or Psychotherapy: Making the Distinction
By Emily Hill, PA-C
Follow these steps to decide between the code for Evaluation
and Management or Psychotherapy Services.
Despite what seems to be an increasing and endless list of coding rules and
guidelines, healthcare professionals are still confronted with situations for
which the proper code selection seems ambiguous. The Current Procedural
Terminology (CPT) 2000 manual provides the opportunity to use Evaluation
and Management (E/M) codes as well as psychiatric treatment codes for services
provided to patients who present with emotional or mental health issues. Understanding
the services described by each of these categories is essential to selecting
the proper code. In this article, well look at the distinctions between
the E/M and Psychotherapy Services codes and the steps necessary for selecting
the code that best describes your care of the patient.
Taking the First Step
The first decision you must make is to determine the type of service
you are providing. Are your services best described by the psychotherapy
or the E/M
codes? Lets look at the CPT 2000 definitions.
The psychotherapy codes are a subset of psychiatric treatment services (CPT 90801
to 90899) that include diagnostic and therapeutic services. Psychotherapy is
divided into interactive psychotherapy and insight-oriented, behavior-modifying
and/or supportive psychotherapy services. The CPT 2000 describes psychotherapy
as the "treatment for mental illness and behavioral services in which
the clinician establishes a professional contract with the patient and, through
definitive therapeutic communication, attempts to alleviate the emotional disturbances,
reverse or change maladaptive patterns of behavior, and encourage personality
growth and development." It may include the use of behavior modification
techniques, supportive interactions, cognitive discussion of reality or a combination
of these approaches.
In 1992, a complete restructuring of the codes used to describe patient
visits was completed. These E/M codes encompass the services provided
in the prevention
or diagnosis and treatment of illness, injury or symptoms. They are primarily
defined by the extent of the history, examination and medical decision making
required to address the patients needs. Time spent counseling the patient
or family and/or providing coordination of care can also define the service.
In this instance, counseling takes on a meaning different from that often used
by mental health professionals. For E/M purposes, counseling is a discussion
concerning areas such as diagnostic testing, prognosis, treatment options,
education and risk factor reduction. It is not the type of counseling that
involves the use of "definitive therapeutic communication" such as
that associated with psychotherapy.
The CPT provides clinical examples for selecting E/M services for some
specialties in Appendix D of CPT 2000. Examples for psychiatry include:
visit for a patient abstinent from alcohol and benzodiazepines
who complains of headaches, insomnia and anxiety;
• Office visit for a patient with a history of schizophrenia who has been
seen bimonthly but is complaining of auditory hallucinations;
• Hospital visit for a patient in chronic pain who has attempted suicide;
• Hospital visit for a psychotic, hostile, violently combative adolescent
who is involuntarily committed.
is important to remember that these are only examples. The type of service
selected for each patient encounter must be determined by the particular
Whats the Next Decision?
Once the type of service has been decided, the place of service must
be identified. Both the E/M and psychotherapy codes make a distinction
between the broad categories
of outpatient and inpatient services. A patient is considered an outpatient
until given official inpatient status by the facility; this means that services
rendered in facilities and areas other than a physicians office might
be reported using the outpatient codes. Common outpatient areas include clinics,
emergency departments, observation areas and hospital outpatient facilities.
Psychotherapy services provided in inpatient hospital, partial hospital and
residential care settings are all reported using the same set of inpatient
psychotherapy codes. For E/M services, inpatient care provided to hospital
inpatients and patients in a partial hospital setting is reported using the
hospital inpatient services codes. Residential care is reported using the code
set for nursing facility services.
What Determines the Final Code Selection?
The last step is to determine the content or level of the service. For E/M
services, this is generally the extent of the history, exam and/or medical
decision making. Under certain circumstances, time could be the deciding factor.
The selection of the proper psychotherapy code is based on the face-to-face
time spent with the patient during the session and whether E/M services
are also provided. The E/M component of the psychotherapy codes involves services
such as medical diagnostic evaluation, interpretation of laboratory or other
studies, medication management and physician orders. It is important that your
documentation supports medical evaluation and management when selecting a code
that includes those services. It is also imperative that the face-to-face time
be noted whenever it influences code selection.
Are There Other Considerations?
Although CPT does not restrict the use of the E/M or psychotherapy codes to
certain types of providers, some third-party payers have restrictions. For
example, Medicare does not cover E/M services or psychotherapy services with
medical evaluation and management when provided by psychologists, clinical
social workers or other nonphysician mental health professionals. Other payers
limit coverage of the psychotherapy codes to certain mental health professionals,
thereby denying reimbursement to family physicians and internists, etc., who
report these services.
Emily Hill, PA-C is president of Hill & Associates, a
national healthcare consulting firm specializing in coding and compliance
for physician practices. Her e-mail address is Emily@codingandcompliance.com.
Putting It All Together
The proper code is selected using the following steps:
whether the service is best described by the CPT definition
of E/M or psychotherapy services.
the appropriate place of service and the corresponding set
the appropriate code based on the content of the service.
sure your documentation is complete and accurate, and that
it supports your code selection.
This article is derived from the McMahon Archives.
This information may be time sensitive and was archived on