In 1991, I jumped off into private practice and eagerly signed up to join as many managed care panels as I could. (I’m not recommending the “jumping off” or joining all those panels. But, if you’ve been following this blog for a while, you already know that.)
One of the most confounding things that I was confronted with were CPT codes. No one in graduate school talked about “CPT codes.” No one in any of the agencies I had worked in ever talked to me about those mysterious codes. And, no one in the for profit psych hospital I had just left ever mentioned those codes to me . . . .
Yet, I still thought I was just supposed to magically know about them so I tried to fake it and “act as if” I knew what they were. But, I didn’t have a clue. Perhaps you’ve been in a similar situation?
Of course, this was pre-internet days so I couldn’t hop online and ask Google “What is a CPT code? And, by the way, how do I use them?”
Eventually, I found a therapist in the community who recognized that I was clueless and kindly shared a list of the 5 or 6 codes that she used most often. It would be another handful of years before I realized that these codes were actually regulated and had very specific definitions that dictated when and and under what circumstances to use them. (That was after I had run across and purchased a CPT code handbook for Psychiatrists!) And, yes, I had been coding a few things wrong.
Fast forward two decades and I’m blogging away and keeping an eye out for a billing specialist who was interested in sharing some insights and advice with you guys. And, . . . voila! Denny Chapin reached out to introduce himself and offered to share his insights on the use of CPT codes to help us out. So, here’s a guest post by billing specialist Denny Chapin to clue you in!
(If you are interested in writing a guest post, check out the guidelines here.)
A Guest Post by Denny Chapin
What are CPT Codes?
CPT (Current Procedural Terminology) is a standardized medical code set maintained by the American Medical Association.
CPT codes are five-digit numeric codes describing everything from surgery to radiology to psychotherapy. For psychotherapists that are on managed care panels or provide superbills to their clients, knowing CPT codes is paramount to getting paid in full and avoiding insurance audits.
The amount insurance companies will reimburse depends on a number of different factors (professional credentials, geographic location, etc.), but using the correct CPT Code and add-on code(s) to express the exact service is an important part to the whole process in ultimately determining your payment.
Reporting Errors – Accidental and Otherwise
Errors, accidental or otherwise, will directly impact insurance company’s payment of services. Downcoding (including less services on the claim than actually provided) will usually mean you get paid less, while upcoding (including more services on the claim than actually provided) can get you in trouble with your managed care panels.
It’s also important to note that it might be tempting to maximize your CPT codes to earn higher reimbursements. This is highly recommended against and can get you flagged, audited and removed from insurance panels. Even if this is your biller’s error, the therapist is the one who ultimately bears the responsibility and will be the one penalized.
CPT Codes for Psychotherapy
CPT coding for psychotherapy doesn’t have to be difficult. There are an overwhelming number of total CPT codes (about 8,000). However, only 24 are specifically designated for psychotherapy. To make matters even simpler, nearly all therapists will regularly use an even smaller subset of these 24 codes. CPT codes change from year to year but the psychotherapy codes seldom change. Prior to the change in 2013, the last change in psychotherapy coding was in 1998. In other words, it’s likely that you will only need to learn them once.
CPT Add-On Codes
A CPT add-on code is a code describing a service performed in conjunction with a primary service. Many of these add-on codes are associated with a specific CPT code or a small subset of CPT codes and cannot be used without those particular codes. For example, the CPT code for interactive complexity (+90785) can be used for a diagnostic (90791, 90792) or a normal psychotherapy session (90832, 90834, 90837) but not a crisis psychotherapy session (90839).
Add-on codes are identified by a + sign in front of the number, i.e. +90840 is an add-on code for extra time in the case of crisis psychotherapy. On CMS 1500 forms CPT add-on codes are simply added on a new line.
Criteria for Interactive Complexity (+90785)
Interactive Complexity (+90785) is one of the new add-on codes in the 2013 update. This code is used as an umbrella add-on code and can be used for four different criteria. The most common scenarios typically involve children, although this is not always the case.
Examples of Interactive Complexity include the following:
- the use of play equipment with young children,
- interpreters / translators,
- involvement of parents with discordant views that complicate the treatment plan, and
- the reporting of abuse / neglect.
Note that interactive complexity can be used in conjunction with primary CPT codes for diagnostics, psychotherapy, or group therapy but cannot be used for couples / family therapy or crisis codes. You may download this pdf for additional information on how to use the interactive complexity code in billing.
How Do CPT Codes Affect Reimbursement?
Many therapists question whether or not they are being paid the correct amount. Here are typical rates for reimbursement contingent upon your credentials:
Typical Reimbursements by Type of Therapist
Rates for reimbursement can vary significantly from therapist to therapist but these figures (above) are good benchmarks for comparison. The way CPT codes affect reimbursement is complicated and depends on a therapist’s level of education, location, and license. The AMA has created a code search feature on their website that shows payments based off CPT code and location. This information is somewhat incomplete, is based off medicare payments and does not specify a number of other important factors. However, this tool is still very useful to compare the relative value CPT codes against one another. Private insurance will be correlated with some deviation from these numbers.
Reimbursement by CPT Code (Three Different Geographies)
Data (above) from AMA Codemanager
Key Points on The Use of CPT Codes
- Don’t worry about memorizing all the CPT codes (there’s a lot!) or even all of the mental health ones.
- It’s likely that you will only use a few individual codes on a regular basis.
- If you are just starting out in private practice or just beginning to deal with managed care, keep it simple.
- CPT codes appear far more complex from the outside looking in.
- Here is a CPT Cheat Sheet to help you out.
- And, here is a blog post telling you How and Where to Look Up CPT codes for free!
- Memorize the relevant codes and use Google or other references to find the correct CPT codes for more unique scenarios.
And, finally, if you can’t figure out what you’re looking for, just ask!
About the Author: Denny Chapin is a billing specialist. He runs TheraThink, a private billing company specializing in billing for therapists, that is dedicated to make billing and dealing with insurance companies as simple and pain-free as possible!