Tobi Klein, CPC, RCC Dec 5, 2022 9:30:54 PM 12 min read

Simplifying Behavioral Health Coding

Behavioral Health Coding doesn’t have to be complicated. By using the CPT (Current Procedural Terminology) book written by the American Medical Association (AMA) as a guide below, we break down the basics and simplify each concept to help your practice succeed.

For the purposes of this article, we will focus exclusively on the most common CPT codes for Psychiatry.

Psychiatry Services include Diagnostic Services, Psychotherapy, and other services to an individual, family, or group. These services are provided in all settings of care by a physician or other qualified health care professional. Some psychiatry services may be reported using Evaluation and Management (E/M) services codes for treatment of psychiatric conditions, when appropriate. These codes include Office and other Outpatient Services, Hospital Observation and Inpatient Services, Consultations, Emergency Department Services, Nursing Facility Services, Domiciliary, Rest Home or Custodial Services as well as Home Services. A provider might use an E/M code based only on the time, or length, of the visit for patients with medical conditions complicating their mental issues for which psychotherapy may not work, such as patients with severe cognitive disorders.

Interactive Complexity Code 90785 is an add-on code. It represents communication factors that complicate the delivery of psychiatric services and/or increase the intensity of effort required by the provider in a particular treatment session. One of the following must exist when using this add-on code: the need to manage maladaptive communication, caregiver emotions or behavior; evidence or disclosure of a sentinel event; or use of play equipment or other physical devices to communicate. Use this code in conjunction with Diagnostic Psychiatric Evaluation (90791, 90792), Psychotherapy (90832-90834), (90836-90838), and Group Psychotherapy (90853) codes. Interactive complexity is not a service associated with E/M services when provided without Psychotherapy. The documentation should convey why the patient does not have the ability to interact through normal verbal communicative channels and the rationale for the interactive techniques, as well as recommendations for future care.

Psychiatric Diagnostic Evaluation Codes without (90791) and with Medical Services (90792) are for an evaluation of the patient with the aim of making a diagnosis. CPT 90791 is an integrated biopsychosocial assessment, including information about present and past behavior concerns including history, mental status, and recommendations. The evaluation may include communication with family members and other sources along with ordering and review of diagnostic studies. In certain circumstances, one or more other informants may be seen in lieu of the patient. CPT 90792 includes all elements of CPT 90791 along with other physical examination elements as indicated with E/M services. This code may include medication prescription(s), as well as ordering and review of laboratory or other diagnostic studies. These codes are not time based and can be reported with Interactive Complexity Code 90785. The documentation for these codes should include current problems/symptoms, complete psychiatric and medical history, medications and allergies, mental status examination, and the patient’s ability to respond to their individual treatment plan.

Psychotherapy is the treatment of mental illness and behavioral disturbances through therapeutic communication. The physician or other healthcare professional attempts to alleviate the emotional disturbance(s), reverse or change behavior patterns, and encourage personal growth and development. This type of therapy is divided into two sets of codes based on time spent face to face with the individual patient and may include informants.

  • Psychotherapy with patient stand-alone codes such as CPT 90832 (30 minutes), 90834 (45 minutes), and 90837 (60 minutes).
  • The add-on codes for Psychotherapy with patient when performed with an E/M service are 90833 (30 minutes), 90836 (45 minutes), and 90838 (60 minutes).

The documentation for these E/M services must be separate and significant to report the medical and psychotherapeutic components of the patient encounter. Time cannot be a factor in the E/M portion of the service when reporting with Psychotherapy. Documentation for both sets of Psychotherapy must indicate the following: exact time spent in the encounter, therapeutic maneuvers, behavior modification techniques, a periodic summary, and the progress of goals, the updated treatment plan, and the medical necessity support for ongoing treatment. Exact time must be stated in the encounter notes to select the correct code based on the nearest reporting time: 90832 and 90833 (16-37 minutes), 90834 and 93835 (38-52 minutes), or 90837 and 90838 (53-90 minutes). Interactive complexity 90785 can be reported along with psychotherapy.

Psychotherapy for Crisis is an urgent assessment and history of a crisis state, a mental status exam, and a disposition. The presenting problem is life-threatening, complex, and requires immediate attention. The treatment includes psychotherapy, mobilization of resources to restore patient safety, and psychotherapeutic interventions to reduce the potential for psychological trauma. The physician or other qualified healthcare professional must devote their full attention to the patient and cannot provide services to any other patient during this time (like a critical care service). The patient must be present for all or some of the service. Psychotherapy for Crisis codes 90839 (first 30-74 minutes) and add-on code 90840 (each additional 30 minutes) are used to report this service. The time does not have to be continuous. If less than 30 minutes is spent, the provider should use 90832 or 90833 to report the crisis. Do not report crisis codes in conjunction with CPTs 90791, 90792, 90832-90838, or 90785-90899.

Other Psychotherapy services include Family Psychotherapy (without the patient), 50 minutes (90846), or Family Psychotherapy (with the patient), 50 minutes (90847), Multi-Family Psychotherapy (90849), and Group Psychotherapy (other than multi-family group) (90853). The emphasis of the visit is the patient’s care and the family’s involvement in the patient’s treatment. The documentation must include reporting time of 26 minutes or more. Group Psychotherapy cannot exceed 12 patients. CPT 90785 can be reported along with 90853 for the specified patient requiring interactive complexity.

Documentation for Psychotherapy Services must include the following: time spent in the psychotherapy encounter, patient’s name, and the date of service on every page of the medical record. It must also include the type of service provided, a problem statement along with the diagnosis for medical necessity, any therapeutic treatment, detail of patient-centered discussion, mental status exam, and a summary of the patient’s progress of goals according to the plan of care, including any changes needed. If the encounter is performed as Telehealth, the patient consent for the psychotherapy must be included. More information on Telehealth can be found here.

Pharmacological management, including prescription and review of medication, when performed with psychotherapy services, is indicated with add-on CPT 90863. This code should not be reported with E/M services.

Medicare recognizes the following provider types for Part B Behavioral Health Services:

  • Physicians (MD/DO)
  • Clinical Psychologists (CP)
  • Clinical Social Workers (CSW)
  • Clinical Nurse Specialists (CNS)
  • Nurse Practitioners (NP)
  • Physician Assistants (PA)
  • Certified Nurse-Midwives (CNM)
  • Independently Practicing Psychologists (IPP)
  • Certified Registered Nurse Anesthetists (CRNA).

Additional information from Medicare can be found here. Medicare Advantage and other commercial plans will have their own set of guidelines and must be reviewed individually for compliance. If you have additional questions regarding behavioral health coding, our team is here to help. Contact us to set up a conversation.