May 2023 AI Alert

Psychiatrists Performing Psychotherapy Evaluation & Management (E&M) Services 

Recently, several of our business partners expressed concerns with increased utilization by psychiatrists performing psychotherapy services and billing a high-level of evaluation and management (E&M) service on the same date. This prompted the Codoxo Customer Success team to dive into the claims data for those peer groups to identify outlier trends and behaviors.   

Psychotherapy is the treatment of mental illness and behavioral disturbances in which the focus of therapy is to alleviate the emotional disturbance, reverse or change maladaptive patterns of behavior, and encourage personality growth. Some psychotherapy patients may receive a medical evaluation and management service on the same day. To report both services the two services must be significant and separately identifiable.  

Medical symptoms can sometimes manifest in some psychiatric conditions which need to be addressed.  For the purposes of reporting the psychotherapy and E&M components for the same patient and same date of service, one should remember: 

1. The type and level of E&M service is selected first based on the key components for reporting an E&M (history, examination, and medical decision making). Time alone cannot be the basis of code selection for the E&M component.  

2. The time associated with activities related to the E&M service criteria is not psychotherapy time.  

3. Psychotherapy should not be billed if the total psychotherapy time is less than 16 minutes of therapy. 

Applicable Psychotherapy CPT Codes to Report with an E&M Code 

• 90833- Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (list separately in addition to the code for primary procedure)      
• 90836- Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (list separately in addition to the code for primary procedure) 
• 90838- Psychotherapy, 60 minutes with the patient when performed with an evaluation and management service (list separately in addition to the code for primary procedure) 

Using Codoxo’s Forensic AI Platform to Assist your Plan with Identifying Patterns 

While reviewing a peer group systemically, Fraud Scope can assist your plan with identifying Psychotherapy with E&M services using our AI detection categories, such as Upcoding, Frequent Combinations, Physician Time, or Multiple Claims. 

When reviewing an individual provider, Fraud Scope offers Provider Codes and Query Aggregates as summary analysis tools that quickly identify a provider with outlier claim volume by claim composition, patient percentage and numerous differences in utilization compared to their peer group.   

If you are interested in learning more about Codoxo’s forensic AI platform or would like to speak to Codoxo team member, contact us via info@codoxo.com.