I'm APA's Director of Reimbursement Policy and Quality. Joining me today are my colleagues, Brooke Tranum, Director of Practice Policy, as well as Violet Maloney and Ebony Harris from APA's Education Division. I'm pleased that you're joining us today for today's Emerging Topics webinar series, Evaluation and Management Coding and Documentation, What All Psychiatrists in Clinical Practice Need to Know. Today's webinar is part of APA's Emerging Topics in Psychiatry webinar series. Stay up-to-date on important topics and trends impacting psychiatry by participating in APA's new Emerging Topics webinar series. Presented by specialists across the field, these monthly webinars will explore a range of diverse, pertinent topics and offer a chance to interact with peers and subject matter experts. Today's webinar has been designed and designated for CME 1.5 AMA PRA Category 1 credits for physicians. Credit for participating in today's webinar will be available until February 8, 2023. Slides from the presentation today will be available in the follow-up email and we'll distribute them as a PDF. Next slide. Some housekeeping. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the attendee control panel. We'll reserve 20 to 30 minutes at the end of the presentation for a Q&A session. Now I'd like to introduce the faculty for today's webinar. Joining us today are Dr. Jeremy Musher. Dr. Musher has over 30 years of experience in the psychiatric healthcare industry. He currently serves as Chief Medical Officer and Chief Clinical Officer for Springstone Behavioral Health System, providing inpatient and outpatient services in nine states. Prior to joining Springstone, Dr. Musher was a consultant to healthcare organizations and leaders in a variety of settings. He also provided medical leadership to emergency services at Western Psychiatric Institute and Clinic at the University of Pittsburgh. Dr. Musher represents the APA as advisor to both the AMA CPT editorial panel and the AMA RBS update committee, otherwise known as the RUC. And he serves as a coding educator through the work of APA's Committee on RBRVS Codes and Reimbursement, which he currently chairs. Dr. Sarah Parsons is a triple-boarded psychiatrist based in Kentucky. A Lexington, Kentucky native, Dr. Parsons has over 10 years of clinical practice experience, where she has specialized in women's mental health, HIV, and psycho-oncology. She is currently in a private telehealth practice and treats patients in person for TMS services. Dr. Parsons has served as a CPT coding and documentation educator at both APA and the Academy of Consultation Liaison Psychiatry. Along with Dr. Musher, she is one of APA's advisors to the AMA CPT editorial panel and as such is an ad hoc member of the APA's Committee on RBRVS Codes and Reimbursement. Neither faculty here have any conflicts related to E&M coding and documentation. We do want to encourage everybody to please review the CPT 2023 manual and check with your local Medicare carrier or your commercial payers for any updates and payer-specific guidance. And the information provided here represents the views of the presenters. Next slide, please. Our learning objectives. We are going to review the coding selection criteria for evaluation and management services in all settings. We are going to talk through and understand the medical decision-making table, which will guide you in terms of your coding choice. We're going to apply generally accepted documentation requirements for E&M services and for psychotherapy, and we're going to integrate the current coding and documentation requirements associated with telepsychiatry. And as a reminder, as we go throughout the webinar, please do put your questions in the question and answer box, and we'll look forward to answering those at the end. Dr. Musher? Thank you, Becky. I appreciate the opportunity to be here. So we're going to talk about first an overview of the key changes for 2023. The 2021 outpatient E&M guidelines now apply to all sites of service. There have been no changes to those outpatient guidelines since 2021. The change in inpatient has been that the observation codes have now been deleted starting in 2023, and instructions are to use inpatient codes. For nursing facility services, you would use the nursing facility services codes for psychiatric residential treatment facility services, as well as for group home visits for patients with intellectual disabilities. And for home resident services, they've eliminated the domiciliary codes, and you should use the home resident services codes now for residential substance abuse treatment facility services, as well as all other group home visits. So before we get started with talking about the requirements in 2023 and code selection criteria for the E&M services, I did want to mention one other code, and that's 90792. That's the diagnostic evaluation codes that we've had, and keep in mind that that's also an option for use for initial services in any site of service. So as with our outpatient services since 2021, for history and for exam, all that's needed is any medically appropriate elements. No more bullets, no more location quality, duration, timing, et cetera, for the history, and no more individual specific bullets for exam. There is one exception to this that I'll come to when we talk about inpatient and the conditions of participation and meeting those requirements. So what that means is that a lot now depends on how you document medical decision making, and we're going to go through that in some detail. You have two choices for how to select your code based on either medical decision making or time, but this is not the same time that we've been using with counseling and coordination of care. That no longer is how we use time, so you can forget about counseling and coordination of care criteria. Time is not used at all if you're basing the level of the code on the medical decision making. When you bill E&M along with psychotherapy service, just the way it currently is, the E&M must be selected based on the medical decision making elements and not on time. So let's talk a little bit about medical decision making. First of all, the level is driven by the nature of the presenting problem for that visit. Another way to say that is, how complex is that visit? Is it medically necessary for that visit? Those are the things that go towards the nature of the presenting problem. As it's been, the medical decision making is based on the best two out of three of problems, amount and or complexity of data, and risk. The level must be met or exceeded. So what that means is that you have moderate level for problems and high level for risk. That would be a moderate level visit. Both must be met or exceeded. All visits contain problems and risk. In psychiatry, we often don't have enough elements under data, amount and or complexity of data, to help get you to justify the code level. Therefore, our recommendation is, since all visits contain problems and risk, we recommend that you use problems and risk for the two out of three for all of your visits. Obviously, if your practice contains a lot of data, then you certainly can use that as one of the two out of three. So let's talk some about the definitions. What is a problem? A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter. When is a problem addressed or managed? When it's evaluated or treated at the encounter by the physician or other qualified healthcare professional reporting the service. It also includes consideration of further treatment and testing, even if it's not done after discussing the risks and benefits with the patient or their guardian or surrogate. When is a problem not addressed? Well, if you simply document that another provider is managing a problem, that doesn't count. And if you refer without evaluation or consideration of treatment, that also doesn't count. Now we're going to go through these medical decision-making tables. We've modified the tables that are available from