Join HRG coding expert Vanessa Brumfield as she reviews the coding & documentation requirements for behavioral health. We will Review CPT and documentation guidelines for outpatient behavioral health encounters. We will discuss common behavioral health diagnoses & CMS telemedicine reporting requirements for behavioral health.

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Presented By:
Vanessa Brumfield
Director, HIM Coding and Audit
July 22, 2020
Breaking Down Behavioral Health Coding

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Eligible Providers
• Physicians
• Clinical Psychologists
• Clinical Social Workers
• Clinical Nurse Specialists
• Nurse Practitioners
• Physician Assistants
• Certified Nurse-Midwives
• Independently Practicing Psychologists
https://www.cms.gov/files/document/medicare-mental-health-mln1986542.pdf

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Medical Necessity
“Medicare covers medically necessary and reasonable services or
supplies to treat the patient’s overall diagnosis and condition or
improve a malformed body member. Services must meet the
standards of good medical practice for diagnosis, direct care, and
treatment of the patient’s medical condition, and not mainly the
convenience of the patient, provider, or supplier.”
https://www.cms.gov/apps/glossary/default.asp?Letter=M&Language=English

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CPT Codes
Code Description
Interactive Complexity 90785 (add-on)
Psychiatric diagnostic evaluation with or without
medical services
90791 - 90792
Psychotherapy (time-based) 90832 - 90838
Psychotherapy in crisis (time-based) 90839 - 90840
Psychoanalysis, Family, Group therapy 90845 - 90853
Pharmacologic management (add-on) 90865

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Initial Visit
Psychiatric Diagnostic Evaluation
(90791 – 90792)
Diagnostic assessment with
or without medical services.
• Integrated biopsychosocial
assessment
• May include history, mental
status, & recommendations
• May include physical
examination as indicated
• Communication with family
& other sources
Evaluation and Management
(99201 – 99205)
Evaluation of problem-oriented
condition.
• History
• Exam
• Medical decision-making
• Counseling/coordination of care

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Interactive Complexity
• Delivery of psychiatric services are complicated due to specific
communication factors.
• Documentation:
• Does not have the ability to interact through normal verbal communicative channels
• Include adaptations utilized and rationale for employing interactive techniques
• Recommendations for future care
• Report when one of the following is present:
• Maladaptive communication among participants
• Caregiver emotions or behaviors complicating implementation of treatment plan
• Evidence or disclosure of event and mandated report to third party
• Use of equipment or other devices
CPT DESCRIPTION
90785 Interactive complexity (add-on)
Report with psychiatric diagnostic
eval, psychotherapy w/ E&M, group
therapy

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Psychiatric Diagnostic Evaluation
Documentation
• Current problem/symptoms
• Complete psychiatric and medical
history
• Medication and allergies
• Mental Status Examination
• Patient’s ability and capacity to
respond to treatment
• Treatment plan
• Time

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Psychotherapy
• Treatment of mental illness and behavioral disturbances through therapeutic
communication
• Attempts to alleviate the emotional disturbance(s)
• Reverse or change maladaptive patterns of behavior
• Encourage personal growth and development
• E/M must be separate and significant to report
• Medical and psychotherapeutic components
CPT DESCRIPTION REPORTING TIME
RANGE
90832
90833
Psychotherapy, 30 minutes with patient
Psychotherapy, 30 minutes w/patient w/ an E/M service
16 – 37
90834
90835
Psychotherapy, 45 minutes with patient
Psychotherapy, 45 minutes w/patient w/ an E/M service
38 – 52
90837
90838
Psychotherapy, 60 minutes with patient
Psychotherapy, 60 minutes w/patient w/ an E/M service
53 - 90

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Psychotherapy Documentation
Documentation for Psychotherapy Services
• Must indicate the time spent in the psychotherapy encounter
• Therapeutic maneuvers, such as behavior modification,
supportive or interpretive interactions
• Behavior modification
• Periodic summary of goals, progress toward goals, and an
updated treatment plan must be included in the medical record.
• Medical necessity for ongoing treatment.

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Psychotherapy for Crisis
• Urgent assessment and history of a crisis state, a mental status exam and a
disposition
• Presenting problem: Life-threatening, complex, requires immediate
attention
• Treatment includes:
• Psychotherapy
• Mobilization of resources to defuse crisis and restore safety
• Implementation of psychotherapeutic interventions to minimize the
potential for psychological trauma
90839 Psychotherapy for crisis, first 60 minutes
90840 Each additional 30 minutes

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Other Services: Family Psychotherapy
• Provider meets with the patient’s family with or without the
patient present.
• Emphasis of the visit the patient’s care and the family’s
involvement in the patient’s treatment.
• Reporting time: 26 minutes or more
90846 Family psychotherapy (w/o patient present), 50 minutes
90847 Family psychotherapy, conjoint (w/ patient present), 50
minutes

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Other Services: Family Psychotherapy
• Provider meets with the patient’s family with or without the
patient present.
• Emphasis of the visit the patient’s care and the family’s
involvement in the patient’s treatment.
90849 Multiple family group psychotherapy
90853 Group psychotherapy

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Pharmacologic Management
90863 – Add-on Code
• Including, prescription and review of medication, when performed with
psychotherapy services
• Do not report with E/M codes

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Telemedicine – PHE for COVID-19
Expansion of services include:
• Group psychotherapy
• Psychological and neuropsychological testing
Complete list of services:
https://www.cms.gov/Medicare/Medicare-general-information/telehealth/telehealth-codes
Current CMS reporting:
POS Report based on where the service
would have been provided
Modifier 95

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Diagnoses
Depressive Disorder
• Major
• With psychotic symptoms
• In remission (full or partial)
• Recurrent (with or without psychotic features)
• Single episode (mild, moderate, or severe)
• Organic
• Persistent
Attention Deficit Disorder
• Inattentive type
• With or without hyperactivity
• Combined type
• Other
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Diagnoses
Bipolar Disorder
• Type I or II
• Current (or most recent) episode
• Depressed (with or without psychotic features)
• Hypomanic
• Manic (with or without psychotic features)
• Mixed
• Severe depression (without psychotic features)
• Single manic episode
• Mild, moderate, severe
• In remission
• Full or Partial
• Most recent episode
• Depressed, hypomanic, manic, or mixed

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Diagnoses
Anxiety
• Depression
• Episodic paroxysmal
• Generalized
• Hysteria
• Neurosis
• Panic type
• Reaction
• Separation, abnormal (of childhood)
• State
• Other

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References
• AMA, 2020 CPT Professional Edition
• OPTUM, 2020 ICD-10-CM Professional for Physicians
• Medicare Mental Health Booklet, January 2020
https://www.cms.gov/files/document/medicare-mental-health-mln1986542.pdf
• Telehealth list of behavioral health services
https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

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