CPT and Psychotherapy Webinar

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CPT and Psychotherapy Webinar

apologies for all the difficulties that we find ourselves in tonight unfortunately we’re not at the University I’m actually in a different location and this is very difficult for us to try and coordinate from afar circumstances required that we find ourselves in this predicament so apologies and this will be also on YouTube hopefully without the feedback and also if you have any questions please let us know all right well let’s get the ball rolling okay the presentation obviously it has to do with psychotherapy and we’re gonna focus a great deal on that or approximately 97 slides I want to go into detail as fast as I can because there’s a lot of really important information however let me start off by as I always do emphasizing that there are a lot of organizations supported this work obviously the the most significant group has been the American Psychological Association very pleased that they have been supportive right from the very start but I also need to also emphasize the support of other groups and in addition to APA AMA has been very involved in making sure the psychology is at the table so to speak a lot of people have been behind this I want to acknowledge several of the most important person with in APA at the particular time is randy phelps encourage you to follow his work in his new position and of course the CEO Norma Anderson has been very very supportive of this work as has Katherine Nordal for the practice Directorate outside the APA let me emphasize the work of Jim Georgia Leykis who actually is the person involved with the AMA AMA CPT Rock side of things and Neil Plissken who has replaced me on the panel advisory group and I’ll talk about that in a second there’s lots of people that have contributed although most of it has not been financial and the slide indicates that it’s important for you to appreciate the fact that I am a and for that matter APA does not support this financially they do cover expenses or at least am a does APA used to I’ve been involved in doing this work for a long long time and some of you know that because you’ve heard me before but there may be some newbies here I’ve been involved since approximately late in 1980s when I was president and rec airline a psychological association and assist about 1992 with the AMA on the current procedural terminology group which I’ll discuss in a few minutes but there’s many other things probably one of the more interesting ones and one that’s not often related to these publicly is my appointment on the Medicare coverage advisory panel back in the in the 90s of as well as the the model policy that was put together about 20 years ago it’s important to emphasize that everything I say is aspirational and should not go against the APA ethics code which I was very lucky to it in Part A of the ethics panel as an associate for a number of years and of course HIPAA hell they’re federal regulations as well as stay in province regular regulations that you have to live by one of the most important things however that I can share with you tonight is the next point and that is be careful about the contractual agreements that you participated because those turned out to be major major issues and as I’ll say in a number of occasions this evening in essence this is all about what the insurance company thinks in some ways more so than what you think it’s critical I wish it was otherwise but all things being equal turns out to be a major concern that we need to be aware of so with that in mind let’s let’s move on to the issue of great importance today and that’s the current procedure terminology this is the overview and I’m going to talk about some of the issues in a very broad strokes and then get into detail really a very very deeply more so than I usually do because I’m just talking about psychotherapy just tonight that’s is the primary focus and actually to be honest with you the only focus so let me start it by saying that this material is

copyrighted by the American Medical Association under license by the center of Medicare and Medicare services and this information can be ordered from the AMA and the number is found there as well as the website ok so let’s talk for a moment as I have to see what’s a CPT code in fact I’m actually in a facility in and outside of my state and I was trying to explain to the staff what a code was I said this is actually the number that you circle to get reimbursed for whatever services that you do this is something that everybody seems to understand a couple of things worth mentioning it’s something that healthcare providers do frequently that there should be some empirical support and in addition to that there has to be something that theoretically is applicable and a wide range of settings in a wide range of locations the American Medical Association started this in 1966 primarily by surgeons and subsequently by other physicians and at the present time it’s involving about 8,000 discreet codes the group the panel which I’ll describe in a second is made up of a number of professional than meets three times a year usually a very nice locations think thankfully so but I have to be also honest that they give us these wonderful venues to meet and then they don’t give us the opportunity to enjoy those venues the 8,000 codes that I just refer to you a few minutes ago really to a wide variety of medical and health procedures and to be brutally honest not everyone has a wide range of options as a matter of fact in the case of psychology