Neurology & Pain Management Coding Alert

Tip: Check the family involvement and duration of the psychotherapy.

While managing a chronic debilitating illness like multiple sclerosis, your physician may engage with the patient and/or family to help improve quality of life for the patient. When psychotherapy is part of the treatment that your neurologist provides, don’t ignore that component when it’s time to code. Here’s expert advice on how to submit the right codes for situations when your neurologist may provide psychotherapy – and get the pay you deserve.

Determine Duration of Psychotherapy

Your first step to success is determining the psychotherapy treatment’s duration. Choose between three codes, depending on how long the session lasted:

·         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).

Be careful: “Each code now has a specific amount of time,” says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, CO. “Providers need to choose the code closest to the actual face-to-face time spent with the patient and/or their family.  The code for the higher amount of time would be reported when the face-to-face time has passed the ‘midpoint.’  For example, if a neurologist spent 40 minutes providing psychotherapy services to a patient, he would bill the 90834 new code.  In order to bill the new 90832 code, there must be a minimum of 16 minutes of psychotherapy services.”

Look for E/M Services

Check the clinical note to verify whether the psychotherapy was done in conjunction with an evaluation and management (E/M) service. If so, you need to again confirm the duration of the psychotherapy before assigning a code:

·         +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).

Note that all options are add-on codes. Report the appropriate one with the applicable E/M code, such as 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …).

“After determining the appropriate E/M level of service, only the time spent in psychotherapy should be used to select the correct new add-on code,” says Hammer. “Providers should not include the time spent in performing the primary E/M service in determining which psychotherapy add-on code to report.”

Example: A new patient presents to your neurologist with spasticity in the lower limbs. The neurologist obtains a detailed history and performs a thorough neurological examination that lasts an hour. He explains to the patient the likely cause of the spasticity and the need for relevant investigations. He also spends around 30 minutes with the patient for psychotherapy to help the patient overcome anxiety about the medical condition. In this case, you report codes 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s] are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family) and +90833 for the psychotherapy. “Time CANNOT be used as a determination of the level of the E/M service when psychotherapy services are also provided,” says Marvel.

Confirm the Family Involvement

Your neurologist might schedule a psychotherapy session to discuss how family interactions can benefit the patient and how the care provided can affect the patient’s course of illness. The patient may or may not be present for the session, which guides your coding.

Depending upon whether the patient was present, you’ll report 90846 (Family psychotherapy [without the patient present]) or 90847 (Family psychotherapy [conjoint psychotherapy] [with patient present]). “It is important it remember that the family psychotherapy codes are not based on the amount of time but rather whether the patient was present or not,” says Hammer. “The family psychotherapy codes should be reported only once for the patient, not for each of the family members in attendance.”

Purpose: A family therapy session is designed to help others understand problems the patient is facing. It also helps involve the family in dealing with and helping improve the patient’s condition by working on interpersonal relationships. Before reporting 90846 or 90847, ensure that the session was held for those purposes, not just to provide an emotional support to the patient. In the latter case, you’ll revert to reporting the individual psychotherapy codes.

Example: Mrs. Thompson has multiple sclerosis. The neurologist arranges a session with her family to discuss how they can help enhance her quality of life through potential social support. If Mrs. Thompson is involved in the discussion, report the family psychotherapy with 90847. If the physician only spoke with her family members, submit 90846 instead. Your physician through psychotherapy attempts to “alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development, “adds Hammer.