Get Accustomed to the Latest in Psychiatric Services

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  • January 1, 2013
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Set your mind to big changes in 2013 CPT® mental health reporting.

Just when you get accustomed to the way things are, they change. Reporting psychiatric services in 2013 is a prime example: Although a few psychiatric services remain unchanged in the new year (mostly the family/group psychotherapy codes and the codes in the “Other Psychiatric Services or Procedures” section), the majority of the psychiatric codes are affected by at least one of the three major changes:

  1. The definition of interactive complexity has been expanded.
  2. Psychotherapy codes have been restructured (no longer location specific).
  3. The medication management code is deleted.

Interactive Complexity Definition Expands

Previously, CPT® defined interactive services as those involving “the use of physical aids and non-verbal communication to overcome barriers to therapeutic interaction between the clinician and a patient who has not yet developed, or has lost, either:

  • The expressive language communication skills to explain his/her symptoms and response to treatment, or
  • The receptive communication skills to understand the clinician
  • If he/she were to use ordinary adult language for communication.”

Interactive services, when applicable, had a separate section of codes and were included in the code description.
For 2013, this definition has been expanded dramatically. The expansion is aimed at capturing all situations involving communication barriers or difficulties with the patient—not just patient-driven communication barriers. Per copyrighted CPT® 2013 guidelines, interactive complexity should now be reported in any of the following situations:

  1. “The need to manage maladaptive communication (related to, eg, high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.
  2. Caregiver emotions or behavior that interferes with the caregiver’s understanding and ability to assist in the implementation of the treatment plan.
  3. Evidence or disclosure of a sentinel event and mandated report to third party (eg, abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.
  4. Use of play equipment, other physical devices, interpreter, or translator to communicate with the patient to overcome barriers to therapeutic or diagnostic interaction between the physician or other qualified health care professional and a patient who:
  • Is not fluent in the same language as the physician or other qualified health care professional, or
  • Has not developed, or has lost, either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the physician or other qualified health care professional if he/she were to use typical language for communication.”

Although interactive services are still considered more complex than non-interactive services, they are reported with an add-on code rather than using a separate, specific code set.
Scenario 1 Non-interactive: Patient presents for individual psychotherapy. Patient attends alone. No barriers to communication exist. Patient is cooperative, understands the treatment plan as discussed, and will return next week as scheduled. The individual psychotherapy code, based on face-to-face time, is all the provider would report (90832 Psychotherapy, 30 minutes with patient and/or family member, 90834 Psychotherapy, 45 minutes with patient and/or family member, or 90837 Psychotherapy, 60 minutes with patient and/or family member).
Scenario 2 Interactive: Patient and mother present for patient’s individual psychotherapy session. Patient is highly agitated, uncooperative, and disagrees with the treatment plan as outlined. Patient’s mother is frustrated with the patient and disagrees with portions of the proposed treatment plan. The provider would report both the individual psychotherapy code (90832, 90834, or 90837 based on face-to-face time) and the interactive complexity add-on code (+90785 Interactive complexity (List separately in addition to the code for primary procedure)).
Psychotherapy Codes Are Restructured
Until this year, you could select the appropriate psychotherapy code if you could answer four simple questions:

  • Was the psychotherapy service an interactive service?
  • Where was the service performed?
  • Did the provider also render evaluation and management (E/M) services during the visit?
  • How long was the psychotherapy service (face-to-face time)?

There was essentially one code for each answer combination, as shown in Figure 1.
Figure 1: 2012 Method
For 2013, this section of the CPT® codebook has been dramatically restructured. The questions you’ll need to answer to code services correctly also have changed because where the service was rendered is no longer a factor.
The following questions must be answered to select the appropriate code(s) when psychotherapy is provided:

  1. Why was psychotherapy rendered? (Was the patient in crisis?)
  2. Was an E/M service also rendered during the visit?
  3. Did the service meet the definition of interactive complexity?
  4. How long was the psychotherapy service (face-to-face time)?

Where there was essentially one possible code choice from any given answer combination prior to 2013, your responses to these new questions may direct you to report one or more CPT® codes, as shown in Figure 2.
Figure 2

Medication Management Code Is Deleted

CPT® 90862 has long been used by physicians for reporting medication management, particularly in the inpatient setting. This code was reported when the provider’s service was just managing the patient’s medications. Usually, these were situations in which the patient was an inpatient and the psychologist was overseeing the majority of the patient’s care. The psychiatrist might have seen the patient every day, but his or her focus was the effect of the patient’s psychiatric medications.
For 2013, 90862 is deleted and instructions are added, directing the provider to instead report an E/M code for the medication management service. This change likely represents the biggest impact on reporting provider services because, historically, most providers’ documentation for medication management is minimal and often does not meet E/M reporting requirements.
What about the new code +90863 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List separately in addition to the code for primary procedure)? It describes medication management performed in addition to psychotherapy services, but may be used only by:

  • Providers who do not have the ability to report E/M services; and
  • Providers who have prescriptive authority in their state.

Louisiana and New Mexico currently are the only states where this code may apply.

Additional Changes

The psychiatric diagnostic evaluation codes also have been revised. Codes 90801 and 90802 were deleted and replaced with 90791 Psychiatric diagnostic evaluation and 90792 Psychiatric diagnostic evaluation with medical services. Rather than being based on interactive vs. non-interactive, these codes now differ on whether medical services were performed during the evaluation.
Interactive group psychotherapy (formerly 90857) no longer has its own code. Now, interactive group psychotherapy is reported with two codes: 90853 Group psychotherapy with +90785.

Overall Impact

The 2013 revisions to the psychiatry section simplify the process of coding. The services are now reported in à la carte fashion. It all depends on what services were provided.
Figure 3 will help you walk through specific scenarios; just ask yourself, “What was rendered?”
Figure 3

Anesthesia and Pain Management CANPC

Chandra Stephenson, CPC, CPC-H, CPMA, CPC-I, CANPC, CEMC, CFPC, CGSC, CIMC, COSC, is a consultant at PwC in Indianapolis, Ind. Chandra has been in health care for 10+ years, with experience in coding, billing, compliance, auditing, and instructing. She is president of the AAPC Central Indiana local chapter.
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