Current Procedural Terminology (CPT) codes are essential components of the healthcare billing process. To receive reimbursement for your services and to avoid an audit, it’s critical to use the appropriate CPT codes. However, properly using CPT codes for billing involves understanding a complex system. There are thousands of codes to choose from and many different guidelines to follow. Nevertheless, it is possible to use medical codes correctly and receive maximum reimbursement for your services.
In this post, we’ll cover some basics of behavioral CPT codes, and we’ll provide tips for avoiding claim denials. The better you understand CPT codes, the more time you’ll have to care for patients, and the easier it will be to get paid.
CPT is a uniform coding system developed by the American Medical Association (AMA). This system was first developed in 1966 to standardize terminology and simplify record keeping for physicians and staff. Since its development, CPT has undergone several changes. The most recent edition focuses on using CPT codes to report physician services.
CPT codes describe medical procedures, such as tests, evaluations, surgeries and other procedures performed by a physician on a patient. In a behavioral health setting, CPT codes are used to describe the length of a psychotherapy session, for example, or an intake interview. CPT codes are necessary to receive reimbursement from insurance providers.
How Do CPT Codes Work?
CPT coding tells insurance payers what you would like to be paid for. CPT codes are used alongside the International Classification of Diseases (ICD) codes to paint a full picture for insurance payers, and you need both codes for reimbursement. The ICD code describes the diagnosis and why the treatment was necessary, and the CPT code explains the services provided. An example of a mental health ICD code is F60.3 – the code for borderline personality disorder. An example of a CPT code that may be used with F60.3 is 90832, which is the code for individual psychotherapy for 30 minutes.
CPT codes are divided into three different categories, which we will look at next.
What Are the Three Categories of CPT Codes?
The three categories of CPT codes are:
- Category I: Most coders spend the majority of their time working with Category I codes. These codes are divided into six sections based on the field of healthcare. The six sections of the CPT codebook are Evaluation and Management, Medicine, Surgery, Radiology, Anesthesiology, and Pathology and Laboratory. Each field has its own set of guidelines. The CPT codes under Category I are five digits long.
- Category II: Category II codes contain four digits and are followed by the letter F. Category II codes are optional. They are used to provide additional information and are not used to replace Category I or Category III codes.
- Category III: Category III codes are made of temporary codes that represent new or experimental procedures or technology. For example, if a new procedure is not found in Category I, you might use a Category III code. Category III codes are four digits long and end in the letter T.
Since Category I is used most frequently, here’s a look at the numerical range of codes within this category:
- Evaluation and Management: 99201 to 99499
- Anesthesia: 00100 to 01999 and 99100 to 99140
- Surgery: 10021 to 69990
- Radiology: 70010 to 79999
- Pathology and Laboratory: 80047 to 89398
- Medicine: 90281 to 99199 and 99500 to 99607
Each of these sections contains subfields to correspond to a particular healthcare field and includes guidelines to follow. They also have a variety of modifiers. Modifiers contain two digits and can be added to a CPT code. They describe certain critical parts of a procedure.
Some codes have instructions below them in parenthesis to tell the coder there may be a more accurate code to use. Codes must be as specific as possible for a claim to get accepted.
Why CPT Codes Are Important for Clinicians?
In January of 2013, new CPT codes went into effect for behavioral healthcare. The Health Insurance Portability and Accountability Act (HIPAA) requires health care providers to implement the new codes. During this time, the code 90862 was eliminated and replaced with Evaluation and Management (E/M) codes. Psychotherapy codes, however, remained time-based.
Before 2013, psychiatrists used the 90862 CPT code for outpatient prescribing. Since then, clinicians have had to learn E/M codes. This process has not been easy, but it is necessary for proper documentation and reimbursement. Fortunately, electronic health record (EHR) software like ICANotes has made the transition easier.
ICANotes keeps track of documentation elements in clinical notes and automatically calculates the highest-level E/M code supported by a note. ICANotes makes it easy to establish all the required elements for accurate E/M documentation by providing pre-templated buttons and an easy-to-use interface. With ICANotes, clinicians can stay up to date on CPT changes and make sure they comply with HIPAA.
Effect on the Reimbursement Process
The changes made in 2013 have had a positive effect on reimbursement amounts for clinicians. However, the coding process is more complicated than it used to be. Consider the following differences in payment amounts between 2012 and 2013:
- 90805: In 2012, a 90805 code, which represents psychiatric therapeutic procedures, paid $71.82. In 2013, the equivalent code, 90833, with E/M 99212, paid $85.43.
- 90807: In 2012, a 90807 code, which also represents psychiatric therapeutic procedures, paid $99.39. In 2013, a 90836 code paid $111.30 with an E/M 99212.
Overall, the new system allows you to seek higher, more accurate reimbursement for your services. The catch is that you need to study the codes and ensure proper documentation.
How to Use the Correct Code
Although changes to the coding system seem to increase the reimbursement amount, it is still a complex system. It is not always easy to determine if the required elements have been met to code appropriately for the maximum reimbursement amount. It may help to break the process down into steps for new patients and established patients.
First, behavioral health professionals might bill two types of CPT codes for new patients. These are:
- E/M codes
- Psychiatric evaluation codes
Depending on the situation and time involved, it may be appropriate to bill for both codes. A few guidelines include:
- E/M: Use E/M codes when evaluating a new medical issue. To bill for E/M, you must provide three documentation elements – history, examination and medical decision-making.
