Article - Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33252 Psychiatric Diagnostic Evaluation and Psychotherapy Services. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.The psychotherapy for crisis CPT codes 90839 and 90840 are time-based codes used to report the total duration of time face-to-face with the patient and/or family spent by the physician or other qualified health care professional providing psychotherapy for crisis, even if the time spent on that date is not continuous. For any given period of time spent providing psychotherapy for crisis state, the physician or other qualified health care professional must devote his or her full attention to the patient and, therefore, cannot provide service to any other patient during the same time period. The patient must be present for all or some of the service. Do not report with CPT codes 90791 or 90792.When a patient is referred with an organic diagnosis and a mental health diagnosis is established, the mental health diagnosis should be billed.If a psychiatric diagnostic evaluation with medical assessment is performed, the physician or non-physician practitioner (NPP) may use CPT code 90792 or an evaluation and management (E/M) code.If a patient is unable to communicate by any means, the interactive complexity CPT code 90785 should not be billed. This service is used in conjunction with codes for diagnostic psychiatric evaluation (CPT codes 90791, 90792), psychotherapy (CPT codes 90832, 90834, 90837), psychotherapy when performed with an E/M service (CPT codes 90833, 90836, 90838, 99202-99255, 99304-99310, 99341-99350), and group psychotherapy (CPT code 90853). When billed in conjunction with time-based codes, the documentation must indicate the amount of time spent in providing interactive complexity services.Psychotherapy services (CPT codes 90832-90838) are time-based codes. Start and stop times or total times must be documented for CPT codes 90832, 90834, and 90837. For psychotherapy services performed with an E/M service (CPT codes 90833, 90836, and 90838), it is recognized that the psychotherapy time may not be continuous in a combined psychotherapy with an E/M service. However, since psychotherapy is a time-based code, the expectation would be documentation of the start and stop times or total time of the psychotherapy with an E/M service and documentation of the start and stop times or total time devoted to psychotherapy. The total time does not include the E/M time. Also note that when psychotherapy is performed with an E/M by the same physician or NPP, the documentation should show that they are separately identifiable services. Psychotherapy times are for face-to-face services with the patient. The patient must be present for all or some of the service. In reporting, choose the code closest to the actual time (i.e., 16-37 minutes for CPT codes 90832 and 90833, 38-52 minutes for CPT codes 90834 and 90836, and 53 or more minutes for CPT codes 90837 and 90838). Do not report psychotherapy of less than 16 minutes duration.Prolonged services may not be reported when psychotherapy services billed with an E/M service (i.e., add-on CPT codes 90833, 90836, 90838) are reported. For CPT code 90837 (psychotherapy, 60 minutes with patient), a physician or other qualified health care professional can report a prolonged service code if the psychotherapy service, not performed with an E/M service, is 90 minutes or longer involving direct patient contact.The psychoanalysis CPT code 90845 is not time-related, but the service is usually 45 to 50 minutes in duration. The code may be billed once for each daily session regardless of the time involved.The CPT/HCPCS Group 1 codes G0017 and G0018 are for all non-facility places of service (POS) other than Office.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.When the documentation of time is relevant for coding and payment purposes, time may be documented with start and stop times or with total time.