5 Services Psychiatrists Forget to Bill For

Betsy Nicoletti, MS

Disclosures

January 15, 2019

In This Article

Accurately Document Medication Management and Psychotherapy at the Same Visit

When the code for medication management was deleted from the CPT books, psychiatrists, psychiatric nurse practitioners, and psychiatric physician assistants were told to use evaluation and management (E/M) codes for medication management. The most common code is an established patient visit, as medication management is performed on patients who are known to the prescribing clinician and frequently performed in an office or clinic setting.

If only medication management is performed, the clinician may select the level of office visit (or other E/M service) based on the key components of history, exam, and medical decision-making, or on time.

However, when both medication management and psychotherapy are provided on the same calendar day, the clinician should select an add-on psychotherapy code with the office visit. In this case, the office visit must be selected on the basis of the level of history, exam, and medical decision-making that is performed. The office visit may not be billed based on time. The add-on psychotherapy code is billed based on the time of the psychotherapy.

The problem with this is that the time in the room with the patient is not neatly divided between medication management and psychotherapy. One service doesn't stop suddenly and the other starts up. It is an integrated service with two components, but the documentation required for the coding assumes that this is not the case.

In order to conform to the requirements, the prescribing clinician should document the history and mental status exam and assessment, and base the level of office visit on those components. Then, under the heading of psychotherapy, the clinician should document the type of intervention and the nature of the psychotherapeutic discussion. The clinician should document the time of the psychotherapy, exclusive of medication management. It is awkward at best.

Billing Crisis Codes

There are two time-based CPT codes for seeing a patient in the midst of crisis, doing an urgent assessment, and planning and implementing psychotherapeutic interventions:

90839: Psychotherapy for crisis; first 60 minutes
+90840: Each additional 30 minutes

These codes describe face-to-face time with the patient and/or family member. They may not be reported on the same day as a diagnostic evaluation or psychotherapy. Code 90839 can be used by a psychiatrist, nurse practitioner, physician assistant, social worker, or psychologist who sees a patient urgently for a life-threatening or complex problem that requires immediate attention and intervention.

These codes may be used in any location when a patient needs an urgent assessment and history during a crisis state, a mental status exam, and an immediate plan for psychotherapeutic intervention. It includes the assessment, any psychotherapy provided on that day, mobilization of resources, and the implementation of the therapeutic interventions to prevent or minimize the potential for psychological trauma. According to CPT, the presenting problem is typically life-threatening or complex and requires immediate attention.

These codes are used to report the duration of face-to-face time with the patient and/or family, even if the time spent is not continuous. The patient must be present for all or some of the time, and the healthcare professional must devote all of his or her full attention to the patient during the time that is reported. Code 90839 should be used for 30-74 minutes of time, and; use the add-on code for additional 30-minute increments.

This code cannot be reported in addition to the psychiatric diagnostic evaluation or psychotherapy or other psychiatric services.

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