1. UMass Memorial HealthCare, Inc. Corporate Compliance
2013 CPT Changes
Community Healthlink

2. Objective Introduce 2013 CPT Code changes for Psychiatric Services
Introduce documentation template for pharm managment services
Review E/M leveling and how to appropriately apply codes

3. Definition Add-on code Identified by a + in front of the code
CPT definition –
Add-on codes are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code. All add-on codes found in the CPT book are exempt from the multiple procedure concept (modifier- 51)

4. Interactive Complexity
Add-on code to be reported with:
Diagnostic Psychiatric Evaluations (90791, 90792)
Psychotherapy (90832, 90834, 90837)
Psychotherapy when performed with E/M codes (90833, 90836, 90838, , , )
Group Psychotherapy (90853)
Interactive complexity refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include:
more difficult communication with discordant or emotional family members
engagement of young and verbally undeveloped
impaired patients
Factors typically present with patients who:
have other individuals legally responsible for care
request others to be involved in care during visit (family, interpreter)
require the involvement of other third parties(welfare, probation officer)

5. Interactive Complexity continued
Psychiatric procedures may be reported “with interactive complexity” when at least one of the following is present:
Need to manage maladaptive communication among participant that complicates delivery of care.
Caregiver’s emotions or behavior interferes with the caregiver’s understanding and ability to assist in treatment plan.
Evidence or disclosure of sentinel event and mandated report to 3rd party (state agency) with initiation of discussion of event and/or report.
Use of play equipment, or other physical devices, interpreter, or translator for communication with a patient who:
Is not fluent in the same language as the physician or other qualified health care professionals
Has not developed, or has lost, expressive or receptive communication skills necessary for treatment
When provided in conjunction with psychotherapy services, the amount of time spent by a physician or other qualified health care professional should be reflected in the timed service code for psychotherapy.
Interactive Complexity service is not a factor for evaluation and management service selection except as it directly affects key components

6. Psychiatric Diagnostic Procedures
90801 → 90791, 90792
90791 Psychiatric Diagnostic Evaluation
90792 Psychiatric Diagnostic Evaluation with medical services
Cannot be reported with an E/M code on the same day by the same provider
Cannot be reported with psychotherapy service code on same day
Codes may be reported more than once for the patient when separate diagnostic evaluations are conducted with the patient and other informants.

7. Psychiatric Diagnostic Procedures Continued
Psychiatric Diagnostic Evaluation
Integrated biopsychosocial assessment including:
history
mental status
recommendations
May include communication with family or other sources and review and ordering of diagnostic studies
Psychiatric Diagnostic Evaluation with medical services
Integrated biopsychosocial and medical assessment including:
other physical examination elements as indicated
May include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies

8. Psychotherapy
Same codes regardless of where patient is seen (outpatient or inpatient)
Deleted codes: ;
Now
90832 – Psychotherapy, 30 minutes
90834 – Psychotherapy, 45 minutes
90837 – Psychotherapy, 60 minutes
Psychotherapy, 30 minutes with E/M
– Psychotherapy, 45 minutes with E/M
– Psychotherapy, 60 minutes with E/M

9. Psychotherapy continued
Choose code closest to actual time
90832, (30 min) for minutes
90834, (45 min) for minutes
90837, (60 min) for 53 and more
Actual time should be documented not time ranges
Psychotherapy of less than 16 minutes is not reported

10. Psychotherapy for Crisis
New Codes 90839, 90840
Presenting problem is typically life threatening or complex and requires immediate attention to a patient in high distress
Code includes:
Urgent assessment and history of crisis state
Mental status exam
Disposition
Treatment includes:
Psychotherapy
Mobilization of resources to defuse the crisis and restore safety
Implementation of psychotherapeutic interventions to minimize the potential for psychological trauma
Used to report total duration of face-to-face time with the patient and/or family providing psychotherapy for crisis
Time does not have to continuous
Provider must devote full attention to patient and cannot provide services to other patients during time period
*Only Teaching Physician’s time can be counted

11. Psychotherapy for Crisis Continued
90839 Psychotherapy for crisis; first 60 minutes; used for the first minutes.
reported only once per day
Each additional 30 minutes; report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes.
Example 120 minutes of crisis therapy reported:
90839 x1
90840x2
Less than 30 minutes spent cannot be reported with these codes
Less than 30 psychotherapy
30-74 minutes x1
min 90839x1 and x1
min x1, x2
min 90839x1, x3
min x1, x4

12. Pharmacologic Management
90862 → Evaluation and Management (E/M) Code
( , , , )
The following slides will provide information to select appropriate E/M code
Pilot Template
Example cases
If a patient receives an E/M service and psychotherapy service on the same day by the same provider report
Both the E/M code at the appropriate level AND psychotherapy add-on codes (90833, 90836, 90838)
The two services must be significant and separately identifiable
A separate diagnosis is not required

13. Reporting E/M and Psychotherapy Codes
The two services must be significant and separately identifiable
1. Select the type and level of E/M is based on the key components (history, exam, medical decision making )
Time may not be used as basis of E/M code selection
2. Select psychotherapy service code based on time providing psychotherapy (time spent in psychotherapy must be documented).
Time associated with activities used to meet criteria for the E/M service is not included in the time used for reporting the psychotherapy service
Time spent on history, examination and medical decision making when used for the E/M service is not psychotherapy time.
A separate diagnosis is not required

