How to Avoid Evaluation and Management (E/M) Payment Issues

The Practice Management HelpLine often receives calls from members whose selection of CPT medical evaluation and management (E/M) codes is being questioned by payers. Prior to the major changes that were made to CPT coding in January 2013, psychiatrists who saw patients for individual psychotherapy used timed codes that indicated that the therapy was provided by a physician (90805, 90807, 90809). Nonphysicians had equivalently timed individual psychotherapy codes that did not include medical evaluation and management during the session (90804, 90806, 90808). The codes used by psychiatrists paid slightly higher than the nonphysician codes, with the E/M service being valued at approximately the same level as a 99211 code. This code is for the lowest-level outpatient E/M service for an established patient—a code that does not even require the presence of a physician.

The current coding structure enables psychiatrists to be more accurately compensated for providing higher level E/M services than did the previous codes when they provide both psychotherapy and E/M services. While this change permits more accurate coding and reimbursement, the use of E/M codes has made coding psychiatric services much more complex. Perhaps the most difficult challenge is determining the appropriate level of E/M services provided to a patient. Although the selection is based on the number of elements involved in the history, exam, and medical decision making that occurs during the visit, as defined in the Centers for Medicare and Medicaid Services’ (CMS) guidelines for E/M coding and documentation, the determination of which elements to include must be based on the patient’s presentation. The psychotherapy code is still selected on the basis of time.

For example, you may see a patient with a number of serious psychiatric and medical diagnoses on a regular basis, primarily for supportive psychotherapy. Although the CMS guidelines indicate that the number of diagnoses can drive a higher level of E/M, if a patient with multiple diagnoses is seen weekly and is stable, there is no need to do more than establish that the stability is continuing (which could be done with the lowest level of E/M—99212). In contrast, if the patient has decompensated and you need to change the treatment regimen, then a higher level of E/M is warranted.

Although Medicare appears to be accepting the use of the lowest physician-level E/M service (99212) along with psychotherapy on a regular, even weekly, basis, some of the larger commercial payers are questioning whether E/M services are necessary on such a frequent basis and have been auditing psychiatrists who code this way. Some are demanding documentation from the patient’s record that justifies the medical necessity for the provision of that level of E/M or are denying payment for either the E/M or the psychotherapy. Remember, even if you’re out of network with an insurer, the patient may not be able to collect reimbursement if the medical record does not support the level of care billed. Moreover, sometimes insurers require patients to return payments if an audit fails to support the level of E/M that was billed.

So here’s the bottom line: Select the level of E/M coding for a patient visit on the basis of the patient’s history, exam, and medical decision making required for that day’s visit and whether changes are required in the patient’s treatment regimen. Do not base coding solely on the patient’s number of diagnoses or the overall complexity of the patient’s physical and psychiatric illnesses. ■