procedure code and description
90832 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 30 minutes with the patient and/or family member (time range 16-37 minutes)
90833 – Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 30 minutes with the patient and/or family member (time range 16-37 minutes), when performed with an evaluation and management service. – average fee payment – $60 – $70
90834 Psytx pt&/family 45 minutes
90837 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 60 minutes with the patient and/or family member (time range 53 minutes or more)
90838 – Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 60 minutes with the patient and/or family member (time range 53 minutes or more), when performed with an evaluation and management service.
90785 – Use the add-on code with 90832, +90833, 90834, +90836, 90837 and
90838 for interactive psychotherapy using play equipment, physical devices, language interpreter, or other mechanisms of communication
Psychotherapy
All of the individual psychotherapy codes (90804-90829) are deleted. A new series of psychotherapy codes replaces these codes, with the following differences:
• Site of service is no longer a criterion for code selection.
• Time specifications are changed to be consistent with CPT convention.
• “Individual” is eliminated from the code titles and psychotherapy time may include faceto-face time with family members as long as the patient is present for part of the session.
• Interactive psychotherapy codes are deleted. Interactive Complexity is reported with the add-on code +90785. This new code expands the types of communication difficulties that CPT recognizes (see above, Interactive Complexity).
• Psychotherapy (without medical evaluation and management services) (formerly reported as 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828) are now reported with psychotherapy codes 90832, 90834, and 90837.
• Psychotherapy with medical evaluation and management services (formerly reported as 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, 90829) are now reported with codes for E/M services plus a psychotherapy add-on code, +90833, +90836, and +90838.
Code “Exact” Time (in minutes) Actual Time Range (in minutes) 90832, +90833 30 16-37 90834, +90836 45 38-52 90837, +90838 60 At least 53
Psychotherapy is defined as the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the patient and through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development or support current evaluation of functioning. Psychotherapy services include ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement of family member(s) or others in the treatment process. Although maintenance per se is not covered, helping a patient maintain his/her highest level of functioning, such as a patient with borderline personality disorder, may be covered on a case-by-case basis. These case-by-case considerations must be supported by the evaluation and a plan with clearly identified goal(s).
Psychotherapy time may include face to face time with family members as long as the patient is present for part of the service.
To report both E/M and psychotherapy, the two services must be significant and separately identifiable.
The type and level of E/M service is selected first based upon the key components of history, examination, and medical decision-making.
Time associated with activities used to meet criteria for the E/M service is not included in the time used for reporting the psychotherapy service (i.e., time spent on history, examination, and medical decision making when used for the E/M service is not psychotherapy time). Time may not be used to determine E/M code selection. Prolonged Services may not be reported when E/M and psychotherapy are reported.
A separate diagnosis is not required for the reporting of E/M and psychotherapy on the same date of service.
Psychotherapy for Crisis
A major concept and addition to the psychotherapy section is the addition of codes for psychotherapy for crisis when psychotherapy services are provided to a patient who presents in high distress with complex or life threatening circumstances that require immediate attention.
These codes do not include medical services. In a crisis situation, psychiatrists may prefer the appropriate E/M code.
Documentation for Psychotherapy Services:
The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change.
Behavior modification is not a separate service, but is an adjunctive measure in psychotherapy. Additionally, a periodic summary of goals, progress toward goals, and an updated treatment plan must be included in the medical record.
Prolonged treatment must be well supported by the content of the medical documentation. Documentation must be present in the medical record supporting the medical necessity for ongoing treatment.
To establish medical necessity of the service, claims must be submitted with a covered diagnosis.
Family Psychotherapy
In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder for example, the provider may contact relatives and close associates to secure background information to assist in diagnosis and treatment planning.
Family psychotherapy services are covered only where the primary purpose of such psychotherapy is the
treatment of the patient’s condition. Examples include:
When there is a need to observe and correct, through psychotherapeutic techniques, the patient’s interaction with family members and/or
Where there is a need to assess the conflicts or impediments within the family, and assist, through psychotherapy, the family members in the management of the patient.
Group Psychotherapy
Group Psychotherapy is psychotherapy administered in a group setting with a trained therapist simultaneously providing therapy to several patients. Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional catharsis, instruction, insight, and support. To establish medical necessity of the service, claims must be submitted with a covered diagnosis.
