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Services and Procedures within the Medicine Section

As a medical coder, precision and accuracy are key when looking up codes. It is very important to familiarize yourself with this process and each section of CPT. There are several types of minor procedures and services located in the Medicine section of the CPT manual. Take a few moments to review the Medicine Section Table of Contents that precedes the guidelines and answer the following questions:
Expand your knowledge of the services and procedures highlighted in the Medicine section.
Include the following aspects in the discussion:
 Select one Medicine section subheading of interest and list it
 Provide two coding examples from the subheading identified and include both the codes and the description of each
 Report any parenthetical notes that are associated with the two Medicine codes you selected
 Discuss what types of modifiers may be appropriate to use with the codes selected. Do not use the same code examples as your peers.

Full Answer Section

Two Coding Examples from Psychiatry Subheading:

Code: 90832 Description: Psychotherapy, 30 minutes with patient and/or family member
Code: 90837 Description: Psychotherapy, 60 minutes with patient and/or family member

Parenthetical Notes Associated with the Selected Codes:

For CPT codes 90832 and 90837, the following common parenthetical notes are typically found in the CPT manual's Psychiatry section (and apply broadly to psychotherapy codes):

(For psychotherapy provided with Evaluation and Management (E/M) service, see 90833, 90836, 90838, 90839, 90840)
- Explanation: This note directs the coder to different codes (e.g., 90833, 90836) if psychotherapy is provided in conjunction with a separate E/M service on the same day. The codes 90832 and 90837 are for standalone psychotherapy sessions.
(Do not report 90832, 90834, 90837, 90839, 90845, 90846, 90847, 90853, 90868, 90875, 90876, 90880, 90887, 90889 in conjunction with 99202-99215)
- Explanation: This is a crucial "do not report" note indicating that these standalone psychotherapy codes (like 90832 and 90837) should not be billed on the same day as a standard outpatient E/M service (office or other outpatient visit codes 99202-99215) by the same provider. If both an E/M service and psychotherapy were provided, the combined codes (e.g., 90833, 90836) should be considered.
(Report 90832, 90834, 90837, 90839 for services 16-37 minutes, 38-52 minutes, 53 or more minutes, and 53 or more minutes, respectively.)
- Explanation: This note clarifies the typical time ranges associated with each psychotherapy code. For 90832, it's 16-37 minutes; for 90837, it's 53 minutes or more. This is vital for selecting the correct time-based psychotherapy code.
(Do not report 90832, 90834, 90837, 90839 in conjunction with 90791, 90792, 90833, 90836, 90838, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90875, 90876, 90882, 90885, 90887, 90889, 90899)
- Explanation: This note specifies other psychiatry codes that should not be reported concurrently with 90832 or 90837, as they may represent overlapping services or different types of psychiatric encounters (e.g., diagnostic evaluation, family psychotherapy with patient present).

Types of Modifiers Appropriate to Use with Selected Codes:

For psychotherapy codes like 90832 and 90837, several modifiers may be appropriate depending on the specific circumstances of the service.

Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of a Procedure or Other Service:
- Applicability: This modifier would be appropriate if a physician performs a separately identifiable E/M service (e.g., a medication management visit, 99213) and a psychotherapy session (90832 or 90837) on the same day.
- Usage Example: If a psychiatrist sees a patient for 20 minutes to manage their psychiatric medications and then conducts a separate, distinct 30-minute psychotherapy session (90832), the E/M code (e.g., 99213) would be appended with modifier 25 (e.g., 99213-25). The 90832 would be reported without a modifier, as it is the primary procedure. This situation is why the CPT manual also provides combined E/M and psychotherapy codes (e.g., 90833, 90836), which might be more appropriate depending on the integrated nature of the service. However, if the services are truly distinct, 25 can be used.
Modifier 59 - Distinct Procedural Service:
- Applicability: This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It's often used to identify that two procedures that are usually bundled or not reported together were distinct and medically necessary.

Sample Answer

As a medical coder, I understand the critical importance of precision and accuracy in code look-up, and the CPT manual's Medicine section is indeed rich with various services and procedures requiring careful attention. For this exercise, I will select the subheading of Psychiatry.

Medicine Section Subheading: Psychiatry

The Psychiatry subheading (CPT codes 90785-90899) covers a range of services related to mental health, including diagnostic services, psychotherapy, psychiatric pharmacologic management, and other psychiatric services.