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Billing 90833: Therapy add-on

This article provides tools to support clinician decision-making for billing. It contains guided steps for how to bill patients for psychiatric services at Rula, outlines example scenarios, details information on medical decision-making (MDM), and has a list of current CPT codes for psych outpatient services. Additional resources are linked at the bottom.

Guided steps

  1. Decide if you are going to bill by time or complexity. If complexity, then use the usual E/M code. May use the MDM chart below for guidance.
  2. If you choose time, decide how much time you'll bill.
    If E/M, bill 99214, 99215, etc. based on time.
  3.  If you choose billing E & M on complexity, determine if provided psychotherapy; additionally, choose how complex the medical management was. (E.g. 16 minutes psychotherapy + 99214).
  4. Document appropriately for the code(s) chosen.

Remember that if you use add-on psychotherapy codes, you must choose your E/M code based on MDM and not time!

Example: E/M AND PSYCHOTHERAPY

To determine the correct codes to use:
• E/M – base the code on the complexity of the service that meets the appropriate MDM criteria. • Psychotherapy time – determine the approximate amount of time spent on the E/M portion of the visit, subtract that from the total time of the service, and if the remaining time was spent providing psychotherapy, use the appropriate code based on that time. Document the time of the psychotherapy and divide the note into two sections; one for the E/M portion of the work and a “separately identifiable” section for the psychotherapy component.Keep in mind that E/M work takes time and the more complex the visit, the more time it should take. Some insurers are questioning weekly visits of 99215 +90833 psychotherapy with total time of 30 minutes.

You should ask yourself two questions:

  1. If seeing patients frequently, is the E/M work medically necessary at the level I billed?
  2. Did I appropriately allot a reasonable amount of time, as part of the total time of the visit, for the E/M level I billed?
    Note: Rules can vary by payer.

Medical decision making (MDM)

  • The level of MDM is driven by the nature of the presenting problem for that visit. How complex is that visit?
  • Best two out of three – Problems, Amount and/or Complexity of Data, and Risk (the level must be met or exceeded)
  • All visits contain problems and risk.

In psychiatry, we often don’t have enough data to help justify the code level – recommend using Problems and Risk as the “two out of three.”


Key definitions
PROBLEM

  • Problem
    • A disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at time of the encounter.

  • When is a problem addressed or managed?
    • When it is evaluated or treated at the encounter by the provider reporting the service.
    • Includes consideration of further treatment/testing that may not be done by virtue of risks/benefits or patient/guardian/surrogate choice.

  • When is a problem NOT addressed?
    • Simply documenting that another provider is managing the problem.
    • Referral without evaluation or consideration of treatment.

E/M CODE SELECTION BY TIME

  • Counseling and/or Coordination of Care is no longer relevant to determining time
  • Time is defined as total time on the date of the encounter related to the service, including both face-to-face and non-face-to-face time. Time includes:
    • Preparing to see patient (e.g., review of tests, records)
    • Obtaining and/or reviewing separately obtained history
    • Performing a medically necessary appropriate exam and/or evaluation
    • Counseling and educating the patient/family/caregiver
    • Ordering medications, tests, or procedures
    • Referring and communicating with other healthcare professionals (when not reported separately)
    • Documenting clinical information in the electronic or other health records
    • Independently interpreting results and communicating results to the family
    • Care coordination (when not reported separately)


2023 CPT codes psych for outpatient

Note: There have been no changes since the 2021 updates.

99213
MDM: 1 stable chronic illness with Rx management (stable ADHD, MDD in remission)
Time = 20-29 minutes – Document total time or start/stop time

*Patient that consistently meet 99213 should be considered for referral back to their PCP for management

99214
MDM: 1 or more chronic illness that is worsening, progressing or with side effects + Rx management
2 chronic stable diagnoses, + Rx management
1 undiagnosed new problem (rule out)
Time = 30-39 minutes – Document total time or start/stop time

99215
MDM1 or more chronic illness with severe exacerbation, progression or side effects of tx
1 acute or chronic illness that poses a threat to life or bodily function
Decision to admit to higher level of care can be counted whether patient accepted admission or not.
Time = 40-54 minutes – Document total time or start/stop time


Psychotherapy with E/M 90833
E/M must be documented and billed based on Medical Decision Making – MDM
Psychotherapy must be billed based on time

Note: Remember that if you use add-on psychotherapy codes, you must choose your E/M code based on MDM and not time!

