Renew Your Understanding of Psychiatric Services

Proper documentation for restructured psychotherapy CPT® codes in 2013 is key.

By Lynn Handy, LPN, CPC, CPC-H, CPC-I, CHC, CCS-P

It’s well into 2013, and you’ve been using the restructured psychotherapy codes (90832-90837) for some time. Now is a perfect time to review the new requirements for reporting these services. Are your physicians documenting their services appropriately to ensure proper reimbursement? Let’s see.

Don’t Worry About Where, Just When

Evaluation and Management – CEMC

For individual psychotherapy, there are no longer separate codes for inpatient and outpatient settings. These psychotherapy services are face-to-face services with the patient (and/or family member, with the patient present for some or all of the service), described by the following CPT® codes:

90832    Psychotherapy, 30 minutes with patient and/or family member

90834    Psychotherapy, 45 minutes with patient and/or family member

90837    Psychotherapy, 60 minutes with patient and/or family member

The specific time assigned to a code may differ from the actual time the practitioner provided psychotherapy. In general, select the code that most closely matches the actual time spent. CPT® provides flexibility by identifying time ranges that may be associated with each of the three codes:

90832: 16 to 37 minutes

90834: 38 to 52 minutes

90837: 53 minutes or longer

Do not bill psychotherapy codes for sessions lasting less than 16 minutes.

When psychotherapy and an evaluation and management (E/M) service are performed during the same encounter, you should instead report the appropriate add-on code in addition to the E/M service code. The add-on codes are:

+90833 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

+90836 Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

+90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

 Coding E/M services by time is a common option for psychiatric providers, but should not be confused with psychotherapy time. Most E/M services may be billed by time if over 50 percent of the total time is spent counseling the patient and family and/or coordinating care. It’s important to note, however, that if the new psychotherapy add-on codes are reported with an E/M service, the E/M level cannot be selected based on time.

Not All Services Are Billable Time

The time spent arranging for services, providing reports, and communicating with other healthcare professionals is not included in the length of the psychotherapy session. Such activity is considered post-service work, and is already “built into” the psychotherapy codes. This is not new for 2013; these activities were considered post-service work under the psychotherapy codes effective in 2012.

Minimum Documentation Guidelines

For claims payment of psychotherapy services, providers must document at a minimum:

  • Date of service
  • Time spent with the patient (length of session)
  • Specific therapeutic maneuvers used (e.g., cognitive restructuring, behavior modification) to produce therapeutic change
  • Clearly documented diagnosis: for each visit and related to treatment and therapy
  • Periodic summary of goals, progress toward goals, and an updated treatment plan
  • Progress or lack of progress toward the goals stipulated in the individual treatment plan
  • Legible provider signature

E/M: No Longer Optional

Prior to 2013, when a medical evaluation was performed at the time of the psychotherapy, the E/M service was included in the psychotherapy service (that is, the E/M was not separately reported). With the introduction of 90832-90837, when an E/M service represents a portion of the work performed at the encounter, the E/M visit becomes the primary CPT® code reported. This requires the provider to determine the appropriate E/M code category and level of service rendered, as supported by documentation, in addition to the elements described above for psychotherapy.

Because this concept may be less familiar to mental health professionals and their coders, let’s explore the documentation requirements for E/M services as it pertains to psychiatric services. Although both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services are an option, let’s focus on the 1997 guidelines using the psychiatric single organ system exam.


There are a few challenges when trying to document the history requirements for psychiatric services. The history of present illness (HPI) is a subjective description of findings from the patient and should not be confused with the psychiatric exam elements.

Four HPI elements are required for a detailed and comprehensive history. Anything less would lower the history element to either problem-focused or expanded problem-focused. HPI must be documented by the provider (not the nursing or support staff) and would resemble something similar to this:

The patient complains of severe depression for the past 3 months with a lack of appetite, inability to stay focused at work, and frequent headaches. She has been taking Zoloft for the past 2 months with no improvement.

The example statement provides at least four HPI elements: severity, duration, associated signs and symptoms, and modifying factors.

The review of systems (ROS) require a minimum of 10 systems for a comprehensive history, but only two systems are required for a detailed history that will support 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity, or 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity (level III new patient or level IV established patient).

Don’t forget: Patient history forms are a great timesaver and typically include all systems and an inventory of the patient’s past, family, and social history (PFSH). To allow credit for the information included on the patient history form, the provider must document his or her review of the information. Table A is a snapshot of the history documentation requirements.