CPT in order to be more specific towards psychiatry. And I want to call your attention to some of the things that we've done so that you can refer back to this. If you look at the small print, it basically says some of the things that I've already said. The MDM is selected based on the nature of the presenting problem, on the date of the encounter, the best two out of three, et cetera. Under that, it says use MDM or time, not both. This is important. You don't need to record time unless time is the basis upon which you've made the decision for the level of the visit. So in the first column, what we've done is we're going to go through tables for straightforward, low, moderate, and high for medical decision-making. And on the first column to the left, you'll see that in this example, straightforward, we've given you the outpatient, inpatient, and nursing facility codes that are relevant for this table for, in this case, straightforward. The times next to each code, so for instance, outpatient, the times for 99202, one of the initial outpatient codes, and 99212, the lowest level subsequent outpatient code, those times are the times, total times, on the date of service that you can use if you meet those times, that can serve as the level, justification for the level of the visit. The next column talks about number and complexity of problems. For straightforward, all you need is one self-limited or minor problem. I'm not going to be addressing the amount or complexity of data in these tables, because as I said, we recommend that you use problems and risk. And the third column is risk. For straightforward, you only need minimal risk. An example would be a visit for adjustment disorder following the death of a spouse, patient stable, no medications indicated. If you notice on the left, lower part of the slide, it says italicized red text signifies psychiatric-specific examples developed by the APA committee. So we've given you some examples of the kinds of conditions and situations that would meet these criteria. Purple text, which there isn't any on this particular slide, but there will be, signifies new text that has come into the 2023 manual. So in 2023, there have been some additional examples for the medical decision-making table, and you'll see those in purple text. So that's straightforward. And we said a self-limited or minor problem. What is that? It's a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status. So now let's move on to looking at low medical decision-making. And again, you can see in the first column which of the codes for outpatient, inpatient, and nursing facility meet the level of low. And what the number and complexity of problems would be. So for low, you could have two or more self-limited or minor problems, or one stable chronic illness, an example being major depressive disorder recurrent in remission, or one acute uncomplicated illness or injury, an example being adjustment disorder with depressed mood, or, and this is the text in purple, these have been added to the table in the 2023 CPT manual, you could have one stable acute illness or one acute uncomplicated illness or injury requiring hospitalization or observation level of care. Again, we're going to skip the data column and look at risk. So what is low risk? Well, an example might be a patient seen for a follow-up visit for major depression, stable on medication, and refills provided. This would be for an outpatient at a 99213 level. That would be an example. Now we'll move on to talking about what a stable chronic illness is. That was one of the criteria. Well, stable, for the purposes of categorizing medical decision-making, is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. A stable chronic illness is a problem with an expected duration of at least one year or until the death of the patient. And for the purpose of defining chronicity, conditions are treated as chronic whether or not the stage or severity changes. The example that is given in the manual is uncontrolled diabetes and controlled diabetes are a single chronic condition. The risk of morbidity without treatment is significant. Now we'll move to the moderate level medical decision-making table. Again, the column on the left has the appropriate codes for outpatient, inpatient, and nursing facility. The most commonly used inpatient subsequent care code is 99232, which is here. And you can meet criteria for that that we're going to talk about, or you could meet the time, total time on the date of the visit, 35 minutes in this case for 99232. I do want to point out that in the past, when we looked at time as a factor for inpatient, it had to be time on the unit. That no longer applies. If you use time, it's any, you can be any place as long as the time devoted to that patient's care is the total time on the date of service. And this would also qualify for a 99214, an outpatient follow-up code. So let's look at number and complexity of problems for moderate. One or more chronic illnesses with exacerbation, progression, or side effects of treatment. One major depressive disorder recurrent moderate, or two or more stable chronic illnesses, schizophrenia and alcohol use disorder, for example. One undiagnosed new problem with uncertain prognosis, such as cognitive decline, or one acute illness with systemic symptoms. As an example, anorexia with bradycardia and amenorrhea, or substance use disorder presenting an acute withdrawal. Or finally, one acute complicated injury. We usually wouldn't be looking at injuries. The risks table here for moderate risk, once, in order to meet moderate risk, all you really have to do is be prescribing medication. Has to be prescription medication, not over the counter. For a diagnosis or treatment significantly limited by social determinants of health. So an example would be a patient whose adherence to treatment is impacted by homelessness. So what is a chronic illness with exacerbation, progression, or side effects of treatment? It's an illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects. And what is an acute illness with systemic symptoms? Well, it's an illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue, in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problem or acute uncomplicated illness. And systemic symptoms may be general or they may be from a single system. So now finally, we're going to look at medical decision making at the high level. Again, you can see on the left column, this would include 99215, the highest level outpatient code, as well as 99233, the highest level inpatient subsequent care code. The number and complexity of problems include one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment. An example would be major depressive disorder recurrent, severe, with significant functional decline, or severe akathisia from treatment of schizophrenia with antipsychotic medication. Another might be one acute or chronic illness or injury that poses a threat to life or bodily function. So an example might be schizophrenia with command hallucinations to kill family members whom the patient believes are imposters or depression with suicidal ideation and plan. The risk would include drug therapy requiring intensive monitoring for toxicity. And an example for us might be management of plazapine or possibly the initiation of lithium, not the maintenance of lithium that doesn't really require intensive monitoring like the initiation phase. Also decision regarding hospitalization or escalation of hospital level care, a decision not to resuscitate or to deescalate care because of poor prognosis or the use of parenteral controlled substances. So if in an outpatient setting, you're considering having a patient be admitted to a hospital, that would fall under high risk. Once the patient's in the hospital, you need to consider that all inpatients are at higher risk than outpatients by definition. So once they're in the hospital, we still have to decide if the patient is at a 99231 level, 32 level, or 33 level. So