HealthCare News

Psychiatric Documentation

Issue: #397 NOV2017

Topic: Behavioral Health

Blue Cross Blue Shield of North Dakota (BCBSND) uses CPT®, HCPCS® and ICD-10® manuals as well as other nationally recognized standards for coding and billing purposes, unless BCBSND has published a specific policy stating otherwise. Documentation must support all requirements for each code submitted on a claim; for example, time-based codes must include documentation that supports the number of minutes spent face-to-face with the provider unless otherwise specified in the manual. Documentation that does not support a submitted code will result in that claim line being denied.

There are two families of codes describing the delivery of psychiatric services: Evaluation and Management (E&M) codes and “procedure” codes in the Medicine section of the CPT® Manual.

Under either family of codes, the nature and severity of the presenting problem drives the intensity and level of the clinical encounter. As delineated in CPT®, the level of the history, examination and medical decision-making is dependent on the clinical decision-making and the nature of the presenting problem.

Psychotherapy time reporting is delineated per CPT® time basis for code-selection rules. The primary diagnosis for psychotherapy services must be provided. Other diagnoses may be listed on the claim as well as the medical record; however, the documentation must support the primary diagnosis billed. The presence of a payable diagnosis does not guarantee the service will be covered.

Time associated with activities used to meet criteria for the E&M service may not be included in the time used for reporting psychotherapy. Additionally, when billed with psychotherapy, time cannot be the key controlling factor for E&M code selection. Documentation must clearly delineate between time spent on psychotherapy and time spent on history, exam and medical decision-making related to the E&M service, or the claim will be denied.

BCBSND previously held a webinar regarding “Psychotherapy CPT Coding.” A copy of the slides may be seen by going to, “Providers,” “Provider Services,” “News & Education,” “Provider Webinars,” “Past Webinars,” “Psychotherapy CPT Coding.” To demonstrate medical necessity and appropriateness of a psychiatric treatment session, the BCBSND reviewers look at the following information in the chart notes:

  • For assessment notes:
    • Presenting complaint and history of presenting problem
    • Symptoms
    • Current functioning and impact of symptoms on functioning
    • Mental status observations
    • Past psychiatric history
    • Family psychiatric history
    • Pertinent medical history
    • Current medications
    • Impression
    • Diagnosis
    • Treatment strategy
    • Date of services, starting time and ending time of the session
  • For progress notes:
    • Mental status observations
    • Current level of symptomatology as it relates to diagnosis
    • The specific therapeutic intervention and how it is being applied (current impression)
    • Diagnosis (if diagnosis changes, document new data to justify)
    • Current treatment strategy
    • Date of services
    • Starting time and ending time of the session if performing and coding for psychotherapy

Note: Providing all the information suggested above is not necessary in every note, but failure to provide adequate information to determine medical appropriateness and necessity may result in a denial of the claim or a reduced allowance.

All inpatient and outpatient notes are to “stand on their own”; i.e., while it is allowable to refer to previous notes for elements of the history or examination that are static, each note should include specific documentation of the current findings (subjective and objective), the medical decision-making and the subsequent intervention and treatment plan for that contact regarding the specific medical illness or problem.

For inpatient services, it is expected that patients will have meaningful face-to-face contact with a licensed and credentialed independent attending provider each day. Inpatient telehealth visits will be limited to those visits allowed based on BCBSND telehealth policy. The provider will personally obtain the interval history and examination and review/revise the treatment plan as appropriate. A continued stay is based on continued need. Care delivery (including any necessary consultations, diagnostics, therapies and transfer to specialized treatment settings) needs to be balanced between expediency and consideration of the patient’s other unique characteristics and circumstances. Waiting for a consultation or test result or completing a specific number of days in a treatment program is unlikely to meet medical necessity criteria.


Republished Articles

In an effort to clean up HealthCare News, we will be reviewing past articles. Articles that are no longer relevant will be archived. Articles found in this section are still relevant and are being republished.