depending on how you view things or what state you might work in what kind of license that you might have we’re talking about 50 or 60 codes total and the codes are broken up in different categories psychiatry feedback central nervous system assessment physical medicine and Rehab health and behavior assessment and management team conference and evaluation and management historically we lived almost exclusively under psychiatry codes matter of fact that’s indeed how we lived until relatively recently we added the central nervous system testing codes back in the 90s the health and behavior code about 10-15 years ago and for what it’s worth those are going to be addressed at another time and we’re revaluing those so if you get the opportunity to participate in a survey for the hmb codes please consider those now more than ever we’re moving into other areas physical medicine rehabilitation team conference and of course you Holy Grail for a good portion of healthcare and that’s evaluation and management but today we’re only going to be focusing on psychiatry and specifically the so called mental health codes involving psychotherapy so and that’s just what we have here is three types of codes what I call the psychiatric or mental health codes were started in 1970s we’ve seemed to have some difficulties understanding exactly when those were made available but it appears to be about that time the near psychological testing codes which I mentioned to you just a few minutes ago to health and behavior codes and of course the new evaluation management codes and for that matter the wonderful sort of pioneering opportunities that lie ahead whether telehealth codes which I’ll address to with you this evening at least very briefly all right so again we’re gonna stick with the psychiatric codes and for another day and another dollar so to speak will address the neuropsychological and health behavior codes at a later time okay so let’s start by addressing this very simple question which obviously seems ridiculous to you and I but let’s make sure that we understand it and that is what is psychotherapy and you can see from this slide psychotherapy is the treatment for mental illness and behavioral disturbance in which the clinician establishes professional contract with a patient and through definitive therapeutic communication attempts to alleviate emotional disturbances reverse or change my adaptive patterns of behavior and encourage personality growth now let’s kind of take take a look at this this is a couple things worth mentioning okay first of all the big one is that we have a mental illness okay and and the mental illness are it’s really the though if you will the limitations of what we can work in and in essence we do not deal

with medical illnesses or or for that matter any kind of neuropsychological neurological illnesses okay excuse me a second and and in essence there’s some kind of relationship that goes on this case is called professional contract and there’s a therapeutic communication that attempts to alleviate emotion serves a reverse or change maladaptive behavior patterns so in essence it’s about mental illness it’s about therapy and you are trying to attempt this is a critical point attempt not necessarily result this is will become a big issue as time goes on because we’re moving into a situation from fee-for-service or fee for performance and we’ll have to remember that the focus is on attempting not necessarily alleviating alright so a quick side point this is a an issue that I think bears some discussion let’s talk about incident to instant to is feasible assuming the psychology provides direction and regularly involved in the care of the patient now let’s let’s stop for a moment what’s his number one a physician and this is a standard example a physician actually ends up providing a service for example you have a particular activity such as physical and during that time the nurse provides some additional support for example they take your blood pressure temperature weight and so forth that is actually incident to incident to the physician so it’s actually billed under the physician’s name as if the physician did the service and in essence this is the critical issue and the reason I say that is because the assumption is that it’s a physician that’s actually responsible for the service and it sort of subsume under that the question that some people have brought up is can a psychologist for that matter Sekai just provide incident to services in other words could I hire a bunch of social workers have them do psychotherapy and then for me to sign off I said they were doing that well the answer is it depends first of all how do you do this and then second of all with the insurance company allows it first first of all instant to is not hiring a whole bunch of people and having them do their own thing it means that you provide direction and you regularly are involved in the care of the patient so for example you might tell someone else you need to do cognitive here for psychotherapy focus primarily in depression we do the following symptoms and then have the price should come back to you say five sessions later and you make the decision as to what to do with the patient it is not having someone else do psychotherapy from beginning to end and in turn having no information whatsoever what’s going on and just simply signing off that’s not incent into essentially is what we might call fraud so as a consequence you have to be extremely careful what you’re doing that’s not incident to that’s quite different and I believe just my own