This page addresses follow-up questions and additional information pertinent to our webinar
Behavioral Health Service Codes: Right State of Mind-Meeting Documentation and Medical Necessity Requirements.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.
Q: Can psychotherapy be reported incident-to?
A: Yes. Make sure incident-to requirements are met. Services are integral to patient’s normal course of treatment, during which the physician or NPP has personally performed an initial service, initiated the course of treatment, and is actively involved in course of treatment. Physician or NPP provides direct supervision, meaning they are present in the office suite and immediately available. Medicare and state-authorized personnel are employed by the physician/group practice. Incident-to can only be performed in place of service 11.
Q: Is a treatment plan required for psychotherapy services?
A: Medicare Administrative Contractors generally expect treatment plans to be documented in the medical record to support medical necessity. The plan should include a diagnosis and/or symptoms necessity of psychotherapy, type, frequency, and duration of service(s) to be provided, and the expected improvement or outcome. Along with the initial plan, periodic updates to the patient’s progress, goals and any updates to the treatment applicable should be entered into the medical record.
Q: There are times when the psychiatrist opts to use an E/M instead of a 90792 for a diagnostic evaluation with medical services. If interactive complexity was used as part of the visit, can +90785 be reported with the E/M?
A: There are situations where an Evaluation and Management (E/M) code may be used instead. However, add-on code +90785 can only be reported with psychiatric diagnostic evaluation codes and psychotherapy codes. Do not report +90785 with E/M codes.
Meet the Presenter: Emily Lomaquahu, CPC, CPMA, CEDC
Emily is a Senior Coding Quality Auditor for Haugen Consulting Group and brings over a decade of experience to the profee team! She began her career as an auditor and with her keen eye for detail, she quickly found it was a perfect fit. Emily thrives in a collaborative environment and enjoys creating high-quality trainings to help providers and coders navigate charts and improve their accuracy. She earned a bachelor’s degree from the University of Colorado, in Denver. Emily specializes in Evaluation and Management (E/M), Primary Care, Anesthesia, Emergency Department, and Neurology, though she says Anesthesia and Neurology are her favorites! She is a Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA) and Certified Emergency Department Coder (CEDC).
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