of third parties such as child welfare agencies
 At least one of the following must be present:
 Need to manage maladaptive communication
 Caregiver emotions or behavior that interfere with caregivers assistance in
implementing the treatment plan
 Evidence or disclosure of a sentinel event and mandated report to third party
 Use of play equipment, other physical devices, interpreter or translator for a
patient who
— Is not fluent in the language of the physician
— Hasn’t developed or has lost expressive language skills or receptive
communication skills to understand the provider
School of Medicine Compliance 843-8638
Psychotherapy – for billing purposes
 Defined as the treatment for mental illness and behavioral disturbances
in which the therapist, through definitive therapeutic communication,
attempts to alleviate emotional disturbances, reverse or change
maladaptive patterns of behavior and encourage personality growth
and development.
 Includes ongoing assessment and adjustment of psychotherapeutic
interventions and may include involvement of family member(s) or
others in the treatment process.
 Maintenance psychotherapy is not usually covered.
Well-documented
sessions for helping a patient maintain his/her highest level of
functioning, such as a patient with borderline personality disorder, may
be covered on a case-by case basis.
School of Medicine Compliance 843-8638
Documentation of Psychotherapy Services
The note for each encounter must include:
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The amount of time spent in psychotherapy,
The therapeutic maneuvers employed during the session such as
behavior modification, supportive, or interpretive interactions and
The purpose of the psychotherapy
Additionally, a periodic summary of goals, progress towards
goals, and an updated treatment plan must be included in the
medical record
School of Medicine Compliance 843-8638
Psychotherapy Services
 Psychotherapy without medical evaluation and
management services:
 90832 (16-37 minutes)
 90834 (38-52 minutes)
 90837 (53 or more minutes)
 Psychotherapy time may include face to face time with
family members as long as the patient is present for part of
the service.
 Do not bill psychotherapy codes for sessions less than 16
minutes duration.
 Interactive complexity is reported by also billing 90785
School of Medicine Compliance 843-8638
E&M with Additional Psychotherapy Services
Psychotherapy with evaluation and management services
are reported with an E&M service and a psychotherapy
add-on code:
 90833 (16-37 minutes)
 90836 (38-52 minutes)
 90838 (53 or more minutes)
If less than 16 minutes, no psychotherapy is billable.
School of Medicine Compliance 843-8638
E&M service with Psychotherapy
 Requires differentiating E&M history gathering, physical
exam and decision making from psychotherapy
 The time spent in psychotherapy must be documented
separately from the E&M service.
 Example documentation:
“The patient was seen for a total of 50 minutes. 25 Minutes
was spent in psychotherapy. The psychotherapy was
supportive in nature with the goal of continuing remission of
the patient’s depressive symptoms and to help the patient in
coping with his cognitive deficits.“
School of Medicine Compliance 843-8638
E&M service with Psychotherapy
 The E&M level is chosen before the amount of time spent
in psychotherapy.
 Psychotherapy inherently includes some ongoing
assessment
 An E&M service with psychotherapy may not be billed
based on time counseling.
 Prolonged services may not be reported with an E&M and
psychotherapy.
 The OIG is actively reviewing E&Ms with psychotherapy for
appropriate documentation
School of Medicine Compliance 843-8638
E&M service with Psychotherapy
 In most cases, the level of E&M service when billed with a
psychotherapy add-on is expected to be a lower level than
an E&M service without psychotherapy because
 the frequency of evaluation of the patient when psychotherapy is
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part of the treatment plan
psychotherapy includes ongoing assessment that may not be also
billed as E&M services
 Benchmark data from academic psychiatrists compiled by
the Association of American Medical Colleges shows over
50% are billed at 99213 when psychotherapy is also
performed:
99211
99212
99213
99214
99215
2.1%
17.6%
54.4%
24.9%
0.9%
School of Medicine Compliance 843-8638
Billing Psychotherapy with an E&M service
School of Medicine Compliance 843-8638
Choosing the Correct Outpatient Category
Outpatient E&M Categories
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•
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School of Medicine Compliance 843-8638
Consultation
New
Established
Use of Consultation Codes
 Outpatient Consult Codes: 99241-99245
 Use when expert opinion or advice is requested by an
appropriate source involved in patient’s care
 Does not include patients “referred for management of a
condition” or self referred
 Use outpatient consultation codes only one time per request,
subsequent visits are established
 Written or verbal request must be documented in the
rendering providers note and the consultant's opinion
communicated by written report to the requesting provider.
School of Medicine Compliance 843-8638
Documenting Consultations
Documentation of a consultation request must be clearly
stated in the note:
WRONG: Mr. Patient referred by Dr. Jones for
management of GERD symptoms.
RIGHT: “Mr. Patient is seen in consultation at the request
of Dr. Jones for evaluation of abdominal pain.”
School of Medicine Compliance 843-8638
New Patient
 New Patient CPT codes: 99201-99205
 Has not received any professional evaluation and
management (E&M) services from the physician or
another physician of the same specialty who belongs
to the same group practice within the past three
years, including inpatient, outpatient or emergency
room.
 A patient would still be considered “new” if a
diagnostic procedure was billed without an E&M visit
charge.
