UPDATE: Coding and billing longer sessions is possible, but more difficult than before

One of the biggest problems providers have with the new psychotherapy code changes is time. The codes are now for only 30-, 45-, or 60-minute sessions – and more on those numbers later. The 70- and 80-minute session codes are gone.

“It’s part of a push toward shorter-term interventions,” said Nina Marshall, MSW, director of public policy for the National Council for Behavioral Health. For providers who use the evaluation and management (E/M) codes instead of psychotherapy codes, there is increased documentation time, she says. “All in all, we’re seeing reimbursement going down – that’s what we’ve been hearing from our members,” Marshall tells Behavioral Healthcare.

Medicaid, the primary payer for mental health services, uses CPT, but also uses state-based codes. This varies from state to state; some states only use HCPCS codes, instead of CPT codes, for psychotherapy, says Marshall. In general, there are more state-based codes for addiction treatment services, with mental health services tending to use the CPT codes. HCPCS codes allow for day treatment services and intensive outpatient services, while CPT codes allow for medication management and psychotherapy.

E/M codes are multi-piece puzzles

Just because a patient has a more severe diagnosis doesn’t necessarily mean you can bill a higher-level E/M or a longer psychotherapy session, she adds. “A more severe diagnosis could work for a higher level code, but it depends on what takes place in that session.” The E/M code depends on more than just time, there’s medical decision-making, history, and more, she says. “People are used to using just one code for a medication-management visit, but that’s not how it works anymore,” she says, comparing E/M codes to the pieces that comprise a jigsaw puzzle.

Likewise, having a session involving a dual diagnosis doesn’t automatically rate a higher level E/M code. “You might have two chronic conditions but still have a lower level E/M code,” says Marshall.” Again citing the puzzle, she notes that suicidal ideation would constitute one higher risk element in determining the E/M code level, but that other parts of a visit may constitute lower level elements. “It’s everything taken together.”

There are a few other important things to note about E/M codes, too: 

1.  They are only for use by medical staff, such as physicians, psychiatric nurse practitioners, nurse practitioners, and physician assistants, says Marshall. They cannot be used by psychologists or social workers.

2. E/M codes are discussed in two sets of guidelines – 1997 and 1995. Psychiatrists, being medically based, use the 1997 guidelines, because these can be used in “single-system” reviews – in other words, evaluations that don’t involve the entire body. Thus the 1997 guidelines fit when the examination, history, and medical decision making all focus on the psychiatric component, says Marshall.

3. Note that counseling – in E/M coding speak – does not mean the same thing as counseling in a psychotherapist’s language.”This is not psychotherapy,” Marshall clarifies. This type of counseling is defined “as discussion with a patient and/or family concerning the recommended studies, risks and benefits, and instructions for treatment.” she notes. “Time spent doing this kind of counseling can be used under one condition when determining an E/M level – if most of the visit time is spent on counseling.”

Documenting longer sessions

It’s a truism among coders that “if it wasn’t documented, it wasn’t done.” And it is absolutely true that documentation for psychotherapy can be much more time-consuming that documentation for medical visits, but it’s essential to getting paid. In general, documentation for psychotherapy should include the focus of the session and the type of modality used (i.e., CBT,), said Marshall.

Despite the loss of several popular codes,  “It is still possible to bill for 90- or 120- minute sessions,” Marshall said. To do this, you would need to use prolonged services codes.

These codes come with challenges of their own. The first, she warns, is that not every payer is using these codes. “Payers expect people to use 30- or 45- minute sessions, which cut you off at 52 minutes. This puts people who do longer sessions in a bind.” The bind is that now, the 60 minute code covers everything from 53 minutes up to 89 minutes. So, she explains,“you can’t use prolonged services codes until you get to 89 minutes.”

Quinten A. Buechner, president and CEO of ProActive Consultants (Cumberland, Wis.) specializes in psychiatric codes. He agrees that “options for codes are reduced” in 2013. But he notes that code 90832 still gives the usual 16-60 minutes for routine psychotherapy services.

To bill longer times, Buechner advises that you need to “step outside your comfort zone” and use prolonged services codes. You can use prolonged services codes (99354 and 99355 for outpatient, 99356 and 99357 for inpatient) in addition to E/M codes to bill for a longer visit. These codes are for services provided beyond what is “usual” for the E/M code, and are used to report the total amount of face-to-face time spent on a given date. These are “time-based” add-on codes, so they have special significance to psychotherapy services. However, they cannot be used in combination with psychotherapy codes, but only with E/M codes.

Note that prolonged services with a duration of less than 30 minutes are not reportable. Anything from 30-74 “extra” minutes is reported with 99354, appended to the E/M code you select. 99355 is used for each additional 30 minutes above the 99354 code.

Buechner says that these codes represent “unknown territory” to psychiatrists, psychologists, or other mental health practitioners. However, he says that if one considers the plethora of codes that others, including primary care physicians, must use to get paid, learning and knowing how to use E/M and prolonged services codes isn’t such a tall order after all.

Payer policies

You should find out what the payer policy is regarding the use of prolonged services codes. The fact that these codes appear in CPT books doesn’t mean a payer will reimburse them – or reimburse them generously. Still, providers across the country, including Medicaid providers, are still getting up to speed with the 2013 CPT changes, so the question remains timely. And, you’ll want to make sure that if the policy requires that you bill the patient when the insurer doesn’t cover the costs, that you do follow through with that billing. Bear in mind that the times for the prolonged services codes must bein addition to the time for the E/M codes, and that the E/M codes require more than just time in terms of documentation.

E/M examples

Here are two examples of straight E/M scenarios, from the American Psychiatric Association.

CPT code 99213:A 42-year-old male established patient with a history of bipolar II disorder, last seen 2 months prior, is in for an office visit. Interval history taking focuses on the presence/absence of symptoms, the patient’s level of social/vocational function, and the patient’s adherence to the medication regimen. A mental status examination focuses on the patient’s affective state. The patient’s lithium blood level is reviewed. The side effects of the medication are reviewed, and prescriptions for the same medications are provided.

Explanation for code choice:In order to make a decision about medications, the psychiatrist must do an expanded problem-focused history and examination. An expanded problem-focused history includes one to three elements of a review of systems. The actual medical decision to continue the medication regimen is of low complexity, simply requiring two of the three key components to match.

CPT code 99214, based on time spent on counseling and coordination of care: A patient returns to a psychiatrist’s office for a medication check. The encounter takes a total of 25 minutes, during which time more than 12.5 minutes is spent explaining to the patient about how a newly prescribed medication works, how to establish a routine so that no doses will be missed, and the possible side-effects of the medication and what to do if they occur.

The appropriate E/M code would be 99214 (office or outpatient service for an established patient). This is based on the 25-minute time, not on the detailed history and examination and moderately complex medical decision making that would be required to use this code if counseling and coordination had not taken up more than 50 percent of the time.