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CPT Coding Changes

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  Combining E&M and Psychotherapy Codes on a single encounterOct 28, 2013 6:19 PMMark Soucy
  RE:Combining E&M and Psychotherapy Codes on a single encounterOct 29, 2013 10:30 AMLaurie Burke
 

1.
Combining E&M and Psychotherapy Codes on a single encounter
From: Mark Soucy
To: CPT Coding Changes
Posted: Oct 28, 2013 6:19 PM
Subject: Combining E&M and Psychotherapy Codes on a single encounter
Message:
In my clinic we code for psychotherapy and for E&M.

I do not use time for the E&M code, but rather it is based on the required number of elements for a given E&M code.  For example:

I see a patient for a follow-up visit.  The patient has both Bipolar Disorder Type I MRE Depressed, Hypertension, and Fibromyalgia.   I include short supportive psychotherapy for about 16 minutes and use code 90832 (16 - 30 minutes pf psychotherapy) plus a review of vital signs, review of systems (at least 3 systems) and note the patient's progress with medication and focused areas related to her illnesses.  I add the 99213 E&M code (moderate complexity). To deal with the time factor (for psychotherapy) I note the start time and the end time of the encounter in the progress note.  For this encounter the start time is 2:59 PM and the stop time is 3:30.  Then at the end of the progress note I document "I spent 16 minutes of 31 minutes providing supportive psychotherapy focused on ________.  This way for auditors, it is clear that 16 minutes (the minimum for 90832) of the encounter was devoted to psychotherapy.  The elements to justify the E&M coding are documented, as well.    This has proven (so far) to be acceptable to our auditors.

Mark  

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Mark Soucy
Associate Professor
UT Health Science Center San Antonio
San Antonio TX
(210) 567-5893
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2.
RE:Combining E&M and Psychotherapy Codes on a single encounter
From: Laurie Burke
To: CPT Coding Changes
Posted: Oct 29, 2013 10:30 AM
Subject: RE:Combining E&M and Psychotherapy Codes on a single encounter
Message:
Mark- Thanks so much for your post- it was very helpful.  Your documentation is right on target for audits and will help me update my progress notes.

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Laurie Burke, PMHNP/CNS-BC
Psychiatric Nurse Practitioner
Family Behavioral Health Associates
Midlothian, Va 23112
804-245-1610
laurie1119@verizon,.net

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