Group therapy, since it involves psychotherapy, must be led by a person who is authorized by state statute to perform this service. This will usually mean a physician, clinical psychologist, clinical social worker, physician assistant, certified nurse practitioners, clinical nurse specialist, or other person authorized by the state to perform this service.
Limitations for Psychotherapy
While a variety of psychotherapeutic techniques are recognized for coverage, the services must be performed by persons authorized by their state to render psychotherapy services.
Psychotherapy services does not include teaching grooming skills, monitoring activities of daily living (ADL), recreational therapy (dance, art, play) or social interaction. It also does not include oversight activities such as housing, or financial management.
Severe and profound mental retardation is never covered for psychotherapy services.
Psychotherapy services are not covered when documentation indicates that senile dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective.
Multiple-family group psychotherapy is for those situations where family dynamics are occurring due to a commonality of problems in the family members under treatment and would generally be non-covered by Medicare. Such group therapy is directed to the effects of the patient’s condition on the family, and does not meet Medicare’s standards of being part of the provider personal services to the patient.
Group therapy does not include socialization, music therapy, recreational activities, art classes, excursions, sensory stimulation or eating together, cognitive stimulation, or motion therapy.
Self-help groups or support groups without a qualified professional present are not covered. When covered the group size should be of a size that can be successfully led (e.g., maximum of 12 people).
Psychotherapy Codes (with the patient and/or family member present): 90837/99354/9935
The CPT code 90837 Psychotherapy can no longer be billed for multiple units. This code may now only bebilled for the first hour of service. If there are multiple units for this service on the same day for the same member, DMS has directed use of the following add-on codes for subsequent hours if medically necessary.
• one (1) unit of 90837 (first hour – 60 minutes),
• one (1) unit of 99354 (second hour – 60 minutes), and
• up to two (2) 30-minute units of 99355 (third hour).
Providers may bill up to a maximum of three (3) hours of individual, family, or group psychotherapy or any combination to a client per day if medically necessary.
Family Psychotherapy: 90846 (without the patient present) 90847 (with the patient present) This service is limited to one (1) unit per member, per day. Add-on codes cannot be utilized with this service. If this service is provided to the same member, on the same day as psychotherapy services, please bill for psychotherapy services only as the 90837 allows for psychotherapy with patient and/or family member. Group Psychotherapy (other than of a multiple-family group): 90853
This service is limited to one (1) unit per member, per day. Add-on codes cannot be utilized with this service. Please note, this service may be billed for services provided to the same member, same day as psychotherapy with separate time interval.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Indications of Coverage and/or Medical Necessity:
This part of the policy has been divided into seven (7) sections addressing the following services:
I. Psychiatric Diagnostic Evaluation and Psychiatric Diagnostic Evaluation with Medical Services
II. Psychotherapy
III. Group Psychotherapy
IV. Family Psychotherapy
V. Psychoanalysis
VI. Interactive Complexity Services
VII. Psychotherapy for Crisis
Section II: Psychotherapy (procedure Codes 90832-90838)
Psychotherapy is the treatment of mental illness and behavior disturbances, in which the provider establishes a professional contact with the patient and through therapeutic communication and techniques, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, facilitate coping mechanisms and/or encourage personality growth and development.
Insight oriented, behavior modifying, and/or supportive psychotherapy refers to the development of insight or affective understanding, the use of behavior modification techniques, the use of supportive interactions, and the use of cognitive discussion of reality, or any combination of the above to provide therapeutic change.
Psychotherapy will be considered medically necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning. Psychotherapy services must be performed by a person licensed by the state where practicing, and whose training and scope of practice allow that person to perform such services.
Psychotherapy must be provided as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnoses. Some patients receive psychotherapy alone, and others receive psychotherapy along with medical evaluation and management services. These services involve a variety of responsibilities unique to the medical management of psychiatric patients such as medical diagnostic evaluation (i.e. evaluation of co-morbid medical conditions, drug interactions, and physical examinations), drug management when indicated, physician orders, interpretation of laboratory or other diagnostic studies and observations. The patient should be amenable to allowing insight-oriented therapy such as behavioral modification techniques, interpersonal psychotherapy techniques, supportive therapy, and cognitive/behavioral techniques to be effective.
