Q - I am providing therapy for a child, and both parents meet with me separately on the same day for the same member-- mom with the child for 45-50 minutes (without dad present), then dad with the child for 45-50 minutes (without mom present).
I have been billing for one session of family psychotherapy with client present, but I am wondering if it is okay to bill for two units of family psychotherapy with client present? --can one bill for two units of 90847 on the same day? Or would it be more appropriate to bill for two units of 90834, psychotherapy, 45 minutes with patient and/or family member?
A - In general, payers do not cover two family psychotherapy services with the patient present in one day. Try thinking of it this way: there is 1 client (the child); there isn’t an upper limit time for billing 1 unit of the service (though some payers have a minimum); so, you are seeing the client for 90 minutes and bringing in one family member at a time. And, that’s the way a payer or auditor would see it.
Q - A client was in crisis when she came in for her regular appointment. A second 60-minute session was scheduled with her the same day to utilize the crisis to move her forward in her therapy. How would the second hour be coded to get paid for it (90839 +90840 +90840)?
A -The CPT codes 90839 and 90840 are used for emergency sessions with patients who are in high distress and under complex or life-threatening circumstances that demand immediate attention. It's important to note that 90840 is an add-on code that must be used in conjunction with 90839.
In a crisis scenario, 90839 is billed for the first 60 minutes (though it can be used for 30-74-minute sessions), and 90840 is billed for each additional 30 minutes. Using both of these codes together requires that the session lasts 75 minutes or longer.
If you don't meet the time required to bill one or both of these two crisis codes, you can bill the standard CPT code for the session, such as 90832 (individual psychotherapy, 30 minutes). In this description, it seems as if the patient came for a regularly scheduled session of 1 hour during which the crisis situation was discovered.
The crisis necessitated a second one-hour encounter. The recommended coding is 90837 for the regularly scheduled hour (at which the crisis elements were prominent) and 90839 for the encounter prompted by the crisis. Due to national correct coding initiative (NCCI) auto-edits, it may be necessary to append the 90837 with the modifier -59.
Q - I have a provider that is seeing patients for an initial visit, plus a 60-min psychotherapy on the same day. Can he bill out a 90791 and a 90837? He's not a prescriber so can't bill e/m codes.
A - Billed without modifier, a psychotherapy by the same provider on the same day as a diagnostic visit is not allowable (wouldn’t pass NCCI edits). The theory (the AMA, not me) is that 90791 has no minimum or maximum time attached, therefore is only content based, and that any counseling (or psychotherapy) provided adjunct to the visit is included in the time spent and payment.
I think the only way to be paid for this would be to add the modifier 59 to the 90791 and submit both services on the same claim. It’s not clear how one would document the need for this immediate psychotherapy based on the outcome (one assumes) of a just completed diagnostic interview. It would certainly have to be an unusual occurrence and not a pattern of diagnostic visits followed by an hour of psychotherapy.
If the services are provided by two different providers, the 59 modifier would be appended and both claims would/should be paid whether on the same or different claims.
Consider this: if the patient’s appointment is for a diagnostic interview (90791) and there is need for additional time due to challenges (for example, high anxiety, high reactivity, repeated questions, or disagreement), adding the code for interactive complexity (90785) may be more.
Q - We are starting a weekly drop-in group facilitated by an LCSW for existing patients. The group will be art-focused, with an emphasis on interventions that reduce stress, improve emotion regulation, encourage problem-solving skills, and boost mood. During the group, patients will also have the opportunity to meet with a medical provider, and he will bill appropriately for those visits. We are hoping that this group will help patients access medical care promptly, and provide a therapeutic benefit in the process. For JCC members who attend this group, would it be appropriate for me to use g0176 (activity therapy)? Do you know whether g0176 requires a linked mental health assessment and treatment plan? Is it for Medicare only? I think the alternative is 96153.
A- The easy part, first: I think it would be very difficult to make the case that anything you are calling a “drop-in” service will meet the federal definition of psychotherapy. My 40 years of experience doing this leads me to believe that you can no longer order psychotherapy on a “PRN” or as needed basis – those days have long passed. Nearly every service beyond emergent care, or a very temporary change in modality, requires all the regulatory bells and whistles.
Consider this: regarding the G-code part of the question, what’s the activity? What you describe is a care coordination model, with emergent/urgent medical care available. If that’s an accurate understanding of what you’ve outlined, I’d be willing to bet the farm (probably yours, not mine) that we could work with JCC to “find a way” if this is truly doing as advertised.
Q - When counselors are required to appear in court after being subpoenaed, since there is no billable code to compensate for the time and the occasional stipend from the court does not cover costs, can the provider bill the attorney directly some fee that is more in line with the cost of the service and is there any rule (similar to not being able to bill a no-show fee) for OHP clients? Does it matter if it’s a criminal case or permanency hearing? And, if attorneys are just being excessive and are unwilling to work with the provider (I.E. being ok with records and an affidavit versus having to actually appear in court), do they have any recourse? Wondering if there's just a general way to deter what seems to be developing into a growing issue and what our rights as agencies are within this process.
