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2016 CPT Code Changes for Mental / Behavioral Health

CPT (Procedural) Codes Changing Again for Mental Health
Yep - it's time again: we just caught our breath from the ICD-10 transition, and now it's time for more changes. This time, the updates concern the Current Procedural Terminology (CPT) codes. Whereas ICD codes are for diagnosis: ie, why the client is seeing you, CPT codes are for billing: what type of treatment was provided.

CPT codes are used to receive reimbursement for the services provided: they request payment for service(s). ICD codes support the CPT codes: the service was necessary because of the client's diagnosis / need. See "For Mental Health, how do DSM, CPT, and ICD Codes Interact?" for more details.

Changes to Behavioral Health E/M Codes

+99354 and +99355 are add-on codes for prolonged services. They now apply to prolonged face-to-face outpatient psychotherapy in addition to prolonged face-to-face Evaluation and Management (E/M) codes. Prolonged codes start at >45 minutes.

You should now utilize a primary E/M or psychotherapy code, one 99354 code per day (30-74 minutes in addition to the time spent on the initial/primary service), and as many units of 99355 to match the total time spent with the client.

Note: the above guidelines apply to outpatient services only. Check the table in your CPT code book to record the correct time codes.

New Codes for Mental Health & Psychiatry

There are two new add-on prolonged service codes: +99415 and +99416. They are used to document prolonged face-to-face clinical staff service with physician, NP or PA supervision. The same rules apply as above.

Since these codes are used for clinical services under supervision of a prescriber, they will obviously apply more to a psychiatry or intensive outpatient (IOP) setting.

Note: the above guidelines apply to outpatient services only. Document the services provided and the length of time they took. If you are reporting additional procedures, document the time and note that they are excluded so no payer suspects you of double-dipping for reimbursement.

Misc

Any CPT code with a "+" prefix must be reported with a primary code. These are add-on codes and should never appear alone on a claim.

More Information

As with ICD and DSM, the only definitive source are the actual code resources, in this case, the CPT book from the AMA: you should refer to your CPT book to ensure compliance and accuracy. For more complimentary tools, check out our CPT Code Changes Resource Center.

Sources Include: Manage My Practice Blog (Mary Pat Whalen)

Questions From the Audience: Facility-Level Billing

We were recently asked "How does PIMSY handle facility level billing – head in the bed or attendance based billing? How does it handle physician encounter and is there any support for E/M coding decisions?"

See our Inpatient Services page for information about how PIMSY manages "head in the bed" or attendance based billing. Regarding E/M coding support, this is something we excel at: PIMSY automatically checks for add-on codes, authorizations, etc.

We have several standard features built in, and others that can be customized to the individual practice. We can set up the billing matrix in a number of ways to handle facility-based billing. Let us know if you'd like more information.

 

(Disclaimer: Ultimately, it is the responsibility of each practice to ensure legal and industry compliance. PIMSY EMR/SMIS has gathered information from various resources believed to be authorities in their field. However, neither PIMSY EMR/SMIS nor the authors warrant that the information is in every respect accurate and/or complete. PIMSY EMR/SMIS assumes no responsibility for use of the information provided. Neither PIMSY EMR/SMIS nor the authors shall be responsible for, and expressly disclaim liability for, damages of any kind arising out of the use of, reference to, or reliance on, the content of these educational materials. These materials are for informational purposes only. PIMSY EMR/SMIS does not provide medical, legal, financial or other professional advice and readers are encouraged to consult a professional advisor for such advice.) 

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