Psychotherapy services are not considered to be medically reasonable and necessary when they are rendered to a patient who has a medical/neurological condition such as dementia, delirium or other psychiatric conditions, which have produced a severe enough cognitive deficit to prevent effective communication with interaction of sufficient quality to allow insight oriented therapy (i.e. behavioral modification techniques, interpersonal psychotherapy techniques, supportive therapy or cognitive/behavioral techniques). In these cases, evaluation and management or pharmacological codes should be used.
Psychotherapy services are not considered to be medically reasonable and necessary when they primarily include the teaching of grooming skills, monitoring activities of daily living, recreational therapy (dance, art play), or social interaction.
Psychotherapy times are for face-to-face services with the patient and/or family member. The patient must be present for all or some of the service. In reporting, choose the code closest to the actual time (i.e., 16-37 minutes for 90832 and 90833, 38-52 minutes for 90834 and 90836, and 53 or more minutes for 90837 and 90838). Do not report psychotherapy of less than 16 minutes duration.
Some psychiatric patients receive a medical evaluation and management service on the same day as a psychotherapy service by the same physician or other qualified health care professional. These services to be medically necessary should be significantly different and separately identifiable.
Section III: Group Psychotherapy (procedure Code 90853)
Group Psychotherapy is a form of treatment administered in a group setting with a trained group leader in charge of several patients. Since it involves psychotherapy it must be led by a person, authorized by state statute to perform this service. This will usually mean a psychiatrist, clinical psychologist, licensed clinical social worker, certified nurse practitioner, or clinical nurse specialist. The group is a carefully selected group of patients meeting for a prescribed period of time during which common issues are presented and generally relate to and evolve towards a therapeutic goal. Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional outpouring, instruction, and support. Medical diagnostic evaluation and pharmacological management may continue by a physician when indicated. The group size should be of a size that can be considered therapeutically successful (i.e., maximum 12 people).
Group therapy will be considered medically necessary when the patient has a psychiatric illness and /or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior patterns or maladaptive functioning in personal or social settings. The issues presented and explored in the group setting should evolve towards a theme or a therapeutic goal. Group psychotherapy must be ordered by a provider as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnosis. This treatment plan must be adhered to and should be endorsed and monitored by the treating physician or physician of record. The specialized skills of a mental health care professional must be required.
Group psychotherapy services are not considered to be medically reasonable and necessary when they are rendered to a patient who has a medical/neurological condition such as dementia, delirium, or other psychiatric conditions, which have produced a severe enough cognitive deficit to prevent effective communication including interaction of sufficient quality with the therapist and members of the group. Other services such as music therapy, socialization, recreational activities/recreational therapy, art classes/art therapy, excursions, sensory stimulation, eating together, cognitive stimulation, or motion therapy are not considered to be medically reasonable and necessary.
Section IV: Family Psychotherapy (procedure Codes 90846, 90847)
Family Psychotherapy is a specialized therapeutic technique for treating the identified patients’ mental illness by intervening in a family system in such a way as to modify the family structure, dynamics, and interactions which exert influence on the patient’s emotions and behaviors.
Family psychotherapy sessions may occur with or without the patient present. The process of family psychotherapy helps reveal a family’s repetitious communication patterns that are sustaining and reflecting the identified patient’s behavior. For the purposes of this policy, a family member is any individual who spends a significant amount of the time with the patient and provides psychological support to the patient, which may include but is not limited to a caregiver or significant other.
Family psychotherapy will be considered medically reasonable and necessary only in clinically appropriate circumstances and when the primary purpose of such psychotherapy is the treatment/management of the patient’s condition. Examples are as follows:
•when there is a need to observe and correct, through psychotherapeutic techniques, the patient’s interaction with family members; and/or
•where there is a need to assess the conflicts or impediments within the family, and assist, through psychotherapeutic techniques, the family members in the management of the patient.
Family psychotherapy must be ordered by a provider as an integral part of an active treatment plan for which it is directly related to the patient’s identified condition/diagnosis.
Family psychotherapy must be conducted face to face by physicians (MD/DO), psychologists, or other mental health professionals licensed or authorized by state statutes and considered eligible for reimbursement.
Family psychotherapy is considered to be medically reasonable and necessary when the patient has a psychiatric illness and/or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior or maladaptive functioning.
In certain types of medical conditions, such as the unconscious or comatose patient, family psychotherapy would not be medically reasonable or necessary. Also, procedure code 90849 (Multiple family group psychotherapy) would not be considered treatment directly related to the patient’s care and therefore would not be considered medically necessary.
