Psycotherapy

spaustat

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What are the documentation guidelines for billing family and individual therapy on the same date of service?

I'm thinking there should be two separate notes, one with time specifically documented. And each session should be during a different time period. CMS allows a modifier to bill both on the same date - would a 51 be used or 59?

Thanks,
 

GaPeach77

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I completed an assignment for a mental health behavior center last year. For interactive therapy which includes family therapy on the same DOS as individual therapy you would want to use a -59 for distinct procedural svc. I wouldnt use -51 because that is for multiple procedures OTHER then E/M levels according to AMA's CPT definition. If med records are requested after using this modifier, which is very common, then make sure the therapist documents why the family counseling or family interaction was needed, such as a child would not communicate without parents help, etc.
 
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