Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90785, 99215, and 90833 billed for date of 
service August 30, 2021. 
 
You asked the Plan to pay for procedure codes 90785, 99215, and 90833. You say that these codes are payable. 
The Plan denied your request. The Plan says for code 99215-CR, the documentation failed to meet the required 
key components when billing for an evaluation and management (E&M) service of high medical decision 
making. For code 90833, the documentation of the E&M service/time and psychotherapy service/time were not 
significant and separately identifiable (because code 99215 is also not supported). For code 90785, the 
American Medical Association says that Interactive complexity is reportable when there is either a documented 
sentinel event, use of play equipment, devices or interpreter is required to overcome communication barriers or 
there is a documented need to manage maladaptive communication or caregiver emotions/behavior to assist in 
treatment. The documentation does not support payment of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 90785 is Interactive complexity (List separately in 
addition to the code for primary procedure).  The definition of code 99215 is office or other outpatient visit for 
the evaluation and management of an established patient, which requires a medically appropriate history and.or 
examination and high level of medical decision making,.  When using time code selection, 40-54 minutes of 
total time is spent on the date of the encounter. The definition of code 90833 is Psychotherapy, 30 minutes with 
patient when performed with an evaluation and management service (List separately in addition to the code for 
primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 90785, 99215, and 90833. Our reviewer 
says that payment of these codes is not supported in the medical record. Our reviewer found for code 90785, 
the office note does not specify communication difficulties, and how this procedure was performed.  Therefore, 
this procedure cannot be verified. For code 99215, the note from the office visit does not support a high level of 
medical decision making as only prescription medication was performed. Also, this procedure is not separately 
identifiable from code 90833.  The documentation states "Duration visit: 1510-1625-75 minutes." Therefore, 
time for each procedure code cannot be verified. For code 90833, the documentation does not support this 
procedure as a separate procedure from code 99215, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 90785, 99215, and 90833 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 90785, 99215, and 90833 billed for date of 
service August 30, 2021.