School of Medicine Compliance 843-8638
Established Patient
 Established Patient CPT codes: 99212-99215
 Has received an E&M service from the division
within the past three years—any venue inpatient,
emergency room or consultations
School of Medicine Compliance 843-8638
Visit Components
Consults and new patient visits must include all three of the
following components – established patient visits must include
any two of the three:
 History
Click these links for more information
– History of present illness
– Review of systems
– Past family and social history
 Physical examination
 Medical decision Making
– Diagnosis and management options
– Amount and complexity of data reviewed
– Overall risk
School of Medicine Compliance 843-8638
Documenting History
History example
1995 Physical Exam
1997 Single Organ Exams
Documenting MDM
Risk Table
Psychotherapy for crisis
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Psychotherapy for crisis is an urgent assessment and history of a
crisis state, a mental status exam and a disposition.
The treatment includes psychotherapy, mobilization of resources to
defuse the crisis and restore safety, and implementation of
psychotherapeutic interventions to minimize the potential for
psychological trauma.
The presenting problem is typically life threatening or complex and
requires immediate attention to a patient in high distress.
Report the total duration of time face to face with the patient and/or
with the family.
The patient must be present for at least some portion of the service.
School of Medicine Compliance 843-8638
Psychotherapy for crisis
 90839 is billed for the first 60 minutes
 Add 90840 for each additional 30 minutes after
the initial hour
 Psychotherapy for crisis of less than 30 minutes
is reported with standard psychotherapy codes
School of Medicine Compliance 843-8638
Other Psychotherapy Services
The following services are not time-based:
 Family psychotherapy - medically necessary treatment of the family
unit when maladaptive behaviors of family members are exacerbating the
patient’s illness in the treatment process.
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90846 without the patient present
90847 patient and family
90849 multiple family group psychotherapy
 90853 Group psychotherapy - personal and group dynamics are
discussed, allowing emotional catharsis, instruction, insight and support
 90845 Psychoanalysis (not reimbursed by most insurers)
School of Medicine Compliance 843-8638
Psychotherapy services
Psychotherapy is not covered if:
 Documentation indicates that dementia has caused
significant cognitive deficiency to prohibit establishing a
therapeutic relationship.
 Patient suffers from profound mental retardation.
School of Medicine Compliance 843-8638
Central Nervous System Assessments
Clinical Psychologists may bill:
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96101 – Psychological testing (includes assessment of
emotionality, intellectual abilities, personality and psychopathology,
eg MMPI, Rorschach, WAIS)
96116 – Neurobehavioral status exam (clinical assessment of
thinking, reasoning and judgment, eg acquired knowledge,
attention, language, memory, planning and problem solving and
visual spatial abilities.
96118 – Neuropsychological testing (eg Halstead-Reitan
Neuropsychological Battery, Wechsler Memory Scales and
Wisconsin Card Sorting Test)
96125 – Standardized cognitive performance testing (eg Ross
Information Processing Assessment)
School of Medicine Compliance 843-8638
Central Nervous System Assessments
 It is expected that the administration of these tests
will generate material that will be formulated into a
report.
 A minimum of 31 minutes must be provided to
report any of the testing “per hour” codes
(psychologist’s or physician’s time)
 Bill both time spent face-to-face with the patient and
interpreting and preparing the report
 Bill the quantity of hours spent
School of Medicine Compliance 843-8638
Medicare’s Teaching Physician (TP) Attestation Requirement
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The teaching physician (TP) does not have to duplicate any resident
documentation.
The TP must be present during performance of the resident’s key
portions of the service or personally repeat the key portions
The TP must personally document his or her presence for E&M
services.
Documentation by a resident of the presence and participation of
the TP is not sufficient.
The resident note alone, the TP note alone or a combination of the
two may be used to support the level of service billed.
Documentation may be dictated and typed, or a computer-inserted
statement if it is initiated by the TP.
School of Medicine Compliance 843-8638
Medicare’s Examples of Unacceptable TP notes
1. "Agree with above." followed by legible countersignature or
identity;
2. "Rounded, Reviewed, Agree." followed by legible countersignature
or identity;
3. "Discussed with resident. Agree." followed by legible
countersignature or identity;
4. "Seen and agree." followed by legible countersignature or identity;
5. "Patient seen and evaluated." followed by legible countersignature
or identity; and
6. A legible countersignature or identity alone.
The preceding six and similar statements don’t make it possible
to determine whether the TP was present, evaluated the patient,
and/or had any involvement with the plan of care.
School of Medicine Compliance 843-8638
Medicare Guidelines for Supervision of Psychotherapy
• The TP presence requirement met by concurrent
observation of the service by video or one-way mirror.
• Must be present for entire period of time billed if
psychotherapy code is used.
School of Medicine Compliance 843-8638
Medicaid Requirements
Medicaid requires that the TP be "immediately available" to the
resident and patient and use "direct supervision". Direct supervision
does not necessarily mean that the TP must be present in the room
when the service is performed. The degree of supervision is the
responsibility of the TP and is based on the skill, level of training and
experience of the resident as well as the complexity and severity of
the patient's condition. Written documentation in the medical
record for Medicaid patients must clearly designate the supervising
physician and be signed by that physician.
School of Medicine Compliance 843-8638
Where To Get Help
• http://www.med.unc.edu/compliance
• School of Medicine Compliance Office 919-843-8638
 Heather Scott, CPC, SOM Compliance Officer
 Dana Petty, CPC, SOM Compliance Review Analyst
 Nirmal Gulati, MS, CPC, SOM Compliance Auditor
 Tracy Riggs, FNP, SOM Compliance Consultant
School of Medicine Compliance 843-8638