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). 1 Psychologists Services 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. 7/17/17 Page 2 Psychologists Services 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. 7/17/17 Page 3 Psychologists Services . 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 7/17/17 Page 4 Psychologists Services 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