A family psychotherapy session generally lasts for at least 45-50 minutes.
Section V: Psychoanalysis (procedure Code 90845)
Psychoanalysis is a treatment modality that uses psychoanalytic theories as the frame for formulation and understanding of the therapy process. These theories provide a focus on increasing self-understanding and deepening insight into emotional issues and conflicts which underlie presenting emotional difficulties. Typically therapists make use of exploration of unconscious thoughts and feelings which may relate to underlying emotional conflicts, interpretation of defensive processes which obstruct emotional awareness, and consideration of issues related to sense of self-esteem.
Psychoanalysis uses a special technique to gain insight into a patient’s unconscious motivations and conflicts using the development and resolution of a therapeutic transference to achieve therapeutic effect. It is a different therapeutic modality than psychotherapy.
The medical record must document the indications for psychoanalysis, description of the transference, and that psychoanalytic techniques were used. The physician using this technique must be trained and credentialed in its use. Clinical nurse specialists (CNS) and nurse practitioners (NP) are not eligible for payment for psychoanalysis. It is not a time-related code, but the service is usually 45 to 50 minutes in duration. The code may be billed once for each daily session regardless of the time involved. Psychoanalysis is generally considered unsuitable for psychoses.
Section VI: Interactive Complexity Services (procedure Code 90785)
Interactive complexity refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients.
The interactive complexity techniques are utilized primarily to evaluate children and/or adults who do not have the ability to interact through ordinary verbal communication. In the aforementioned instances, it involves the use of physical aids and nonverbal communication to overcome barriers to the therapeutic interaction between the clinician and the patient who has not yet developed or has lost either the expressive language communication skills to explain his/her symptoms and response to treatment or the receptive communication skills to understand the clinician if he/she were to use ordinary adult language for communication. An interactive technique may include the use of inanimate objects such as toys and dolls for a child, physical aids, and non-verbal communication to overcome barriers to therapeutic interaction, or an interpreter for a person who is deaf or in situations where the patient does not speak the same language as the provider of care.
If a patient is unable to communicate by any means, the interactive complexity codes should not be billed. This service is used in conjunction with codes for diagnostic psychiatric evaluation (90791, 90792), psychotherapy (90832, 90834, 90837), psychotherapy when performed with an evaluation and management service (90833, 90836, 90838, 99201-99255, 99304-99337, 99341-99350), and group psychotherapy (90853).
Interactive complexity may be reported with psychotherapy when at least one of the following communication factors is present during the visit:
• The need to manage maladaptive communication among participants (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) 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 third 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.
• 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 has lost expressive or receptive language skills to use or understand typical language.
Section VII: Psychotherapy for Crisis (procedure Codes 90839-90840)
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. 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.
procedure/HCPCS Codes
90785 Psytx complex interactive
90791 Psych diagnostic evaluation
90792 Psych diag eval w/med srvcs
90832 Psytx pt&/family 30 minutes
90833 Psytx pt&/fam w/e&m 30 min
90834 Psytx pt&/family 45 minutes
90836 Psytx pt&/fam w/e&m 45 min
90837 Psytx pt&/family 60 minutes
90838 Psytx pt&/fam w/e&m 60 min
90839 Psytx crisis initial 60 min
90840 Psytx crisis ea addl 30 min
90845 Psychoanalysis
90846 Family psytx w/o patient
90847 Family psytx w/patient
90853 Group psychotherapy
specific Coverage Requirements
Section I. Psychotherapy Psychiatric Therapeutic Procedures (90832-90838, 90845-90853, 90865
Codes 90832-90838 represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy
Codes 90845-90853 represent psychoanalysis, group psychotherapy, family psychotherapy, and/or interactive group psychotherapy
Code 90865 represents narcosynthesis for psychiatric diagnostic and/or therapeutic purposes.
Codes 90832-90838 represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy
Description: Procedures 90832-90838 (psychotherapy) are defined as “the treatment for mental illness and behavioral disturbances in which the physician or other qualified health care professional through definitive therapeutic communication attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development.” (CPT 2013, Professional Edition, p.485)
Documentation: The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change. Behavior modification is not a separate service, but is an adjunctive measure in psychotherapy. Additionally, a periodic summary of goals, progress toward goals, and an updated treatment plan must be included in the medical record. Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.
