Psychiatry
Coding, Billing and Documentation Guidelines

Course Learning Objectives

 

This training serves as an educational purpose for psychiatrists and other healthcare providers to properly document, code and bill for mental health services.

Length of Course

The length of this course is approximately 35 minutes.

Contact Information

For questions regarding this course or any other coding, documentation and/or billing compliance issues, please contact the Office of Billing Compliance at (305) 243-5842 or our Help Line (305) 243-HELP (4357), 1-877-415-HELP (4357).

  

Medicare Rule for Teaching Physicians

PSYCHIATRY SERVICES

For Psychiatry Programs, the requirements for the presence of the Teaching Physician during the service may be met by concurrent observation of the service by use of a one-way mirror or video equipment.

Audio-only equipment does not meet this exception.

NOTE: The Teaching Physician supervising the residents must be a physician (i.e., the Medicare Rule for Teaching Physician policy does not apply to psychologists who supervise psychiatry residents in approved programs).

 

Medicare Rule for Teaching Physicians, Continued

TIME-BASED CODES

For procedure codes determined on the basis of time, The Teaching Physician must be physically present for the time period for which the claim is made.  The time spent by the resident, in the absence of the Teaching Physician, should not be included in determining what level to bill a time-based code.

The following procedure codes falling into this category are:     

The time spent by the physician providing Psychotherapy and/or Psychological Testing to the patient, must be documented in the medical record.

Psychiatric Diagnostic Interview Examination

PROCEDURE CODE: 90801

The Psychiatric Diagnostic Interview Examination is considered to be medically necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior patterns or maladaptive functioning in personal or social settings, which may be suggestive of a psychiatric illness.

This examination may also be medically necessary when baseline functioning is altered by suspected illness or symptoms.

The Psychiatric Diagnostic Interview Examination is not considered to be medically necessary when:

  1. It is rendered to a patient who has a medical/neurological condition such as dementia, delirium or other psychiatric conditions, which have produced, a severe enough cognitive defect to prevent effective communication and the ability to assess the patient
  2. A request for second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurologic processes.
  3. Routine performance of additional Psychiatric Diagnostic Interview Examinations to patients with chronic conditions.

 

Psychiatric Diagnostic Interview Examination, Continued

psychiatry.jpg A Psychiatric Diagnostic Interview Examination can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient

An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for a psychiatric condition.

 

Psychiatric Diagnostic Interview Examination, Continued

Billing Guidelines

An Evaluation and Management (E&M) service may be substituted for an initial Psychiatric Diagnostic Interview Examination provided that the required elements of the E&M service (History, Examination and Medical Decision Making (Plan of Care) were performed and are clearly documented in the patient's medical record.

 

Psychiatric Diagnostic Interview Examination, Continued

Documentation Requirements

The documentation maintained by the provider in the patient's medical record, must indicate the medical necessity of the Psychiatric Diagnostic Interview Examination.

The presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms which may be suggestive of a psychiatric illness or are sufficient to significantly alter baseline functioning and the diagnostic interview examination report which includes:

In circumstances where other persons (family or other sources) are interviewed in lieu of the patient, documentation must include the elements outlined previously, as well as the specific reason(s) for not interviewing the patient. Any notations where family members provide patient information should be included.

 

Individual Psychotherapy

PROCEDURE CODES: 90804-90909, 90816-90819, 90821-90822

Individual Psychotherapy is considered medically necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning.

Individual Psychotherapy services are not considered to be medically necessary when they are rendered to a patient who has:

In these cases, Evaluation and Management (E&M) or Pharmacologic Management codes should be used.

Individual Psychotherapy, Continued

In addition, Psychotherapy services are not considered to be medically reasonable and necessary when they include:Dancing.jpg

Psychotherapy sessions of approximately 75 to 80 minutes (90808-90809, 90821-90822) should not be routinely used and should be reserved for exceptional circumstances.

NOTE: Psychotherapy services must be performed by a person licensed by the State of Florida and whose training and scope of practice allows that individual to perform such services.

