Primary Care Coding Alert

Question: May a family physician bill for 90862?

Pennsylvania Subscriber Answer: Yes, any physician may bill for 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy). CPT doesn't restrict the code to a particular type of doctor, such as a psychiatrist. 

The problem with using 90862, however, is that many payers will not reimburse for the code. Because 90862 is in the psychiatric section of CPT, insurers may deny payment due to mental-health carve-outs.

You may avoid such denials with an E/M code. If the prescription management involves a face-to-face service, you may report an office visit (9921x) instead of pharmacological management (90862).

For instance, if the patient sees a nurse for a prescription refill or dose change, you may report 99211. Alternatively for visits in which the doctor treats the patient, you could use a higher-level office visit code, such as 99212-99215 (Office or other outpatient visit for the E/M of an established patient ...).