Part B Insider (Multispecialty) Coding Alert

Published on Fri Apr 18, 2014 PDF

Replace Outpatient E/M codes with a single G code for Medicare PHP claims.

According to the latest Comprehensive Error Rate Testing (CERT) results, improper documentation of time has been leading to overpayments, especially for claims involving psychotherapy with E/M codes.

The report released in an MLN Matters article dated March 18th revealed that “the main error that CERT has identified with the revised psychiatry and psychotherapy codes is not clearly documenting the amount of time spent only on psychotherapy services.”

The problem area: The article identifies that many coders have not been documenting time spent on “psychotherapy services” alone and are providing the time spent by the clinician on the entire session that includes the psychotherapy and the evaluation and management of the patient. Since time spent on the E/M service should not be added to the time spent for psychotherapy, this is generating improper payments for the psychotherapy service.

Example: If your clinician is performing a psychotherapy session for 35 minutes and performs an evaluation and management of the patient for an additional 10 minutes, you’ll be wrong if you document the time as simply 45 minutes. If you do this, you may end up claiming for +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]) along with an E/M code, when actually, you need to be sending in your claim for +90833 (…30 minutes…) with the appropriate E/M code.

“As noted below, even though the psychotherapy lasted 35 minutes, you will report the 30-minute code, +90833,” points out Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Code +90833 actually represents a range of psychotherapy time from 16 to 37 minutes,” adds Moore. 

Action plan: If you need to avoid scrutiny for overpayments, you will need to look into patient documentation to check the exact amount of time your clinician is spending on providing the psychotherapy service versus the E/M service.

If your clinician is not differentiating the time spent on psychotherapy and the E/M service and providing these details in the patient documentation, you will need to inform your clinician that this is necessary in order to enable correct coding and payment for both the services.

So, in the example described above, you will need to document time for psychotherapy as “35 minutes” and send in a claim for +90833 along with the appropriate E/M code. Even though time spent in E/M is not used to determine the level of the E/M code you will select in this example, you may still want to document the time spent in the evaluation and management, so the payer will be able to differentiate the amount of time your clinician spent in providing the psychotherapy service and the amount of time he spent on the evaluation, if the claim is audited. 

Understand Time Rules for Correct Code Determination

On the basis of time spent by your psychiatrist in providing psychotherapy, you’ll report one of the following CPT® add-on codes when an E/M service is performed in the same session:

• +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…
• +90838 –Psychotherapy, 60 minutes…

Even though the descriptor to these codes describes specific time spent during the session, you’ll have to use the CPT® time rules that provide time ranges that you can use for each of these above mentioned codes. These time ranges will help you determine exactly which of the three codes you’ll use to report a session.

As per CPT® time rules, you’ll report +90833 for a psychotherapy session that lasts between 16 minutes to 37 minutes, +90836 for a session that lasts between 38 minutes to 52 minutes and +90838 for a session that is 53 or more minutes. “Psychotherapy of less than 16 minutes is not separately reportable,” observes Moore. 

Coding tip: When a psychotherapy session where no E/M service is provided lasts for more than 90 minutes, you can use prolonged services codes (99354-99357) as an add-on code to 90837 (Psychotherapy, 60 minutes with patient and/or family member). However, if your clinician provides E/M services and conducts a prolonged psychotherapy session you cannot use the prolonged services codes along with the +90838.  As per Correct Coding Initiative (CCI) edits, prolonged services codes form column two codes for +90838 with the modifier indicator ‘0,’ which tells you that you cannot use these codes together under any circumstances.

Don’t Use Outpatient E/M Codes For Medicare PHPs

Even though location is no longer necessary in determining which of the psychotherapy codes you will use to report a session, you’ll need to bear in mind the location when determining the appropriate E/M code.

The MLN Matters article that was released also directs your attention to this point. It states that “effective January 1, 2014, when E&M services are paid under Medicare’s Partial Hospitalization Program (PHP) and not in the physician office setting, the CPT® outpatient visit codes 99201-99215 have been replaced with one Level II HCPCS code - G0463.”

So, if you are reporting for a PHP and your clinician performs a psychotherapy session that involves an evaluation and management, you should not report outpatient E/M codes (99201-99215). Instead, you will only have to report G0463 (Hospital outpatient clinic visit for assessment and management of a patient), irrespective of the level of evaluation and management performed.

To know more about the Comprehensive Error Rate Testing (CERT) program’s reviews of claims for Part B Psychiatry and Psychotherapy Services, check the MLN Matters article at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1407.pdf