Seven Tips for Optimizing Your Outpatient Billing with the New CPT Codes*

Vikram Shah MD, MBA & Stuart L. Lustig, MD, MPH

Are you confused and frustrated by the new CPT codes? Then you're not alone. The new evaluation & management (E&M, E/M) codes used by all medical providers to report medical services provided during an encounter are designed to better capture the complexity and sophistication of our work, but the codes themselves can be complex! This article is not an exhaustive primer on CPT codes; rather, we’ve distilled some key concepts based on the missed opportunities we've noticed when we compare medical charts to billing records.

1. Code either elements of the History of Present Illness (HPI), or the status of chronic conditions, whichever are more numerous.

Scoring for the history component may be based on either the number of chronic conditions you are treating (and these do not have to be a formal diagnosis per se), OR the number of elements evaluated of one or more acute condition (e.g. context, severity, modifying factors, etc.). Pick the higher of these two.

2. Review of Systems (ROS) - Remember to take credit for assessing side effects from medication when appropriate.

Although many psychiatrists may not need to complete or document a review of systems for medically stable patients, be sure to count discussions about medication side effects under the appropriate system, e.g. sleep/appetite as constitutional, palpitations as cardiac, decreased libido as genito-urinary, etc. Assessing side effects is part of what doctors do.

3. Mental Status Exam (MSE) - Be sure to document what you are probably doing anyway.

While you do not need to complete or document a full mental status on every patient, e.g. muscle strength assessment can be omitted on most patients without relevant complaints, it’s easy enough to document other components of an exam, such as appearance, that you’re automatically assessing anyway from the moment the patient walks in. You could consider developing an appropriate checklist that includes the relevant elements of each MSE component, for example:
Affect: Range: ______Quality_____ Congruence with Mood_____ Appropriateness______.
That way, the documentation can be relatively quick and painless.

4. Coordination of care – be sure to include time

Appropriate E/M coding can be determined based either on complexity of the patient encounter or time spent on counseling and/or coordination of care (Please review what constitutes counseling and coordination of care in the American Medical Association’s Current Procedural Terminology book.) Some patient encounters may require a significant amount of your time on the phone with clinicians, such as when referring a patient to an emergency room for inpatient hospitalization. In such cases, the appropriate E/M code should be determined based on time spent in coordination of care and not by the complexity of the patient encounter. Documentation should indicate the total encounter time and reflect that at least 50% of the time spent was for coordination of care. In these cases, 25 minutes earns a 99214 code, 15 minutes earns 99213, and 10 minutes earns 99212.

5. Child psychiatrists in particular – remember the add-on code for interactive complexity, 90875, when doing play therapy.

Interactive complexity can be added on to individual and group therapy codes and initial assessment codes (90791 or 90792) when specific equipment, such as toys, is used for the assessment; when dealing with maladaptive communication among participants; or when a sentinel event, such as abuse, must be reported to a third party.

6. You may bill for both evaluation & management and psychotherapy.

Documentation should include the time spent for psychotherapy. The time spent for E/M activity should not be included in the time spent for psychotherapy. The E/M code, in this case, must be determined on the basis of the complexity of patient encounter. The number of minutes spent in psychotherapy determines which psychotherapy code you should add on: 16-37 minutes: 90832; 38-52 minutes: 90834; 53+ minutes: 90837.

7. Do what's clinically necessary, and document accordingly.

As per Centers for Medicare and Medicaid services (CMS), the medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. They caution against upcoding when a lower level E/M code would suffice. In other words, for a stable patient with no complaints who comes in every 3 months for antidepressant prescription refill, no need to complete or document a comprehensive history including past, family and social history, and a complete work up including muscle strength and gait, or the equivalent of a 99215, when the effort for a 99212 or 92213 is what your patient needs.

We hope this information is helpful. Also, the American Psychiatric Association has excellent online resources to help decipher the new CPT codes at www.psych.org/cptcodingchanges, along with a useful template for clinical notes.

* This information herein is for educational and informational purposes only. The presenters assume no liability or responsibility for action or behavior based on this article.

The final decision for the coding of a procedure must be made by the physician considering the latest version of American Medical Association's Current Procedural Terminology book, regulations for insurance carriers and any local, state or federal laws that apply to the physician's/health care professional's practice.