CPT Code Basics: What You Should Know

Current procedural terminology (CPT) codes are essential components of the health care 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.

Table of Contents

What Are CPT Codes?

What are CPT Codes?

CPT is a uniform coding system developed by the American Medical Association (AMA). The AMA first established this system 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 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 get paid for. CPT codes, alongside the International Classification of Diseases (ICD) codes, paint a full picture for insurance payers, and you need both types 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 a provider may use with F60.3 is 90832, which is the code for individual psychotherapy for 30 minutes.

There are three distinct categories of CPT codes, which we will look at next.

What Are the Three Categories of CPT Codes?

The three categories of CPT codes are as follows.

  • Category I: Most coders spend the majority of their time working with Category I codes. There are different sections of these codes, based on the field of health care. The six sections of the CPT codebook are Evaluation and Management, Medicine, Surgery, Radiology, Anesthesiology and Pathology and Laboratory. Each field has a unique set of guidelines. The CPT codes under Category I are five digits long.
  • Category II: Category II codes contain four digits, followed by the letter F. Category II codes are optional. They provide additional information and are not a replacement for Category I or Category III codes.
  • Category III: Category III codes are temporary, and represent new or experimental procedures or technology. For example, if you can’t find a new procedure 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 the most frequently used, 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 health care field and includes guidelines to follow. They also have a variety of modifiers. Modifiers have two digits, and you can add them to a CPT code. They describe specific critical parts of a procedure.

Some codes have instructions below them in parentheses to tell the coder there may be a more correct 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 health care. 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 a provider has met the required elements to code appropriately for the maximum reimbursement amount. It may help to break the process down into steps for new and established patients.

First, professionals might bill two types of behavioral health 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 the following.

  • 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 it takes more time to complete the initial evaluation.

Regarding established patients, the rules allow you to bill an E/M service with every psychotherapy visit, but they don’t require you to do so with every encounter. Only bill E/M services if you addressed and documented a separate medical issue 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.

The 3 Major Components of E/M Documentation

The three major components of effective E/M Documentation

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, review of systems and the family and social history.
  • 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 this required information can turn a psychotherapy session with E/M services into a confusing ordeal regarding documentation. Here are a couple of crucial elements to remember.

  • Pass the midpoint: You must pass the midpoint to bill for a given amount of time. For example, the midpoint between 30 minutes and 45 minutes is about 38 minutes. To bill for 45 minutes of psychotherapy, then, the session must be longer than 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 Code Examples

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: 30 minutes of individual psychotherapy
  • 90833: 30 minutes of individual psychotherapy performed with an E/M service
  • 90834: 45 minutes of individual psychotherapy
  • 90836: 45 minutes of individual psychotherapy performed with an E/M service
  • 90837: 60 minutes of individual psychotherapy
  • 90838: 60 minutes of individual psychotherapy performed with an E/M service
  • 90847: 50 minutes of family psychotherapy with the patient present
  • 90846: 50 minutes of family psychotherapy without the patient present
  • 90853: Group psychotherapy
  • 96101: Psychological testing, interpretation, and reporting per hour by a psychologist
  • 96102: Psychological testing per hour by a technician
  • 96111: Developmental testing

New CPT Codes for Mental Health Services

Every year, health care professionals can expect revised or new mental health CPT codes. According to the American Psychological Association, as of Jan. 1, 2020, psychologists must use new therapy CPT codes to get reimbursed for health behavior assessment and intervention (HBAI) services from third-party payers. Providers use HBAI services to address psychological, emotional, cognitive or behavioral issues that impact the treatment of a physical health problem. Psychologists may provide these services to an individual, group or a patient’s family to help the client cope with physical health conditions.

HBAI codes are not for mental health services, and they require a physical health diagnosis, or an ICD code. Here are the revised codes.