personal opinion there very few people actually do incident to most everybody is doing who-knows-what so with that let’s talk about the psychotherapy because the psychotherapy codes the neces came into being I know 101 2013 and now are in full force unless if that means that and a neces that means that there is no way that you can do anything but what we have available at this particular point all right so what is it that’s going on big changes in the interview and the actual psychotherapy itself and as you can see the primary issue is time and intensity the whole concept is to make it more granular all right let me explain every five years CMS decides what codes and needs to be reviewed and they decided some time ago that psychotherapy goes need to be reviewed so an effort to do that CBT which I’m actually on the panel I’m not an advisor

like I was that’s new applicants position requests it then a small workgroup convene and that group met to 2010-2011 to give the charge for a larger work group that met 2011 and 2012 the original panel planning workgroup involved essentially myself two psychiatrist I believe one of the person and our job was to tell the so called planning workgroup here’s what we want and the difficulty associated with that is essentially that we did not believe that the type of psychotherapy that was being done today reflected a type of fact psychotherapy that was found in the workbook or that is a CPT panel a book that’s published every year in essence when we actually decided to redo this that goal was to modernize the codes the eventual Advisory workgroup which is really the one that’s if you were more public and so forth so on including nurse your psychiatrist psychologist and Social Work social workers an internal workgroup was also convened by the APA and that was led by Randy Phelps and since that’s an internal workgroup I won’t share the members but I will tell you this that it was a stellar group of individuals very committed to try and making the new psychotherapy codes much much more up-to-date and an essence to do this we had recommendations from a variety of sources but the real focus as she could see from this next slide is that we wanted increased viability in other words making codes that were useful and accountability interestingly there was no bias theoretically proposed in other words it was not biased toward psychology towards psychiatry and the focus was consensus in essence we didn’t vote or at least that group didn’t vote because I was not part of the work group it was theoretically people came to understand as a group and I had to be honest again this was turned out to be a a lot more difficult than people ever anticipated and the reason for that is that some people just did not play as fair at least from the outside perspective as I thought they should these are the individuals who have represent us as you can see psychiatry is heavily involved here but again these folks are part of the AMA process and as a consequence they have a delicate the last time this was done was oh boy about two decades ago and we had 27 new codes nine code revisions and a code delicious delicious this go-around we have 11 new codes for code revisions and 27 code the lesion so in essence we end up with a significant change I would say if this is not the largest changes you can see it’s actually not in terms of volume it’s the largest change in terms of paradigm and here we go so in Tucson in February 2012 the panel accepted several things the first and it was to me a huge surprise because it was brought to the panel is the number-one issue or the first issue I should say not surely number one to establishing my code for pharmacologic treatment and then the revision of psychiatry guidelines the lesions of codes addition of others and I’m going to go into some detail so the big one is the change in the psychiatric diagnostic interview and the second big one is the most frequently used psychotherapy codes so this is a big issue this next slide is a complicated issue for many many many reasons first of all we have at this particular point only three times 3045 and 60 we are working on an IT but this

is a mistake that’s based on enough on the fact that the only available data available to us anyway on the user psychotherapy was the Medicare data the reason for that all the other insurance companies that’s private to information and we did not have access to it turns out that even though there was a 90 minute code and the originals psychotherapy dataset that code is rarely used by Medicare patients so it’s very difficult to propose to a panel that’s basically empirically driven that indeed we need to consider having a nine-minute code when in reality it just wasn’t happening at all and as a consequence we ended up with 30 45 and 60 because there was data to support those now having said that I want to emphasize one more time the issue of intensity intensity we really ended up with two levels let me explain this in this next slide when I put this together on the original workgroup the idea was as follows I believe that at least in my own mind there was probably three levels of intensity there was what I call the counseling experience often experientially base secondly there was the standard experience which is what you and I might call empirically based psychotherapy and there was a complex experience which is the kind of experience that you might have when you have a crisis situation to be honest what I was trying to do is trying to establish a enm or evaluation management triple level that we discussed the idea of a five