Coding Behavioral

Health Services

April 2017

Current Procedural

Terminology (CPT) Coding

CPT Changes for 2017

Significant revision in 2013

2017

Individual vs. family psychotherapy

Family member changed to informant

Direction on reporting time spent providing

psychotherapy services

Direction on how to report both individual & family

psychotherapy on the same date of service

Direction of reporting E/M level and time based

psychotherapy code on the same date of service

Evaluation & Management

(E/M) Coding

1995 vs. 1997 Guidelines

Biggest difference is in Examination Documentation

1995- multi-system exam

1997- specialty specific exam

Medicare only requires that one set is followed

Documentation

Components to selecting E/M levels

History

Examination

Medical decision making

Counseling

Coordination of care

Nature of presenting problem

Time

Key Components

Documentation of History

The CPT Manual’s levels are based on 4 types of history

documentation

Problem Focused

Focused Expanded Problem

Detailed

Comprehensive

Documentation of History (cont.)

Chief Complaint is required for all levels of the history

CC, ROS, PFSH- listed separate vs. included in HPI

Using previous ROS and/or PFSH documentation

Document any changes and date of earlier ROS/PFSH

Ancillary staff or patient forms may provide ROS & PFSH

Must be noted info recorded by someone else

Notation that physician reviewed documentation

History of Present Illness

Description of the development of the patient’s present illness.

Elements

Location

Quality

Severity

Duration

Timing

Context

Modifying factors

Associated signs and symptoms

Status of at least 3 chronic or inactive conditions

Review of Systems

Identifies signs/symptoms by organ system that the patient is

experiencing or has experience

• Constitutional

symptoms

• Eyes

• Ears/Nose/Mouth/Thro

at

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Integumentary

• Neurological

• Psychiatric

• Endocrine

• Hematologic/Lymphatic

• Allergic/Immunologic

Past Medical, Family, Social

History

Past history- illnesses, operations, injuries

Family history- illness of pt’s family; may be hereditary or place

the pt at risk

Social- smoking, drinking, living situation, marital status

HPI Calculation Table

Documentation of

Examination

Levels are based on 4 types of exam documentation

Problem focused

Expanded Problem

Detailed

Comprehensive

1997 Guidelines-

General Multi-system Exam vs.

Single Organ System Examination

General Multi System

Exam

Level Single Organ System

1-5 elements identified by · in one or more organ

system(s) or body area(s)

Problem

Focused

1-5 elements identified by ·

6 or more elements

identified by · in one or

more organ system(s) or

body area(s)

Expanded

Problem

Focused

6 or more elements identified

by ·

2+ elements identified by · from any 6 areas/systems or

12+ elements identified by ·from 2+ organ systems or

body areas

Detailed

9+ elements identified by a · using the psych exam template

2+ elements identified by ·from 9 organ systems or body

areasCompreh

ensive

Document all elements

in bolded outline system

boxes and 1+ element in

unbolded system boxes

Documentation of

Examination (cont.)

Specific abnormal and relevant negative findings of the

examination must be documented

A brief statement or notation indicating "negative" or

"normal" is sufficient to document normal findings

related to unaffected area(s) or asymptomatic organ

system(s)

General Multi-System Exam

Organ Systems/Body Areas

Constitutional

Eyes

ENT/Mouth

Neck

Respiratory

Cardiovascular

Chest/Breasts

Gastrointestinal/Abdom

en

GU

Lymphatic

Musculoskeletal

Skin

Neurologic

Psychiatric

Psychiatric Specialty Exam

Organ Systems/Body AreasOrgan System/Body

Area

Elements of Examination

Constitutional • Measurement of any three of the following seven vital signs: 1)

sitting or standing blood pressure, 2) supine blood pressure, 3)

pulse rate and regularity, 4) respiration, 5) temperature, 6)

height, 7) weight

• General appearance of patient

Musculoskeletal • Assessment of muscle strength and with notation of any atrophy

and abnormal movements

• Exam of gait & station

Psychiatric • Description of speech including: rate, volume, articulation,

coherence, and spontaneity with notation of abnormalities

• Description of thought processes including: rate of thoughts,

content of thoughts, abstract reasoning, and computation

• Description of associations

• Description of abnormal psychotic thoughts including:

