Coding errors can occur from ‘up-coding’, ‘down-coding’, or miscoding. Up-coded services are billed at a level higher than the actual level of the service performed. For example, a 20- to 30- minute individual psychotherapy service billed as a 45- to 50-minute service is an up-coded service. Conversely, a down-coded service is billed at a lower level than the actual level of the service performed.
The OIG’s report found that the majority of miscoded individual psychotherapy claims lacked documentation to justify the time billed. Individual psychotherapy can be billed as one of three time periods: 20 to 30 minutes, 45 to 50 minutes, or 75 to 80 minutes. Because reimbursement of psychotherapy services is based on face-to-face time spent with the patient, practitioners are required to document in the medical record the time spent with the patient. Providers must note that Section 1833(e) of the Act requires that providers furnish “such information as may be necessary to determine the amounts due” to receive Medicare payment.”
One of the principal causes of miscoded services occurs because no time is documented. When this happens, the services should be billed at the lowest possible time period. Miscoding for psychotherapy services also occurs when documentation in the medical record indicates that the actual services were not psychotherapy but totally different services, such as E&M services, medication management, psychological evaluation, and group psychotherapy. Medication management may be billed under one of two codes: 90862 (psychiatric pharmacologic management) or M0064 (brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic, and personality disorders).
Related Article: MEDICAID DOCUMENTATION FOR BEHAVIOURAL HEALTH PRACTITIONERS
Practitioners who provide E&M services in conjunction with psychotherapy need to document the E&M services and psychotherapy in the medical record. If only psychotherapy is documented, the practitioners should use codes for services solely for psychotherapy. Providers should thoroughly familiarize themselves with documentation guidelines for E&M services.
Miscoding for E&M services can occur when the E&M services are billed at a higher level than the medical record documentation supports. E&M services levels vary based on:
- The extent of the patient history obtained,
- The extent of the examination performed, and
- The complexity of medical decision-making.
Additional causes of E&M coding errors reported in the OIG report included billing E&M services:
- For an initial visit when the services were rendered during a subsequent visit. Reimbursement rates for subsequent E&M visits are typically less than those for initial visits.
- When the services should have been billed as psychiatric diagnostic interview examinations, consultations, or psychotherapy, which are reimbursed at a lower rate.
- Where the place of service (e.g., inpatient) does not match the place of service indicated in the medical record (e.g., outpatient).
Maintaining proper documentation for mental health is a challenging task and accurately coding as per documentation requires special expertise. E2E Medical Billing Services can help you in mental health medical billing and coding. In case of any assistance for medical coding for mental and behavioral health, you can call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com