Part B Insider (Multispecialty) Coding Alert

Published on Fri Mar 21, 2014 PDF

When CPT® revised the psychotherapy and psychiatry codes last year, many mental health clinicians started using the codes immediately without giving much thought to how documentation would have to change to support the codes. CMS has taken note of the most common issues with this code set and recently released MLN Matters article SE1407 to set the record straight. 

“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 article states. Because the psychotherapy codes can be reported with E/M codes, your documentation will have to include not just the total time spent during the visit, but the specific amount of time spent performing psychotherapy.

“Because time is indicated in the code descriptor for the psychotherapy CPT® codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E/M service,” CMS says in the article.

If you bill an E/M service and a psychotherapy code (such as 90836) but you only have one notation of the time spent (such as “50 minutes”), CMS will request a refund for the overpayment and will tell you that you’ve made a billing error.

To read the complete MLN Matters article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1407.pdf.