Recent Audits Provide Documentation Lessons for Behavioral Health

Coding for behavioral health services should be straightforward. There are a limited number of codes in the psychiatry section of the Current Procedural Terminology (CPT) book. Physicians and non-physician practitioners (such as advanced practice nurses and physician assistants) can report evaluation and management (E/M) services and codes in the psychiatry section, but this adds just a few E/M codes. And yet, two recent Office of the Inspector General (OIG) reports found significant errors on audit.

The first report from spring of 2022 audited a single psychiatrist. Why did the OIG audit this particular psychiatrist? The answer is simple: volume. “After analyzing Medicare claims data for Part B psychotherapy services provided during 2019, we identified a New York City provider that was among the highest reimbursed individual providers in the Nation.”

The second OIG report from May 2023 audited behavioral health services performed by multiple practitioners and practices. The report has a chart that compares the Local Coverage Determinations (LCDs) of any Medicare contractor who has a policy.

Groups that provide behavioral health services can and should learn from the results of these two audits.

Documenting Time for Psychotherapy

Psychotherapy services involve time-based codes. All psychotherapy documentation must show the total time of the face-to-face psychotherapy services. Neither CPT nor the Centers for Medicare and Medicaid Services (CMS) require start and stop times, although some private payers do. The most common error is using appointment times. The appointment time is rarely the actual, exact time of the visit. Visits can begin or end early or late and take more or less than the scheduled time.

Total Number of Sampled Enrollee Days for Which Providers Did Not Meet Medicare Requirements, by Type of Deficiency

Source: Medicare Improperly Paid Providers For Some Psychotherapy Services, Including Those Provided via Telehealth, During the First Year of the COVD-19 Public Health Emergency

In both audits, the OIG did not always find that psychotherapy was documented. In some cases, treatment plans were missing. Medicare does not have a national coverage determination (NCD) for psychotherapy, but some Medicare contractors do. These state that there must be an individualized treatment plan unless the therapy will be only a few brief services. (See pages 39-40 in the above report for a summary of Medicare Administrative Contractors.)

The treatment plan should indicate the type of treatment, frequency, expected duration, diagnosis, and expected goals. Treatment must be expected to improve the patient's symptoms and to prevent relapse. It is not necessary that the goal be to restore the patient to pre-diagnosis functioning.

Treatment plans need to be reviewed and updated, including whether or not the patient is progressing toward meeting the goals. Practices who are asked by payers to submit psychotherapy documentation should always include the treatment plan, even though the treatment plan may have been developed at a prior visit. Treatment plans are not typically reproduced or carried forward into each individual psychotherapy session.

Same Day Psychotherapy and Medication Management

Psychiatrists, psychiatric nurse practitioners, and physician assistants can provide two services on the same day. They can provide medication management, which is reported with an E/M service, and psychotherapy.

When both services are provided, they must be documented. The documentation must support that the psychotherapy service was provided in addition to medication management.

The code for medication management, which is typically an office visit code, must be selected based on medical decision-making. The psychotherapy code is selected based on the time of the psychotherapy alone, not the combined time of medication management and psychotherapy.

Time may never be double counted. The note should clearly describe the interactive psychotherapy services that were performed.

When psychotherapy is provided in a non-facility, such as an office (place of service 11), incident-to billing is allowed. Practitioners who have incident-to billing as part of their statutory benefit are physicians, physician assistants, clinical nurse specialists, nurse midwives, and clinical psychologists.

According to the Medicare Benefit Policy Manual, these are the requirements of incident-to services:

To be covered incident-to, the services of a physician or other practitioner, services and supplies must be:

• An integral, although incidental, part of the physician’s professional service (see §60.1);

• Commonly rendered without charge or included in the physician’s bill (see §60.1A);

• Of a type that are commonly furnished in physician’s offices or clinics (see §60.1A); and

• Furnished by the physician or by auxiliary personnel under the physician’s direct supervision (see §60.1B).

For example, if a psychiatrist is reporting social workers’ services under the psychiatrist’s provider number, the psychiatrist would have had to see the patient first and established the plan of care, stay involved in the care of the patient, and be physically present in the suite of offices when the service was provided.

Behavioral health departments and independent practices would be wise to review these two OIG reports and pay particular attention to documenting psychotherapy on the day of medication management and time spent in psychotherapy for all therapy visits.

Betsy Nicoletti MS, CPC, has worked to simplify coding for medical practices for more than 20 years. She is the founder of CodingIntel.com, providing citation-based coding resources.