Hi, I’m Angela James at the Centers for Medicare & Medicaid Services. Did you know that the main reason Medicare denies claims is because there’s insufficient documentation? That’s right, proper payment and sufficient documentation go hand in hand. Today, I have some pointers to help you submit documentation properly for psychiatry and psychotherapy services. Let’s start with the Evaluation and Management (E&M) code. The E&M code should be based on the complexity/intensity of the patient’s condition. Next, the psychotherapy code is based on the time spent providing psychotherapy. So, what happens when both of these services – the E&M AND psychotherapy happen on the same day with the same provider? Both services are payable if they are significant and separately identifiable and billed using the correct codes. And, the way to do this is to use an “add-on” code. Here’s how “add-on” codes work: First, an add-on code is only payable if you report it with an appropriate primary service performed on the same day. The time you spend on the E&M service is separate from the time you spend on psychotherapy. And here’s an important rule – time is indicated in the code descriptor for the psychotherapy HCPCS codes. Make sure you clearly document the time spent providing psychotherapy rather than entering one time period for the E&M service. You may be wondering what to do when the time doesn’t match these times. The general rule is to find the one that matches closest. There are codes with ranges to help. Documenting the amount of time you spend with a patient is only one part of the puzzle. Make sure you also include these 3 things so you have sufficient documentation: 1. Modalities of treatment you’ve provided to help the patient (things like cognitive restructuring, behavior modification) 2. Progress to date 3. Updated treatment plan Now, let’s talk through an example of insufficient documentation: – A psychiatrist billed for – level 4 E&M service (99214) – 60 minutes of psychotherapy (90838). Unfortunately, the documentation submitted for review didn’t include the amount of time spent in the psychotherapy encounter. When the reviewer asked for additional documentation, what the provider sent didn’t include specific goals or a treatment plan. Without proper documentation, the claim was scored as an insufficient documentation error and the Medicare Administrative Contractor (MAC) recouped payment. Now, often providers are concerned about HIPAA violations related to the sharing sensitive information from psychotherapy notes. Patient authorization isn’t required to release information excluded from the definition of psychotherapy notes. And, the provider should release the non-psychotherapy note material to demonstrate medical necessity. So, what happens if you have combined information excluded from the definition of psychotherapy notes with a psychotherapy note (e.g., symptoms)? In this case, extract the information needed to support that a Medicare claim is reasonable and necessary. Now, this short video is an overview of the main points you need to know about submitting documentation properly for psychotherapy. To learn more, search for “psychotherapy” on cms.gov and read the National and Local Coverage Determinations, Federal register notices, MLN articles, or Manual instructions.