Coding and Reimbursement

The Current Procedure Terminology (CPT) code set is used to denote the medical and surgical procedures and diagnostic services rendered by clinicians. The CPT coding system provides a uniform language for describing these services for all billing and documentation and, under HIPAA, is required to be used to record care by all health care professionals in the United States.

For the clinician, the key to appropriate insurance reimbursement lies in accurate procedure coding. Coding errors can lead to delayed payments or rejections of submitted claims. Consistent errors may trigger audits, or even charges of fraud and abuse, and removal from managed care networks. Always verify CPT information with the AMA’s current CPT manual, which is the ultimate authority on procedure coding.

When billing outpatient E/M on the basis of time, psychiatrists may now use the total time on the date of the service related to the patient encounter, not just the face-to-face time.
This includes:

• Preparing to see the patient (e.g., review of test, records)
• Obtaining and/or reviewing separately obtained history
• Performing a medically necessary exam and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other healthcare professionals (when not reported separately)
• Documenting clinical information in the electronic or paper health record
• Independently interpreting results of tests/labs and communication of results to the family or caregiver
• Care coordination (when not reported separately)

Counseling and/or coordination of care will no longer need to dominate the service for these codes. Use the billing practitioner’s time only, not clinical or non-clinical staff time. The nature of the work must require practitioner knowledge and expertise. Waiting on hold for pre-cert authorization would not qualify; a peer-to-peer discussion with a physician at an insurance company would qualify.

E&M (Evaluation & Management) Codes – Time Based

Adoption of New Time Standards: CPT 2024 has removed the time ranges from both new and established office/outpatient E/M codes, replacing them with a single total time amount. This change is aimed at making the office codes more consistent with the language of other timed E/M codes.

Use only clinician time, not staff member time, when using time to select an office/outpatient code and the add-on prolonged care code.

Prolonged Service With or Without Direct Patient Contact on the Date of an Office or Other Outpatient Service (99417 & G2212)

Two new prolonged service codes were created for use when outpatient E/M services exceed each 15 minutes beyond the highest level E/M code (99205, 99215). One is for use with Medicare patients (G2212) and the other is a CPT code (99417). Check with your non-Medicare payers to determine which to use and check the specific requires for use which vary between the two codes.

The new add-on prolonged services code may only be used with 99205 and 99215. It may not be used with any other office/outpatient code.

• You can’t report the new add on code on the same day as non-face-to-face prolonged care codes 99358, 99359 or face-to-face prolonged care codes 99354, 99355.
• The time reported must be 15 minutes, not 7.5 minutes.
• The entire 15 minutes must be done, in order to add on this new, prolonged services code to 99215 and 99205.

Consultation without patient present

1. Select an E&M: (99213/99214, etc)
2. Add: 90887 to encounter
3. Include Dx: Z71.0  – Person encountering health services to consult on behalf of another person as primary dx

90887 is used when the treatment of the patient may require explanations to the family, employers or other involved persons for their support in the therapy process. This may include reporting of examinations, procedures, and other accumulated data.

90846 – Family Psychotherapy without patient present