Procedure codes 90832-90838 (psychotherapy for 30 to 60 minutes) – report the code closest to the actual time (i.e., 16-37 minutes for 90832 and 90833, 38-52 minutes for 90834 and 90836, and 53 or more minutes for 90837 and 90838. Procedure codes 90833, 90836 and 90838 are add on codes that should be used in conjunction with evaluation and management (E/M) codes 99201-99239, 99304-99337, 99341-99350.
For psychotherapy sessions lasting 90 minutes or longer, the appropriate prolonged service code should be used (99354-99357). The duration of a course of psychotherapy must be individualized for each patient. Prolonged treatment may be subject to medical necessity review. The provider must document the medical necessity for prolonged treatment.
Comments: While a variety of psychotherapeutic techniques are recognized for coverage under these codes, the services must be performed by persons authorized by their state to render psychotherapy services. Healthcare providers would include: physicians, clinical psychologists, registered nurses with special training (as described in the “Indications” section), and clinical social workers. Medicare coverage of procedure codes 90832-90838 does not include teaching grooming skills, monitoring activities of daily living (ADL), recreational therapy (dance, art, play) or social interaction. Therefore, procedure codes 90832-90838 should not be used to bill for ADL training and/or teaching social interaction skills.
Psychotherapy codes that include an evaluation and management component are payable only to physicians, NPs and CNSs. The evaluation and management component of the services must be documented in the record. A psychotherapy code should not be billed when the service is not primarily a psychotherapy service, that is, when the service could be more accurately described by an evaluation and management or other code.
The duration of a course of psychotherapy must be individualized for each patient. Prolonged treatment may be subject to medical necessity review. The provider must document the medical necessity for prolonged treatment.
Codes 90845-90853 represent psychoanalysis, group psychotherapy, family psychotherapy, and/or interactive group psychotherapy
Code 90845:
Description: Procedure code 90845 involves the practice of psychoanalysis using special techniques to gain insight into and treat a patient’s unconscious motivations and conflicts using the development and resolution of a therapeutic transference to achieve therapeutic effect. It is a different therapeutic modality than psychotherapy.
Documentation: The medical record must document the indications for psychoanalysis, description of the transference, and the psychoanalytic techniques used.
Comments: The physician or other healthcare professional using this technique must be trained by an accredited program of psychoanalysis. 90845 is not time defined, but the service is usually 45 to 50 minutes and is billed once for each daily session.
Codes 90846, 90847, 90849:
Description: Procedure codes 90846, 90847, 90849 describe the treatment of the family unit when maladaptive behaviors of family members are exacerbating the beneficiary’s mental illness or interfering with the treatment, or to assist the family in addressing the maladaptive behaviors of the patient and to improve treatment compliance. Code 90846 is used when the patient is not present. Code 90847 is used when the patient is present. Code 90849 is intended for group therapy sessions to support multiple families when similar dynamics are occurring due to common issues confronted in the family members under treatment.
Documentation: The medical record must document the conditions described under the “Description” and “Comments” sections relative to codes 90846, 90847, and 90849.
Comments: The Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 70.1, states that family psychotherapy services are covered only where the primary purpose of such psychotherapy is the treatment of the patient’s condition. Examples include:
When there is a need to observe and correct, through psychotherapeutic techniques, the patient’s interaction with family members (90847).
Where there is a need to assess the conflicts or impediments within the family, and assist, through psychotherapy, the family members in the management of the patient (90846 or 90847).
The term ‘family’ may apply to traditional family members, live-in companions, or significant others involved in the care of the patient. Codes 90846 and 90847 are not timed but are typically 45 to 60 minutes in duration.
Codes 90846 and 90847 do not pertain to consultation and interaction with paid staff members at an institution. Facility staff members are not considered “significant others” for the purposes of this LCD.
Code 90849 represents multiple-family group psychotherapy and is generally non-covered by Medicare. Such group therapy is usually directed to the effects of the patient’s condition on the family and its purpose is to support the affected family members. Therefore, code 90849 does not meet Medicare’s standards of being a therapy primarily directed toward treating the beneficiary’s condition. Claims for 90849 may be approved on an individual consideration basis.
Code 90853:
Description: Code 90853 represents psychotherapy administered in a group setting, involving no more than 12 participants, facilitated by a trained therapist simultaneously providing therapy to these multiple patients. The group therapy session typically lasts 45 to 60 minutes. Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional catharsis, instruction, insight, and support.