- Psychiatric evaluation: Use psychiatric evaluation codes for a diagnostic assessment. You may need to use these codes more than once if more time is needed to complete the initial evaluation.
Regarding established patients, you are allowed to bill an E/M service with every psychotherapy visit, but it is not required with every encounter. E/M services are only to be billed if there is a separate medical issue that was addressed and documented during the encounter. For example, if you address the side effects of medication during a visit, you might bill for an E/M visit in addition to a psychotherapy session.
However, if a patient has been stable and on the same medication for years and attends a psychotherapy visit, you can only bill for the psychotherapy session. You cannot bill for E/M because there are no medical or medication concerns expressed during the visit. Also, to bill for E/M, your documentation must prove your active management or discussion of a medical or medication problem that is distinct from the psychotherapy service.
To determine the appropriate E/M code, you need to use supporting documentation in the medical record. The documentation must include the following three sections:
- History: The history section must include the history of present illness (HPI), review of systems (ROS) and the past family and social history (PFSH).
- Examination: The examination section includes the type of examination performed based on your judgment, the patient’s history and the nature of the problem. You will need to document one to 14 elements depending on the level of examination.
- Medical decision-making: The medical decision-making section includes the number of diagnoses or treatment options documented during the specific encounter, the complexity of the data reviewed, and the risk of complications.
All of this required information can turn a psychotherapy session with E/M services into a confusing ordeal regarding documentation. Here are a couple of keys to remember:
- Pass the midpoint: You must pass the midpoint to bill for a certain amount of time. For example, the midpoint between 30 minutes and 45 minutes is about 38 minutes. To bill for 45 minutes of psychotherapy, you must pass 38 minutes.
- Keep them separate: The time associated with the E/M service cannot count toward the time of the psychotherapy service. The E/M service must be significant and distinct from the psychotherapy service.
In short, if you provide psychotherapy with an E/M service, bill the E/M service based on the three major components – history, examination and medical decision-making – with a psychotherapy code, and document both the E/M work and psychotherapy work separately.
Common Mental Health CPT Codes
Here is a list of the most commonly used CPT codes in mental health. This list is nowhere near complete, but it gives you an idea of frequently used codes and their meanings:
- 90791: Psychiatric or psychological intake interview without medical services
- 90792: Psychiatric intake interview with medical services
- 90832: Thirty minutes of individual psychotherapy
- 90833: Thirty minutes of individual psychotherapy performed with an E/M service
- 90834: Forty-five minutes of individual psychotherapy
- 90836: Forty-five minutes of individual psychotherapy performed with an E/M service
- 90837: Sixty minutes of individual psychotherapy
- 90838: Sixty minutes of individual psychotherapy performed with an E/M service
- 90847: Family psychotherapy with the patient present
- 90846: Family psychotherapy without the patient present
- 90853: Group psychotherapy
Tips for Maximizing Reimbursement and Avoiding Insurance Claim Denials
To avoid issues with claims, you mostly want to remember that medical necessity determines the level of service to bill. It would not be appropriate to document a higher level of service if a lower level of service is needed. Always make sure the documentation supports the level of care being billed. Here are a few more tips to keep in mind:
1. Ensure Correct Coding
To receive reimbursement, a clinician must complete accurate coding. Coding errors can lead to payment delays or rejected claims. Frequent or consistent errors could lead to an audit or charges of fraud. Strive for the highest accuracy, and cut down on simple errors like incorrect patient information or policy number mistakes. Always refer to the AMA’s most recent CPT manual to make sure you use the right codes in your practice.
Also, make it a habit to check and recheck work, and make sure to read all the notes included with the codes. Encourage staff members to do the same. One of the most common causes of claim denials is the improper use of modifiers. Therefore, make sure to familiarize yourself with modifiers before using them. Modifiers can be the difference between maximum reimbursement and reduced reimbursement, so it’s important to review the rules.
2. Claim Only What’s Medically Necessary
Medicare and other payers define what’s medically necessary in their own way, but in general, it’s about doing what’s right for the patient at the right time. Making a claim for a service that is not a medical necessity will likely get denied.
To help demonstrate a medically necessary claim, make sure to choose the appropriate ICD code and link it to the associated CPT codes that are valid for the visit. This enables staff and insurance payers to see the reason for each service.
3. File Claims on Time
Claims must be submitted by a certain deadline. Medicare claims, for example, must be filed no later than 12 months after the date of service. This can vary depending on the payer, and some claims may be due within 90 days or 180 days after service. By meeting deadlines, you’ll ensure you receive the right reimbursement.
4. Emphasize Quality Documentation
Poor documentation can affect the reimbursement process. Make sure everyone in your practice understands the value of correct, legible and complete documentation. Otherwise, it will be difficult to make an accurate or complete claim.
5. Identify and Educate
Identify coding errors, review past mistakes and aim to correct the errors by educating staff and staying current on any code changes. Schedule regular training meetings to keep information fresh and share any updates.
Proper coding requires knowledge and practice. Most behavioral health clinicians want to spend their time and energy providing patient care – not worrying about coding and claims. ICANotes EHR can step in and take care of the work for you so you can get back to doing what you love.
With ICANotes, you can expect automatic coding at the highest reimbursement level possible to ensure claims get accepted and you get paid. Without the need to fix errors or resubmit claims, you’ll save time, money and energy. To experience the benefits of ICANotes firsthand, sign up for a free trial today!