PIMSY 2013 CPT Code Changes: Basic Q&A
HELP! How can I make sure that I’m in compliance with the upcoming CPT® code changes!?
- The new CPT® codes for Psychiatry and Psychotherapy are mandated on a federal level by HIPAA, and all practitioners are required to be in compliance with the change in codes as of January 1, 2013. Additionally, the old codes that are being replaced will no longer be in existence and can no longer be used. There will be no delay in these changes.
- The changes will affect billing systems, contracts with payers and documentation requirements. Insurers, including Medicaid and Medicare, can make pricing and coverage decisions within the remaining, new and modified codes. You may need to amend your contracts with payers, public and private.
- Further research is required by each practice before the January 1st change date to make sure that practices code to their payers’ specifications, public and private. While this informational guide in intended to help practices make sense of the change regulations, it is the responsibility of each practice to insure compliance, and we highly recommend that practices obtain their own copy of the AMA 2013 CPT® Code Book for details (800.621.8335). You can obtain an overview in chart form on our CPT® Code Changes PDF and access additional resources via our CPT Code Changes Resource Center.
What about old and new codes straddling the change-over date of January 1st, 2013? If you have open authorizations that straddle the change-over period, you may need to apply for new authorizations. The former codes may not have been included in the maximum visit limits. Now, with psychiatrists using the e&m (evaluation & management) codes, if those codes are included in the maximum event limits, the authorizations will be exhausted more quickly.
Ok, so what are the major changes that I need to be aware of? What’s the overall picture before I start calling all of my payers? Can you give me the specific code change basics?
- The changes affect CPT® codes, which are the numeric codes used for billing; not the ICD-10 or DSM-IV or 5 codes, which are for diagnosing.
- The new CPT® codes for Psychiatry and Psychotherapy are mandated on a federal level by HIPAA, and all practitioners are required to be in compliance with the change in codes as of January 1, 2013. Additionally, the old codes that are being replaced with no longer be in existence and can no longer be used.
- Whereas the old codes were differentiated by the site of service, the new codes are not limited by the site of service; the same codes will be used in any site of service. Inpatient and outpatient psychotherapy codes will be replaced by a single set of codes to be used for both settings.
- With the old codes, e&m was fixed at the lowest level, meaning what a nurse could do without the physician present. The new codes allow for different levels of both psychotherapy and e&m (evaluation and management) work.
- All mental health professionals will use the same appropriate codes for psychotherapy, but psychiatry will change how they bill for medical services.
- The 3 new psychotherapy codes have specific time restrictions, versus the time range of the previously used codes.
- Add-on codes have been created for psychiatry, which are services performed in addition to a primary service and are therefore not stand-alone.
- The code numbers & descriptions for 90845, 90846, 90847, 90849 and 90853 (psychoanalysis, family psychotherapy (both with and without the patient), multi-family group psychotherapy and group psychotherapy) will not change.
- 90785 has been added for interactive complexity.
- New codes have been added for crisis.
- There will be new add-on codes for specific services that can only be provided in combination with other diagnostic evaluation, psychotherapy and group psychotherapy services: ie, psychotherapy plus e&m work. They allow for a 2nd code to be billed with the primary service code, and the current codes for interactive psychotherapy are being eliminated and replaced with add-on codes to expand their interactive complexity.
- The new interactive complexity add-on code, 90785, is used when there are factors that complicate the delivery of a mental health procedure and may be reported with codes for diagnostic evaluation, psychotherapy and group psychotherapy. At least one of several circumstances identified in the 2013 CPT® code book that complicate the delivery of care must pertain in order for providers to bill the interactive complexity code as an add-on to the principal psychiatric procedure.
New Psychotherapy & Diagnostic Codes
- The new basic psychotherapy codes are:
90832: 30 minutes with patient and/or family member, no longer site specific
90834: 45 minutes with patient and/or family member, no longer site specific
90837: 60 minutes with patient and/or family member, no longer site specific
What happens if the session is in between 30-45 minutes and/or 45-60 minutes?
Between 1-15 minutes: not reported
90832: between 16-37 minutes: patient must be present for all or some of service
90834: between 38-52 minutes: patient must be present for all or some of service
90837: 53 minutes and beyond: patient must be present for all or some of service
- 90801 and 90802 will be replaced by 1 of 2 e&m codes: 90791 will be used for the psychiatric diagnosis evaluation without a medical evaluation provided by any mental health provider. 90792 will be used for the psychiatric diagnosis evaluation provided by a physician and including medical services, such as lab evaluation, prescriptions, etc.
These codes can only be used once per day. They can’t be reported with e/m code on the same day by the same provider. They can’t be reported with psychotherapy service codes on the same day.
New Crisis Codes
- 90839 has been added for a crisis psychotherapy session requiring urgent assessment and history of the crisis state, mental status exam and disposition. There is an add-on code to be used if the session lasts longer than 60 minutes: +90840 for each additional 30 minutes beyond 60 minutes.
- In order for the new crisis codes to apply, the presenting problem must typically be life threatening or complex and require immediate attention to a patient in high distress.
- The new crisis psychotherapy codes are now covered under “carrier pricing”, means that payment amount is now determined by the carrier/payer, not CMS. Please consult the 2013 CPT® code book for additional information.
- 90862, pharmacologic management, has been eliminated and is replaced by new add on code +90863: pharmacologic management, including prescription and review of medications, when performed with psychotherapy services. This add-on code is reported only with the standard psychotherapy codes 90832, 90834, 90837.
- Prescribing health care professionals who provide evaluation and management (E/M) services as well as psychotherapy will also have additional options, depending on the type of service provided: they can report an e&m code along with a psychotherapy add-on code if both e&m and psychotherapy are provided; or they can simply report an e&m code if only e&m is provided.
- There is a HCPCS (Healthcare Common Procedure Coding System) code, M0064, that may be used for a brief (5-10 minute) office visit for monitoring or changing drug prescriptions for the treatment of mental, psychoneurotic and personality disorders. Check with your payers for approval of code M0064!
- The e&m (evaluation and management) codes are a category of CPT® code. They begin with a 99 and end with a 1 or 2, which indicates their level of complexity: e&m codes ending in 1 are the least complex while 2 are the more complex.
- When using both e&m and psychotherapy codes, both services must be separately identifiable. Time is the basis for the psychotherapy codes but not the e&m code, and time spent on e&m services is not counted towards psychotherapeutic services.
- For example, what was formerly coded as 90805, outpatient psychotherapy with e&m services, 20-30 minutes would now be coded as the appropriate e&m code +90833 (30 minutes), +90836 (45 minutes) or +90838 (60 minutes).
Disclaimer: PIMSY EMR/SMIS has gathered information from various resources believed to be authorities in their field. However, neither PIMSY EMR/SMIS nor the authors warrant that the information is in every respect accurate and/or complete. PIMSY EMR/SMIS assumes no responsibility for use of the information provided. Neither PIMSY EMR/SMIS nor the authors shall be responsible for, and expressly disclaim liability for, damages of any kind arising out of the use of, reference to, or reliance on, the content of these educational materials. These materials are for informational purposes only. PIMSY EMR/SMIS does not provide medic al, legal, financial or other professional advice and readers are encouraged to consult a professional advisor for such advice.
CPT Copyright 2011 AMA. All Rights Reserved. The AMA 2013 CPT Code Book can be purchased at: www.amabookstore.com or by calling 800.621.8335. Visit our resource center and check out our Additional Q&A post for additional information.
Leigh-Ann Renz is the Marketing & Business Development Director for PIMSY EMR.