A- In most cases, it is either the state v our client, or, our client v the state. In some straight parent/parent or parent/family custody battles, it may be that we get pulled in via subpoena to testify for one side or the other. In the latter (straight custody) you may be able to negotiate some sort of appearance fee if you are willing to risk fighting a subpoena and the testimony is so valuable to one party, they consider paying you a fee. But, I would recommend you consider the impact this stance would have on opinions regarding the impartiality of your clinical practice.
The two caveats in this one: 1). I have been called in both civil and criminal cases as an expert witness and, in turn, been paid for my time. But, to be clear, that’s not what we’re talking about; 2). I’m not your lawyer.
In most cases, if you are handling the subpoena for records correctly, there is some negotiation room in the appearance factor. But, you should have someone else in your organization be arguing that for you and that’s going to be very dependent on the lawyers. If you are in private practice, feel free to make your own argument against appearance, but, it is not wise to refuse or to refuse unless you are compensated. In the eyes of the court, there is very little difference – you are simply in violation of the subpoena.
Consider this – have your own policy and process regarding how subpoenas for paper and appearance are handled. Make part of it that someone reaches out to the issuer of the subpoena. I think JCC made available some suggestions for how to respond to subpoena through the training sessions from last year. Check it out.
Most of the time clinicians are appearing for their clients, in one capacity or another, and get paid by an agency unless in private practice.
If you are in private practice, you can sometimes negotiate your way out of an appearance if they have the records. I don’t know of an or prohibition about negotiating a fee, but, it’s a subpoena.
In either case, entity or private practice, there are rules about charging for copies of the record.
Q - How do I bill when I provide multiple services provided in one session like service planning, psychotherapy and case management?
A - Multiple services must be separately identifiable encounters or they are not billable. For instance, a client may receive medication management and psychotherapy on the same day. So long as those processes occur at distinctly separate encounters, they can be billed separately and should both be payable. The phrase “in one session” implies a single encounter and would not qualify for separate claims.
Q - How do I bill for treatment planning as well as an initial comprehensive assessment? Would it be 90791 and H0032 and can I bill for them on the same day if a session lasts 90 or 120 minutes?
A - H0032 is intended to be used when a separate encounter is required for coordinating/discussing/completing a treatment plan with your client. It is not intended to be used solely for the completion of a document by the provider. On rare occasions, it may be necessary to have a separately identifiable encounter for coordinating/discussing/completing a treatment plan with the client on the same day as another encounter. In such cases, the documentation for both encounters should clearly indicate the need for the separate encounters.
Multiple services must be separately identifiable encounters or they are not billable. For instance, a client may receive medication management and psychotherapy on the same day. So long as those processes occur at distinctly separate encounters, they can be billed separately and should both be payable. The phrase “a session” implies a single encounter and would not qualify for separate claims for these two services.
Q - When there are co-facilitators of a group, which one should be included as the rendering provider on the claim?
A - If both providers are eligible to bill for the service, the rendering provider could be either co-facilitator though not both. If only one co-facilitator is eligible to bill for the service, or if one provider has a higher credential level than the other, then the claim would include that provider as the rendering provider.
PLEASE NOTE: 1) It is assumed that “co-facilitator” indicates that both participated for the full group session. 2) While not a violation of a rule, it might be difficult to support that a claim is filed by one provider while another documented the service.
Q - If you can’t use the telemedicine modifier with routine phone calls, can you use the modifier with the usual outpatient office as the POS code and 90837 for an online session? And, is it ok to conduct secure, HIPAA-compliant online sessions in each of these situations that will also be reimbursed?
A - Oregon’s rule for defining telemedicine is quite expansive. It does cover telephone calls when they can be considered “patient consulting”. That is not to say that calls made to make or confirm an appointment, ask or answer simple questions, or, deal with an issue that is not clinical in nature fit into that category. But, if the phone call can accurately be described as consultation (in the medical definition of the term) in content, then it could be covered. However, the psychotherapy codes should only be used for that purpose. They are not catch-all codes. You should code the call using the CPT/HCPCS code that is most accurate to describe the work done
a. Client is ill and cannot travel to office but we have a session via Zoom.
b. Client is traveling, so have a Zoom session.
- In my opinion, so long as the session is medically necessary, it would fit the definition of telemedicine.
c. Client is moving and establishing services and eligibility for Medicaid-
- In my opinion, so long as the session is medically necessary, it would fit the definition of telemedicine.
funded services or other mechanisms to pay for therapy will take a while
and they are very much in need of transitional support.
- Until some sort of coverage is established this is a self-pay client. Payer rules do not necessarily apply. But, state licensing rules do apply and you’d want to be aware of any jurisdictional practice issues, such as crossing state lines.
Q - A Psychologist embedded in a Primary Care setting will be expanding his code set to psychotherapy codes. He is looking to track incident to billing and had questions for 2 scenarios:
(Assuming here that the billing is done by the PCP office or clinic.) a. The PCP has a well child check and calls the Psychologist in to the room to
address a positive depression screen. Is there a modifier code that can be
added to the well child check by the PCP so that it can be flagged as a BHC
b. The PCP has an illness visit and calls the Psychologist in and based on
- There is no modifier established as of yet for integrated care. However, assuming the PCP reviews the psychologist’s comments or stays in the room, the E/M level increases and/or a prolonged service code is appended to the E/M.
time and complexity bills the appropriate E&M code. Is there a modifier that
can be added to the illness visit that can flag that visit as one where a BHC
- Same as the previous question.