Table A: A chief complaint is required for all history levels.

History Level HPI ROS PFSH
Problem Focused 1 None None
Expanded Problem Focused 1 1 None
Detailed 4 2-9 1
Comprehensive 4 10 2 or 3

Exam: Psychiatric Single Organ System (1997 Guidelines)

Although you may use the 1995 or 1997 guidelines to determine the level of the E/M service documented, the examination many mental health providers perform resembles the psychiatric examination in the 1997 guidelines. Choose the guidelines that are most advantageous to the provider, which may differ from encounter to encounter.

Just remember: If the 1997 examination is used to score the exam portion of the visit, the remainder of the visit must also be scored using the 1997 guidelines. Likewise, if the 1995 guidelines are used, they must be used for the entire visit note.

See Table B for the number of elements required for each level of the 1997 psychiatric specialty examination.

Table B: The number of elements required for each level of the 1997 psychiatric exam.

Exam Level Elements
Problem Focused 1-5 elements
Expanded Problem Focused At least 6 elements
Detailed At least 9 elements
Comprehensive All elements from constitutional and psychiatric exam and one element from musculoskeletal

The elements of the “Documentation-psychiatric Exam 1997 Documentation Guidelines” include:


Measurement of any three of the following seven vital signs:

  • Sitting or standing blood pressure
  • Supine blood pressure
  • Pulse rate and regularity
  • Respiration
  • Temperature
  • Height
  • Weight (may be measured and recorded by ancillary staff)
  • General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)


  • Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic), with notation of any atrophy and abnormal movements
  • Examination of gait and station


  • Description of speech, including: rate, volume, articulation, coherence, and spontaneity with notation of abnormalities (e.g., perseveration, paucity of language)
  • Description of thought processes, including: rate of thoughts, content of thoughts (e.g., logical vs. illogical, tangential), abstract reasoning, and computation
  • Description of associations (e.g., loose, tangential, circumstantial, intact)
  • Description of abnormal or psychotic thoughts, including: hallucinations, delusions, preoccupation with violence, homicidal or suicidal ideation, and obsessions
  • Description of the patient’s judgment (e.g., concerning everyday activities and social situations) and insight (e.g., concerning psychiatric condition)
  • Complete mental status examination including:
    • Orientation to time, place, and person
    • Recent and remote memory
    • Attention span and concentration
    • Language (e.g., naming objects, repeating phrases)
    • Fund of knowledge
    • Mood and affect

Medical Decision-making

Many articles have been written about the importance of medical decision-making (MDM) and the nature of the presenting problem as a driving factor when choosing the level of E/M services. With the increased use of electronic health record systems, the history and exam can become over-documented and may not align with the level of service and medically necessary information to accurately assess the presenting problem. As a result, the industry is seeing more medical necessity reviews initiated by the Centers for Medicare & Medicaid Services (CMS) and other payers.

The three elements of MDM are:

  • Number of diagnosis/management options
  • Amount of data reviewed/ordered
  • Patient risk

For example: An established patient is seen for medication management by a psychiatrist with a history of anxiety disorder, depression, and attention-deficit/hyperactivity disorder (ADHD). The patient states he is doing well on the present medication with no episodes of anxiety or depression. The patient also states he is able to focus and complete tasks at work, and feels that the Ritalin dosage is working. The psychiatrist performs a detailed psychiatric exam. He determines the patient’s three chronic conditions are stable, and refills all medications. This encounter supports 99214 (level IV established patient office visit) because the MDM is moderate, with three stable established conditions, and moderate risk (medication management).

Knowledge Is a Powerful Anecdote

The introduction of new psychotherapy CPT® codes and methodology for reporting therapy services as of Jan. 1, 2013 require a renewed understanding of the documentation required for selecting an E/M CPT® code. Over-coding the E/M portion of the service when rendered and not documenting appropriately may lead to increased risk while under-documenting the E/M portion would result in lost revenue. Providers and coders who do not fully understand these requirements should seek additional education to remain compliant when reporting services.



Lynn Handy, LPN, CPC, CPC-H, CPC-I, CHC, CCS-P, speaks at various national coding, compliance, and auditing associations. Handy is the senior director of professional coding services at Sinaiko Healthcare, a division of Altegra Health.

Latest posts by admin aapc (see all)

Leave a Reply

Your email address will not be published. Required fields are marked *