Coding and Reimbursement

The Current Procedure Terminology (CPT) code set is used to denote the medical and surgical procedures and diagnostic services rendered by providers. The CPT coding system provides a uniform language for describing these services for all billing and documentation and, under HIPAA, is required to be used for procedures provided by all providers and payers in the United States. The Centers for Medicare and Medicaid (CMS) assigns values to those CPT codes covered by Medicare and most insurance companies base their reimbursements on the values established by CMS for these procedure codes.

For the provider, the key to appropriate insurance reimbursement lies in accurate procedure coding. Coding errors can lead to delayed payments or rejections of submitted claims. Consistent errors can trigger audits, or even charges of fraud and abuse, and removal from managed care networks. Always verify CPT information with the AMA's current CPT manual, which is the ultimate authority on procedure coding.

DSM Diagnostic and Coding Clinic

Access resources, find coding updates, learn about reimbursement issues and help with the transition to ICD-10.

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Procedure Coding Resources for APA Members

2017 CPT Code Changes

Download the CPT Code Changes in 2017.

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The Basics

• CPT Primer for Psychiatrists
• Frequently asked questions about coding and documentation
• WATCH: Documenting Psychotherapy — One-Minute CMS Video

Evaluation and Management (E/M)

• Documentation Guidelines for Evaluation and Management (E/M) Services: Review information on and download resources from the CMS Medicare Learning Network (MLN) Educational Documentation Guidelines for Evaluation and Management (E/M) Services page.
• E/M Services Guide: Coding by Key Components (summary chart)
• Patient Examples Outpatient E/M Visits
• Centers for Medicare & Medicaid Services 1997 Documentation Guidelines for Evaluation and Management Services, abridged and modified for psychiatric services
• Codes and Documentation for Evaluation & Management with Vignettes
• E/M Documentation Templates
  
  • Intial Evaluation New Patient Outpatient (99201-99205), Initial Hospital Care (99221-99223), Initial Nursing Facility Care (99304-99306)
  • Established Patient Outpatient (99211-99215), Subseq Hosp Care (99231-99233), Subseq Nursing Fac Care (99311-99313)

CPT Coding Webinars/Training Options

CME courses devoted to general CPT coding and CPT coding using evaluation and management codes as well as a CPT workshop are offered each year at the APA Annual Meetings.

• Register for APA online CME courses on Evaluation and Management CPT Coding and Documentation for Psychiatrists; free to APA members
• Review 2014 Annual Meeting Course Materials for Seminar 13: CPT Coding and Documentation (Updated material will be posted following APA's 2015 Annual Meeting in May)
  • CPT Coding for Psychiatric Care in 2014
  • CPT Coding for Psychiatric Care in 2014 Background Material
• Review past APA webinars and presentations
• American Academy of Child and Adolescent Psychiatry (AACAP) CPT webinars and presentations
• For fee-based, live online training, including templates, visit MusherGroup.com
• Basic online E/M coding tools and webinars from E/M University

FAQ: Billing Psychiatric Collaborative Care Management and General Behavioral Health Intervention Codes

APA has developed a set of frequenlty asked questions, including those developed by CMS and additional information.

Download FAQ

Procedure Coding for Smoking-Cessation Counseling

There are several procedure codes available to describe services provided to encourage behavior change in individuals who use tobacco.

See more resources on smoking cessation and mental illness.

Interactive Complexity Guide

A new concept in 2013, interactive complexity refers to 4 specific communication factors during a visit that complicate delivery of the primary psychiatric procedure. Report with CPT add-on code 90785.