 

 

Individual Psychotherapy, Continued

The following are the procedure (CPT) codes that should be used when billing Individual Psychotherapy with or without Evaluation and Management services:

90804

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient;

90805

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face; with Medical Evaluation and Management services

90806

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient;

90807

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face; with Medical Evaluation and Management services

90808

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient;

90809

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face; with Medical Evaluation and Management services

90816

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient;

90817

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face; with Medical Evaluation and Management services

90818

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient;

90819

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face; with Medical Evaluation and Management services

90821

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient;

90822

Individual Psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face; with Medical Evaluation and Management services

  

Individual Psychotherapy, Continued

The following are the Diagnosis (ICD-9) Codes that support medical necessity:

290.0 - 299.91 Senile Dementia Uncomplicated - Unspecified Pervasive Developmental Disorder, Residual State
300.00 - 316 Anxiety State unspecified - Psychic Factors associated with Diseases Classified Elsewhere
317 Mild Mental Retardation
318.0 - 318.2 Moderate Mental Retardation - Profound Mental Retardation
331.0 Alzheimer's Disease

Billing Guidelines

 

Individual Psychotherapy, Continued

Documentation Requirements

Providers must documentation the medical necessity of each psychotherapy session in the patient's medical record.

Documentation must include the following:

1. assessment of patient's problems

2. examples of behavior modification

3. supportive interaction

4. discussion of reality

5. degree of patient participation and interaction with the therapist

6. reaction of the patient to the therapy session

7. goal oriented outcomes and changes or lack of changes in patient symptoms and/or behavior as a result of the psychotherapy session

 

Individual Psychotherapy, Continued 

Documentation Requirements, Continued

For a patient with profound mental retardation (ICD-9 318.2), additional documentation must be kept in the medical record showing the following:

For Acute Problems, documentation should indicate that the treatment is expected to improve the mental health status or function of the patient.

For Chronic Problems, documentation should indicate that stabilization of mental health status or function is expected.

Treatment plans for patients receiving outpatient psychotherapy services need to be updated at least every three (3) months.

NOTE: In the event that Psychotherapy sessions (codes 90808-90809, 90821-90822) of approximately 75-80 minutes are performed, providers must document the medical necessity and define the exceptional circumstances for providing these services in the patient's medical record.

Family Psychotherapy

PROCEDURE CODES: 90846-90847 

Family Psychotherapy (90846-90847 and 90849) is considered medically necessary only in clinically appropriate circumstances and when the primary purpose of such Psychotherapy is the treatment/management of the patient's condition.

Family Psychotherapy would be appropriate under the following circumstances:

  1. When there is a need to observe and correct the patient's interaction with family members, through psychotherapeutic techniques.
  2. When there is a need to assess the conflicts or impediments within the family and assist through psychotherapeutic techniques, the family members in the management of the patient.
  3. When the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning.

 

Family Psychotherapy, Continued

Family Psychotherapy would not be considered medically necessary for certain medical conditions, such as a patient who is unconscious, comatose or:

Family Psychotherapy must be ordered by a provider as an integral part of an active treatment plan that is directly related to the patient's condition/diagnosis.

Family Psychotherapy may occur with or without the patient present.

 

Family Psychotherapy, Continued

The following are the Diagnosis (ICD-9) Codes that support medical necessity:

290.0 - 299.91 Senile Dementia Uncomplicated - Unspecified Pervasive Developmental Disorder, Residual State
300.00 - 316 Anxiety State unspecified - Psychic Factors associated with Diseases Classified Elsewhere
317 Mild Mental Retardation
318.0 - 318.2 Moderate Mental Retardation - Profound Mental Retardation
331.0 Alzheimer's Disease

 

Family Psychotherapy, Continued

Billing Guidelines

 

Family Psychotherapy, Continued

Documentation Requirements

The documentation in the patient's medical record must indicate the medical necessity of each Family Psychotherapy session and include the following:

 

Family Psychotherapy, Continued

Documentation Requirements, Continued

For patients with profound mental retardation (ICD-9 318.2), additional documentation must be kept in the medical record that demonstrates the patient's ability to effectively communicate with the physician, family members and interact with sufficient quality while improving or alleviating the emotional disturbances, reverse or change maladaptive patterns of behavior and be taught coping mechanisms for loss acceptance if indicated.

For Acute Problems, documentation should indicate that the treatment is expected to improve the mental health status or function of the patient.

For Chronic Problems, documentation should indicate that stabilization of mental health status or function as expected.

The rationale for any departure from the plan or extension of therapy should be documented in the medical record. Treatment plan for the patient receiving Family Psychotherapy needs to be updated at least every three (3) months.