what are the kinds of things that put them at higher inpatient risk? They've already met a higher threshold to be in the hospital. What then adds to that risk level in the hospital that would bring them to a 33 level? We're recommending things like patient being on a one-to-one or a line of sight observation. The patient has been in seclusion or restraint and you're seeing them for your next visit. Or the patient has received an emergency medication, a now order for medication and you're seeing them for the next visit, excuse me. Or anyone who's on a forced medication protocol. Now, these are examples that we've given. These are not in the CPT manual and you may have other high level changes that you think meet that. That's up to a decision you have to make about what meets the category once you know what the kinds of things that are in the table and how they can be met. So what's a chronic illness with severe exacerbation progression or side effects of treatment? Severe exacerbation or progression of a chronic illness or severe side effects of treatment that have a significant risk of morbidity and may require escalation in level of care. An acute or chronic illness with exacerbation and or progression of side effects of treatment that poses a threat to life or bodily function in the near term without treatment is the definition here. Okay, let's move on now and we've talked about the medical decision-making table and how you meet those. Now let's talk about time as the alternative way to meet the level of care criteria. As I said, counseling and coordination with care is no longer relevant. And time now is defined as total time on the date of the encounter related to the service. Can't be time spent day before or day after, just on that day. It now includes both face-to-face and non-face-to-face time. And here's a list of the kinds of things that are included. Preparing to see a patient, obtaining or reviewing separately obtained history, performing a medically necessary exam or evaluation, counseling and educating the patient, ordering medications, referring and communicating with other healthcare professionals, documenting clinical information and your record, independently interpreting results and communicating results to family and care coordination, as long as you've not reported that separately. Now let's talk for a minute about E&M plus psychotherapy. This is an integrated service. So you're not starting psychotherapy, stopping it, starting E&M, stopping it, restarting psychotherapy. It's an integrated service. When you do more than 16 minutes of psychotherapy, in addition to an E&M service, you can build both the E&M code and the appropriate psychotherapy code. And these are the three codes for 30, 45, and 60 minutes of add-on psychotherapy. The E&M service is selected on the basis of the medical decision-making, not time when it's done along with psychotherapy. This is the way it is currently and remains so. So you can't use those times in the table that we've been looking at if you're also doing psychotherapy and billing it. You have to do the medical decision-making part by the elements that we talked about. So when you want to determine the correct code to use for E&M and psychotherapy, the E&M portion of the visit is based, as it is for any E&M work, on the complexity of the service that meets the appropriate MDM criteria. The psychotherapy time is determined by the approximate amount of time spent on the E&M portion of the visit, subtracted from the total time of the service. And if the remaining time was spent providing psychotherapy, use the appropriate psychotherapy add-on code based on that time. Document the time of the psychotherapy and divide the note into two sections, one for the E&M portion of the work and a separately identifiable section for the psychotherapy component. Now, this is important. Keep in mind that E&M work takes time, and the more complex the visit, the more time it should take. Some insurers are questioning weekly visits of 99214 plus 90836, the 45-minute psychotherapy code, with total times of that visit of being 50 to 55 minutes. So the reason for that is that the psychotherapy portion of a 9921... I'm sorry, of a 90836 would have to be minimally 38 minutes, and a 99214 needs to take some time. So that doesn't give you very much time if it's a 50-minute visit. You should ask yourself two questions. If you're seeing a patient on a weekly basis, is the E&M work medically necessary at the level I build? And did I appropriate a lot for a reasonable amount of time as part of the total time of the visit for the E&M work that I build? Please note that rules can vary by payer. Some insurers are requiring that you document total time of the service in addition to what CPT says, which is you do need to document the time spent in psychotherapy. Now, I mentioned earlier about inpatient and documentation requirements. Inpatient, if you're using the E&M codes, sorry, if you're using the E&M codes, inpatient documentation for psychiatry also needs to meet the conditions of participation under Medicare for psychiatry. And that means that regardless of whether you're using the initial day codes for inpatient, the 992212 or three series, or the 90792, either one, if you're doing an initial psychiatric evaluation for an inpatient, you need to meet the conditions of participation requirements. And here's some examples of what those include. Past history of psych, past family, educational, vocational, occupational, and social history. You need to describe attitudes and behavior. And your mental status needs to include appearance, behavior, emotional response, thought content, cognition, estimate of intellectual functioning, memory functioning, and orientation. And keep in mind that joint commission requires and CMS require that when you say what the estimate of intellectual functioning is, you have to say how you came to determine that. Memory functioning, how you determine that. So it's important to follow those guidelines for inpatient in addition to the CPT billing. Okay, we're gonna now go through some documentation examples. Now, before I go into these, I do wanna mention that what you'll see are examples in a particular format. It's more of a narrative format. This is just one way to document. You don't have to follow this particular way as long as you capture the required elements and show the medical necessity for what you're doing. So let's get started with the 99212 code. I'm gonna give you some examples for outpatient, inpatient, and the psychotherapy with E&M work. Starting with the lowest outpatient code, 99212. It's important to include a chief complaint. There are a couple of reasons for this. Primarily, it's a good way to succinctly capture the medical necessity for the visit. For inpatient, you also should include a quote from the patient about why they're being seen because that's something the Joint Commission frequently is looking for. So for 99212, this is a follow-up visit for retired recently widowed patient grieving the loss of his wife six months ago. History, Sam states that he's been improving and has taken my advice to spend more time with his grandchildren. He finds himself smiling more, but with occasional sad periods when he gets tearful thinking about his wife. He has not had any thoughts of suicide. Appetite is good and he is concentrating better. Exam, as above. Medical decision-making, continued gradual improvement in mood, not taking any more sleeping medicine which was over the counter. Discussed his wishes regarding follow-up visits and we agreed at his request to meet on a PRN basis going forward. Diagnosis, uncomplicated bereavement. So what's the rationale? This is pretty straightforward and that's the level. It's a self-limited problem and minimal risk. Now let's look at a 99213. Follow-up visit for a patient with recurrent major depressive disorder and remission. History, Margaret tells me that she's been doing pretty well since our last visit three months