  • Code 96156 replaces codes 96150 and 96151: To bill for a health and behavior assessment or reassessment, psychologists must now use the code 96156. The new code for assessment services is now event-based, rather than time-based.
  • Code 96152 is now 96158 plus 96159: The code 96152 for an individual, face-to-face health behavior intervention is now 96158 for the first 30 minutes. List the code 96159 separately for each additional 15 minutes of the intervention.
  • Code 96153 is now 96164 plus 96165: The code96153 for a face-to-face group health behavior intervention is now 96164 for the first 30 minutes. Tack on the code 96165 for each additional 15 minutes of service.
  • Code 96154 is now 96167 plus 96168: The code 96154 for a face-to-face family health behavior intervention with the patient present is now code 96167 for the first 30 minutes. Use the code 96168 for each additional 15 minutes.
  • Code 96155 is now 96170 plus 96171: The code 96155 for a face-to-face family health behavior intervention without the patient present is now 96170 for the first 30 minutes. Use the code 96171 for each additional 15 minutes.

Common Behavioral Health Case Management CPT Codes

Like licensed counselors, clinical social workers who provide psychotherapy services use CPT codes to get reimbursed. Here’s a CPT description list of frequently used codes, according to the National Association of Social Workers:

  • 90832: 30 minutes of psychotherapy
  • 90834: 45 minutes of psychotherapy
  • 90837: 60 minutes of psychotherapy
  • 90785: Interactive complexity add-on 
  • 90839: 60 minutes of psychotherapy for crisis
  • 90840: Each additional 30 minutes of psychotherapy for crisis
  • 90791: Psychiatric diagnostic evaluation
  • 90845: Psychoanalysis 
  • 90847: 50 minutes of family psychotherapy with the patient present
  • 90846: 50 minutes of family psychotherapy without the patient present
  • 90853: Group psychotherapy

Telehealth CPT Codes

With an increasing number of behavioral health professionals moving their practices online, it helps to know CPT codes for virtual therapy. Telehealth CPT codes are especially relevant today under the Coronavirus Preparedness and Response Supplemental Appropriations Act, which expands access to Medicare telehealth services. 

According to the Centers for Medicare and Medicaid Services, telehealth visits are the same as in-person visits and get paid at the same rates. Therefore, you will use the identical CPT code for a virtual therapy session as you would if you were billing for a face-to-face meeting. For example, if you meet with a patient online, you would still use the code 90832 for 30 minutes of psychotherapy. However, you would apply different modifiers for telehealth services, as follows.

  • 95 modifier: Addthe modifier 95 to the appropriate CPT code. This modifier describes a real-time interaction between a clinician and patient via a telecommunications system, such as through video conferencing. You may also use the modifier GT instead.
  • 02 for place of service: Use Code 02 to describe the place of service (POS) as a telecommunications system. It may replace the commonly used POS code 11, which describes providing therapy in an office.

As you’ll see, some telehealth codes belong to the Healthcare Common Procedural Coding System (HCPCS). HCPCS codes are not part of the CPT set, and they cover specific services and products needed to provide care. HCPCS codes consist of a single letter followed by four numbers. Here are codes you might use specifically for telehealth.

  • G2012: Virtual check-in or brief, patient-initiated visit
  • G2010: Remote evaluation of a recorded video or image provided by an established patient
  • 99421: Online digital evaluation and management service conducted via patient portal for an established patient, five to 10 minutes of cumulative time over seven days
  • 99422: Online digital evaluation and management service conducted via patient portal for an established patient, 11 to 20 minutes of cumulative time over seven days
  • 99423: Online digital evaluation and management service conducted via patient portal for an established patient, 21 or more minutes of cumulative time over seven days

Non-physician health care professionals may use the codes G2061, G2062 or G2063 to provide an online assessment and management service for an established patient.

Tips for Maximizing Reimbursement and Avoiding Insurance Claim Denials

If you hope 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 it is unnecessary. Always make sure the documentation supports the level of care you are billing. Here are a few more tips to keep in mind.

Tips for Maximizing Reimbursement and Avoiding Insurance Claim Denials

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 crucial to review the rules.

2. Claim Only What’s Medically Necessary

Medicare and other payers define what’s medically necessary in different ways, but in general, it’s about doing what’s right for the patient at the right time. Filing 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. Doing so enables staff and insurance payers to see the reason for each service.

3. File Claims on Time

You must submit claims by a specific deadline. For example, Medicare requires you to file no later than 12 months after the date of service. These dates 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

Inadequate 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.

Use ICANotes Behavioral Health EHR for Fast & Accurate Billing

Use ICANotes for Fast and Accurate Billing

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!

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Last updated on May 13th, 2020

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