Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor
May is Mental Health Awareness Month!
What better time to bring awareness to mental health and discuss documenting and coding for these services and the recent OIG (Office of Inspector General) audit? Mental health continues to plague millions of adolescents and adults in the United States daily, significantly increasing those suffering from anxiety disorders. The Anxiety & Depression Association of America (ADAA) states that 6.8 million adults, or 3.1% of the population, are affected by Generalized Anxiety Disorder (GAD), and 15 million adults or 7.1% of the U.S. population, are affected by social disorders. In addition, anxiety disorders affect 31.9% of adolescents between 13 and 18 years old. 2020 National Survey of Children’s Health (NSCH) showed that 7.8% of children ages 3 to 17 had a current anxiety disorder; 0.7% reported severe anxiety. These numbers also increased significantly during and after the COVID-19 Pandemic.
Recent Increase in Mental Health Cases
Per the APA (American Psychological Association), many psychologists also said they had increased workloads and longer waitlists than before the pandemic, which shows the increased need for psychotherapy services.
WHO (World Health Organization) stated that the COVID-19 Pandemic triggered a 25% increase in the prevalence of anxiety and depression worldwide. One primary explanation for the rise is that the unprecedented stress during the pandemic was caused by social determinants of health, such as social isolation; restaurants, schools, jobs social events spaces were all shut down for months. Linked to this were constraints on people’s ability to work, seek support from loved ones and engage in community activities. Loneliness, fear of infection, suffering and death for oneself and loved ones, grief after bereavement and financial worries have also all been cited as stressors leading to anxiety and depression. Among health workers, exhaustion has been a significant trigger for suicidal thinking.
This increase in the frequency of mental health problems has coincided with severe interruptions to mental health services face to face services, leaving huge gaps in care for those who need it most. For much of the pandemic, services for mental, neurological and substance use conditions were the most disrupted among all essential health services reported by WHO. Many people who could not access face-to-face care have sought support online via telemedicine/telehealth services, signaling the lawmakers’ urgency for reliable and effective digital tools available and easily accessible.
What is Psychotherapy?
Psychotherapy is the treatment of mental conditions through verbal communication and interaction. CPT also list psychotherapy as 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 heavier, and encourage personality growth and development.
These services are utilized by psychiatrists, other qualified healthcare professionals, psychologists, social workers, and nurses with the CPT 9000 series code set. Psychotherapy is a time-based code requiring total time/actual time to be documented in the mental record. As well as time for any applicable add-on codes for specific services provided in combination with the base code. CPT code description has a minimum time for the code sets that can be reported. There were flexibilities to time requirements during the pandemic that should be reviewed to ensure all reporting was compliant during that time period.
The description of psychotherapy in the CPT is described as time spent with the patient and family. Some patients may also have medical evaluation and management services performed during the same day as psychotherapy; the physician or qualified health care professional performs these E/M. The psychotherapy service and the E/M must be significant and separately identifiable to report both services on the same day. In other words, documentation must support the significance of both services/medical necessity.
- E/M code level codes are selected based on Medical Decision Making
- Time spent on the activities of the E/M services is not included in the time used for reporting the psychotherapy service. Therefore, time may not be used as the basis for E/M code selection, and prolonged services may not be reported when psychotherapy with E/M (90833, 90836 and 90838) is reported.
- A separate diagnosis is not required to report E/M and psychotherapy on the same date of the services.
- 90832-90838 include psychotherapy of individual patients on an ongoing assessment and adjustment to psychotherapeutic interventions and may include involvement of informants, and collaterals, in the treatment process.
- 90846-90847 are used for family psychotherapy; these codes may be reported on the same day as 90832-90838. If the documentation supports these services, we separate and identifiable services.
- 90839-90840 are psychotherapy codes provided to a patient in a crisis state and cannot be reported in addition to psychotherapy codes 90832-90838.
- 90785 is an add-on code to be reported for interactive complexity services when provided in conjunction with psychotherapy codes 90832-90838.
