UPDATE: Because of the large number of questions from our audience and providers, we would like to answer a common question from the outset.
After ICD10, how have CPT codes changed?
They have not! Please read on!
Second update: If you have a question about billing you’d like our expertise on, you can ask your mental health billing questions and search our archive.
CPT (Current Procedural Terminology) is a standardized medical codeset maintained by the AMA. CPT codes are five digit numeric codes describing everything from surgery to radiology to psychotherapy. For therapists that are on managed care panels or provide superbills to their clients, knowing your CPT codes is paramount to getting paid in full and avoiding insurance audits. The amount insurance companies will reimburse depends on a number of different factors (professional credentials, geographic location, etc.), but using the correct CPT Code and add-on code(s) to express the exact service is an important part to the whole process and in ultimately determining your payment!
Errors, accidental or otherwise, will directly impact insurance company’s payment of services. Downcoding (including less services on the claim than actually provided) will usually mean you get paid less, while upcoding (including more services on the claim than actually provided) can get you in trouble with your managed care panels. It’s also important to note that it might be tempting to maximize your CPT codes to earn higher reimbursements. This is highly recommended against and can get you flagged, audited and removed from insurance panels. Even if this is your biller’s error, the therapist is the one who ultimately bears the responsibility and will be the one penalized.
CPT Coding for Therapy
CPT coding for psychotherapy doesn’t have to be difficult! There are an overwhelming amount of total CPT Codes (~8,000), however only 24 are specifically designated for psychotherapy. To make matters even simpler, nearly all therapists will regularly use an even smaller subset of these 24. CPT is a large and dynamic code set that changes year to year, but the psychotherapy codes seldomly change. The most recent change for psychotherapy codes took place in 2013, previously 1998. In other words, you only really need to learn them once!
CPT Add-on Codes
A CPT Add-on Code is a code describing a service performed in in conjunction with a primary service. Many of these add-on codes are associated with a specific CPT Code or a small set of CPT Codes and cannot be used otherwise. For instance, the CPT Code for interactive complexity (+90785) can be used for a diagnostic (90791, 90792) or a normal psychotherapy session (90832, 90834, 90837) but not a crisis psychotherapy session (90839).
Add-on Codes are identified by a + sign in front of the number, i.e. +90840 is an add-on code for extra time in the case of crisis psychotherapy. On CMS 1500 forms CPT Add-on codes are simply added on a new line.
The most common CPT Codes used by therapists:
- 90791 – Psychiatric Diagnostic Evaluation (usually just one/client is covered)
- 90792 – Psychiatric Diagnostic Evaluation with medical services (usually just one/client is covered)
- 90832 – Psychotherapy, 30 minutes (16-37 minutes).
- 90834 – Psychotherapy, 45 minutes (38-52 minutes).
- 90837 – Psychotherapy, 60 minutes (53 minutes and over).
- 90846 – Family or couples psychotherapy, without patient present.
- 90847 – Family or couples psychotherapy, with patient present.
- 90853 – Group Psychotherapy (not family).
- 90839 – Psychotherapy for crisis, 60 minutes (30-74 minutes).
- +90840 – Add-on code for an additional 30 minutes (75 minutes and over). Used in conjunction with 90839.
- +90785 – Interactive Complexity add-on code. Covered below.
There are also E/M (evaluation & management) in conjunction with psychotherapy, used by authorized prescribers. Coding E/M is trickier, harder to document and more vulnerable to audit but usually results in greater reimbursement. There’s also a series of E/M codes that are used without the psychotherapy component. For more in-depth coverage on E/M coding for psychotherapy there are some good free webinars released by AACAP on E/M CPT Codes.
- +90833 – E/M code for 30 minutes of psychiatry (used with 90832).
- +90836 – E/M code for 45 minutes of psychiatry (used with 90834).
- +90838 – E/M code for 60 minutes of psychotherapy (used with 90837).
- Psychotherapy must be at least 16 minutes.
- Time is very important and should be rounded to the nearest CPT Code.
- Outpatient vs. Inpatient is not important.
- E/M codes can only be used by prescribers (MD, DO, APN, PA).
Criteria for Interactive Complexity (+90785)
+90785 is one of the new add-on codes in the most recent CPT update in 2013. This code is used as an umbrella add-on code and can be used for four different criteria. The most common scenarios usually involve children, although this is not necessarily always the case.
Common Examples of Interactive Complexity:
- The use of play equipment with young children.
- Involvement of parents with discordant views that complicate the treatment plan.
- Report of abuse/neglect.
Interactive complexity can be used in conjunction with the primary CPT Codes for diagnostics, psychotherapy, or group therapy and cannot be used for couple/family therapy or crisis codes.
+90785, can be used with: 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90853.
Am I Being Underpaid? Was I Paid the Right Amount?
Here’s typical rates depending on the therapist’s credentials:
Typical Reimbursements by Type of Therapist
|Type of Therapist||Reimbursement/Session|
|Marriage Family Therapists||~$60-65|
These rates can vary significantly therapist to therapist but are good benchmarks for comparison. How about CPT Codes? How do they affect the rate of reimbursement? This is a difficult and complex calculation, depending on the level of education, location, and license. The AMA has created a code search feature on their website that shows payment based off CPT Code and location. This information is somewhat incomplete and is based off medicare payments and does not specify a number of other important factors. However, this tool is still very useful to compare the relative value CPT Codes against one another. Private insurance will be correlated with some deviation from these numbers.
Reimbursement by CPT Code (Three Different Geographies)
|Reimbursement (Rest of CA)||Reimbursement (Los Angeles)||Reimbursement (WA)|
Data from AMA Codemanager. These numbers are useful for relative comparison of individual CPT Codes and geography.
If you are just starting out or just beginning to deal with managed care, keep it simple. CPT Codes appear far more complex from the outside looking in. Make a quick cheatsheet. Don’t worry about memorizing all the CPT Codes (there’s alot!) or even all of the mental health ones. You will likely just use just a few individual codes. Memorize the relevant codes and use google or other references to find the correct CPT codes for more unique scenarios.