level system which allowed for different kinds of complexities to to be involved in other words it just didn’t seem like what psychotherapy fit all everything there was different kinds of psychotherapy and I wanted to make sure that they’d be covered some seemed very easy and some seem much harder with that in mind I wanted to propose that now the original idea was to propose that according to discipline however discipline specific codes are not kosher within the system so we ended up deleting that and we went the idea that or at least there’s two levels that could be easily identified standard interactive complexity and if you will as you’ll see later on there is your so-called crisis code all right so let’s focus a little bit on psychiatric interviewing do you see a psychiatric interview that we have the so-called nine oh nine oh seven nine one two report psychiatric diagnostic evaluation and integrated by a psychosocial assessment including history men of status and recommendations the evaluation may include communication with family other sources some review an ordering of diagnostic studies this replaces the old nine oh eight oh one now let’s tackle this a little bit first of all it says integrated biopsychosocial so it’s really a mishmash or whatever number one – it is history mental status and recommendation that is the bottom line if you ever get audited you have to have at least those three things it may include this is a very new radical idea communication with family this is something that we did not have historically we now have at the present time and by that I mean we have the opportunity to try and gather collateral information which we historically could do because before the 908 oh one was a singular non timecode just this one as you see turns out to be very robust most of us have opportunity to do prescription privileges 907 92 applies to you if it doesn’t then which is actually probably most of us is 907 9 1 as I mentioned already history mental status review an order of diagnostic studies and recommendations these are the basic things that you should have in an interview as you can see from this

one 907 91 and that’s in its companion it’s actually 92 excuse me do not include psychotherapy services this is just diagnostic interview and includes examination of patient I change information or in lieu of the patient other informants this is really really critical you appreciate this point that unlike the other code you can’t interview more than one person historically we couldn’t do that in this case you can do that and and the following reassessments are permitted from different days so you can do multiple psychiatric interviews and you can report more than once when separate interviews are conducted this is now a super robust code relative to the old 908 o1 if you’re doing interview please consider the following past psychiatric history chemical dependency history family history social history treatment history and medical history this appears to be the basic criteria required required to pass an audits a type of activity all right you do a review of the system’s safety lethality aggression and competency in fact just all things being equal you could actually construct if you could imagine this a an interview form that contains this data the data is found on slide quote 7 and again slide 8 notice that you can get this from mental status and you should include a diagnosis which include which involves the actual diagnosis of DSM personality continuing medical factors psychosocial stressors and current level of functioning so and that’s just this gives you a rough idea why you should pursue followed by a treatment plan what is it that you’re going to provide or suggest to the patient includes consideration medication psychotherapy tests that you might do level care and informed consent for treatment if you are going to pursue that yourself and what is the disposition to or with the patient all right so again nine oh seven nine one psychiatric interview without medication management and nine tube with medication manager now let’s shift our focus and talk for a few minutes about psychotherapy itself there very well be this is a focus of the order the reason you’re in this evenings presentation with a secretary paradigm notice again on the left hand column that we have three standard interactive and crisis in the time of psychotherapy we have 30 45 and 60 and appreciate the fact that you can have standard psychotherapy that’s brief regular or extended interactive psychotherapy is 30 45 or 60 in crisis very limited in many ways is 30 to 74 and for every additional 30 minutes we will talk about each of those in great detail again this is the definition of psychotherapy and then when I describe for you earlier all right so what about these new psychotherapy code what did this particular point they’re not so new first of all there’s no need for having inpatient or outpatient codes they’re all the same and we will not use interactive psychotherapy it said there is a new add-on code called Interactive complexity which is found under the rubric of 907 85 and again we’ll discuss his and some detail the psychotherapy service codes 832 to 837 include ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement of other family members the patient must be present for some or all the service so what does this mean this essentially means that unlike the prior psychotherapy code you are allowed to involve other people and it could very well be that the involvement of the primary focus for example the patient may be very limited one minute or two minutes and the the

