Knowledge Base Article

A common mnemonic device to aid memory is to come up with a short sentence or phrase using the first letters of what you are trying to remember. Since it is spring and we are planning our vegetable garden, for PGATO I came up with “please gather all the okra.” If you have never grown okra, you may not realize the gathering demands of okra in the miserably hot, sultry days of late summer. The reward however is the delicious, Southern dish of fried okra. For Medicare services, rewards are two-fold – one is helping patients to recover or improve and two is the Medicare reimbursement you receive if you have followed all of Medicare’s requirements for billing, coding, and documentation. Like okra plants can be prickly, so can Medicare requirements.

PGATO is my memory tool for remembering all of the components for proper documentation to support billing of psychotherapy - plan, goals, activity, time, and outcomes. CPT codes 90832-90838 represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy. Reviews by the Comprehensive Error Rate Testing (CERT) contractors have identified issues with missing documentation.

Plan and Goals

A recent CERT review (see Cahaba Article Psychotherapy Codes) has identified errors in outpatient psychotherapy CPT codes 90832 and 90834, Type of Bill 13X. The primary issue identified on review was the absence of a signed, individualized plan of care for the services billed.

The individualized treatment plan must state the type, amount, frequency and duration of the services to be furnished and indicate the diagnoses and anticipated goals. Treatment goals should be measurable and objective. Documentation should include specific therapeutic interventions planned and an estimated duration of treatment.

Services must reasonably be expected to improve the patient’s condition. The treatment must be designed to reduce or control the patient’s psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient’s level of functioning. Psychotherapy services are not covered for severe and profound intellectual disabilities. Also, psychotherapy services are not covered for dementia patients when documentation indicates that dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective. When a patient has dementia, the capacity to meaningfully benefit from psychotherapy must be documented in the medical record.

Activity and Time

Another CERT review as described in MLN Matters Article SE1407 identified the main error as not clearly documenting the amount of time spent only on psychotherapy services.

The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change. Behavior modification is not a separate service, but is an adjunctive measure in psychotherapy.

A variety of techniques are recognized for coverage under the psychotherapy codes; however, the services must be performed by persons authorized by their state to render psychotherapy services (such as physicians, clinical psychologists, registered nurses with special training, and clinical social workers). Medicare coverage of procedure codes 90832-90838 does not include teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction.

Psychotherapy codes 90832-90838 are timed codes and the documentation must support the time billed as a psychotherapy encounter. The time associated with these codes is for face-to-face services only with the patient (or patient and family). In general, providers should select the code that most closely matches the actual time spent performing psychotherapy. CPT® provides flexibility by identifying time ranges that may be associated with each of the three codes:

• Code 90832 (or + 90833) 30 minutes: 16 to 37 minutes
• Code 90834 (or + 90836) 45 minutes: 38 to 52 minutes, or
• Code 90837 (or + 90838) 60 minutes: 53 minutes or longer

Do not bill psychotherapy codes for sessions lasting less than 16 minutes.

CPT codes 90833, 90836, and 90838 are add-on codes for psychotherapy services provided with an evaluation and management (E&M) service. Both services are payable if they are significant and separately identifiable and billed using the correct codes. Time spent for the E&M service is separate from the time spent providing psychotherapy and time spent providing psychotherapy cannot be used to meet criteria for the E&M service. Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.

Outcomes

A periodic summary of goals, progress toward goals and an updated treatment plan must be included in the medical record. The general expectation is that the treatment plan will be updated at least every three months.

There are no specific limits on the length of time that services may be covered, but the duration of a course of psychotherapy must be individualized for each patient. As long as the evidence shows that the patient continues to show improvement in accordance with their individualized treatment plan, and the frequency of services is within the norms of practice, coverage may be continued. However, prolonged periods of psychotherapy must be well-supported in the medical record and include a description of the necessity for ongoing treatment.

You may want to come up with your own memory tool for remembering to include all the required documentation components of psychotherapy. However you choose to remember, meeting Medicare’s prickly requirements will help guarantee appropriate payments.