ago. Her PCP has not changed her hydrochlorothiazide blood pressure medicine. She's been sleeping and eating well. Her return to work has been good for her and she's functioning well in that setting. She has resumed her usual activities and has had no suicidal ideation nor periods lasting more than a few minutes of sadness throughout the day. We agreed to continue the fluoxetine at 40 milligrams. Exam as above and the MDM stabilizing mood in patient with recurrent episodes of depression will continue fluoxetine 40 milligrams daily. Prescription given for three months, return in three months or PRM, major depressive disorder recurrent for the diagnosis. The code selection rationale is, this is a low level medical decision making. The problems are stable chronic illness and the risk is moderate, drug prescription. However, although this patient has moderate risk due to being on a prescription medication, her number and complexity of problems are low, one stable chronic illness and no data were reviewed. In terms of medical necessity for this visit, a 9923, I'm sorry, 99213 seems appropriate. Although she has hypertension and is taking medication for it, the psychiatrist is not managing this condition and thus it would not count as a second chronic illness for this visit. 99214, this is follow-up medication management visit for a 54-year-old man with history of bipolar disorder and alcohol use disorder last seen three months ago. Tom states he's been doing well on his current regimen of medications. He's been sticking to a stable routine as we previously discussed. His work has been good and his relationship with his wife is improving, although it remains bumpy. He is getting at least six hours of sleep at night and works hard at going to bed and getting up at the same times. He has had none of the early signs of an impendicmatic episode that we have discussed. He proudly tells me he is now about to celebrate two years of sobriety. He continues to attend regular AA meetings and stays in regular contact with his sponsor. Exam, appropriately dressed and groomed male with full affect and stable mood, no evidence of hypomania or depression and no suicidal ideation or intentions. Speech is normal rate and rhythm, no evidence of psychosis. For medical decision-making, Tom remains stable on his current medication regimen, discuss possible return to marital therapy, but he wants to think about it before restarting, upcoming two-year anniversary of sobriety. Diagnosis, bipolar I disorder and partial remission and alcohol use disorder. Plan, continue with Lamotrigine 200 milligram daily, continue with AA meetings and sponsor support, will assist with return to marital therapy if patient and wife agree, next appointment in three months or PRN. Let's look at the rationale. The problems are two stable chronic illnesses, the bipolar I disorder and alcohol use disorder, and the patient has moderate level risk for prescription with prescription drug management. And that meets the criteria for moderate. Now let's look at the highest level outpatient code. This is a follow-up visit for a 45-year-old female patient with recent exacerbation of chronic depression with intermittent suicidal thoughts. Sarah tells me that she has been spending a lot of time in bed still with periods of crying and low appetite. She has lost about five pounds in the past two weeks. She awakens about 3 a.m. every night and can't get back to sleep. She has been having thoughts that her family would be better off without her and has considered what it would be like to be dead and continues to feel the presence of those she has loved who are now dead. She says it brings her a sense of peace to consider being with her dead parents. She is taking her bupropion and eripiprazole as prescribed. The exam as above with passive suicidal thoughts, some vague hallucinatory experiences and more movement toward acting on her wish to be with her dead parents. Worsening depression, major depressive disorder and suicidal thoughts with movement toward action in patient with history of prior suicide attempts when in an acute depressive episode like this. Discuss with her and her husband my recommendation for hospitalization at this time. She is reluctant, but trust my judgment. Her husband is very supportive. We'll make arrangements for hospitalization and I will speak to her inpatient psychiatrist. Follow-up post-hospitalization and possible partial hospitalization. Diagnosis, major depressive disorder, recurrent, severe with psychotic features. So the rationale for code selection here is the level is high, the patient has chronic illness with severe exacerbation and because we had to consider hospitalization here, the risk level is high. Now let's look at an example of E&M plus psychotherapy. Chief complaint, follow-up visit for a 40-year-old executive with chronic depression and relationship problems being seen for weekly psychotherapy and medication management. History, Susan states that she's been taking her fluoxetine regularly with no complaints or side effects. Exam, improved mood, no SI. Medical decision-making, continued gradual improvement in mood, continued fluoxetine, 20 milligrams. Now there's a separately identifiable section of the note after the major depressive disorder recurrent for the psychotherapy. Time spent in psychotherapy, approximately 40 minutes. Modality, psychodynamic. Goals, reduction in depressive symptoms and improved relationship with husband. Focus, relationship issues with her husband, working on developing more awareness of alternative understanding of her husband's behavior and his openness to discussing her feelings and perceptions. Please note that I've included here the time, the modality, the goals and the focus. And that's because a number of LCDs, local carrier decisions for Medicare, require those things for the psychotherapy portion of the note. So let's talk about the selection here. The level of medical decision-making here, we said was straightforward. And the reason for that is based on medical necessity for weekly medication management visits. So even though this patient has a stable chronic illness and moderate risk prescription drug management and would typically meet criteria for low-level medical decision-making at 99213, the level of E&M work done on this date of service is straightforward, associated with checking on side effects or other complaints, which meets medical necessity for a 99212. If the patient had been experiencing side effects that warranted further exploration, but were determined not to require a medication change, for example, mild headache or nausea, and were tolerable with the thought that side effects may go away with time, a 99213 may have been appropriate. If the patient was experiencing side effects that were significant and found to be intolerable, for example, vomiting, and the medication was changed with a discussion of risk alternatives and side effects, a 99214 may have been warranted. Circumstances justifying a 99215 need to be highly complex, for example, report of suicidal ideation with a possible plan and discussion or consideration of hospitalization. The 90836 psychotherapy code was chosen based on the time spent providing psychotherapy. So the total time of the visit was considered, subtracting out the approximate time of the E&M portion, and the remaining time spent in psychotherapy was approximately 40 minutes, warranting the 90836 code. The estimated time spent in psychotherapy, 40 minutes in this case, should be documented. When considering time, keep in mind that the E&M work requires time, which should be accounted for within the total time of the visit. Higher complexity E&M work requires more time. When added to the time attributed to psychotherapy, the total time of the visit should make sense. So for example, say you met with a patient for a total time of 20 minutes and billed a 99214 and a 90833, the 30-minute code. Because the 90833 must count for at least 16 minutes of the total