Expert Explains Updated CPT Codes, How to Estimate E/M, Therapy Time

For 2017, the Centers for Medicare and Medicaid Services (CMS) has made some editorial changes to psychiatric service codes that are important for psychiatrists and other behavioral health  care providers to be aware of. Additionally, there remains confusion about how to determine the time and document psychotherapy add-on services when combined with Evaluation and Management (E/M) services. I’ll address both of these important topics in this article.

Since the adoption of the revised psychotherapy codes in 2013 (90832 to 90838), there has been confusion about the meaning of “patient and/or family member” replacing the previously used “individual psychotherapy” term. With these changes, CMS has been concerned that psychiatrists and other behavioral health care providers aren’t clear about when to bill for individual psychotherapy work with a patient, with the occasional participation by a family member, and when to bill using a family psychotherapy code.

To clarify this, as of 2017, CMS has changed the code description for 90832 to 90838 from “Psychotherapy, __ minutes with patient and/or family member” to “Psychotherapy, __ minutes with patient.” The CPT guidelines go on to note that although the codes “describe psychotherapy for the individual patient, times are for face-to-face services with patient and may include informant(s),” which is a broader interpretation as to who can be present in addition to the patient. CMS has further clarified that to bill for individual psychotherapy (90832 to 90838), the patient must be present for at least a majority of the session.

Also, there is a change to the family psychotherapy codes (90846, 90847), which have never been time-based codes. Starting in 2017, CMS has modified the code to require a time of 50 minutes. However, because of something called the “CPT Time Rule,” which allows for billing a code once half the threshold time has been reached, these codes can be billed once you’ve spent at least 26 minutes with the family. Be sure to start adding the time spent when documenting these codes. On a positive note, CMS clarified that you can bill for both individual psychotherapy and family psychotherapy on the same day as long as the services are separate and distinct.

APA continues to get questions about how to determine the time for the psychotherapy portion of a combined E/M plus psychotherapy service. No one ever expected us to carry stop watches in the sessions, and we were clear when these codes were created that the service is an integrated service. We don’t start and stop psychotherapy distinct from E/M. The combined E/M and psychotherapy work is integrated in the session, and the times are all meant to be approximate. We are expected to first think of the entire time of the visit, then consider how much time was spent performing the E/M work, subtract that from the total time of the session, and if the remaining time was spent in psychotherapy, calculate that time as the psychotherapy time and bill accordingly (90833+ [16-37 minutes]; 90836+ [38-52 minutes]; 90838+ [53+ minutes]).

When doing this, keep in mind the “typical times” for the E/M portion of the work noted after each code description in the CPT manual. Billing a 99214 with a typical time of 25 minutes but repeatedly subtracting only 10 minutes to attribute more time to the psychotherapy portion—because you believe you can do the E/M work much faster than your colleagues—may raise questions in an audit. Any time under 16 minutes of psychotherapy should not be billed as a psychotherapy add on. When documenting the session, remember that the psychotherapy must be “significant and separately identifiable.” Make sure to record the psychotherapy separately in your documentation with the approximate time spent, not mixed in with the E/M documentation. Most payers want to see the time of the psychotherapy portion along with documentation of the modality of psychotherapy utilized, the goals of psychotherapy, and the focus of that session. Be sure to review your Medicare Administrative Contractor’s (MAC’s) Local Coverage Determination (LCD) that specifies your region’s specific requirements. This can usually be found by going to your Medicare Administrative Contractor’s website and typing “psychotherapy” into the LCD search engine and reviewing the section on documentation requirements.

If you have questions, APA members can contact the Practice Management Helpline at [email protected] for assistance. ■