hallucinations, delusions, preoccupation with violence, homicidal

or suicidal ideation, and obsessions

• Description of the patient's judgement and insight

• Complete mental status exam- orientation to time/place/person,

recent & remote memories, attention span/concentration,

language, fund of knowledge, mood & affect

Medical Decision Making Based on 4 types complexity of MDM

Straightforward

Low Complexity

Moderate Complexity

High Complexity

Complexities are based off of

three forms of MDM

Number of possible diagnoses and/or number of

management options considered

Amount and/or complexity of medical records,

diagnostic tests, and/or other info that must be

obtained, reviewed and analyzed

Risk of significant complications, morbidity, and/or

mortality, comorbidities associated w/ pt’s presenting

problems, diagnostic procedures and/or possible

management options

Number of Diagnoses or Management

Options Number of possible dx and/or management options

An assessment, clinical impression, or diagnosis should be

documented

Further treatment should be documented

Referrals/consultations should be documented

Minimal Limited Multiple Extensive

Diagnoses 1

establishe

d

1 established

& 1 rule out

2 rule out or

differential

2+ rule out or

differential

Problems Improved Stable

Resolving

Unstable

Unchanging

Worsening

Marked Change

Management

Options

1-2 2-3 3 changes in

treatment plan

4+ changes in

treatment plan

Amount and/or Complexity of

Data to be Reviewed Any ordered diagnostic services should be documented

Review of diagnostic services

Old records & other sources of information

Discussions w/ others that interpreted diagnostic services

Independent visualization/interpretation

Minimal Limited Moderate Extensive

Medical Data 1 source 2 sources 3 sources Multiple sources

Diagnostic

Tests

2 3 4 More than 4

Review of

Results

Confirmato

ry review`

Confirmation

of results w/

another

physician

Results

discussed w/

physician

performing

test

Unexpected

results,

contradictory

reviews, requires

additional reviews

Risk of Significant Complications,

Morbidity, and/or Mortality

Based on the risks associated with the presenting

problems, diagnostic procedures, and possible

management options

Comorbidities/underlying diseases

Invasive Diagnostic Procedure

Ordered, scheduled, or performed

Urgent invasive diagnostic procedure

Ordered or referred, stated or implied

Modified Table of Risk TablePresenting Problems Diagnostic

Procedures Ordered

Management Options Selected

Minimal One self limited problem Lab tests-

venipuncture or

urinalysis

Reassurance

Low 2 or more self-limited or

minor problems with one

stable, chronic illness or

acute uncomplicated illness

-Psychological

testing

-Skull Film

-Psychotherapy

-Environmental intervention

-Referral for consultation

Moderate -One or more chronic illness

with mild exacerbation,

progression, or side effects

of treatment or

-2 or more stable chronic

illnesses or undiagnosed

new problem with uncertain

prognosis

Electroencephalogra

m

-Neuropsychological

testing

-Prescription drug management

-Open-door seclusion

-Electroconvulsive therapy-

inpatient, outpatient, routine;

no comorbid medical conditions

High -1 or more chronic illnesses

with severe exacerbation,

progression, or side effect

of treatment or

-Acute illness with threat to

life

-Lumbar puncture

-Suicide risk

assessment

-Drug therapy requiring intensive

monitoring

-Closed-door seclusion

-Suicide observation

Electroconvulsion therapy- with

comorbid medical condition

-Rapid intramuscular neuroleptic

administration

-Pharmacological restraint

Medical Decision Making Once each section of the MDM is configured, the following

table is used to determine the overall MDM of the visit.

Straightforwar

d

Low

Complexity

Moderate

Complexity

High

Complexity

Number of

diagnoses or

management

options

Minimal Limited Multiple Extensive

Amount and/or

complexity of

data reviewed

Minimal/None Limited Moderate Extensive

Risk of

complications

and/or morbidity

or mortality

Minimal Low Moderate High

Time Based E/M Levels

Counseling and/or coordination of care dominates 50%+

of physicians time

Total record of time must be documented

Counseling and coordination of care should be described

in depth

Inpatient Discharge Codes

New Office Visit

Established Office Visit

Initial Hospital & Observation

Subsequent Hospital &

Observation

Psychotherapy Coding

Psychotherapy Codes

Time Based

“Unit of time is attained when the mid-point is passed.” CPT Time Guidelines

90832 & 90833- 16 – 37 minutes

90834 & 90836- 38 – 52 minutes

90837 & 90838- 53 or more minutes

Prolonged Service Codes

For psychotherapy sessions that are 90 minutes or longer face to face with the patient

Add on codes

E/M Levels & Psychotherapy

Codes

Different codes based on reporting with or

without an E/M level

Used when medical management is provided in

addition to

E/M based on components of history, exam, MDM

Time used to meet E/M level requirements is not

included in reported psychotherapy time

Separate diagnosis is not required

E/M level should be listed first followed by

psychotherapy code

Interactive Complexity

Specific communication factors that complicate the delivery of a psychiatric procedure- psychotherapy, evaluation, etc.

Must meet one of the following in order to report:

Need to manage maladaptive communication (related to e.g. high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care

Caregiver emotions or behavior that interferes with caregiver’s understanding & ability to assist in the implementation of treatment plan

Evidence or disclosure of a sentinel event and mandated report to 3rd part (abuse or neglect with report to state agency) with imitation of discussion of the sentinel event and/or report with patient and other visit participants.

Interactive Complexity (cont.)

Must meet one of the following in order

to report: (cont.)

The time providing interactive complexity

should be included in the psychotherapy

codes

Not considered a factor for Evaluation &

Management coding

Psychotherapy for Crisis

Presenting problem is typically life threatening or

complex and requires immediate attention

Accumulative time for date of service

Does not have to continuous

Can be with patient and/or family

If less than 30 minutes- refer to 90832 or 90833

Ohio Medicaid Behavioral

Health Redesign

Implementation & Provider

Resources

Date of service July 1, 2017

www.bh.medicaid.ohio.gov

Coding & Reimbursement

Rate Chart

Under provider manuals section of BH redesign website

Resources

American Medical Association (2017), Current

Procedural Terminology (CPT), Professional Edition

American Medical Association ,CPT Assistant

The Ohio Behavioral Health Redesign. Retrieved from

http://bh.medicaid.ohio.gov/

Centers for Medicare & Medicaid Services. (1997) 1997

Documentation Guidelines for Evaluation & Management

Services Retrieved from

https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-

MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

Disclaimers

The information provided in this presentation is intended for educational and informational purposes to describe current coding practices. However, KT Coding & Transcription, Inc. assumes no responsibility or liability for the results or consequences that may arise from information obtained from this presentation. The information contained in the presentation is provided for information purposes only and represents no statement, promise or guarantee concerning levels of reimbursement, payment or charge. Although prepared for use by professionals, the presentation information should not be utilized as a substitute for professional services in specific situations. If legal advice is required, the services of a professional should be sought.

CPT Disclaimer -- American Medical Association (AMA) Notice CPT codes, descriptions and other data only are copyright 2017 American Medical Association. All rights reserved.