90833-30 minutes (16 -37 minutes of therapy)
· Used in addition to E/M service

90836-45 minutes (38 - 52 minutes of therapy)
· Used in addition to E/M service

90838-60 minutes (minimum 53 minutes of therapy)
· Used in addition to E/M service*

One note is acceptable but must be able to identify the 2 distinct services

*At Rula, we only use the 90833 therapy code in Psych services.

Examples:

99213
CC: F/U visit for a patient with recurrent major depressive disorder, in remission.
Hx: Margaret tells me that she has been doing pretty well since our last visit 3 months ago. Her PCP has not changed her HCTZ blood pressure medicine. She has been sleeping and eating well, her return to work has been good for her, and she is functioning well in that setting. She has resumed her usual activities and has had no suicidal ideation nor periods lasting more than a few minutes of sadness throughout the day. We agreed to continue the fluoxetine at 40 mg. Exam: As above.
MDM: Stabilizing mood in patient with recurrent episodes of depression. Will continue fluoxetine 40 mg daily. Rx given for 3 months. Return in 3 months or prn.
Dx: Major depressive disorder, recurrent.


99213 – CODE SELECTION RATIONALE
Code Level of MDM Problem(s) Risk
99213 Low Stable chronic illness (MDD, recurrent) Moderate
Prescription mgmt.


Code Selection Rationale: Although this patient has moderate risk due to being on a prescription medication, her Number and Complexity of Problems are low (one stable chronic illness), and no data were reviewed. In terms of medical necessity for this visit, a 99213 seems appropriate. Although she has hypertension and is taking medication for it, the psychiatrist is not managing this condition, and thus it would not count as a second chronic illness for this visit

 

90833 Therapy add on Billing requirements

Separate documentation from E/M for therapy (can include as a separate section under the plan)

Note: At Rula, we provide the option to use the Ambience auto scribe tool to help capture this data for you which can ease the documentation burden of this section

Therapy Note
Substance use Hx:
-EtOH: ***
-drugs: ***
-tobacco: ***


Diagnosis/Assessment: ***
Patient is a *** with *** here today for ***. Patient is is not *** responding to therapy and medication combination.


Therapy Plan:
***
-c/w combination therapy and med management
-c/w psychotherapy

Time on psychotherapy: ***

Type of psychotherapy provided:
Supportive therapy,
Motivational interviewing,
Insight oriented therapy,
Crisis stabilization,
Safety planning,
Coping skills,
Psychodynamic therapy,
Cognitive behavioral therapy,
Behavioral therapy,
Acceptance Commitment therapy,
DBT,
Utilized empathic listening, validation, psychoeducation based feedback to establish therapeutic alliance thereby improving treatment adherence.

 

To target the following goals:

  • Increase coping strategies,
  • Address cognitive distortions,
  • Improve interpersonal skills, Behavioral activation,
  • Decrease self-harm,
  • Decrease substance use,
  • Improve self-care,
  • Improve relational/social/occupational and/or academic functioning,
  • Mitigate exacerbation of psychiatric symptoms, Utilized empathic listening, validation, psychoeducation based feedback to establish therapeutic alliance thereby improving treatment adherence.
    • Provided Insight-oriented therapy to alleviate emotional disturbances
    • Utilized DBT techniques to help improve insight and reverse or change maladaptive patterns of behavior
    • Encouraged personality growth and development through empathetic listening and validation,
    • Discussed CBT techniques to target maladaptive patterns of thinking, identify triggers,
    • Provided CBT & mindfulness tips and tools to address recent stressors,
    • Provided brief solution-focused counseling to address ***
    • Used CBT techniques to identify automatic thoughts that trigger feelings of anxiety and depression
    • Utilized solution-focused brief therapy to explore patients motivation for change, factors underlying current problems and possible solutions for change.
    • Psychoeducation provided discussed alternative treatment to manage anxiety including exercise, mindfulness techniques, and the "calm app."
    • Discussed skills and techniques for management of ADD symptoms and recommended reading “ ADD friendly ways to manage your life.”
    • Discussed behavioral activation techniques to encourage patient to reach out in the community, engage in hobbies, socialize, engage in outdoor activities, etc
    • Discussed concept of self-image and body weight. Discussed preoccupation with eating and over-evaluation of shape and weight. Discussed goals ie decrease frequency of weighing self, increase meals ***
    • Utilized DBT techniques to help improve insight regarding mood stabilization and mood regulation.
    • Utilized DBT techniques to address interpersonal stressors and managing expectations
      Recommend DBT skills training book and discussed different components.
    • Utilized CBT and behavioral activation techniques to increase activity level and thereby improve behaviors that worsen depressive symptoms.
    • Utilized CBT techniques to manage panic attacks including deep breathing and progressive muscle relaxation.
      ***

Additional resources

Updated

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