Psychotherapy is on Medicare’s Radar

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Psychotherapy involves treating mental illness and behavioral issues by engaging in therapeutic communication. Through this process, a physician, advance practice provider, or other qualified health care professional aims to alleviate emotional disturbances, reverse or modify maladaptive behavior patterns, and foster personality growth and development.

The codes listed below are included in the active TPE (Targeted, Probe, and Educate) review. Psychotherapy codes are based on time. The CPT code that most closely matches the actual time spent is selected. Psychotherapy should not be reported if the time spent is less than 16 minutes. Additionally, this set of codes permits time-based billing after reaching the midpoint. While not all time-based codes support this approach, the psychotherapy services mentioned do allow it.

CPT Codes

90832 – Psychotherapy, 30 minutes with patient
90834 – Psychotherapy, 45 minutes with patient
90837 – Psychotherapy, 60 minutes with patient

Top TPE Denial Reasons:

Medical necessity: The documentation submitted was incomplete as it lacked evidence of medical necessity for the following reasons:

There was insufficient evidence to confirm that the practitioner was operating within their scope of practice.
The service lacked evidence to be considered medically reasonable and necessary for psychotherapy.
There was insufficient evidence to substantiate the duration of the psychotherapy service provided.

Insufficient documentation:

Documentation was not submitted in a timely manner to support the services billed to Medicare.
The documentation provided for review did not substantiate the number of units billed in relation to the time spent performing the service. Consequently, it was recoded to reflect the appropriate service level based on time.
The documentation provided for review lacked adequate evidence of the necessary physician supervision (incident-to) to bill Medicare under the physician’s services.

The MLN Matters 198542 article (page 23) states that the incident-to requirements for behavioral health include certain exceptions not applicable to other services, such as E/M services.

“We offer an exception to the direct supervision requirement for incident to behavioral health services provided by auxiliary personnel. In other words, incident to behavioral health services can be provided under the general supervision of a physician or an NPP instead of direct supervision. Under general supervision, the physician or NPP may be contacted by phone, if necessary, as the physician’s or NPP’s presence isn’t required during a procedure.

Physicians, NPPs, and practitioners can also serve as auxiliary personnel and provide services and supplies incident to the personal professional services of another physician or NPP. Appropriate payment can be made to the other supervising physician, or NPP in this case, if you meet all the incident to requirements.”

Keep in mind that the healthcare providers (e.g., LCSW) who utilize this particular code set are typically not physicians or advance practice providers. CPT has a complimentary set of add-on codes (90833, 90836, and 90838) to use when the MD/ACP is also reporting evaluation and management services. These codes were not included in the TPE active review.

Documentation Tips

The TPE identified four key areas of information that are missing in the medical record based on their reviews.

Diagnosis and symptoms to support medical necessity for psychotherapy
Start and stop time or total time
Name, signature, and credentials of person performing the service
Name and credentials of supervising physician or advance care practitioner (if applicable)

For an in-depth review of the documentation requirements, a link to the Novitas psychotherapy checklist is provided below.

Resources

MLN Matters 1986542

TPE Psychotherapy

Novitas JH: Psychotherapy Documentation Checklist

Novitas Behavioral Health Page

Federal Register 42 CFR 410.26 and 42 CFR 410.27