Auditing Same Day Psychotherapy and E&M Services: The Time Trap

by  Scott Kraft, CPC CPMA
Oct 28th, 2016 - Reviewed/Updated Aug 17th

A problem-focused E/M service and the provision of psychotherapy on the same date of service are both separately payable, when medically necessary. A typical scenario is when the

provider treats the patient's diagnoses by documenting the appropriate level of history, exam and medical decision making - such as a decision to change medications, or even keep medications the same - and also provides psychotherapy services for the patient.

When auditing these services, here are some key things to remember. First, the E/M service is selected first based on the previously mentioned history, exam and medical decision-making. The documentation used to support the E/M service may not be used to support the psychotherapy service.

The psychotherapy service is a time-based code, and none of the time spent on the E/M service can be counted toward the psychotherapy service. From a documentation perspective, providers should be encouraged to specifically document that the time in the note is spent on

psychotherapy. Typical psychotherapy documentation would include a mental status exam, description of the type of psychotherapy provided, the patient's current functional status and any improvements or decline noted in the patient's condition.

These services are billed with 90833 as an add-on code to the E/M service for a psychotherapy service of 30 minutes, 90836 for a service of 45 minutes and 9088 for a service of 60 minutes. Using the rules associated with time-based billing, documented time of 15 minutes or fewer is not supported; 16 to 37 minutes is supported as 90833; 38-52 minutes is supported as 90836 and 53 or more minutes is supported as 90838.

Prolonged services are not separately reportable when a psychotherapy service and E/M service is billed on the same date of service. The diagnosis for the E/M service and the psychotherapy service may be the same. Remember, the time documented must solely support the psychotherapy service. When the provider's documentation of time also reflects elements of the E/M service and the note doesn't clearly distinguish the psychotherapy time, then no time can definitively be credited to the psychotherapy service. In these instances, psychotherapy billing would not be supported because there must be documentation of the time.

Two more tips to remember:

• When an E/M service is not being billed, the psychotherapy codes are 90832 for 30 minutes, 90834 for 45 minutes and 90837 for 60 minutes. These codes may not be billed with an E/M service.

• Even though these psychotherapy services describe psychotherapy with patient and/or family member, the patient must be present for at least some of the service. Documentation showing only counseling for the family cannot be billed with these codes. CPT code 90846 describes family psychotherapy without the patient present.