actual time turns out to be the one of the other significant other involved in the concomitant psychotherapy codes a 3-2 to a 3/8 this thought described time-base face to face with a family and/or the patient so let’s discuss this for a moment psychotherapy unlike testing which we’ll talk about next month it’s all about face to face only you cannot build for activities away from the patient the code is based on the one this actual is to the closest time in the case of 30-minute psychotherapy you cannot bill it unless you’ve done at least 16 minutes worth of therapy anything else to be totally unacceptable all right let’s operationalizes 3-2 or 30 minutes is anything between 16 and 37 24:38 252 and 3/7 anything over 53 couple caviar it is assumed that the same psychotherapy has always been 45 minutes and is assumed further that the current psychotherapy that’s considered standard continues being the 45 minute shifting codes because a real person may not be in anyone’s best interest here we go again 30 45 60 we will have a solution in the works for the 90 minute activity in the very near future we’ve been working on it ever since we discovered the mistake and at this particular point we believe there may be a solution alright so a couple of things cider service is no longer recorded so as I mentioned the same reimbursement seeing code is used for inpatient and outpatient now what is involved in inter service that is the service provided to the patient objective information interval history examination of symptoms mana status changes current stressors coping style and whatever psychotherapy you use one thing that may be worthwhile keep in mind that this information is what is considered to be acceptable by CMS and for that matter AMA so it’s a consequence as you’re putting together your own if you will record it may be may be of some value to use this information as a foundation for your medical record or if you will psychological record all right in terms of 908 37 you said prolonged current service code however keep in mind that we have a solution coming up for you very soon this is a summary of the different things that I mentioned so far most of us are not going to be doing evaluation of management so we’re looking at three two three four and again if you will three seven which we’ll talk about and really briefly later on as well all right now this is an issue of great concern some people are not sure what interactive complexity looks like this is intended to mean that you’re having to do something more with the patient than average so let’s talk about what that may be first it’s an add-on code the code is nine oh seven eight five all right let’s look at interact the complexity refers to specific communication factors that complicate the delivery common factors include difficulties with communication this coordinate motion family members and so forth so on let’s look at this slide this is in many ways the bottom line if you have one of the following four things interactive complexity should be used as an add-on is it maladaptive communication so problematic that you’d have to go the extra mile the patient doesn’t want to be there so you have to

explain it to them maybe you have to engage in some a rapport building and so forth to caregiver emotions or behavior that interferes the patient doesn’t mind but the significant other doesn’t want them to be there evidence of disclosure or sentinel event and then psychotherapy experience for example you realize that you have to report this to the nurse and something is going on there tonguing their pill that requires a sentinel event documentation so it makes it interactive complexity and finally they use of equipment including interpreter translator this actually was an ELISA recently you can use the translator but all you’re gonna get in addition to the basic psychotherapy activity or a reimbursement is a minimal add-on so it does not necessarily mean you’re gonna get 15 30 50 100 dollars extra all right it may involve family maybe reported more than once and the service reported only once per day let’s step back cuz I now have told you about to psychotherapy code what I call basically use gender code and secondly what I call your interactive code now let’s go on to the third that’s why we call the crisis code the crisis code is provided to a patient and crashes state reporting with the codes 908 e39 and or for that matter a 400 should say the on the circumstance you’ll see that may not be reported addition to psychotherapy you don’t necessarily do this in addition psychotherapy you do this in lieu of psychotherapy the presenting problem must be life-threatening the treatment involves a bunch of things psychotherapy mobilization of resources defusing crises restoring safety and so forth the service may report even if the time spent on that date is not continuous so you can do it two hours in the morning one hour in the afternoon and so forth the time for the route that’s involved in psychotherapy the individual can devote or I should say should devote the full attention to the patient it’s not like you can do this and do psychotherapy on someone else this is it the only thing you can do that time and the patient must be present for some of the services not all of it and does not have to be continued with it within the data service 29 and a4l are reporting the total duration of time total duration not just emits and increment the total duration there can be two units five units the presenting problem again it’s life-threatening and you should do an assessment