Psychiatry medical billing and coding key services to document
Psychiatry Medical Billing and
Coding - Key Services to Document
Staying up-to-date with the latest codes is crucial to successfully code for
psychiatric services as well as those of all other medical specialties.
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Accurate medical coding services are critical for any medical specialty including
psychiatry to ensure correct and timely reimbursement for services provided to
patients. Coding errors like upcoding can impact any practice and the consequences can
be severe. A 2018 AMA blog had highlighted the case of a psychiatrist who was fined
$400,000, and permanently excluded from taking part in Medicare and Medicaid in part
due to upcoding error in claim submission. The issue was that he billed for 30- or 60-
minute face-to-face sessions with patients when, in reality, he was only meeting with
patients for 15 minutes each to do medication checks.
Medscape’s latest article discusses how to accurately code certain key services that
psychiatrists often provides.
Psychiatric diagnostic evaluation and re-evaluation
Psychological testing and evaluation is done to determine the cause of psychological
symptoms and disorders, and to determine the correct diagnosis and follow up with the
appropriate course of treatment.
This diagnostic evaluation is usually reported with two codes - one with medical services
for use by psychiatrists, psychiatric nurse practitioners, and psychiatric physician
assistants; and another for an evaluation without medical services for use by social
workers, psychologists, and other licensed therapists.
90791 Psychiatric/psychological diagnostic interview without medical services
90792 Psychiatric diagnostic interview (for prescribers / medical services)
Medical services may consist of any medical activities such as performing elements of a
physical exam or considering writing a prescription or modifying psychiatric treatment
based on medical co-morbidities.
Some key points regarding these codes in CPT book include:
These codes may be used instead of seeing the patient if information needs to be
obtained from family members, guardians, or others
They may be billed more than once if the patient is seen on one day and a family
member or other party is interviewed on another day. Here, both evaluations can
be reported as if provided to the patient
No time limit is instructed about the frequency of reporting the psychiatric
For a break in treatment, or if a patient needs a new evaluation after a
hospitalization, it may be billed again
Do not bill these codes on the same day as psychotherapy in crisis codes
Medication management and psychotherapy
Both these procedures have to be documented at the same visit. With the deletion of
medication management codes, psychiatric practices were recommended to use
evaluation and management (E/M) codes.
Established patient visit codes are most common (CPT 99201–99215), as medication
management is frequently performed in an office or clinic setting. Also, it is performed
on patients who are known to the prescribing clinician.
99212 for a stable patient, who just needs a prescription refill,
99214 for a patient with a very complex situation
If only medication management is performed, the clinician may select the level of
office visit (or other E/M service) based on the key components of history, exam,
and medical decision-making, or on time.
When both medication management and psychotherapy are provided on the
same day, make sure to select an add-on psychotherapy code with the office
Psychotherapy code is billed based on the time, while the office visit must be
selected based on the level of history, exam, and medical decision-making that is
Crisis codes are used for emergency sessions with patients who are in high distress and
under complex or life-threatening circumstances that demand immediate attention.
90839: Psychotherapy for crisis; first 60 minutes
+90840: Each additional 30 minutes
These codes describe face-to-face time with the patient and/or family member and can
be used in any location when a patient needs an urgent assessment and history during a
crisis state, a mental status exam, and an immediate plan for psychotherapeutic
intervention. While the code 90839 needs to be used for 30-74 minutes of time, add-on
code can be used for additional 30-minute increments. Remember not to report these
codes in addition to the psychiatric diagnostic evaluation or psychotherapy or other
Blog.therapynotes.com explains that when billing crisis codes, make sure the
A preliminary assessment of risk, mental status, and medical stability
The need for further evaluation or referral to other mental health services (if
Communication with contacts who may have pertinent information for the
Substance use (if applicable)
Outcome of the session
Individual and family therapy
Also referred to as counseling or psychotherapy Individual therapy, individual therapy
allows the patient to freely provide information with no negative consequence. At the
same time, family therapy help aid the person back to recovery.
90846 Family psychotherapy (without the patient present), 50 minutes
90847 Family psychotherapy (conjoint therapy) (with the patient present), 50
Because the code is defined as 50 minutes, over 25 minutes must be spent in order to
bill the code. In cases where family members are present in an individual therapy
session, the focus of this therapy is on the individual. So, bill the individual
Interactive Complexity Add-on Code
According to CMS, “Interactive Complexity (90785) is an add-on code specific for
psychiatric services and refers to communication difficulties during the psychiatric
procedure.” This code may be added to the diagnostic psychiatric evaluation (90791,
90792), to psychotherapy services (90833–90838), and to group psychotherapy (90853).
Interactive complexity can be reported with psychiatric procedures when at least one of
the following communication difficulties is present:
The need to manage maladaptive communication related to high anxiety, high
reactivity, repeated questions, or disagreement among participants that
complicates delivery of care
Caregiver emotions/behavior that interfere with implementation of the
Patient with limited language proficiency
Use of play equipment, physical devices, interpreter or translator to overcome
significant language barriers
As these coding and documentation can be time consuming and labor intensive,
psychiatric practices, individual psychiatrists, clinics, community mental health centers
and hospitals can rely on professional medical billing companies to prepare their
medical claims. Such companies will provide services from experienced coders who are
up to date with the latest psychiatry medical coding standards.