John Femino, MD, FASAM
| December 24, 2012
15 years is a long time – psychiatric and behavioral health services are now being changed by the AMA CPT committee. Brand new codes were created and old frequently used codes were eliminated. These coding revisions were announced in the fall and the changes are supposed to activate for January 1, 2013. Expect that most insurers will implement the codes and not accept the old ones, and so prepare for possible suspensions or denials.
I will briefly review the coding changes and then address the implications and challenges that present to our members. For those of you (the majority of our members) who are not psychiatrists and do not have a behavioral health provider number and profile, these changes will not affect you. For those who employ substance abuse counselors or other mental health professionals in your office, you will be affected as the new codes apply to all behavioral health providers and not just psychiatrists.
The old coding schema was based upon time based psychotherapy services with and without pharmacotherapy. Pharmacotherapy could be billed as a distinct med visit or combined with psychotherapy. The new codes continue time based psychotherapy services with a three time based tiers, but changed the durations from 30, 60 and 90 minutes to 30, 45 and 60 minutes. They maintained the definition of a unit of service as when the mid-point is passed, so that the 30 minute code may range from 16-37 minutes, 45 minute code can be 38-52, and the 60 minute code, anything over 53. Services longer than 60 minutes may add modifier 22, but be aware that modifier codes may result in manual processing, procedural delays and medical record requests for documentation justification.
The major change for 2013 transfers pharmacological services from psychiatric specialty services into the general medical category of evaluation and management codes (E/M codes). The very commonly used “med visit” code (90862) has been eliminated and replaced with use of medical E/M codes [99211-99215. Medical management services combined with psychotherapy will require two codes – the E/M for the med management and an “add on” code for the psychotherapy (90833, 90836 or 90838 for 30, 45 or 60 minutes)]. It is unclear at this time how insurers will process two codes on the same date of services, so it is imperative that each provider check request clarification of coding rules.
A major challenge will be that the new coding schema will require mixing time based and severity based documentation requirements. Time based services require documentation of treatment issues, treatment service duration and modality of treatment provided. E/M codes are much more medically oriented and choice of coding visits depends upon the extent of four domains: comprehensiveness of history and examination, extent of review of system involvement and complexity of medical decision making and risk of complications. Gone are the days of a brief med visit as a standalone code. Gone are the days of making twice as much per hour for multiple med visits with minimal documentation. Documentation for E/M services should be organized in this manner – a major change that could create potential problems in organizing psychotherapy notes into a medical format.
One component that I suspect will be confusing for both providers and insurers is the definition and documentation of time spent for talking therapy. Not all talking services are considered the same – counseling during E/M services involves discussion of such issues as explanation of illness, monitoring of progress, pharmacotherapy and issue of treatment planning and prognosis, etc. Psychotherapy services require documentation of therapy provided to alter course of illness, such as cognitive behavioral, insight oriented therapy, etc. Patient discussion will now need to be split into two documentation formats.
This alone will be challenging, but will be even more complicated by the fact that severity based E/M codes can be converted into time based codes by application of the 50% rule. For example, if less than 50% of the E/M visit was spent counseling the patient, then the documentation of the four domains of severity of problems and complexity of visit are not needed. The E/M codes switches to a time based code ranging from 5 minutes for a limited 99211-99212 codes, to 45 minutes for a 99215. The 50% rule requires documentation in the medical record of the percentage of time spent for counseling and must only include direct face to face time spent.
I have not been able to find any references on the web or on coding sites that has yet given a definitive answer for these overlapping talking therapy issues. Until guidance is provided in more detail, we have to rely upon a few examples within the 2013 AMA coding manual. I recommend that each psychiatric provider call each of their participating insurers and go on their websites for additional information, rather than making assumptions that later are overruled during a retrospective payment audit.
Other changes include new evaluation codes, crisis intervention codes and two categories of add-on codes – for psychotherapy included with the E/M visit as described previously and for interactive complexity (90785). Add-on codes need to be combined with another services including initial evaluation codes, psychotherapy codes, non-family group psychotherapy codes and E/M codes. The psychiatric diagnostic interview (90801) has been replaced by 90791 for new patients without medical evaluation and 90792 with medical evaluation.
So, what advice do I have for our members and myself. First – buy a 2013 AMA CPT book and read the sections yourself, rather than delegating the issue to your billing staff. Next - ask, ask, ask. Then – prepare for the reimbursement schedule. Contact your insurer prior to January 1st, as they are required to make fee schedule changes by this date.
I hope that this overview has been helpful and provides enough information to get going a lively discussion with your staff, your patients and your insurers. Feel free to post comments on the website and contact me directly.