Documentation: The record must indicate that the guidelines under the “Description” and “Comments” sections were followed.
Comments: Group therapy, since it involves psychotherapy, must be led by a person who is licensed or otherwise authorized by the state in which he or she practices to perform this service. This will usually mean a psychiatrist, psychologist, clinical social worker, clinical nurse specialist, or other person authorized by the state to perform this service. Registered nurses with special training, as described in the “Indications and Limitations of Coverage and/or Medical Necessity” section, may also be considered eligible for coverage. For Medicare coverage, group therapy does not include: socialization, music therapy, recreational activities, art classes, excursions, sensory stimulation or eating together, cognitive stimulation, or motion therapy, etc.
As a reminder, code 90785 is used when the patient or patients in the group setting do not have the ability to interact by ordinary verbal communication and therefore, non-verbal communication skills are employed or an interpreter may be necessary.
Code 90865 represents narcosynthesis for psychiatric diagnostic and/or therapeutic purposes
Description: Procedure code 90865 is used for the administration of sedative or tranquilizer drugs, usually intravenously, to relax the patient and remove inhibitions for discussion of subjects difficult for the patient to discuss freely in the fully conscious state.
Documentation: The medical record should document the medical necessity of this procedure (e.g., the patient had difficulty verbalizing their psychiatric problems without the aid of the drug). The record should also document the specific pharmacological agent, dosage administered, and whether the technique was effective or non-effective.
Use of CPT code 90865 is restricted to physicians (MD/DO) only.
Section II. Psychotherapy in Crisis 90839-90840
Description: “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.” (CPT 2013, Professional Edition, p.486)
Documentation: The record must indicate that the guidelines under the “Description” and “Comments” sections were followed.
Comments: “Codes 90839, 90840 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. 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.” (CPT 2013, Professional Edition, p.486)
Billing and Coding Guidelines
The main error that CERT has identified with the revised psychiatry and psychotherapy codes is not clearly documenting the amount of time spent only on psychotherapy services.
The correct E&M code selection must be based on the elements of the history and exam and medical decision making required by the complexity/intensity of the patient’s condition.
The psychotherapy code is chosen on the basis of the time spent providing psychotherapy.
When a beneficiary receives an Evaluation and Management Service (E&M) service with a psychotherapeutic service on the same day, by the same provider, both services are payable if they are significant and separately identifiable and billed using the correct codes. New add-on codes (in the bulleted list below) designate psychotherapeutic services performed with E&M codes. An add-on code (often designated with a “+” in codebooks) describes a service performed with another primary service. An add-on code is eligible for payment only if reported with an appropriate primary service performed on the same date of service.
Time spent for the E&M service is separate from the time spent providing psychotherapy and time spent providing psychotherapy cannot be used to meet criteria for the E&M service. Because time is indicated in the code descriptor for the psychotherapy procedure codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.
For psychotherapy services provided with an E&M service:
• Code + 90833: Psychotherapy, 30 minutes with patient and/or family member when performed with an E&M service (list separately in addition to the code for primary procedure)
• Code + 90836: Psychotherapy, 45 minutes with patient and/or family member when performed with an E&M service (list separately in addition to the code for primary procedure)
• Code + 90838: Psychotherapy, 60 minutes with patient and/or family member when performed with an E&M service (list separately in addition to the code for primary procedure)
For psychotherapy services provided without an E&M service, the correct code depends on the time spent with the beneficiary.
• Code 90832: Psychotherapy, 30 minutes with patient and/or family member• Code 90834: Psychotherapy, 45 minutes with patient and/or family member
• Code 90837: Psychotherapy, 60 minutes with patient and/or family member In general, providers should select the code that most closely matches the actual time spent performing psychotherapy. procedure® provides flexibility by identifying time ranges that may be associated with each of the three codes:
• Code 90832 (or + 90833): 16 to 37 minutes,
• Code 90834 (or + 90836): 38 to 52 minutes, or
• Code 90837 (or + 90838): 53 minutes or longer
Do not bill psychotherapy codes for sessions lasting less than 16 minutes.
Psychotherapy codes are no longer dependent on the service location (i.e., office, hospital, residential setting, or other location is not a factor). However, effective January 1, 2014, when E&M services are paid under Medicare’s Partial Hospitalization Program (PHP) and not in the physician office setting, the procedure outpatient visit codes 99201-99215 have been replaced with one Level II HCPCS code – G0463. Further information about this code can be found in the CY 2014 OPPS/ASC final rule that was published in the Federal Register on December 10, 2013.
