Documentation Guidelines Effective Date Psychotherapy CPT Codes for 7/17/17 Psychologists Services Revision Letter B Applies To: UNMMG

1.0 Purpose

The American Medical Association (AMA) created new CPT codes in 2013 for Psychiatry, with guidance from the American Psychiatric Association. The UNMMG Medical Group, Inc. (UNMMG) follows the specific documentation and billing guidelines of the Centers for Medicare and Medicaid Services (CMS) when applicable. Non-compliance with these documentation requirements affects UNMMG’s ability to bill and receive appropriate reimbursement from the payers. This document provides specific guidelines for Psychologists only.

2.0 Scope

This guidance applies to UNM Health System providers. See Paragraphs 4.0 through 4.6.4 below for the following CPT codes specific to Psychologists only.

3.0 Approved Providers for Mental Health Service

 In order for a Psychologist to qualify as a provider, the practitioner must meet the following requirements:

o Hold a doctoral degree in psychology

o Be licensed or certified on the basis of the doctoral degree in psychology by the state in which he/she practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive and therapeutic services directly to individuals.

4.0 Psychiatric Diagnostic Evaluation (90791) – (May be used by Psychologists)

4.1 Psychiatric Diagnostic Evaluation - 90791

This code is used for an initial diagnostic interview exam that does not include any medical services. The documentation should include a chief complaint, a history of present illness, communication with family or other sources, a psychosocial history, a complete mental status examination, and review and ordering of diagnostic studies.

Documentation requirements:

 The diagnostic interview is indicated for the initial or periodic diagnostic evaluation of a patient for suspected or diagnosed psychiatric illness. (A second provider seeing the patient for the first time may also use this code).

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 It may be utilized again for the same patient if a new episode of illness occurs, an admission or a re-admission to inpatient status due to complications of the underlying condition occurs, or when re-evaluation is required to address a new referral question.

 Certain patients, especially children and geriatric patients may require more than one visit for the completion of the initial diagnostic evaluation. The indication for another assessment should be based on medical necessity.

 Interactive procedures are covered for patients whose ability to communicate is impaired by expressive or receptive language impairment from various causes. These may include conductive or sensorineural hearing loss, deaf mutism, aphasia, language barrier, or lack of mental development (childhood).

 Medical records should reflect in legible form the elements outlined:

 Date  Referral source  Length of session (these are not timed codes, however, the standard length of time is generally considered to be between 45 minutes and 1 hour) The total number of timed minutes must be documented in the patient’s medical record, per Novitas LCD, #L35101 (Revision Effective Date 07/13/17)  Content of session  Therapeutic techniques, and approaches including medications  Assessment of the patient’s ability to adhere to the treatment plan  Identity of person performing service (legible signature)  For interactive therapy, the medical record should indicate the adaptations utilized in the session and the rationale for employing these interactive techniques  Multi-axial diagnosis  The medical record documentation must support the medical necessity of the service.

 Associated Information on documentation requirements:

 All documentation must be maintained in the patient’s medical record and available to the contractor upon request.  Every page of the record must be legible and include appropriate patient identification information [e.g., complete name, dates of service(s)]. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing care to the patient.  The submitted medical record must support the use of the selected ICD-10CM code(s).  The submitted CPT/HCPCS code must describe the service performed. The medical record documentation must support the medical necessity of the services.

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4.2 Interactive complexity CPT code-90785 (Add-on codes may only be reported in conjunction with other codes, never alone).

4.2.1 Used in conjunction with the following “primary procedures”:

 Psychiatric diagnostic evaluation-90791  Psychotherapy-90832, 90834, 90837  Group psychotherapy-90853

4.2.2 May not report with;

. Psychotherapy for crisis-90839 & 90840 . E/M alone-i.e. E/M service not reported in conjunction with a psychotherapy add-on service . Family psychotherapy- 90846, 90847, 90849

4.2.3 Typical Patients: Interactive complexity is often present with patients who:

 Have other individuals legally responsible for their care, such as minors, or adults with guardians

or

 Request others to be involved in their care during the visit, such as adults accompanied by one or more participating family members or interpreter or language translator

or

 Require the involvement of third parties, such as child welfare agencies, parole or probation officers or schools.

4.2.4 Documentation guidelines: When at least one of the following communication factors is present during the visit:

. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.

. Caregiver emotions or behaviors that interfere with implementation of the treatment plan.

. Evidence or disclosure of a sentinel event and mandated report to a 3rd party (e.g. abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.

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. Use of play equipment, physical devices interpreter or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not developed or lost expressive or receptive language skills to use or understand typical language.

Per the Center for Medicare and Medicaid Services (CMS), 90785 generally should not be billed solely for the purpose of translation or interpretation services” as that may be a violation of federal statute.

