Skip to Content

Provider Manual

Mental Health Medication Management

Last Updated on August 28, 2018

There have been a number of questions from providers about billing for outpatient medication management services and the use of appropriate CPT coding, particularly when there is split therapy with a psychiatrist and another provider. Security Health Plan management has attempted to define an approach that is fair and ensures that members receive the proper level of care.

Provision of therapy by more than one provider entails many complex issues. Such relationships imply clinical and ethical responsibilities and may involve liability issues. There are three types of recognized relationships when psychiatrists work with other providers, namely collaboration, consultation, and supervision. These relationships can be ambiguous at best with indistinct boundaries, or redundant, counter-productive, or just plain sloppy at worst. There is a mandate to define these respective roles. Delineation of responsibility should be determined by the collaborators then discussed with the patient to clarify roles and to obtain the patient’s consent to the arrangement. The clinical record should document this discussion including the date this relationship was established. Questions in this area are not only important in establishing roles and responsibilities but can be quite revealing of the patient’s understanding and expectations of the various care givers and treatments.

The primary billing codes used are:

  • 90862 – Defined as pharmacological management including prescription use and review of medication with no more than minimal psychotherapy
  • 90805 – Individual psychotherapy approximately 20 – 30 minutes face to face, with medical evaluation and management services
  • 90807 – Individual psychotherapy approximately 45 – 50 minutes face to face, with medical evaluation and management services
  • 90809 – Individual psychotherapy approximately 75 – 80 minutes face to face, with medical evaluation and management services
  • 99201 through 99275 – Evaluation and Management (E/M) services provided in a physician’s office

Evaluation and management codes for new and established patients have clearly defined criteria for documentation of history, examination and complexity of medical decision making which are available from Medical Group Management Associates Service Center at 1-303-397-7888. Use of these codes does require a treatment plan.

The use of medicine codes (for example 90805, 90807) implies that psychotherapy is being performed along with medical evaluation management services (medication management). Some psychiatrists routinely use PT codes 90805 and 90807 for all medication management visits. If that psychiatrist is the sole provider and is doing therapy and medication management, then this is an acceptable use of these codes. However, if that patient is in therapy with another therapist such as a social worker or psychologist and is also currently receiving psychotherapy from their psychiatrist, this implies that this is an exceptionally complicated patient and a treatment plan should justify the need for the patient receiving dual psychotherapies and clarify their respective roles.

When each patient of a psychiatrist is billed for CPT code 90805, utilization review again questions the validity of such a practice. Sometimes a medication check is just that, and should be billed with a 90862 CPT code. Use of codes 90805 – 90807 implies that the primary focus of the visit is psychotherapy; likewise use of 90862 indicates the purpose of the visit is mainly medication management.

When each patient of a psychiatrist is billed for CPT code 90805, utilization review again questions the validity of such a practice. Sometimes a medication check is just that, and should be billed with a 90862 CPT code. Use of codes 90805 – 90807 implies that the primary focus of the visit is psychotherapy; likewise use of 90862 indicates the purpose of the visit is mainly medication management.

Comments:

  • “I only see patients for 30 minutes; anything less than that is unethical.”

Response: CPT code 90862 is not a time-based code. Sometimes a medication check is just a medication check and it is “unethical” to bill using a higher level code unless you are doing psychotherapy.

  • “Children are complicated; I always use CPT code 90805.”

Response: Some children are more complicated than others. They may require psychotherapy. The definition of CPT 90862 does involve minimal psychotherapy. Is more than minimal psychotherapy required for the routine refill of ADHD meds for children?

  • “The doctor is slow, he always uses CPT codes 90805 and 90807, because of time spent.”

Response: This is not a justification for the use of these codes.

  • “CPT codes 90805 and 90807 pay more.”

Response: Again, this is not a justification for the use of these codes.

When psychotherapy and medication management are needed or in particularly complicated cases that require simultaneous psychotherapy with one provider along with psychotherapy and medication management with a psychiatrist, this need should be justified and documented. At Security Health Plan we are particularly concerned about the appropriate utilization of our members’ benefits. It is our responsibility to coordinate care and to ensure member care is not redundant or counter-productive and that therapists communicate with each other. We have seen situations where our members’ benefits do become exhausted prior to the end of the year and/or therapists are not communicating with each other.