Example: A geriatric psychiatrist (physician) billed for a level 3 E&M service (99213) and 45 minutes of psychotherapy (90836). The medical record contained one entry for the date of service and, at the top, a notation: “45 minutes”. It did not indicate whether the 45 minutes was spent providing the psychotherapy services or both services. An overpayment for the psychotherapy service and a billing error occur when there is no separate entry for the amount of time spent performing psychotherapy services.
Psychotherapy 90832-90834, 90836-90838
* Time conventions are consistent with procedure convention (more than 50 percent of stated time must be spent in order to report the code).
* Psychotherapy time may include face-to-face time with family members as long as the patient is present for part of the session.
add-on codes 90833, 90836, 90838.
o To report both an E/M code and a psychotherapy add on code, the two services must be significant and separately identifiable.
o The type and level of E/M service is selected first based upon the key components of history, examination, and medical decision making.
o Time may not be used as the basis of the E/M code selection
ICD-10 Codes that Support Medical Necessity
F01.51 Vascular dementia with behavioral disturbance
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
F03.90 Unspecified dementia without behavioral disturbance
F03.91 Unspecified dementia with behavioral disturbance
F04 Amnestic disorder due to known physiological condition
F05 Delirium due to known physiological condition
F06.0 Psychotic disorder with hallucinations due to known physiological condition
F06.1 Catatonic disorder due to known physiological condition
F06.30 Mood disorder due to known physiological condition, unspecified
F06.31 Mood disorder due to known physiological condition with depressive features
F06.32 Mood disorder due to known physiological condition with major depressive-like episode
F06.33 Mood disorder due to known physiological condition with manic features
F06.34 Mood disorder due to known physiological condition with mixed features
F06.4 Anxiety disorder due to known physiological condition
F06.8 Other specified mental disorders due to known physiological condition
F07.0 Personality change due to known physiological condition
F07.81 Postconcussional syndrome
F07.89 Other personality and behavioral disorders due to known physiological condition
F07.9 Unspecified personality and behavioral disorder due to known physiological condition
F09 Unspecified mental disorder due to known physiological condition
F10.10 Alcohol abuse, uncomplicated
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.121 Alcohol abuse with intoxication delirium
F10.129 Alcohol abuse with intoxication, unspecified
F10.14 Alcohol abuse with alcohol-induced mood disorder
F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions
F10.151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations
F10.159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified
F10.180 Alcohol abuse with alcohol-induced anxiety disorder
F10.181 Alcohol abuse with alcohol-induced sexual dysfunction
F10.182 Alcohol abuse with alcohol-induced sleep disorder
F10.188 Alcohol abuse with other alcohol-induced disorder
F10.19 Alcohol abuse with unspecified alcohol-induced disorder
F10.20 Alcohol dependence, uncomplicated
F10.21 Alcohol dependence, in remission
F10.220 Alcohol dependence with intoxication, uncomplicated
F10.221 Alcohol dependence with intoxication delirium
F10.229 Alcohol dependence with intoxication, unspecified
F11.10 Opioid abuse, uncomplicated
F11.120 Opioid abuse with intoxication, uncomplicated
F11.129 Opioid abuse with intoxication, unspecified
F11.20 Opioid dependence, uncomplicated
F11.21 Opioid dependence, in remission
F11.220 Opioid dependence with intoxication, uncomplicated
F11.221 Opioid dependence with intoxication delirium
F11.222 Opioid dependence with intoxication with perceptual disturbance
F11.229 Opioid dependence with intoxication, unspecified
F11.23 Opioid dependence with withdrawal
F11.24 Opioid dependence with opioid-induced mood disorder
F11.250 Opioid dependence with opioid-induced psychotic disorder with delusions
F11.251 Opioid dependence with opioid-induced psychotic disorder with hallucinations
F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified
F11.281 Opioid dependence with opioid-induced sexual dysfunction
F11.282 Opioid dependence with opioid-induced sleep disorder
F11.288 Opioid dependence with other opioid-induced disorder
F11.29 Opioid dependence with unspecified opioid-induced disorder
F11.90 Opioid use, unspecified, uncomplicated
F12.10 Cannabis abuse, uncomplicated
F12.20 Cannabis dependence, uncomplicated
F12.21 Cannabis dependence, in remission
F12.220 Cannabis dependence with intoxication, uncomplicated
F12.221 Cannabis dependence with intoxication delirium
F12.222 Cannabis dependence with intoxication with perceptual disturbance
F12.229 Cannabis dependence with intoxication, unspecified
F12.250 Cannabis dependence with psychotic disorder with delusions