4.2.5 The following examples are NOT considered interactive complexity:

o Multiple participants in the visit with straightforward communication o Patient attends visit individually with no sentinel event or language barriers o Treatment plan explained during the visit and understood without significant interference by caretakers emotions or behaviors

4.3 Psychotherapy Codes with No E/M Service:

 CPT code-90832 Individual Psychotherapy-16 to 37 minutes-face to face with patient, and/or family member.

 CPT code-90834 Individual Psychotherapy- 38 to 52 minutes-face to face with patient, and/or family member.

 CPT code- 90837 Individual Psychotherapy-53 minutes or more-face to face with patient, and/or family member

4.3.1 Documentation guidance for Psychotherapy-All the following elements should be contained in or readily inferred from the medical record:

4.3.1.1 Type of service (individual, group, family, interactive, etc.).

The medical record must indicate in legible form, the time spent in the psychotherapy encounter and the therapeutic maneuvers such as behavior modification, supportive interactions and interpretation of unconscious motivation that were applied to produce therapeutic change or stabilization.

All the following elements should be contained in or readily inferred from the medical record:  Type of service (individual, group, family, interactive, etc.)  Content of session  Therapeutic techniques and approaches, including medications  Identity of person performing service

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 For interactive therapy, the medical record should indicate the adaptations utilized in the session and the rationale for employing these interactive techniques  For services that include an E/M component, the E/M services should be documented  Group therapy session notes can be organized according to the general session note guidelines for individual therapy appearing above, or the clinician may elect to use the following group note format: o One group note that is common to all patients includes documenting date, length of time for each session, and key issues presented. Other group members’ names should not appear in this note. o An additional notation or addendum to the group note, for each patient’s record commenting on that particular patient’s participation in the group process and any significant changes in patient status.

4.3.2 Coverage Indications, limitations, and/or Medical Necessity

4.3.2.1 Psychotherapy will be considered medically necessary when the patient has a psychiatric illness or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning.

4.3.2.2 Psychotherapy services must be comprised of clinically recognized therapies that are pertinent to the patient’s illness or condition. The type, frequency and duration of services must be medically necessary for the patient’s condition under accepted practice standards.

4.3.2.3 There must be a reasonable expectation of improvement in the patient’s disorder or condition, demonstrated by an improved level of functioning, or maintenance of level of functioning where decline would otherwise be expected in the case of a disabling mental illness or condition, or chronic mental disorders.

4.3.2.4 The patient must have the capacity to actively participate in all therapies prescribed. To benefit from psychotherapy, an individual must be cognitively intact to the degree that he/she can engage in a meaningful verbal interaction with the therapist. For patient’s suffering from dementia, the type and degree of dementia must be taken into account in planning and evaluating effective psychotherapeutic interventions. If psychotherapy is provided to a patient with dementia, the patient’s record should support that the patient’s cognitive level of functioning was sufficient to permit the patient to participate meaningfully in the treatment.

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4.3.2.5 Psychotherapy services are never covered for severe and profound mental retardation (ICD 10-CM codes F72 and F73). Severe mental retardation is defined as an IQ 20-34 and profound mental retardation is defined as an IQ under 20.

4.3.2.6 The duration of psychotherapy must be individualized for every patient. The provider of service must document in the patient’s record the medical necessity for continued (prolonged) treatments.

4.3.2.7 Psychotherapy services are not considered reasonable and necessary when they primarily include teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction. Therefore, these services should not be reported for Activities of Daily Living (ADL) training and/or socialization activities.

4.3.2.8 Group Therapy (CPT codes 90853 and 90785) is defined as psychotherapy administered in a group setting with a trained group leader in charge of several patients. The group should not exceed 10 participants and the sessions should be at least 45 to 60 minutes in duration. While a video or movie may be used as an adjunct to the sessions, this modality should not be used as a replacement for the therapist’s active participation and the majority of the session should involve the interaction between the participants and the therapist leading the session. If group psychotherapy is provided to a patient with dementia, the patient’s record should document that the patient’s cognitive level of functioning was sufficient to permit the patient to participate meaningfully in the treatment.

4.3.2.9 Family Therapy (CPT codes 90846 and 90847) will be considered reasonable and necessary only for treatment of the Medicare beneficiary’s mental illness and not the family member’s problems. Family therapy is appropriate when intervention in the family interactions would be expected to improve or stabilize the patient’s emotional/behavioral disturbance. Family therapy is commonly the major treatment, especially for children and also for the elderly. Where both husband and wife are covered by Medicare, such therapy may be the most effective treatment for both individuals.

CPT Code 90846 (family psychotherapy without the patient present) does not represent routine consultation with staff about the patient’s progress and treatment. Facility staff members are not considered caregivers for purposes of this policy; however, caretakers in group-living facilities may be considered for the purpose of these policies.