time of the visit, it doesn't make sense that you completed the complex work of a 99214 in four minutes. Now let's talk about a couple of inpatient follow-up codes, starting with the 99232, the most commonly used. Chief complaint, follow-up visit for a patient with a recent suicide attempt, quote, I'm scared to go home, end quote. Recall that I said for inpatient, they typically, they being Joint Commission and CMS, typically want a quote from the patient. History, patient is three days post-overdose attempt at home. In family session yesterday with her husband, she expressed anger towards him for his infidelity, ruminating about this today. Exam, some passive suicidal thoughts that her children would be better off without her, cognitively intact, no evidence of psychosis, very sad with some anger at her husband, no medical sequelae after overdose. Medical decision-making, addressing the precipitance of overdose attempt, still uncertain of her safety at home. No side effects noted after starting fluoxetine. We'll consider raising to 40 milligrams tomorrow. Diagnosis, major depressive disorder, single episode, severe with suicide attempt. And the rationale, although this patient has an acute illness that poses a threat to life, which means a high level of problem complexity, her risk level is moderate, as she is on prescription medication and not on higher levels of observation, and she hasn't been in seclusion or restraint, et cetera. So the best two out of three here would be a moderate level overall, and therefore a 99232. And now the 99233, the highest level inpatient, subsequent care code. Chief complaint, follow-up visit for patient with psychotic illness. Quote, they tried to kill me, end quote. History, patient is on his fourth day of hospitalization. Last night, he attacked another patient who his auditory hallucinations told him was going to kill him. He was briefly placed in seclusion and received a PRN of Haldol and Ativan. Exam continues with paranoid beliefs as well as auditory hallucinations, sometimes of a command type. Easily irritated and aggressive at times. MDM remains on aggression precautions, line of sight observation, a lansipine increased last night, no side effects noted. Maintain availability of PRNs for psychotic agitation. Diagnosis, schizophrenia, multiple episodes, currently in an acute episode. And the code selection rationale, pretty straightforward, high level, acute illness that poses a threat to life or bodily function. And high risk, patient is on line of sight observation and in seclusion. And now I'd like to turn it over to Dr. Parsons, who's going to talk about prolonged services and telepsychiatry. Sounds good. All right, next slide please. All right, so they've built a lot of changes to the prolonged services code for 2023. The biggest change is that there's a difference now between the CPT codes and the codes that CMS will be using. CPT now only has two codes to designate prolonged services. Those are 99417 and 99418. CMS chose not to adopt any CPT codes for prolonged services and created four G codes that can be used to designate prolonged services. Next slide. So we'll start with the CPT codes first and discuss those. And then we'll talk about the CMS code second. So for CPT, the 99417 code identifies a prolonged outpatient service. So you can add that to an E&M for office visits, consultations, or home or residence services. The 99418 identifies an inpatient prolonged service to inpatient admissions, discharges, consultations, or also includes nursing facilities under that code. So each of these codes represents an additional 15 minutes of total time with or without direct patient contact beyond the required time of the primary E&M service. And it needs to be a primary timed E&M service. If the time that you go above and beyond the established time does not meet the criteria of 15 minutes, then it is not to be reported. Another change for 2023 is that the prolonged services codes cannot be added to psychotherapy codes alone. It would only need to be used in adding to a E&M code. Next slide. And this is a great chart that is a good reference for those using CPT codes. This talks about the primary E&M services to which a prolonged service code can be added. That's in the first column. Second column has the prolonged service code appropriate to use for that primary code, and then a time threshold to report, and then the time that you're counting to report that prolonged service code. So I'll go through the first row as an example. So a new patient outpatient visit, a 99205. So the time associated with that code in CPT is 60 to 74 minutes. So for CPT, they're using that lower number as a jumping off point to establish that prolonged service time. So 60 plus 15 would be 75. So at 75 minutes, that's the threshold at which you can report one 99417 prolonged service code. If there is additional time on the day of the visit, for each 15 minutes on top of that, you can report another 99417. And that is the same for all of the codes below there on the chart. Next slide. For CMS, so this is separate. So CPT has changes and CMS has separate codes that they're using. They created four G codes that will be used in different settings. So they have the G-2212 for outpatient services, and then the G-03167 and eight for inpatient nursing facility and then home or resident services. So again, each of these are going to represent a 15 minute period of time beyond the base E&M code that is a timed E&M code. And again, just like CPT, these will not be available to be used with primary psychotherapy codes, only with E&M codes. Next slide. And this is another chart equivalent to the CPT chart. So this is addressing only the CMS codes, the G codes. And this goes through the eligible primary E&M service to which you can add a prolonged service code. And that second column addresses the prolonged service code to be added. And then the third column talks about time spent. And this is an important distinction between CPT and CMS. So if you look at the about midway to the bottom, so for nursing facility visits, home and residential visits, and then for the cognitive assessment and care plan, the time reported can be not only on the date of the visit, but also include potentially a day to three before or three to seven days after. So if you look at each individual setting and code associated, that can be your basis for adding up the total time spent with or without patient contact and to be billed in that way. The threshold time is a little bit different than with CPT, rather than going based on the smaller of the range. So for example, with the new outpatient code, it's 60 to 74 minutes, if you remember. For CPT, they based it on the 60 minute. For CMS, they're gonna go to the 74. So the threshold to report that prolonged service code for a new outpatient would be 89 minutes. And we'll make sure to update this chart with the threshold times for you before those handouts are sent to you after. Next slide. And then moving on to telehealth. So telehealth has become definitely a big part of psychiatry during the pandemic and hopefully beyond. And that's what we need to know how to bill and code for those things. So the modifier for a telehealth psychiatric or telehealth physic, excuse me, will be 95NGT for live audio and video telehealth services. So CMS uses the modifier 95. Some commercial payers are using 95 as well and others are using GT. So those are the two modifiers that should be used for the audio and video telehealth services. There also is the availability to use audio only E&M services. And that has been extended to a lot of specialties during the pandemic, but that will end for most specialties as of 2023. But for mental health and substance use disorders, that will be extended throughout the entirety of 2023. So audio only E&M service delivery will be accepted. And the modifiers for use with audio only is 93FQ. So for audio and video, we have the above 95GT and for audio only 93FQ. So that's an