Medicare Identifies Numerous Improper Payments Associated With Psychiatry and Psychotherapy Codes

Medicare has uncovered numerous improper payments associated with psychiatry and psychotherapy CPT codes that underwent revision on Jan. 1, 2013.

This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter (pdf), a newsletter from CMS developed to help providers understand the major findings identified by Medicare administrative contractors, recovery auditors and other governmental organizations, such as the Office of Inspector General.

As the newsletter notes, the main error Medicare's Comprehensive Error Rate Testing (CERT) program identified with the revised codes concerns not clearly documenting the amount of time spent only on psychotherapy services. Selection of the correct evaluation and management (E&M) code must be based on the elements of the history and exam and medical decisionmaking required by the complexity/intensity of the patient's condition. Choose a psychotherapy code on the basis of the time spent providing psychotherapy.

When a beneficiary receives an E&M service with a psychotherapeutic service on the same day, by the same provider, Medicare will pay for both services if they are significant and separately identifiable and billed using the correct codes.

New add-on codes (as identified 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. Medicare notes that 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. Since time is indicated in the code descriptor for the psychotherapy CPT 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.

The new add-on codes for psychotherapeutic services performed with an E&M services are as follows:

  • +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).
  • +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).
  • +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. These codes are as follows:

  • 90832: Psychotherapy, 30 minutes with patient and/or family member.
  • 90834: Psychotherapy, 45 minutes with patient and/or family member.
  • 90837: Psychotherapy, 60 minutes with patient and/or family member.

In general, Medicare advises selecting the code that most closely matches the actual time spent performing psychotherapy. CPT provides flexibility by identifying time ranges that may be associated with each of the timed codes:

  • 90832: 16-37 minutes
  • 90834: 38-52 minutes
  • 90837: 53 minutes or longer

Medicare says you should 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 and not in the physician office setting, the CPT outpatient visit codes 99201-99215 have been replaced with one Level II HCPCS code: G0463.

Insufficient Documentation Causes Most Improper Payments

Medicare notes that insufficient documentation is the cause of most of the improper payments identified by the CERT program. "Insufficient documentation" means that something was missing from the medical records. Examples:

  • No documentation of the amount of time spent with the patient (length of the session);
  • No documentation of modalities of treatment furnished (e.g., cognitive restructuring, behavior modification) to effect improvement;
  • No documentation of progress to date; and
  • No updated treatment plan.

Examples of Improper Payments for Psychiatry and Psychotherapy Services

Medicare provides the following as examples of improper payments for psychiatry and psychotherapy services:

Example: Insufficient documentation and no additional documentation received. A geriatric psychiatrist (physician) billed for a level 3 E&M service (99213) and 45 minutes of psychotherapy (90836). A print out from an electronic health record showed an authenticated visit note indicating total face to face time of 45 minutes. The record did not separately indicate the time spent providing psychotherapy services. Additional requests for the physician's documentation supporting the time spent in the psychotherapy encounter and for the psychotherapy maneuvers provided on the billed date of service did not result in any other documentation.

The CERT reviewer scored this claim as an overpayment due to insufficient documentation and the Medicare Administrative Contractor (MAC) recouped the payment from the provider.

Example: Insufficient documentation. A neuropsychiatrist (physician) billed for a level 4 E&M service (99214) and 60 minutes of psychotherapy (90838). An office visit note was provided that included this statement: "…more than 50% of the time was spent in counseling or coordination of care. This visit lasted 60 minutes." No other documentation was submitted. Specifically, the psychotherapy service documentation did not indicate the time in minutes, and the documentation submitted did not adequately describe the service defined by the HCPCS code billed.

The CERT reviewer scored the psychotherapy service as an overpayment due to insufficient documentation. The MAC recouped the payment from the provider.

Example: Insufficient documentation. A psychiatrist (physician) billed for a level 5 E&M service for a new patient (99205) and 60 minutes of psychotherapy (90838). The documentation submitted for review did not include the amount of time spent in the psychotherapy encounter. Additional requests for the physician's documentation of this information were made and an addendum to the record (dated seven months after the date of service) was received. The additional information did not contain specific goals or a treatment plan.

The CERT reviewer scored the psychotherapy service as an overpayment due to insufficient documentation and the MAC recouped the payment from the provider.

Example: Insufficient documentation. A professor of psychiatry (physician) billed for a level 3 E&M service (99213) and 45 minutes of psychotherapy (90836). Detailed office notes that supported both the E&M service and psychotherapy services were provided. However, the documentation stated "35 minutes of cognitive-behavior therapy." The code was changed to 90833, which indicates 30 minutes with patient and/or family member when performed with an evaluation and management service.

The CERT reviewer scored the psychotherapy service as an overpayment due to a service incorrectly coded and the MAC adjusted the payment.

Benefits of Outsourcing Psychiatry and Psychotherapy

If you are struggling to properly code and bill for psychiatry and psychotherapy services, you may not only be leaving money on the table but could risk overbilling for services, thus triggering a false claims investigation that may result in your receiving a significant fine.

To avoid these scenarios, consider outsourcing your psychiatry medical billing to PGM Billing. PGM has more than 30 years of coding and billing experience, and is well-versed in the nuances of medical billing for psychiatry. The veteran PGM team works with providers to increase their collections revenue, decrease costs and reduce coding and billing errors. 


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