Psychiatry Coding & Reimbursement Alert

Published on Thu Nov 03, 2016 PDF

Watch for situations involving extended evaluations too.

If your clinician is performing an extended psychotherapy or an evaluation and management (E/M) service, you may be able to get additional reimbursement for the extended session by reporting an appropriate prolonged service code.

Select Apt Prolonged Service Code Based on Location and Time

When your psychiatrist sees a patient for an extended psychotherapy session or an evaluation, and if reporting only a psychotherapy code or an E/M code will not accurately cover the time spent by your clinician, you may be able to claim for the additional time spent by reporting a prolonged service code.

For reporting the prolonged service code, you will have to choose from the following add-on codes based on (a) the time that your clinician spent for the extended service as well as (b) the location in which your clinician performed the service:

• +99354 (Prolonged evaluation and management or psychotherapy service[s] [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service])
• +99355 (…each additional 30 minutes [List separately in addition to code for prolonged service])
• +99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour [List separately in addition to code for inpatient Evaluation and Management service])
• +99357 (…each additional 30 minutes [List separately in addition to code for prolonged service]).

So, depending on the time spent, you will have to report +99354 alone or with appropriate additional units of +99355 when your clinician performs the prolonged service in an office or in an outpatient setting. If the services were provided to an inpatient or a patient in an observation setting, you will report the prolonged service with +99356 with or without additional unit(s) of +99357, again based on the time spent by your clinician for the extended service.

Understand Where You can Report Prolonged Services Codes in Psychiatry

In a psychiatry practice, you can use prolonged services codes when your clinician performs an extended psychotherapy session or an E/M service code. However, you cannot report a prolonged service code with all the psychotherapy codes. “Only one psychotherapy code is allowed with prolonged services,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, PA.

“Prolonged services can be reported with 90837 (Psychotherapy, 60 minutes with patient and/or family member),” says Rebecca Yowell, deputy director for reimbursement policy at the American Psychiatric Association. “The only psychotherapy service that may be billed with a prolonged service is CPT® 90837,” Falbo reiterates.

Psychotherapy codes that you use are time based codes. Of these codes, 90837 and +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]) are the codes that are used for the maximum time duration spent in performing psychotherapy. However, you do not have any other specific code to report when your clinician spends more than the time listed in these codes performing the psychotherapy service.

In such an instance, when time specifications are met, you can report the extended time spent by your clinician using the appropriate time and location specific prolonged service code(s). However, as specified earlier, you can report prolonged service add-on codes only with 90837.

“You cannot bill prolonged services with the add-on code 90838 (the psychotherapy code you use when you also do an E/M service),” Yowell says. “Prolonged services codes cannot be reported with CPT® +90838,” Falbo reasserts.

If you look at Correct Coding Initiative (CCI) edits, you will notice that prolonged service codes are bundled into the add-on code +90838. The modifier indicator to these edits is ‘0,’ which means you cannot overcome the edit using any modifiers with either of the codes. So, prolonged services codes can only be used with 90837 and not with +90838 under any circumstance.

E/M codes: Since your psychiatrist is allowed to report E/M codes for any evaluation and management service that he performs, you can also use prolonged services codes when the E/M service is extended beyond the typical time mentioned for the service.

Unlike the psychotherapy codes, you can report prolonged services codes with any level of E/M service. “You can report prolonged care services with any level of E/M code, but it’s important that the documentation support the reason why and give the details of the service” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med, a medical auditing, coding and education organization in Pittsburgh, Pa.

Every E/M code has a typical time component specified in its descriptor. When all other criteria for selecting the particular E/M code have been met and the time taken by your clinician in performing the E/M service has been extended beyond the time mentioned in the descriptor, you can look at reporting a prolonged service code (if time stipulations for reporting the add-on prolonged service code has been met).

For instance, the typical time for 99204 is 45 minutes. If time spent in performing the E/M is beyond this time, you can look at reporting the appropriate prolonged service code(s), based on the amount of time spent.

Know the Time Stipulations of Prolonged Service Codes

When you are planning on reporting an extended psychotherapy or an E/M session with the add-on prolonged services code(s), you should know the time specifications of these codes to know if you can report these codes for the session. The time spent should be face-to-face, direct contact with the patient. Any non-face-to-face service time cannot be added while calculating the time spent in performing the service. “The insurance company would like to see actual minutes if possible (clock time),” Hauptman says. “Otherwise, it must be very clear about how much time was spent in prolonged services. The documentation must also detail the facts about the visit that took longer.”

Psychotherapy service: You report 90837 when the psychotherapy session lasts for 53 or more minutes. “For psychotherapy visits lasting 90 minutes or longer, the appropriate prolonged service code (99354-99357) should be used,” says Melody Lidmila, CPC, CEC, Coding specialist at the University of Colorado Health, in Loveland, CO. “The provider must document the medical necessity for a prolonged visit.”

If the session lasts beyond 60 minutes duration, you will need to follow CPT® time rules to understand whether or not you can report +99354 (or +99356) for the extended period of time. You can report +99354 (or +99356) when the extended session lasts between 30-74 minutes longer than the one hour mentioned in the time descriptor for 90837.

“Since the psychotherapy service (90837) is 60 minutes in length you can bill the prolonged services code beginning at 90 minutes,” Yowell says. “A minimum of 90 minutes must be documented for the encounter (e.g., 60 minutes of psychotherapy, plus at least 30 minutes of prolonged services),” Falbo adds.

You report the add-on code +99355 (or +99357) in addition to +99354 (or +99356) when the extended session lasts between 75-104 minutes.

E/M codes: The same time rules hold good when you are planning on reporting prolonged services with an E/M code also. “It must meet a minimum of 30 minutes beyond the typical time for the given CPT® code,” Falbo says.“For example, if the visit supports CPT® 99214, which has a typical time assigned by AMA of 25 minutes, then the provider needs to spend a minimum of 55 minutes to begin billing prolonged service codes.”

Note: The base codes, +99354 and +99356 should be reported only once on one calendar date of service for a patient. For time spent beyond specified for these base codes, it should be reported with appropriate units of the add-on codes, +99355 and +99357, as appropriate. When calculating the time, you should remember that time spent in performing the service need not be continuous. If your clinician is seeing the patient in split sessions, you collate the time spent and report one unit of the base code and an appropriate number of units of the additional codes.