The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Outpatient Psychotherapy L39853.
General Coding
Psychiatry and Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases.
Providers referenced; physicians, nonphysicians (clinical psychologists, independent psychologists, NPs, PAs, CNMs, etc.), provide services within the scope of their state license and clinical practice/education.
Individual Psychotherapy CPT® codes should only be used when focus of treatment is on individual psychotherapy.
Psychiatric service CPT® codes should not be used when other CPT® codes, such as an evaluation and management (E/M) service or pharmacologic code is more appropriate.
Interactive Complexity (90785) is an add-on code specific for psychiatric services. It refers to communication difficulties during a psychiatric procedure. This code is to be reported in conjunction with other codes (90791-90792, 90832-90834, 90836-90838, 90853) and is excluded when coding for the following: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T, 90839,90840, 96136-96139, 96146, 96130-96133.
Communication difficulties include:
- Other individual responsible for the care of the patient, adults with guardians.
- A request for another individual to be involved with care during a visit, such as family members, interpreter or translator.
- Requiring the participation of a third party.
Interactive Complexity may be reported with:
- The need to manage maladaptive communication (related to anxiety, high reactivity, repeated questions, etc.) among participants, complicating delivery of care.
- Caregiver emotion/behavior interfering with delivery of care.
- Reporting to a third party, such as negligence or abuse, initial evidence/disclosure of a sentinel event with patient and visit participants.
- Overcoming language barriers.
This code is not to be reported in conjunction with crisis codes 90839, 90840.
Psychotherapy codes 90832, 90834 and 90837 refer to psychotherapy without medical management.
90833, 90836, 90838 are for psychotherapy with medical E/M. These are add-on codes in addition to the appropriate E/M codes. E/M codes alone do not include psychotherapy services.
For psychotherapy sessions greater than 90 minutes, medical records must document face-to-face time spent with the patient and medical necessity to be reimbursed.
Psychotherapy codes 90846 and 90847 refer to family psychotherapy. These codes do not pertain to history taking or E/M counseling services. This does not include the supervision of therapy by professional caretaker or staff.
Psychotherapy code 90853 refers to group therapy. If medically necessary, code 90785, medical complexity, may be billed in conjunction with this code.
Psychotherapy crisis code is 90839, first 60 minutes. Code 90840 is for each additional 30 minutes. These are standalone codes, 90840 must be billed with 90839.
Biofeedback is not a service covered by Medicare for psychosomatic disorders.
Billing Guidelines
If coding for both E/M services and psychotherapy services, the two services must be significant and separately identifiable.
For the same date of service, there is no requirement for a separate diagnosis.
Site of service is not always applicable to psychotherapy; psychotherapy codes are applicable in all settings.
Documentation Requirements
- Time spent in the psychotherapy encounter as well as the therapeutic interventions (behavioral modification, supportive interaction, interpretive interactions) utilized to encourage therapeutic change.
- Behavioral modification is not a separate service; it is an adjunct to psychotherapy.
- Periodic summary of goals
- Progress toward the goals set
- Updated treatment plans, generally, every three months, should include estimated duration of treatment and treatment goals, the targeted symptoms should be outlined, and the treatment goals related to behavioral changes, though processes and /or medications detailed.
- Presence of a psychiatric illness and/or a demonstration of emotional/behavioral symptoms sufficient to alter base-line functioning.
- Detailed summary of the session including: therapeutic intervention, degree of patient interaction and participation as well as documentation of the goal-oriented outcomes and any progression or lack thereof in the patient’s symptoms/ behavior.
- In a Family psychotherapy session without the patient present, there must be documentation of themes addressed in the session, descriptive documentation of the therapeutic interventions, the degree of patient participation and interaction with the family members, the reaction to the group, the group’s reaction to the patient and any changes/lack of changes in patient symptoms and/or behavior as a result of the therapy session.
- Documentation is not to include privileged information.