F12.251 Cannabis dependence with psychotic disorder with hallucinations
F12.259 Cannabis dependence with psychotic disorder, unspecified
F12.280 Cannabis dependence with cannabis-induced anxiety disorder
F12.288 Cannabis dependence with other cannabis-induced disorder
F12.29 Cannabis dependence with unspecified cannabis-induced disorder
F12.90 Cannabis use, unspecified, uncomplicated
F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated
F13.120 Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated
F13.20 Sedative, hypnotic or anxiolytic dependence, uncomplicated
F13.21 Sedative, hypnotic or anxiolytic dependence, in remission
F13.220 Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated
F13.221 Sedative, hypnotic or anxiolytic dependence with intoxication delirium
F13.229 Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified
F13.230 Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated
F13.231 Sedative, hypnotic or anxiolytic dependence with withdrawal delirium
F13.232 Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbance
F13.239 Sedative, hypnotic or anxiolytic dependence with withdrawal, unspecified
F13.24 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood disorder
F13.250 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions
F13.251 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations
F13.259 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified
F13.26 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder
F13.27 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia
F13.280 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorder
F13.281 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual dysfunction
F13.282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
F13.288 Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorder
F13.29 Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic-induced disorder
F13.90 Sedative, hypnotic, or anxiolytic use, unspecified, uncomplicated
F14.10 Cocaine abuse, uncomplicated
F14.120 Cocaine abuse with intoxication, uncomplicated
F14.20 Cocaine dependence, uncomplicated
F14.21 Cocaine dependence, in remission
F14.220 Cocaine dependence with intoxication, uncomplicated
F14.221 Cocaine dependence with intoxication delirium
F14.222 Cocaine dependence with intoxication with perceptual disturbance
F14.229 Cocaine dependence with intoxication, unspecified
F14.23 Cocaine dependence with withdrawal
F14.24 Cocaine dependence with cocaine-induced mood disorder
F14.250 Cocaine dependence with cocaine-induced psychotic disorder with delusions
F14.251 Cocaine dependence with cocaine-induced psychotic disorder with hallucinations
F14.259 Cocaine dependence with cocaine-induced psychotic disorder, unspecified
F14.280 Cocaine dependence with cocaine-induced anxiety disorder
F14.281 Cocaine dependence with cocaine-induced sexual dysfunction
F14.282 Cocaine dependence with cocaine-induced sleep disorder
F14.288 Cocaine dependence with other cocaine-induced disorder
F14.29 Cocaine dependence with unspecified cocaine-induced disorder
F14.90 Cocaine use, unspecified, uncomplicated
F15.10 Other stimulant abuse, uncomplicated
F15.120 Other stimulant abuse with intoxication, uncomplicated
F15.20 Other stimulant dependence, uncomplicated
F15.21 Other stimulant dependence, in remission
F15.220 Other stimulant dependence with intoxication, uncomplicated
F15.221 Other stimulant dependence with intoxication delirium
F15.222 Other stimulant dependence with intoxication with perceptual disturbance
Covered Services and Limitation
Items and services that can be included as part of the structured, multimodal active treatment program, include:
Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, clinical nurse specialists, certified alcohol and drug counselors);
Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if required, must be a component of the physicians treatment plan for the individual;
Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients;
Drugs and biologicals that cannot be self administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29);
Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals;
Family counseling services for which the primary purpose is the treatment of the patient’s condition;
Patient training and education, to the extent the training and educational activities are closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition; and
Medically necessary diagnostic services related to mental health treatment.
Limitations
Noncovered Services-Benefit category Denials
Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;
Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or
Patients who are otherwise psychiatrically stable or require medication management only.
Noncovered Services-Coverage Denials
Services to hospital inpatients;
Meals, self-administered medications, transportation; and
Vocational training.
Noncovered-Reasonable and Necessary Denials
Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of a PHP; or
Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization.
CPT codes 90875 and 90876
