Per CPT¹, “Psychotherapy is the treatment of mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.”²  CPT provides distinct codes for reporting face-to-face Psychotherapy with two different approaches (see the CPT code section 90832 - +90838).  Either an Evaluation and Management (E/M) code can be submitted in tandem with a Psychotherapy add-on code, or a standalone Psychotherapy code can be submitted.  The tandem approach requires that, aside from the Psychotherapy work, a significant, separate, and distinct E/M code can be supported from the medical record.

The Psychotherapy counselling code interval, CPT 90832-90838, includes six time-based codes.  Description of standalone code 90834, for example, is:

Psychotherapy, 45 minutes with patient

…and description of the add on code 90836, for reporting with an E/M, is:

Psychotherapy, 45 minutes with patient when performed with an evaluation and management service.

Medical record support for all codes in this interval should include these three elements³:

1. A time interval for each time-based code must be documented (either a total Psychotherapy time or, if continuous, start and end times dedicated to this service).
2. The therapeutic maneuvers that were applied must be documented.
3. A periodic summary of goals, progress toward goals, and an updated treatment plan must be documented.

When billing one of these Psychotherapy add on codes +90833/+90836/+90838, the Psychotherapy add-on code documentation mentioned above must stand distinct and separate from the support of whatever parent E/M code was also billed on the same date of service (DOS).  Some of these E/M codes when submitted alone can be either supported by medical decision making (MDM) or time, but when these E/M codes function as the parent code of a Psychotherapy add-on code, time can NOT be used as supporting element, as the add-on code is itself time based.  From CPT Assistant, August 2022⁴:

Question: What is the current guidance for reporting E/M services with psychotherapy codes 90833, 90836, and 90838? Per CPT coding conventions, time is not an allowable component for E/M code selection in this situation because psychotherapy services are time-based codes. Both services cannot be assigned based on time…

Answer: MDM is the correct criterion for E/M level selection when E/M services are performed in conjunction with psychotherapy codes 90833… 90836, … and 90838”

When submitting such a code pair, distinct work elements required by CPT must be documented for both the E/M parent code (MDM) and the add-on code (time).  The auditor must be able to pull separately from the medical record the required elements of each CPT code to consider the pair supported.

In an Office of Inspector General (OIG) audit from July 2020 (a review of 2017-18 calendar year claims) of Medicare Payments for Psychotherapy Services, 111 of 120 claims failed to comply with CMS billing requirements, resulting in at least 3.3 million dollars in overpayments.  The main deficiency involved a failure of treatment notes to support services billed.³  This reveals a broad theme of provider failure to supportively document Psychotherapy Services, a theme which also impacts commercial claims. 

Detection of aberrant Psychotherapy claim patterns--whether this involves identifying impossible time-based code hours submitted by a provider or provider group, whether this takes the form of repetitive patterns of same E/M with same Psychotherapy add on codes, or some other pattern--can lead to a fruitful FWA medical record audit.  After such detection, if a complex FWA medical record review of a sample of such claims fails to consistently support the Psychotherapy services submitted, the Plan can progress to a full FWA investigation of a provider or provider group with confidence that either fraudulent billing occurred for services not rendered or in the least a consistent pattern of inaccurate claim submission has been discovered. 

To improve healthcare fraud detection for your Plan, Context4 Healthcare’s Program Integrity Solution can provide detailed, up-to-date, Anti-Fraud detection software that can identify aberrant Psychotherapy patterns in your claims.  Contact us if you are interested in more details about the products we offer.

REFERENCES

1. CPT copyright © 2021 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association.
2. CPT 2022 Professional Edition, American Medical Association, page 729.
3. On-Site Psychological Services, P.C.:Audit of Medicare Payments for Psychotherapy Services, Amy J. Frontz,Department of Health and Human Services, Office of Inspector General, A-02-19-01012, July 2020.https://oig.hhs.gov/oas/reports/region2/21901012.pdf
4. CPT Assistant, American Medical Association, August 2022, Questions and Answers, Medicine: Psychiatry, page 16.