The CPT coding system was created to provide a uniform language for describing medical and surgical procedures and diagnostic services that would facilitate more effective communication between clinicians, third-party payers, and patients. The 2013 CPT Manual is the most recent revision of the 4th edition of the book.
The AMA’s CPT coding system is now used almost universally throughout the United States. The Transaction Rule of the Health Insurance Portability and Accountability Act (HIPAA) requires the use of CPT codes by all who are covered by HIPAA. The CPT codes comprise Level I of the HCPCS (Health Care Financing Administration Common Procedure Coding System) codes used by Medicare and Medicaid. Every healthcare provider who is paid by insurance companies, or whose patients are reimbursed by insurance companies, should have a working knowledge of the CPT system.
Although changes to the coding system seem to increase the reimbursement amount, it is still a complex system. It is not always easy to determine if the required elements have been met to code appropriately for the maximum reimbursement amount. It may help to break the process down into steps for new patients and established patients.
First, behavioral health professionals might bill two types of CPT codes for new patients. These are E/M codes and Psychiatric evaluation codes. Depending on the situation and time involved, it may be appropriate to bill for both codes. A few guidelines include:
E/M: Use E/M codes when evaluating a new medical issue. To bill for E/M, you must provide three documentation elements – history, examination, and medical decision-making.
Psychiatric evaluation: Use psychiatric evaluation codes for a diagnostic assessment. You may need to use these codes more than once if more time is needed to complete the initial evaluation.
You are allowed to bill an E/M service with every psychotherapy visit, but it is not required with every encounter. E/M services are only to be billed if there is a separate medical issue that was addressed and documented during the encounter. For example, if you address the side effects of medication during a visit, you might bill for an E/M visit in addition to a psychotherapy session.
However, if a patient has been stable and on the same medication for years and attends a psychotherapy visit, you can only bill for the psychotherapy session. You cannot bill for E/M because there are no medical or medication concerns expressed during the visit. Also, to bill for E/M, your documentation must prove your active management or discussion of a medical or medication problem that is distinct from the psychotherapy service.
Supporting Documentation for E/M Code
The documentation must include the following three sections:
History: The history section must include the history of present illness (HPI), review of systems (ROS) and past family and social history (PFSH).
Examination: The examination section includes the type of examination performed based on your judgment, the patient’s history and the nature of the problem. You will need to document one to 14 elements depending on the level of examination.
Medical decision-making: The medical decision-making section includes the number of diagnoses or treatment options documented during the specific encounter, the complexity of the data reviewed, and the risk of complications.
Pass the midpoint: You must pass the midpoint to bill for a certain amount of time. For example, the midpoint between 30 minutes and 45 minutes is about 38 minutes. To bill for 45 minutes of psychotherapy, you must pass 38 minutes.
Keep them separate: The time associated with the E/M service cannot count toward the time of the psychotherapy service. The E/M service must be significant and distinct from the psychotherapy service.
In short, if you provide psychotherapy with an E/M service, bill the E/M service based on the three major components – history, examination, and medical decision-making – with a psychotherapy code, and document both the E/M work and psychotherapy work separately.
Medical coding for Psychotherapy is challenging as compared to other medical specialty coding. Outsourcing your medical coding to E2E Medical Billing Services could be a good option as you can dedicatedly focus on your core practice responsibilities only. To know more about our Psychotherapy coding and billing services you can call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com