important distinction to be aware of. So we are currently still in the public health emergency, the PHE. They have not announced when that will be ending, but we should know some things, you know, within the next year. And when they announce it, we will have a 60 day notice as to when the PHE will be ending and a 151 day flexibility to get everything into compliance. That doesn't apply to everything. And we'll go through the specifics of that in a second, but we have a little bit of flexibility. So we'll have a 60 day warning and then 151 days of flexibility before all the requirements take place. So some of the big things that are going to be changing once the PHE is over or ends, in-person visit requirements will start to take effect for patients with mental health disorders. So for Medicare patients, after the PHE and the flexibility period is concluded, all new patients will be required to have an inpatient visit to establish care. All established patients who are already part of the practice or who have been seen via telehealth, and even those who established care during the PHE will be required to be seen in person once every 12 months. So with that, there can be exceptions if there are hardships, for example, travel time is a problem, mobility challenges, scheduling is an issue. As long as that is documented in the record, there can be exceptions to that required 12 month in-person visit. However, that exceptions do not apply to the new patients that need to be seen in person. Next slide. Okay, for prescribing controlled substances after the PHE has concluded, it's important to note that not for all patients, this is not just Medicare patients or private insurers for all patients, in-person visit requirements for prescription of controlled substances will resume the day that the PHE ends. So when we have that 60 day warning that it will be ending that day, after the 60 day warning that day, everything will become under the in-person visit requirements. That 151 day flexibility period will not apply to this requirement. So that's important to note as well. So it is recommended that patients, or is required that patients be seen in person before initiating a controlled substance. And then also every 24 months after that, those are the federal rules around controlled medications. Most states have their own policies, which are not more lenient, but potentially are more strict than that as far as the frequency of in-person visits following a controlled medication being prescribed. All right, and then next slide. So some key policy considerations with telehealth moving forward. So once the PHE has concluded, it's gonna be required again, that you be licensed in each state in which you're providing care, and that includes telehealth care. You will also need a DEA in each of the states for which you are prescribing controlled medications. Often the DEA registration requires that you be licensed in that state, as well as have an in-state office address. So that's gonna be important moving forward as we get prepared to transition care back under the in-person requirements that we have all of those things met. Be sure that you have checked with your state medical board and your APA district branch to know exactly where your state falls as far as the rules around licensure, prescriptive authority, and coverage of telehealth services in your state, because they may be vastly different than the federal regulations. Next slide. So here's a list of APA resources that are available to folks. At any point in time, APA does have a website where we do updates on coding and reimbursement issues. We'll be updating the site around the 2023 changes in the next few weeks. So please look there for more information. APA also, for APA members, offers a APA practice management helpline, questions around coding documentation. If you're having issues around prior auth or anything related to private payers as well as Medicare, you can send an email to practicemanagementatpsych.org and we'll do our best to respond. We also try to put timely information in psychiatric news. There was a recent article at the end of October, beginning of November, around coding for outpatient E&M services. So be sure if you didn't see that, that had examples, the examples we use today, and some commentary about how best to do that. So we encourage you to watch psychiatric news as well. And again, we can't stress enough that it's important to really review the CPT manual. It does come out every year. If you don't buy it every year, you want to buy it in the years where there are big changes like this year. The guidelines are very helpful and they provide a lot of information in a way that's there and available to you and you can refer back to it as needed. Next slide, please. These are the references and what we pulled from for the in preparation of the webinar. Next slide. So we have had a number of questions come in. So I'm going to start. If you have other questions, please get them in the chat. And so bear with me while I look. We're going to start off with some pretty straightforward ones. We had a question as to whether or not you can build a non-coding system or whether or not you can build a 90792, which is the initial evaluation for multiple visits. Is there any rule around how often you can build that 90792 for a new patient? Sure. You want me to take that, Sarah? Yes, the answer is you can. The most common example would be, for instance, if you're a child psychiatrist, you're seeing a child for the first time in your outpatient office, and then you have the parents come back for a subsequent visit, as part of the initial evaluation, you can build two 90792s, one for when you saw the child and one for when you see their parents. The next question is, does total time include time spent discussing a case with a colleague, if you build on an E&M service on total time across the day? I would say yes. I think the general rule of thumb is clinical activity related to the patient captured over that course of that day. The next question is, does a prescription need to be given at the visit to count, or can it be checking on a medication that is prescribed in an ongoing way? So in relation to the E&M level. You mean, does that meet the moderate level of being on prescription medication? Yes. You don't have to write the prescription that time, if the patient is on the medicine that you prescribed and you're checking on how they're doing with it. We've had some questions around selecting the level and when you're doing weekly visits, where on the chart, it may appear to be a 1-3, but you made reference to the fact that it could be a 1-2. Do you wanna talk a little bit more about weekly psychotherapy when done in conjunction with an E&M? Sure. I guess the issue here is medical necessity. Is there medical necessity for, without the psychotherapy, would there be medical necessity for a weekly 9-9-2-1-3 or 4? And unless one of those things is happening that I mentioned in the slide, the answer is probably no. Is there medical necessity for some level of E&M on a weekly basis? Yes. I think we, in talking about it in the committee, I think there's agreement that a psychiatrist or a psychiatric medical provider is checking on the medical aspects every visit that's part of the weekly psychotherapy in a brief way, typically, unless something's going on. So the reason for the selection of the 2-1-2 versus the 2-1-3, where technically they met the 2-1-3 requirements, is because of the medical necessity for weekly E&M. We also had a question around how you distinguish what you've done in psychotherapy versus E&M. And I don't know if there's a hard and fast rule to follow, but in terms of- Attributing the time? Yeah. Well, psychotherapy, I guess there could be some question of overlap, and that's gonna be a decision that the provider is going to make about whether what they were doing was part of the evaluation and management components or the psychotherapy components. Keep in mind