involving a crisis state the Mental Status examination what are you going to do in in all fairness the process for the documentation is really easy for this for this code relative to for example psychiatric interview ok these are time based codes 3:9 is the foundation or base code you report this once you have to have at least 30 minutes if you don’t have 30 minutes you don’t have a crisis so to speak and then after 74 you jump into an 8 for o and the add-on code is for all the extra time in increments of 30 minutes ok so the original base code is 3:9 then subsequent add-on codes it’s for Oh all right I’m gonna pass through these relatively quickly because there’s nothing new here these are old code but I’m just kind of going over them so people are aware of these are for family psychotherapy and family is not defined if you will in the traditional sense it’s more a quote in the modern sense then these are four six four eight four seven and four nine this is with a subsystem or a family like for example a couple and or even several people alright 46 is report service when the patient is not present word to the wise almost nobody reimburses 46 47 a report service that includes the patient some or all the time this is relatively new

the whole idea that you don’t have to have the patient there all the time and they have multiple groups and if you all multiple subgroups you would report 49 this is essentially unchanged what about group psychotherapy and when there’s no family unit per se but a common theme for example PTSD code 907 85 could be used in conjunction with eight five three to report a group psychotherapy code and I might point out to you this is a new issue altogether new and that is you can include interactive psychotherapy and again it’s for the basic code is 5/3 interactive psychotherapy is the add-on code of seven eight five which would you be used on top of the original five three for those of you that work in certain locations such as Louisiana and New Mexico keep in mind that this code is new this code is actually the one that was most problematic for the American Psychiatric Association but from my perspective um that relatively little problem to the American Medical Association as you can see this is a 908 63 which captures pharmacologic management including prescription and review medication performed with the psychotherapy service service so you have to do psychotherapy and provide a prescription for this particularly event okay if you’re a physician you should use evaluation of management codes and the codes are found in this particular slide ok let’s talk a little bit about psychotherapy they’re not patient sometimes you may be in a position to want to get information or affect change by involving non patient you can spend individual time with those people and of course keep in mind and if you do so you have to document it all right so a quick summary here’s the summary of the actual slides you can see the different codes on the left hand side and the codes descriptors on the right hand side this might be a good cheat sheet for you to have in your in your office if you’re wondering about the RV use here they are this is how the codes are valued notice that the psychiatric interview code or 791 continues enjoying a very high level of RV use because the amount of cognitive work associated with it and psychotherapy at 30 is one to five forty five is one six zero and notice by the way that the 60-minute psychotherapy it’s not that different than the psychiatric area code for that matter that the interactive complexity is relatively small I might point out at this particular Junction 3 9 and 400 which is the psychotherapy crisis codes excuse me are not priced at this point at the national level and I think there will be soon and the site far far pharmacologic management code still has a long ways to get acknowledged by CMS and this information includes I found in the final fee schedule which is the actual references found on this particular slide number 64 alright so here’s the issue of payments the individual psychotherapy is probably about 1 to 5 percent reduction and the RV you for the FICO farm code is actually 0.48 but it was not accepted and we thought at one point the group psychotherapy codes would be gonna be reduced but it turns out that they were not so we have the psychotherapy summary codes and you see that in this particular slide you have the interview the psychotherapy and the crisis therapy by interactive complexity and the the so-called psycho farm management code so another way to envision this is that the interview can have interactive complexity and psychotherapy can have interactive complexity so code 907 85 it’s a very robust that code that can be added to interview or actually psychotherapy interventions whether it’s 30 45 or 60 we have new interventions which is psychotherapy crisis and at the psychopharmacological management code these are all very new I know that way to look at this is to consider the following two slides which describe in detail how these particular codes would