14. Evaluation and Management (E/M) Services-Outpatient/Office
New Patient Visits
CPT Codes
A patient is considered new to a physician if the patient has not received professional services from that physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty of same group practice in the prior three (3) years.
Established Patient Visits
CPT Codes

15. Evaluation and Management Codes -Selection Grid - Outpatient
New Patient Office Visit (3 out of 3)
Code
History
Exam
MDM
Time
99201
Prob Focused
StraightF 10
99202
Expanded PF 20
99203
Detailed
Low 30
99204
Comprehensive
Moderate 45
99205
High 60
Office Consultations (3 out of 3)
Code
History
Exam
MDM
Time
99241
Prob Focused
StraightF 15
99242
Expanded PF 30
99243
Detailed
Low 40
99244
Comprehensive
Moderate 60
99245
High 80
Established Patient Office Visit (2 out of 3)
Code
History
Exam
MDM
Time
99211
Physician Presence Not Required 5
99212
Prob Focused
StraightF 10
99213
Expanded PF
Low 15
99214
Detailed
Moderate 25
99215
Comprehensive
High 40

16. Leveling of Evaluation and Management Services
Documentation of History
Chief Complaint
Reason for visit
Required for every E/M service billed.
It establishes and supports the medical necessity and reasonableness for the services billed.
You must state more than “Patient stable. No complaints today.”
The History of Present Illness (HPI) should be documented by the provider.
The Review of Systems (ROS) and Past, Family, Social History(PFSH) may be recorded by ancillary staff or on a patient questionnaire (outcome measurement tools).
The physician must demonstrate that they reviewed the information by confirming or supplementing any information obtained by others.
A physician may review and update a ROS and/or a PFSH obtained during an earlier encounter. This information does not need to be re-recorded, but the physician must either document that there has been no change in the ROS and/or PFSH information or must describe any new changes. The date and location(source) of the earlier ROS and/or PFSH must be documented by the physician in their progress notes.

17. History Table The table below shows the progression of elements required for each level of history, all 3 elements in the table must be met.
99202,99213
99203, 99214
99204,99205,99215

18. 1997 Examination
99202, 99213
99203, 99214
99204, 99205, 99215

19. Type of Medical Decision Making
99203,99213
99204,99214
99205, 99215

20. Table of Risk

21. MDM Level

22. Example Case – Level 3 Established Patient (99213)
context
Progress Note
S: Says that she has been very upset lately because daughter is using heroin again. Pt is requesting to
switch back to valium instead of klonopin because she is still getting quite anxious on the klonopin.
O: subdued, anxious affect; thoughts clear
A: Anxiety disorder NOS
P: switched from klonopin to valium 10 mg TID PRN
Allergies: NKDA
___________________________________________________________________________________________
History: 3 HPI (context, modifying factors, assoc signs/symptoms), 1 ROS (psych), 1 PFSH(allergies)
= expanded problem focused
Exam: 2 bullets = problem focused
MDM: anxiety worsening, no date reviewed, Rx drug management = low
Overall = 99213
Modifying factors
Assoc. signs/symptoms

23. Example Case – Level 4 Established Patient (99214)
Psychiatric outpatient visit Came with staff who is primary community provider. Going to the gym, seeing therapist fairly regularly, maintaining apartment with daily help from staff. Says he is doing well and very happy about going to karate several times per week. “now I just need a job”. Says he is sleeping ok. Still smoking several joints per day and tobacco. Says he enjoys it, helps with his mood. Does not want help to change. Does note that it effects his breathing when he does cardio – advised him this will get worse over time. Complaining of back pain from accident several years ago-in process of going to urgent care at Family Health Center with help of staff to have evaluated. MSE: Alert, but eyes heavy, slow speech, quiet, not angry. Less pressured, no grandiose delusions, no thoughts of harm to self or others. No AH or other delusions. A/P: mood and psychotic symptoms fairly stable, ongoing marijuana abuse. Continue to work with him on health concerns of continued smoking of any type and how this will impact his fitness goals. Ideally will avoid narcotic pain medications for back pain, discussed using NSAIDS, tylenol, exercise. Coordinate with therapist and community support staff. _________________________________________________________________________________________________ History: 4 HPI( quality, context, assoc signs/symptoms, location), 4 ROS(constitutional, respiratory, musculo., psych), 1 PFSH (social) = Detailed Exam: 4 bullet items = Problem focused MDM: 2 stable conditions, 1 new no work up; lab tests ordered, Rx management = Moderate Overall = 99214
Quality
Assoc. signs/symptoms
Context
Location

24. Department of Corporate Compliance
Professional Compliance Department
22 Shattuck Street
Worcester, MA
Fax (508)
Senior Director, Professional Billing Compliance
Debra Nedder
(508)
Compliance Specialists
Traci Watson, CPC Sheila Bembenek, CPC
(508) (508)
Melissa Flis, CPC Patricia Manzi, CCS, CPC, CCS-P, CEDC
(508) (508)
References for presentation material:
CMS Internet Only Manual (IOM) System Pub
American Medical Association’s Current Procedural Terminology (CPT) Book 2013