what we said before about the total time has to make sense. So you can't have a complex E&M visit with a psychotherapy where you're only leaving a few minutes of actual time for the E&M. We had a couple of questions around management of lithium and whether it would be a 9-9-2-1-4 or a 9-9-2-1-5. And I don't know if you want to provide some sort of scenarios as to where it might fall. Well, I would say that, and Sarah, if you differ, I would say that the idea here for a 99215 is the example in the high-risk table is that it's drug therapy requiring intensive monitoring for toxicity. I think most people would agree clozapine fits that for psychiatry. Lithium, I think, fits it as you're starting a patient on lithium, because at that point, you are more intensively monitoring the patient with levels, et cetera, to see if you're going to end up with some toxicity. So I think it's reasonable to consider that a high-level risk at the beginning. However, once the patient has been stabilized on it, it no longer, in my mind, would be considered a high-level risk and would be a moderate risk. I would agree. The only thing I would add is that something down the line popped up as far as kidney function or a change in if the levels came back suddenly high and there had to be some management decisions around dialysis or something along those lines. So that would definitely fall in the higher-risk category. But for someone who's stable and labs are normal, I would agree. There was a question around billing a prolonged services code and when to bill CPT versus the Medicare codes. Yes, so with the Medicare codes, it would just be those who have Medicare. So CMS controls that billing. All commercial payers would be CPT. So it may be, if you do your own billing and coding, then you would just need to be aware of the payer source so that you can code appropriately. Or if you have a billing service or someone else on your staff that does billing, maybe coming up with some sort of communication or they can either do a flip on the backend or you guys can communicate upfront so that the payer source is known. CMS would be the Medicare codes and then CPT would be for all commercial insurers. There was a question about the exam or doing a mental status exam when doing an E&M visit and vitals and whether or not that was something you still had to do. So would one of you like to clarify what must be done? Right, no, nothing must be done anymore. No elements are required with the exception of the items that I mentioned for initial psych eval in a hospital. And that's not related to CPT, that's related to the conditions of participation and vital signs are not part of that. Let's see, I'm sorry, I'm scrolling. There was a question around the changes to billing for time on the inpatient setting and what counts across the course of the day, which is different than what it currently is, what you currently do for inpatient total time. All right, so it's anything you do on the date of the service related to the care of that patient would count towards the time. However, keep in mind that, for instance, things like a morning report where you're getting a report on all of your patients or treatment team meeting where you're going over a number of your patients, the time devoted to that individual patient would count. So if in morning report, you heard about a particular patient and it took 30 seconds, yes, you can add that time. If treatment team meeting, you spent five or 10 minutes on that particular patient that day, yes, that time counts. So anything that specifically counts, anything specifically related to the care of that patient on that day would count, including your documentation time, anything you're doing. Okay, if you take 90 minutes for a 907-92, can you add another code or how best would you want to code for that service? There is no other code that I can think of that would go along with the 907-92 no matter how long it took. And what though would their alternative be if they spent that amount of time with a patient on a single day? They could also bill on time using an E&M service. E&M service and the prolonged service codes would be probably more applicable if it's much longer than that. And I don't know that you'll know the answer to this, so please forgive me up front, but if you're treating a patient with Suboxone, do you think that would be a 99214 or a 99215? I think a 214. I don't see, that's not a drug that requires intensive monitoring for toxicity. We've had a few questions around documentation. If there's a particular style of documentation, someone was asking around sort of using the soap note style whether or not they should pull out the medical decision-making components, any advice on how best to ensure that your documentation is something that's clinically relevant, but also understood should it need to be reviewed? I think that's a decision you need to make as a provider. Personally, I think that you should, you should try and make it as easy as possible for an auditor to know exactly what you were thinking and which criteria you thought you met. So one way to do that, and we didn't show it in these examples, but one way to do that is for the medical decision-making part, you could have the exact criteria for problem that you chose, for instance, an acute problem or a chronic problem or whatever the criteria for the problem that you were meeting, one acute or chronic illness or injury that poses a threat to life, you could actually have either on a template where you check that or write it out and the level of risk, what it was that you were meeting as the level of risk, was it prescription medication or whatever. If you do that and you put it on a template and you put a checkbox, I would strongly recommend that, particularly for the problems, you put what the chronic illness is, what the acute illness is so that the auditor will know exactly what you're thinking. I think that makes it more bulletproof in terms of an audit. Anything you would add to that, Sarah? No, I think it makes sense to transition away from the SOAP note if you find yourself doing more medical decision-making based documenting or time-based, just that your template or your documentation matches up with what's needed to avoid audit or avoid any kind of scrutiny because the SOAP note, just hanging onto that for any other reason doesn't make sense to me, but that's just my opinion. Okay, so when considering hospitalization, what if you decide not to have the patient hospitalized or if hospitalization, but the patient refuses and does not meet criteria for involuntary hospitalization? Good question. That still meets high risk. As long as you are evaluating whether or not the patient should be hospitalized for good reason, I mean, not everybody that you say, oh, well, I thought about whether or not he could go in the hospital, has to be for good reason that you document. Even if you decide based on setting up a safety plan with the patient and their family or whatever, or as you said, they don't meet involuntary commitment criteria, that would still meet the high risk level. We do have a question again around weekly psychotherapy and the fact that 99213 indicates that a medication that 99213 does not require a medication be prescribed. Is that correct? And if I decide as the patient's psychiatrist and the therapist that weekly psychotherapy is needed, doesn't that meet a medical necessity criteria? Well, it meets medical necessity for the psychotherapy portion, but not the E&M portion because the E&M plus psychotherapy are two services that are combined. So yes, you have to meet medical necessity for the psychotherapy, but that goes towards the psychotherapy portion. It doesn't automatically mean then that it meets criteria for the E&M portion. We had a question around the data category and whether or not reviewing notes of others and using screening tools would count as data. I know as the committee haven't spent, we haven't necessarily discussed all the