work across certain scenarios all right so what are the big issues alright let’s talk about the three or two as far as I could see first of all is the fact that 60 minutes is not just for whatever reason has not been well received by some insurance companies it’s important to note that 60 minutes today is not the forty-five minutes of last the lasts go around forty-five minutes last go around and still 45 minutes of this go around have you said that some of us do extend a psychotherapy and you should as much as possible code what you do but make sure there’s a reason and documentation that supports our particular activity now what are we looking at I believe that there’s gonna be a new extended psychotherapy session code that may not be found in traditional way we’ve been debating this issue within CMS to me at AMA and since we’re bound by confident I can’t tell you what things what’s going on but I do believe that by the end of the calendar year we might have a solution for those of you who do work with complex cases attachment borderline cases that require extended intervention or for some reason the patient’s coming from far away so I believe that we’ll be in a position to have assistance for you in the very near future all right let me tell tell you a little about telehealth medicine all right in fact I was talking to my daughter about this yesterday and that is that this is the wave to the Future especially for those of us that work with individuals that have difficulties with transportation or geographically isolated and maybe in other parts of the state critical that you appreciate there has to be a live video conference and that if you will that live video conference needs to have security so there was we did actually a workshop at APA Hawaii where that was debated and the issue of for example Skype fit the criteria of secure the answer is no so theoretically the fees may be minimal but it does give you the opportunity you must use an audio and video feed my tab a professional shortage for example there’s rural it could originate for any number of locations the obvious one is your office and the assumption is that it’s actually same as face-to-face service at this particular time individual psychotherapy and diagnostic interview do qualify for telehealth services so in essence you do not have to see the patient face to face in person just through this electronic secure means and I encourage you to look at the interesting article by dr. Luxton in psychological services and we sent APA guidelines for the practice that tells psychology there are philosophical ethical and empirical well written and bears further discussion and getting acquainted with them so to summarize at this point this is what we have we have basically three columns and we’re working to see any primarily on the psychiatric dsm is the diagnosis the interview is nine oh seven nine one testing will talk about neck go around is 101 and psychotherapy you see as well below in essence what we have at the psychiatric model we have interview that links to testing and testing leads to intervention this is important now you consider that one leads to the other I do appreciate the fact that for many people who do psychotherapy it’s not unusual to link for nine oh seven nine one right two nine oh eight three four and that’s fine because that’s obviously of the standard of care for many practitioners however do always sing that one results or links to the as far as the modifiers I just thought it’d slide in just to alert you that sometimes you have unusual services you have reduced service for example we have a 45-minute session the patient walks out gets upset and you have to code as fifty to one of the issues and I encourage you to be aware of this that some of us work with psychiatrists or other professionals like social workers

and when that happens it’s very often that they accompany will deny the use of to mental health professionals providing services the same day even though one could be medication management and the other ones could be psychotherapy be aware of that limitation and if that’s present you may want to consider using the code 59 and explaining why two services were done by mental health professionals at this point a quick side comment regarding CPT my report it is my feeling that either you have a report for every CP every CPT code that you bill or for that matter that you have within one large report for example multiple levels each sect each section or if you will that section should describe a particular CPT code and the reason for that is not necessary for clinical purposes were for auditing purposes let me take a few minutes of your important time this evening to address the issue of conceptual time what’s time first of all time is what the profession excuse me a professional does not what the patient does interview and assessment codes can be limited or extended intervention codes at this point and I unfortunately have 15 there is no 15-minute code at least for psychotherapy there is more health and behavior so there’s different forms of time but critically appreciate it’s not what the patient does it’s what the profession does however it does involve communicating with others and following up with the patient non face-to-face time sometimes it’s not including the measurement of bill time but has been included in calculated total work of service during the survey process in other words we’re assuming that after the psychotherapy you will then maybe call or talk to the secretary or whatever the case is that is included in the actual survey a unit time is obtained when the midpoint has passed I already went through that that if you do not have 16 minutes you do not have the experience of psychotherapy all right face to face unless otherwise stated in the unit time when the midpoint is passed did not count the time twice and finally when multiple days are involved time is not reset with each end and you do not create a new hour if a continuous service is provided for example as a crisis we warn all units as performed on the date that the service was started – in