CPT & Reimbursement
CPT codes describe medical, including psychiatric, procedures performed by physicians and other qualified health care professionals. The codes are developed and maintained by the American Medical Association and are used by Centers for Medicare and Medicaid (CMS) for reimbursement to Medicare providers. Most insurance companies also base their reimbursements on the values established by CMS.
New AMA Toolkit on Health Insurance Exchange Grace Period
For members who have patients who have purchased coverage through health insurance exchange, check out the AMA’s new toolkit about the grace period for nonpayment of premiums (with the assistance of premium tax credits). The new toolkit, available at www.ama-assn.org/go/graceperiod, becomes part of the AMA’s collection of Affordable Care Act (ACA) resources for physicians and includes the following:
- Step-by-step guide to the ACA ‘grace period’
- Grace period collections policy checklist
- Model financial agreement language for patients receiving Advance Premium Tax Credits
- Sample letter: Grace period notice to patients
Reimbursement Issues with the New Codes?
Insurance companies continue to implement the CPT codes that went into effect in 2013, plus DSM-V, and many are preparing for ICD-10. If you still have “how to” questions or if you are having issues with reimbursement, let AACAP know. There are different reimbursement issues in different parts of the country with different insurance companies. Although every situation is different, AACAP is here to help you. We are tracking all of the complaints received and continue to follow up with these insurance companies in partnership with the other associations to resolve these issues. If you are experiencing issues, please contact a member of the Government Affairs and Clinical Practice Department at email@example.com to help you work on potential solutions.
In the meantime, there are several steps you can take:
- Negotiate with the payers - you must negotiate with the insurance providers or you give up your rights to finding better coding solutions for you and your patients.
- Find legal advice - if you have concerns about the contracts offered by the payers.
- Contact your state department of insurance/managed care - let them know about any problems you're encountering. Click here for a list of department leaders by state.
- Lodge a complaint through the American Medical Association - if there is a possible HIPAA violation, you can get more information here.
- Work with your patients and families - make sure they understand the changes (e.g., this is coding only, they won't see a change in their services), how they may affect them (e.g., billing charges and EOBs could be different), and what they can do if they have issues (see our information on insurance appeals and finding help here).
- Work with your regional organization to send a letter to insurance companies. Click here for a sample letter that can be modified for individuals as well.
CPT Training Module
The CPT Training Module is designed to help AACAP members use CPT Codes and provides information on the many code changes occurring annually.
CPT Training Module 2012
(Last updated August 2012)
CPT Training Module 2013
(Last updated November 2012)
CPT Training Module 2015
(Last updated September 2015)
Psychiatry and E/M RVUs for CY 2015
Click here for an excel sheet of the relative value units for the psychiatry and evaluation and management codes for calendar year 2015 per the Centers for Medicare and Medicaid Services.
Psychiatry and E/M RVUs for CY 2013
Click here for an excel sheet of the relative value units for the psychiatry and evaluation and management codes for calendar year 2013 per the Centers for Medicare and Medicaid Services.
Webinars and Support Materials
The following education materials were created by Benjamin Shain, M.D., PhD, with assistance from Sherry Barron-Seabrook, M.D., and David Berland M.D., and special thanks to Virginia Allen, M.D., Lourival Baptista-Neto, M.D., Lisa Ponfick, M.D., and other members of the Healthcare Access and Economics Committee.
The pharmacologic management code (90862) is deleted in 2013. Physicians are instructed to report those services with Evaluation and Management (E/M) codes. Unless you are very familiar with these codes, you will likely benefit from the education material below.
E/M Coding 1: Introduction
This chapter includes: Why Use E/M, History, Examination, Medical Decision Making, and Time. The Chapter 1 webinar can be completed in less than 35 minutes, but anyone new to E/M coding should be prepared to spend more time. We recommend printing the slides to more easily follow and take notes while watching the webinar.
Introduction - Slides Only
E/M Coding 2: Child and Adolescent Psychiatric Outpatients
This chapter includes: a review of basic E/M concepts and detailed descriptions of how to select and document outpatient E/M codes for established and new patients. Chapter 2 will require at least an hour to view. If you are new to E/M coding, you will need to devote more time. We recommend printing the slides to more easily follow and take notes while watching the webinar.
Outpatients - Slides Only
E/M Summary Guide
This guide will assist the user who has not memorized the extensive E/M criteria. The guide does NOT give sufficient information to use these criteria and is not meant as a substitute for the webinars. It is best printed in color, using double-sided printing. Click here to access the E/M Summary Guide.
E/M Patient Examples
This guide provides sample progress notes for specified E/M codes, but it is for illustration purposes only and may not meet documentation criteria for other purposes such as legal or clinical. It is best printed in color. Click here to access the E/M Patient Examples.
Chapter 3: New Psychiatry CPT Codes
This chapter includes: the revamped psychiatry section for 2013, including the use of E/M codes to report medical services, division of diagnostic into medical and nonmedical, changed time ranges, and new concepts of psychotherapy add-on codes, interactive complexity, and psychotherapy for crisis.
New Codes - Slides Only
2012 to 2013 Crosswalk Table
This table lists the commonly used 2012 psychiatry CPT codes and how those services are reported with the 2013 psychiatry codes. Click here to access the 2012 to 2013 Crosswalk Table.
E/M and Psychotherapy Coding Algorithm
This algorithm is a color-coded, selection tree for the various combinations of E/M, psychotherapy, and interactive complexity. Click here to access the Algorithm.
Interactive Complexity Guide
A new concept for 2013, interactive complexity may be very useful for child and adolescent psychiatrists, referring to 4 specific communication factors DURING a visit that complicate delivery of the primary psychiatric procedure. Report CPT add-on code +90785 in conjunction with certain psychiatric services. See the Interactive Complexity Guide for typical patients and criteria. Click here to access the Interactive Complexity Guide.
APA's Evaluation and Management Coding for Psychiatrists (free for APA members)
Webinar: Answers to Your CPT Questions
If you've already reviewed all of AACAP's products to help you with your coding in 2013, but still have questions, you might find your answer here. This webinar answers real-life questions and scenarios from AACAP members and their billing staff about evaluation codes, E/M codes, interactive complexity and more. (Click the arrows in the right hand corner of the video player to enlarge.)
December 18, 2012
January 25, 2013
David Berland, M.D.
AMA CPT Panel Alternate Advisor
Ben Shain, M.D.
AMA CPT Panel Advisor
If you have coding and other reimbursement questions, please contact, a member of the Government Affairs and Clinical Practice Department at firstname.lastname@example.org or 202.966.7300.
CPT® is a registered trademark of the American Medical Association (AMA).
The American Academy of Child and Adolescent Psychiatry (AACAP) has consulted authors believed to be knowledgeable in their field. However, neither AACAP nor the authors warrant that the information is in every respect accurate and/or complete. AACAP assumes no responsibility for use of the information provided. Neither AACAP nor the authors shall be responsible for, and expressly disclaim liability for, damages of any kind arising out of the use of, reference to, or reliance on, the content of these educational materials. These materials are for informational purposes only. AACAP does not provide medical, legal, financial, or other professional advice and readers are encouraged to consult a professional advisor for such advice.