CPT Code 90847 (family psychotherapy conjoint psychotherapy with patient present)

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4.4 Psychotherapy Codes with E/M Service-CPT codes- 90833, 90836 & 90838.

Psychologist cannot bill for an E/M Service with the above psychotherapy codes

4.5 Limitations

4.5.1 Family therapy sessions with a patient whose emotional disturbance would be unaffected by changes in the patterns of family interaction (i.e., a comatose patient) would not be considered reasonable and necessary. Similarly, an emotional disturbance in a family member, which does not impact on the Medicare patient’s status, would not be covered by that patient’s Medicare benefits.

4.5.2 Multiple family psychotherapy (CPT code 90849) is directed to the effect of the patient’s condition on the family and does not meet Medicare’s standards of being part of the personal service to the patient. Therefore, this service is generally non-covered. If providers feel the multiple family psychotherapy services rendered meet the indications of psychotherapy outlined in this policy, they may follow the redetermination process. 5. Psychotherapy for Crisis

5.1 CPT code-90839 Psychotherapy for crisis; first 60 minutes (30-74 minutes); CPT code-90840- each additional 30 minutes (listed separately in addition to code for primary service 90839).

5.1.2 Documentation Requirement:

 Psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status exam, and a disposition.

 The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma.

 The presenting problem is typically life threatening or complex and requires immediate attention to a patient with high distress.

 The crisis codes are used to report the total duration of time face-to-face with the patient and/or family spent by the physician or other qualified health care professional providing psychotherapy for crisis, even if the time spent on that date is not continuous.

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For any given period of time spent providing psychotherapy for crisis state, the physician or other qualified health care professional must devote his or her full attention to the patient and, therefore, cannot provide service to any other patient during the same time period. The patient must be present for all or some of the service

5.1.3 Do not report Psychotherapy for Crisis with the following CPT codes.

. Psychiatric diagnostic evaluation-90791

. Other Psychotherapy-90832 to 90838

. Interactive Complexity-90785

. Family psychotherapy (without the patient present)-90846

. Family psychotherapy (with the patient present)-90847

. Multiple-family group psychotherapy-90849

6. Family psychotherapy

6.1 CPT code-90846 Family Psychotherapy (without the patient for 50 minutes)

Documentation requirements:

o This code is used when a psychiatrist or psychologist provides therapy for the family of a patient without the patient being presence.

o The therapist provides family psychotherapy in a setting where the care provider meet’s with the patient’s family. The family is part of the patient evaluation and treatment process.

o Family dynamics as they relate to the patient’s mental status and behavior are a main focus of the sessions and can be extended whenever medically necessary.

o Under Medicare rules, 90846 is only covered if the therapy is clearly directed toward the treatment of the patient, rather than to treating family member who may have issues because of the patient’s illness.

6.1.2 CPT code-90847 Family psychotherapy

o Family psychotherapy (conjoint psychotherapy with patient present).

o This code is used when the therapy includes the patient and family members for 50 minutes

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6.1.3 Documentation requirements:

o The therapist provides family psychotherapy in a setting where the care provider meet’s with the patient and family. The family is part of the patient evaluation and treatment process.

o Family dynamics as they relate to the patient’s mental status and behavior are a main focus of the sessions and can be extended whenever medically necessary.

o Documentation should include specific participation, contributions and reactions of each family member.

6.1.4 Multiple-family group psychotherapy CPT code-90849

This code is used when a psychiatrist or psychologist provides psychotherapy to a group of adult or adolescent patients and their family members for 50 minutes. The usual treatment strategy is to modify family behavior and attitudes.

6.1.5 All psychotherapy services described above are payable to psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse practitioners CNSs and PAs with these exceptions:

o CSWs are not eligible for payment for inpatient services (defined as inpatient hospital settings, partial hospitalization setting or skilled nursing homes for beneficiaries who are at that time receiving benefits under Medicare Part A payment for skilled services) represented by these codes: 90832, 90833, 90834, 90836, 90837, 90838, and 90785.

o CNSs may not render Psychoanalysis (CPT 90845)

o Psychotherapy codes that included an E/M component (90833, 90836, 90838) are payable to MDs, DOs, qualified CNSs, Nurse Practitioners and Physician Assistants. Each element of these services (therapy and E/M) must be reasonable and necessary and should be documented in the patient’s records.

7.0 Related Documents and Hyperlinks:

Novitas LCD for the State of New Mexico #L35101- Psychiatry Codes

www.apapracticecentral.org/reimbursement/billing/psychotherapy-codes.pdf

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8.0 Revision History:

Effective Rev Date Letter Document Author Description of Change 09/04/2014 A Kay Kennedy Initial Release.

07/17/2017 B JoAnn Martinez Revision

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