other words if you start psychotherapy crisis on Friday and spills over into Saturday morning then at that point you would put all your activities on on if you will Friday if on the other hand you start again with a different variation of the theme of the crisis on Saturday it behooves you to consider a new crisis code on that second day what’s not face-to-face time you can see the information contained in this very busy side including communication and so forth so on this is a very complex life that has a lot of narrative but also gives you a very clear definition of what’s non face-to-face that is often included in the psychotherapeutic experience and one more time here we go here’s what 60 minutes might look like now let’s talk about how you document time I do not believe that elapsed time is any longer accepted in fact if you haven’t done elapsed times don’t worry about it let’s go right to start and stop times if you start seeing a patient 101 and you finish it 148 put that down you may want to have backups for all this your scheduling system testing sheet any any kind of information that could provide some backup to the fact that you actually provided the service so for example we do not throw away our schedule books or for that matter our electronic books simply because this provides a backup to the fact that we did provide that service and we find that in two different locations the record itself and the scheduling sheets a few issues regarding time and this is just a very generic idea because we don’t know for a fact but therapy for individual is one unit per group could be 8 units interview most likely it looks like 1 2 3 so can you do an interview that’s 4 or

5 hours yes but you automatically become an outlier and that decreases the like or increases the likelihood of an audit all right so let’s kind of bring it all together what do we have here this is a new paradigm psychotherapy is different in many ways now we have a paradigm that includes if you will three levels if you just to put it in simple terms standard psychotherapy more complex psychotherapy and crisis I could hear but that’s one issue first of all we have 30 45 and 60 minutes we probably will have 90 minutes you for a while also keep in mind that unlike the old 908 oh one the new psychotherapy psychiatric interview code allows you to do collateral interviews over many days with more than one person this is a very robust code relative to what we have historically have so in essence what we have now is an entirely different view of how psychotherapy works it really mirrors much more of the if you will the E&M codes we have different levels it provides more robustness uh and in some ways you might even argue that it might provide some reimbursement opportunities but theoretically is intended to capture modern-day psychotherapy much more so than the prior codes that were historically available now in terms of resources I provided several available to you they’re found in the different slide that I’m showing you and I do point out that in my website psychology coding comm you can find different forms that I use for psychiatric interview and in psychotherapy these by no means the perfect ones but it might be a way for you to start some basic information of how to proceed in developing your own forms that apply to your practice parameters having said that you can find more information at the American Medical Association bookstore and of course the contact information for the American Psychological Association association with advancements like therapy and of course some of the other things that I’ve mentioned to you before including the so called psychology coding comm which we do our very best to keep up on a regular basis this presentation will be available at YouTube sometime next week I sincerely apologize for us taking as long as we did we actually did a dry run a couple of days ago and we thought we had it done we typically do this at the University and we are not in position to do so because of unforeseen circumstances that one day maybe I’ll explain but at this particular juncture we believe that we’ve provided at least enough information to get you rolling and with that in mind I’ll put this terrible picture of myself and say thank you very much for your attendance and if I can figure out how to work on this I’ll open up chat or I should say questions and answers so what questions it says it’s disabled so maybe we can go to chat and if you have questions and I can do the questions this way will attend to them and if not please send them to me at Puente at psychotherapy doc assume you had at UNCW calm and we’ll address them at that point so I’m not sure if we have the opportunity to ask questions but let’s see if we can try to do so I’m not sure if we do well with that in mind it looks like we do not have the enable function or at least I don’t have the capacity to do so so I’ll call it a day at this particular juncture I appreciate you very much attending this evenings presentation we will make this available on YouTube as I mentioned and if you have any questions I prefer that you send them to me by email at Puente at UNCW edu and remember the psychology coding comm website which has a lot of this information and more so thank you very much for you participating and apologies one more time for the difficulties we have technically and look forward to the next presentation on testing we may do one after that an H and B I’m not sure if we’ll have the opportunity to include that at the next one but look forward to providing that thank you and have a good evening