Physicians who are used to wrestling with complex diagnoses, statistical data, long lists, and bureaucratic mandates often throw up their hands in frustration when it comes to choosing the correct Medicare code that will allow them to be paid appropriately.

Several psychiatrists who have mastered the intricacies of the maze that comprises Medicare’s coding and reimbursement requirements resolved some of the mystery for their colleagues at a workshop at APA’s annual meeting last month in Chicago.

Part of the confusion in choosing among the codes stems from the absence of any national documentation standards for the 908 code series comparable to the documentation standards that the AMA and Health Care Financing Administration (HCFA) have agreed on for evaluation and management (E&M) codes, said Chester Schmidt Jr., M.D., chair of the APA Committee on Codes and Reimbursements and chair of the annual meeting workshop.

Some help in deciphering the 908 series codes, which are used for many types of psychiatric care, including medication management and both inpatient and outpatient psychotherapy, may be on the way, Schmidt noted. Several of the regional Medicare insurance carriers have begun circulating specific documentation requirements for services that fall within this group of codes. To reduce the chances that reimbursement claims will be rejected or downcoded, Schmidt strongly urged psychiatrists to contact their local Medicare carrier as soon as possible to obtain a copy of these coding guidelines.

"You’ll also get a list of the diagnoses the carriers will allow certain codes to be used with," Schmidt pointed out, adding that "there are differences from state to state and carrier to carrier."

He noted as well that while the guidelines now apply only to Medicare-eligible services, "much of what Medicare does eventually spreads to commercial [insurance] carriers."

Schmidt, along with panelists Tracy Gordy, M.D., Ronald Shellow, M.D., and Melodie Morgan-Minott, M.D.—all members of the APA committee that deals with coding and reimbursement issues—quickly opened up the floor for coding questions.

Among the advice and information they offered were the following:

• Psychiatrists should feel confident in using CPT code 90801 for initial inpatient evaluations and for initial outpatient visits. One of the E&M codes might be appropriate instead when the level of decision making is more complex or advanced than that commonly associated with 90801, but not, Gordy emphasized, just because E&M codes will produce larger reimbursements.

Psychiatrists can use 90801 again for an initial visit if the patient has to be rehospitalized in the future. For office visits, 90801 can be reused only for the same patient once he or she has completed a course of treatment but then needs to be treated at a future time.

• Frequent use of 90862—medication management with no more than minimal psychotherapy—increases the chances of being audited by the carrier "if you are not using it the way everyone else is," said Gordy. This was in response to a questioner whose use of this code for inpatient services had triggered such an audit. Selecting one of the hospital service codes may be a preferable way to go in some cases, Schmidt suggested. The 90862 code "does not appropriately capture" what many psychiatrists do as an attending physician, he said, for example, "when you do grand rounds, talk with nurses, write orders, and review test results."

• 90862, medication management, does not come with a mandated time requirement, "but the unwritten rule across the country is about 15 minutes," Gordy explained. The time spent, however, does not have to be documented. "If you do more than four of these an hour, you’ll stand out" and be primed for an audit. Three medication-evaluation visits per hour are probably preferable from a coding and reimbursement perspective, he advised.

Morgan-Minott urged psychiatrists at the workshop to determine how their local Medicare carrier "idiosyncratically interprets the requirements for 90862."

• Be careful when submitting psychotherapy claims for treating Alzheimer’s patients. Psychiatrists invite claims rejections when they use a psychotherapy code in anything more advanced than early-stage Alzheimer’s disease. "You should be able to use one of these codes if the patient is cognitively able to benefit from psychotherapy, and you can document this," Shellow pointed out.

The carriers have turned a deaf ear to protests about the number of Alzheimer’s psychotherapy claims they reject, he noted, after identifying considerable misuse of psychotherapy claims for Alzheimer’s patients, more coming from psychologists than psychiatrists, Shellow added.

• Documentation requirements for psychotherapy should usually include the date and type of service; a legible signature, "which is really becoming a major issue," Schmidt said; what occurred during the visit; goals achieved during the session; and medications prescribed. Process notes do not have to be part of the documentation.

Schmidt suggested that psychiatrists should purchase the AMA’s CPT manual and supplement it with the CPT Handbook for Psychiatrists, written by Schmidt and published by APPI.