 

Psych.jpg

 

Pharmacologic Management

PROCEDURE CODE: 90862

Pharmacologic Management includes the prescription, monitoring and review of medication with minimal psychotherapy (a form of psychotherapy in which consistency, support from others and a hopeful attitude are used to contain and sustain the patient through crisis periods, and encourage small gains over time).

Pharmacologic Management is limited to physicians only.

Generally, it is expected that more frequent Pharmacologic Management services may be necessary at the inception of new medication treatment or when the physician needs to adjust the dosage, deals with issues of toxicity and side effects, or medication effectiveness, etc.

As patients become chronic, long-term users of a specific medication, the frequency of Pharmacologic Management services is normally expected to decrease.

BILLING GUIDELINES

Pharmacologic Management and Individual Psychotherapy or Group Psychotherapy services, should not be billed on the same day by the same physician.

 

 

Pharmacologic Management, Continued

Documentation Requirements

The physician must document, in the patient's medical record, the following:

Code 90862 is not intended to refer to a brief evaluation of the patient's state or simple dosage adjustment of long-term medication. This code refers to the in-depth management of psychopharmacologic agents, which are potent medications with frequent serious side effects and it represents a very skilled aspect of patient care.

 

Pharmacologic Management, Continued

Procedure Code: M0064 (Medicare Only)

Brief office visit for the sole purpose of monitoring or changing the drugs used in the treatment of mental, psychoneurotic and personality disorders. It does not include psychotherapy, since the provider is addressing medication management only.

Documentation Requirements

The documentation in the patient's medical record must include:

  

Clinical Psychologists (CPs)

Clinical Psychologists (CPs) services are covered when performed in accordance with Florida State Laws.

Qualifications

Clinical Psychologists (CPs) must meet the following requirements:

Billing Guidelines

Clinical Psychologists (CPs) - (Medicare)

 

Clinical Social Workers (LCSWs)

Licensed Clinical Social Workers (LCSWs) services are covered when performed in accordance with Florida State Laws.

Qualifications

Licensed Clinical Social Workers (LCSWs) must meet the following requirements:

Billing Guidelines:

Licensed Clinical Social Workers (LCSWs) - (Medicare)

 

Clinical Social Workers (LCSWs), Continued

Billing Guidelines, Continued

LCSWs are not allowed to bill for the following services:

- Evaluation and Management (E&M) Services

- Cognitive Development (97532, 97533)

- Psychological Testing (96101, 96102, 96103)

- Biofeedback ( 90875 and 90876)

- Neuropsychological Services (96105 - 96116, 96118-96120) and

- Psychotherapy Services to inpatients of a hospital or partial hospitalization program

 

Psychological Tests 

PROCEDURE CODES: 96101, 96105, 96110, 96111, 96116, 96118

Psychological Tests are considered medically necessary when they meet the following requirements:

Re-evaluation is covered only if the patient exhibited a change in functional speech or motivation, clearing of confusion, or the remission of some other medical condition which previously contraindicated speech pathology or for those conditions which are assumed to result in interval changes in language.

  

Psychological Tests, Continued

Developmental and Cognitive Tests

Developmental testing (96110, 96111) and Cognitive testing (96116, 96118) by a physician or psychologist with interpretation and report per hour, are limited to the following conditions/situations:

Re-evaluation is covered if the treatment plan has been in effect and the re-evaluation will affect further treatment plans.

 

Psychological Tests, Continued

Neuropsychological Tests

Neuropsychological Testing Battery (96118) is intended to diagnose the neuro-cognitive effects of medical disorders that impose directly or indirectly on the brain.

Examples of problems which might lead to neuropsychological testing are:

 

Psychological Tests, Continued

Psychological Tests are not considered medically necessary if:

Repeat psychological or psychiatric evaluations can be accomplished through the clinical interview alone.

 

Psychological Tests, Continued

Billing Guidelines

Psychological Tests, Continued

Documentation Requirements

The documentation in the patient's medical record should include:

As well as:

If the resident/fellow dictates the report, the Attending Physician must document " I personally reviewed the film/recording and the resident's findings, and agree with the final report", before signing the report.

 

Final Assessment

In order to record your answer, you must select the Check Answer button after making your selection. You must answer all questions or your score will not be recorded.

  

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