CPT Coding Q&As From Helpline

Q: I am confused about how to determine the coding of a patient encounter when it includes both medical evaluation and management (E/M) services and psychotherapy. I understand that the E/M code is determined by the complexity of the patient’s presentation and the elements of the history, exam, and medical decision making that are required. What I’m having trouble with is how to determine which timed add-on psychotherapy code to use since the E/M work is not a totally separate event, but is something that occurs throughout the session. If the entire encounter is 45 minutes, how do I determine which psychotherapy code to use?

A: While it is understood that some of the E/M work is integrated in the psychotherapy session, under CPT you must estimate the time spent on the E/M and subtract that from the total time to determine the correct psychotherapy code to use. For example, if you have seen a stable patient for a total of 45 minutes and did minimal E/M work, you might code 99212 and 90836. The E/M was of a brief nature, perhaps only five minutes, so you can use 90836, which indicates the psychotherapy lasted between 38 and 52 minutes. If, however, your patient was experiencing some side effects or other medical issues and you needed to provide more in-depth E/M work, you might use a higher level E/M code, such as 99213 or even 99214, depending on the complexity of the history, exam, and medical decision making involved. You might also use the psychotherapy add-on code of 90833, which indicates that between 16 and 35 minutes of psychotherapy occurred, since doing the higher-level E/M work probably took a minimum of 10 minutes.

Q: What CPT code is appropriate for a psychiatrist to bill for the evaluation of a patient in the emergency room (ER) setting? Would the ER E/M CPT codes (99281-99291) be appropriate if the patient was already seen by a clinical social worker and the clinical social worker was billing for the psychiatric evaluation by using 90791? Or, would the psychiatrist be allowed to bill for CPT code 90792 on the same day that the clinical social worker used 90791?

A: Usually the ER codes are billed by the ER physician who sees the patient in the ER. The psychiatrist who sees the patient in the ER is doing so as an outpatient consultation. He/she could use the E/M outpatient consult codes (99241-99245) or 90792, the code for a psychiatric diagnostic evaluation with medical services. If the patient has Medicare, you can’t bill the consult codes; instead, use the new outpatient E/M patient codes, 99201-99205, or 90792.

If a social worker and psychiatrist each did a complete evaluation of a patient, the social worker could bill a 90791 (the code for a psychiatric diagnostic evaluation that does not include a medical component) and the psychiatrist a 90792. Nonetheless, it is likely that many payers would question why it was necessary for both clinicians to do an initial evaluation, and some payers may have a policy against paying for two evaluations on the same day and therefore may not reimburse for both. Sometimes if a social worker bills for a 90791 and a psychiatrist bills using the E/M consult codes (99241-99245), the payer accepts this combination even if it wouldn’t accept the 90791 + 90792 combination. If the patient is admitted to the inpatient psychiatry service and the same psychiatrist cares for him/her, the psychiatrist can use the initial hospital care E/M codes (99221-99225), which would cover both the consult and initial psychiatric evaluation. ■