components of the data, but maybe just some examples of what would, when you might wanna consider looking in the data category would be good. I do think most folks would probably do best doing the other two columns, but. Sarah, you wanna take that one? Yeah, so how I handle and see that. So data is stuff that you're reviewing that factors into your medical decision-making. So if there's new lab values or they're bringing genetic tests that they've had done before, things like that, I could see being a point of review. However, for me, previous notes kind of falls into that pre-work kind of establishment of the subjective history for a patient. So I don't count the review of records as a data point. And it's also not a new point of information. So that's how I handle it. I would also, just as a practical matter, I don't wanna stop and think in each visit, well, did I get enough data points for this visit to count as one of the two? And then what's the other one? I would rather decide upfront, all of mine are gonna be based on risk and problems because I can identify those and justify it that way and not worry about the data. There are some visits, I think, with some patients. So if it's like I'm doing a workup for sudden onset confusion or memory loss, and I've ordered a bunch of labs and MRI to review, and I have a lot of, I know going into the visit that it's gonna be a heavy data visit. Those are the ones I've used together, but that is definitely not the frequent visits that I have or something that's typically that's happening for me. Thanks. There is a question. If you spend time on a patient's care on a day you do not see the patient, can you include that time anywhere for billing? And there is a CPT code for care provided to patients when you haven't seen them that day. The question is whether or not, not all payers pay that code, but it does exist. And I will, as they answer the next question, I'll look that code up, unless the two of you know what it is off the top of your head. No, but I've never heard of anybody paying for it, but okay. It's one of those you can try to bill and see what happens, but there's no guarantee of coverage. So the next question is, what on the continuum of suicidality, passive death wish, SI without intent or plan, SI with intent and or plan, would qualify as high severity problem from the medical decision-making perspective? Well, I guess it's the definition of, does it pose a threat to life? And I think that's a decision you have to make. I mean, as the provider, do you think that it poses a threat to life? I mean, we've all seen patients who have passive suicidal thoughts for long periods of time, have never acted on them. And I wouldn't personally, you think that that met that level for any specific visit. So I think it's a judgment call and it's your judgment. If a patient is referred for partial hospitalization, would this qualify for a 99215? Because of referred for hospitalization. That's a good question. I think the answer is no. There is one, actually, there's one that gets into how you handle when you're treating patients who have comorbid conditions, medical conditions that you aren't treating and how that factors into the medical decision-making. The example provided is in my practice, the practice is primarily pregnant patients, but I don't treat the pregnancy, only the perinatal issues. The limitation is the risk to the baby or cancer patients who I treat because of the complications with chemotherapy and the interactions with psychiatric meds. And how do you factor sort of those other conditions into your medical decision-making for your visit? Sarah, that's one of your areas of expertise. Yes, so just because it's a medically complex patient doesn't mean that every visit is medically complex. So there may be some visits where the chemo has changed. So we have to look at drug-drug interactions or they're having a reaction. We have to try to figure out what's going on. For a pregnant patient who has had a change in status as far as health goes, but not just based on the fact that they have cancer or that they are pregnant, does that make it every visit a medically complex visit? I don't understand that question. Sorry, I'm sorry. We've actually, there's... I don't know if there's a good answer on this. If you are on a call, if you are on call and the patient is in crisis and the patient refused to go to the hospital, but you have to adjust the medication, how are you going to code that? Well, unfortunately you're not face-to-face with the patient, so you're not going to code that. It's not a visit. Now, when you do see the patient the next time, you can address some of the complexities involved in having made that decision, et cetera. But for that call, there is a telephone code, but again, I'm not aware that anybody really pays for it. Here's a question, again, sort of about time. Under the new system, if you spent 19 minutes face-to-face for an outpatient session with the child and 15 minutes on the phone call with an outside person, say a parent or another person connected to that child's care, and then you spent an additional 30 minutes on something else, can you count all of that time? Or at least that's how I'm interpreting this question. Yes, depending on what the something else was, as long as it's related to the care of that patient and that all of that happens on the same day. Oh, there is a question again around the data and the screening tools. Sorry, I didn't quite understand it, but basically asking if a PHQ or an MDQ, not sure, or similar measures be separate data points to be counted. So would you count each, if you did, let's say a GAT-7 and a PHQ-9, could you? What do you think, Sarah? I do not think that counts as a data point. I think that's part of, I mean, the same thing could be gathered from describing current symptoms and it doesn't really take a high level of interpretation per se. So I think it's a great screening opportunity and to look for trends of how your treatment is working, but I don't count it as a very medically complex interpretation data point for myself. There is a question about, can we use add-on psychotherapy codes for audio-only med management visits? But in order to use the add-on psychotherapy code, you'd have to be billing an E&M service as well. I mean, you can do psychotherapy audio-only with Medicare. Private payers have different rules, so you'd wanna make sure that you can do that. And then right now during the PHE, Medicare would like you to use the telephone E&M services if you're using E&M services along with an add-on psychotherapy code. Private payers, many have allowed the regular outpatient billing, for instance, to be used, but you'd never just bill that add-on psychotherapy code without an E&M code attached to it. Right, and the audio-only extension was CMS-specific, so you would definitely wanna check with commercial payers if that's what you're referring to to make sure that audio-only is still okay with them, and that would be a good opportunity to review which codes would be covered. I think we're coming up on time, and I think we've gone through most of the key questions. So Jeremy, if you could take it to the next slide, we'll wrap up. Again, here's a slide on how you get your CME credit. It provides you all the instructions, and again, these slides will be mailed out afterward. And next slide. We do wanna highlight the January webinar is actually what happens with telepsychiatry after the public health emergency. There were a number of questions in the chat around the telehealth and the PHE, and so we'll make sure that the presenters there are aware of that, and we ask you and invite you to join us next month. Thanks again for attending. ♪ Bright music ♪ Fading out

webinar

APA

evaluation and management coding

documentation

psychiatrists

coding selection criteria

medical decision-making

E&M services

inpatient psychiatric documentation

reimbursement

AMA PRA Category 1 credits

telehealth services