Psychotherapy documentation should include time, as mentioned above, and modalities and additional telehealth documentation if that modality is used. Documentation should also include the reason for the visit, patient location, consent obtained (if telehealth), diagnosis codes (coded to the highest level of specificity documented in the record), other acute or chronic conditions that may affect the patient and care, any new signs and symptoms that may show disease progression or regression, side effects to treatment, functional status, mental health status examination, treatment plan, name, signature and credentials of the person performing the service. CPT and documentation requirements for the specific code sets should constantly be reviewed to ensure that documentation supports the reported CPT code. In addition, Local Coverage Determination (LCD) and National Correct Coding Initiative (NCCI) descriptions should also be reviewed.
Per APA, the pandemic led to a switch to telehealth for many psychologists, and virtually all clinical psychologists continue to provide at least some services remotely (96%), according to the survey. In addition, while few have returned to seeing patients entirely in person since a year ago (about 4% vs 3% in 2020), a more significant number of psychologists have adopted a hybrid approach of seeing some patients in person and some remotely (50% vs 33% in 2020), revealing a slow progression back to the office.
The flexibilities and across-state line waivers allowed providers to provide telehealth services to patients who may have gotten “stuck in other states” or relocated to other states during the pandemic. Telehealth allowed providers to utilize various modalities to communicate with their patients during the PHE, from audio and video telecommunication to audio-only communication for those who did not have access to video or did not want to use video. Modalities and HIPAA-compliant platforms such as:
- Google Hangout video
Providers could manage patients on controlled substances and assess patients faster who may have required escalation or inpatient services.
APA continues to advocate for continued flexibility in insurance coverage of telehealth services, including audio-only telehealth, as well as equal coverage and reimbursement for telehealth services compared to in-person treatment. Telehealth services enable patients from underserved communities—such as rural areas and communities of color—to access these services, often for the first time. For example, 96% of psychologists said telehealth during the pandemic had proven its effectiveness as a therapeutic tool, and 93% said they intend to continue providing telehealth as an option in their practice after the pandemic.
As the PHE ends on May 11th, congress, CMS, HHS and OIG have a list of waivers and flexibility that will expire on May 11th at the end of 2023 and those extended until the end of 2024. Audio-only coverage for approved services can continue to be reimbursed through to December 31, 2024; read our blog post on “What to Expect with Telehealth now that we’re at the end of the PHE”.
OIG’s recent Psychotherapy Audit
The OIG did a recent audit with the results published on May 2, 2023, that stated Medicare Improperly Paid Providers for Some Psychotherapy Services, Including Those Provided via Telehealth, During the First Year of the COVID-19 Public Health Emergency. In response to the COVID-19 PHE, CMS temporarily expanded access to health services provided via telehealth, as mentioned above. As a result, from the sample size reviewed from March 2020 through February 2021 (audit period), Medicare Part B paid $1 billion for psychotherapy services, including telehealth services, provided to Medicare enrollees nationwide.
The results showed that providers did not meet Medicare requirements and guidance when billing for some psychotherapy services, including services provided via telehealth, such as psychotherapy time was not documented and another sample size was missing providers’ signatures. Suppose documentation is missing the provider’s signature. In that case, it is an incomplete note. It should not be submitted for payment until it was signed per the OIG report; providers received $580 million in improper payments for services that did not comply with Medicare requirements, consisting of $348 million for telehealth services and $232 million for non-telehealth services.
The APA quoted a psychologist in their article who stated, “These numbers highlight what we have been saying since the early days of the pandemic—we are facing a mental health tsunami,” “We need to continue to support treatment via telehealth, and we must invest in screening, prevention, and innovative interventions to expand access to various levels of care.”
Psychotherapy is imperative to combat the mental health crisis plaguing the nation. However, as providers continue to provide services via in-person, face-to-face or audio-only calls, documentation must continue to comply with CPT requirements and support services provided/medical necessity and updated treatment plans accordingly. Continued educational training for physicians, other qualified healthcare professionals, coders, and billers are imperative as well os a review of EHR to ensure documentation captures all necessary elements.
Various resources and mental health locations are available nationwide to support people suffering from mental health. Unfortunately, so many people continue to suffer in silence. No one should feel alone or do not know where to go for help. Check out the National Institute of Mental Health (NIH) for more tips and referrals. Also listed is the number for the suicide hotline:
988 (Suicide Hotline)
SAMHSA’s National Helpline, 1-800-662-HELP (4357)
To schedule training on documentation and coding guidelines for psychotherapy and other E/M for your organization or private practice providers, email us today at firstname.lastname@example.org, schedule a call or visit the website and fill out the “contact us” form.