Major changes to the codes in the psychiatry section of the AMA’s manual on Current Procedural Terminology (CPT)—the codes used for billing and documentation for all insurers—will go into effect on January 1, 2013.

“To better reflect the work psychiatrists really do” is the impetus behind the changes, according to psychiatrist Jeremy Musher, M.D., APA’s advisor to the AMA’s Relative Value Update Committee (RUC) and alternate advisor to the AMA editorial panel for the manual Current Procedural Terminology. He noted that the new codes are the result of work by APA with the AMA CPT Editorial Panel and other major mental health associations.

In an interview with Psychiatric News, Musher said a persistent overarching concern has been that the codes commonly used by psychiatrists have primarily consisted of psychotherapy with evaluation and management (E/M) codes (for example, 90805, 90807), which have minimal work attributed to the E/M component, and a fixed low-level medication management code (90862). This “one size fits all” approach doesn’t reflect the complexity of work that clinicians actually do with many of their patients.

“What that has meant is that if a psychiatrist sees a patient in psychotherapy with medication management, regardless of how difficult the patient is from a medical standpoint, the psychiatrist gets paid only for a low level of E/M work,” he said.

Musher outlined five essential areas where the psychiatric codes are being revised, eliminated, or refined. (Specific coding information has been posted on APA’s Web site for members only. See end of article for URL.)

• Changes to the current diagnostic evaluation code (90801) to distinguish whether the evaluation included medical work or did not.

• Refinement of psychotherapy codes, keyed to three levels of time spent with the patient. There are also “add-on” codes when psychotherapy is provided in conjunction with E/M work (for example, medication management). Add-on codes are codes that can be used only in conjunction with another, primary code; they are valued based on intra-service time since the pre- and post-time is accounted for in the primary code.

• Elimination of the pharmacologic management code (90862) and its replacement with existing E/M codes that allow for different levels of work to account for varying patient complexity.

• A new add-on code for “interactive complexity” (see New Code Added for ‘Interactive Complexity’).

• A new code for psychotherapy with a patient “in crisis.”

The following is a summary of each of the changes:

• Diagnostic Evaluation:  The new codes provide for a distinction between an initial evaluation with medical services done by a physician or nurse practitioner and an initial evaluation done by a nonmedically trained practitioner. (Under the current coding system, physicians and nonphysicians use the same code for an initial evaluation though they don’t actually provide the same services.) The new diagnostic evaluation codes can be billed more than once on separate days when separate evaluations are conducted with the patient and other informants.

• Psychotherapy Codes:  There are three new timed codes that can be used for psychotherapy alone in all settings. (Currently the psychotherapy codes distinguish between setting and between whether E/M services or interactive psychotherapy were provided.) Additionally, new “add-on” psychotherapy codes can be used when psychotherapy is done in the same encounter as an E/M service. The new psychotherapy codes will also account for time spent face to face with the patient and/or family. (Current codes represent only time spent with the patient.)

• Interactive Complexity:  In lieu of the current separate codes for interactive psychotherapy, there is now an add-on code for interactive complexity, which may be used when the patient encounter is more complex than standard one-on-one psychotherapy (see New Code Added for ‘Interactive Complexity’).

• Patient in Crisis:  A newly proposed code for “Psychotherapy in Crisis” can be used when a practitioner performs an urgent assessment and history of a crisis state, a mental status exam, and a disposition. Treatment in such a crisis might include psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma. The presenting problem would be typically life threatening or complex and require immediate attention to a patient in high distress. When a crisis encounter goes beyond 60 minutes, an add-on code for each additional 30 minutes can be used.

• Elimination of 90862:  The standard psychiatric pharmacologic management code has been eliminated, and under the new system psychiatrists can use an appropriate E/M code when they do pharmacologic management. This change should benefit psychiatrists in at least two ways: by permitting them to use an E/M code that reflects the medical and psychiatric complexity of the patient and by allowing the use of the psychotherapy add-on codes in conjunction with an E/M code.

Musher told Psychiatric News that this is perhaps the most important change psychiatrists will want to familiarize themselves with. “If a patient who is on two or three different psychotropic medications and also has comorbid conditions—heart disease, thyroid disease, or diabetes, for example—and presents with a worsening of symptoms possibly related to side effects of his or her medications, that patient will require significantly more decision making and critical thinking than does a patient who is stable on a single medication or maybe two.”

Musher explained that using the existing 90862 pharmacologic management code doesn’t distinguish between those two very different patients for payment, whereas using E/M codes allows psychiatrists to select higher-level codes that more accurately reflect the work and receive higher payment for more complicated patients.

If the medically complex patient is also being seen for psychotherapy, the psychiatrist could select the appropriate E/M code, then use one of the psychotherapy codes as an add-on.

Musher acknowledged that the changes may seem initially daunting to psychiatrists long used to the standard psychiatric codes. But he emphasized that the changes should result in more accurate descriptions of complex clinical work and better reimbursement.

And he stressed the importance of APA members familiarizing themselves with the E/M coding system. “Probably the most important change is learning how to use the appropriate E/M code,” he said. “Once psychiatrists understand the changes, they will not be that difficult.”

Specific information about the CPT code changes can be found on APA’s Web site at www.psychiatry.org/cptcodingchanges. Look to future issues for continued coverage of changes to psychiatric codes in the CPT manual.

Becky Yowell and Ellen Jaffe of APA’s Office of Healthcare Systems and Financing contributed to this report.

New Code Added for ‘Interactive Complexity’

In lieu of the current separate codes for interactive psychotherapy, a new add-on code for “interactive complexity” can be used when the patient encounter is more complex than standard one-on-one psychotherapy.

Currently, “interactive” codes are used only when the patient has problems with communications, as with young children for whom play equipment is used or when a translator is required. But the new interactive complexity add-on code can additionally be used in the following situations:

• When there is a need to manage maladaptive communication among participants in therapy that complicates the therapy.

• When caregivers’ emotions or behaviors interfere with their understanding and ability to assist in implementing the treatment plan.

• When there is evidence of a sentinel event that mandates a report to third parties and discussion of the event and/or report with the patient and other participants.

This add-on can be used with the psychotherapy codes, with the nonfamily group psychotherapy code, and with the evaluation and management codes when they’re used in conjunction with psychotherapy services. Although it is expected that this add-on code will be used most frequently in the treatment of children, it can be used any time interactive complexity is present. Documentation will be crucial to show the exact nature of complexity. More information is posted at www.psychiatry.org/cptcodingchanges.