Medical Billing and Coding Healthcare Blog

The Centers for Medicare and Medicaid Services (CMS) recently released a Medicare Learning Network podcast which was intended to clarify the correct use of certain HCPCS modifiers, specifically when billing for wrong surgery on a patient.

CMS discussed the HCPCS modifier -PC (Wrong Surgery on Patient), which was established in CR6405 (pdf), along with two other modifiers, for use in Medicare billing, to be added, where appropriate, to all claim lines related to surgical error.

CMS noted that providers may be incorrectly using the HCPCS modifier -PC to indicate the professional component for certain services not related to surgical error when the modifier -26 should have been used. CMS stated that providers need to be aware that the use of the -PC modifier on Medicare claims will result in a claim being denied.

CMS noted that modifier -PC is used to identify wrong surgery on a patient. The modifier -PC is to be added, where appropriate, to all claim lines related to a surgical error. Modifier -26, on the other hand, is used to identify the professional component of a service or a procedure.

To download the podcast, click here (zip). To download the MLN Matters article on "Clarification of the Use of Modifiers When Billing 'Wrong Surgery on a Patient,'" click here (pdf).

Struggling with how to properly prepare claims for submission to Medicare, Medicaid and other payers? Seeing an increase in denials? Feel like you are spending too much on billing staff? Consider outsourcing your billing to PGM Billing, a leading provider of physician billing services. Contact PGM today to learn how we can help maximize your reimbursement, reduce your costs and streamline operations.

Following substantial changes to the current procedural terminology (CPT) psychiatry codes, the American Psychiatric Association updated its frequently asked questions (FAQs) about coding and reimbursement for psychiatrists.

The update occurred in March. If your organization performs mental health billing and coding, these FAQs may be a valuable resource to review.

The following are the questions addressed in the FAQ:

  • I understand there are now two codes to use for a standard initial psychiatric diagnostic evaluation, 90791 and 90792. Why was this done?
  • I understand that instead of using the previous psychotherapy codes with E/M services (90805, 90807), we now must bill using the appropriate E/M code from the 99xxx series of codes (i.e., 99211, 99212, etc.) and a timed add-on code for the psychotherapy. What exactly is an add-on code?
  • What is an E/M code?
  • I'd never used the CPT evaluation and management codes before, is there somewhere I can find out about how to use them?
  • What E/M code would I be most likely to use to replace the basic E/M services I've been providing to my patients with whom I do psychotherapy and evaluation and management (for which I used to code 90807)?
  • What E/M codes do I use when I see a patient in a psychiatric residential treatment center?  
  • Can I choose the E/M code on the basis of time spent providing counseling and coordination of care and also bill for psychotherapy using the psychotherapy add-on?
  • In my outpatient practice I often see patients for medication management and previously used CPT code 90862, which was deleted in 2013. What code will I use in place of 90862?
  • Are the times listed for the add-on psychotherapy codes in addition to the time spent doing the E/M or is the time spent doing the E/M included in the time listed for the psychotherapy?
  • I am a solo practitioner and generally see my patients for both E/M and psychotherapy on a weekly basis. Does the E/M code I bill limit the psychotherapy code I can bill?
  • I take no insurance in my practice, but give my patients invoices for my services, which they submit to their insurance company for reimbursement. I see my patient regularly for psychotherapy along with medical evaluation, and in the past have always coded for the visit with 90807. Under the new coding format, the patient is required to submit a bill with the new codes. I will code using 99212 (since almost all my patients are stable and just require minimal E/M) and 90836, the add-on psychotherapy code for 45 minutes of psychotherapy. My question is, with the new CPT codes, am I required to apportion my fee between these two codes? If so, is there a reasonable way to do this?
  • I'm a solo practitioner and still file paper claims, how do I fill out the 1500 form to show I've done an E/M service with psychotherapy?
  • I am a child psychiatrist and, in the past, generally billed using one of the interactive psychotherapy codes. What do I use now?
  • I practice at a community mental health center where the billing department has told me that I cannot use E/M codes because "it's not allowed" and because no insurance company, including Medicare, will reimburse for them. I have never understood this and am now wondering whether we will suddenly be able to use E/M codes in 2013 or whether we're going to have trouble getting paid for anything.
  • What CPT code would be appropriate for a psychiatrist to bill for the evaluation of a patient in the emergency room setting? Would the ER evaluation and management CPT codes (99281-99291) be appropriate if the patient was already seen by a clinical social worker and the clinical social worker is billing for the psychiatric evaluation by using CPT code 90791? Or, would the psychiatrist be allowed to bill for CPT code 90792 on the same day the clinical social worker used CPT 90791?
  • If during an evaluation or a follow-up session, meds are NOT prescribed, but the patient is assessed as to whether meds would be appropriate, can we still consider that an E/M?
  • If the psychiatrist sees the patient and does 30 minutes of combined psychotherapy and medication management, and then the patient sees a social worker for 30 minutes of psychotherapy alone, what should they bill?
  • Do you recommend using the E/M new patient codes or 90792?
  • What is the difference between Psychotherapy with E/M versus E/M with Psychotherapy?
  • I am in-network for several insurance companies and they don't seem to be dealing correctly with the new coding. One of them is paying me less than it did last year even though I am providing the same service, albeit using different coding, and another is saying I should collect two copays from my patients even though I know this is wrong. What can I do?
  • What are the times for the various E/M codes for established patients, and is there any reason you couldn't use the 50% counseling and coordination of care for every follow up visit if it applies?
  • What constitutes "counseling and coordination of care"?
  • Is 30 minutes now the minimum face- to- face time for psychotherapy with a patient?
  • Family members of a man with serious mental illness who is not a patient of mine have asked to see me for assistance with navigating the mental health system on behalf of the patient and for help in dealing with the patient at home. I was thinking of using 90846 and calling it Family Therapy without the patient present, but since the patient is not part of my practice this seems questionable.
  • What is the difference between a new outpatient E/M visit versus an established outpatient visit?
  • If you are a small psychiatric office and purchasing CPT books, would it be best to purchase AMA CPT or ICD-9-CM VOL 1-3? Bundles are cheaper.
  • Are there visit note templates that have been developed for psychiatrists to easily check off the bullets necessary for E/M coding?
  • Does 90792 cover deciding and prescribing medications in the session?
  • Are there specific requirements for 90792, and are there other codes for new patients beyond 90791 and 90792?
  • Is the 90863 code for RNs to use?

To view the answers, click here (pdf).

Medical billing for psychiatrists is complex and time consuming. To ensure proper reimbursement is collected, more psychiatrists are outsourcing their medical billing to PGM Billing, one of the nation's leading providers of mental health billing services. Contact PGM today!

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