This post was originally published on June 27, 2018, and updated on February 6, 2020.

In this coding scenario, you will learn one patient’s experience with gender dysphoria and how to assign the correct CPT code for psychotherapy for gender dysphoria based on who was involved in the counseling and how much face-to-face time was spent. 

CPT coding for psychotherapy and patient at counseling session for gender dysphoria

Question:  Patient with gender dysphoria is seen for psychotherapy today due to feelings of anxiety and high levels of stress. Patient was assigned female at birth but never felt comfortable with that identity, nor that of a male. Patient tells the psychotherapist that she prefers that people refer to her as “they” rather than she or he.

Some friends and family members are accepting of patient’s situation, but some are not. This gives patient great stress having to go out in public and deal with people’s reactions. During the therapy session, patient expresses anxiety over menstruation and their changing body.

Discussion took place on how to reduce the dysphoria and how to talk to people about gender to relieve some of the anxiety. The session lasted 45 minutes.  Assign the CPT code.

Answer:

90834, Psychotherapy, 45 minutes with patient

First, if you aren’t sure what gender dysphoria is, I have an entire post about it and how to report many of the gender reassignment procedures in CPT. 

Locate and Verify

Looking in the CPT coding manual Index, see Psychiatric services, psychotherapy, patient, 90832-90838. In the Tabular, we can verify that 90834 is the correct code, as the patient was seen for 45 minutes.

In CPT, psychotherapy services are located in the Medicine/Psychiatry section. Psychiatry includes diagnostic services, psychotherapy, and other services to an individual, family or group. Psychotherapy is the use of therapeutic communication to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior, and to encourage personality growth and development.

Psychotherapy With Patient

Psychotherapy codes for the individual patient are reported with CPT codes 90832, 90833, 90834, 90836, 90837, and 90838. Treatment may include just the patient or it may include patient and an informant, such as a family member or friend. The sessions must be face-to-face, and the patient must be in attendance for all or most of the service except in certain circumstances. These codes are reported when psychotherapy services are provided without evaluation and management services and are based on time.

  • 90832, Psychotherapy, 30 minutes with patient, is reported for 16-37 minutes
  • 90834, Psychotherapy, 45 minutes with patient, is reported for 38-52 minutes
  • 90837, Psychotherapy, 60 minutes with patient, is reported for 53-89 minutes

Psychotherapy services must be 16 minutes or more to be reported.

Prolonged Services

When psychotherapy services for an individual are 90+ minutes, 90837 should be reported, along with the appropriate prolonged service code (99354-99357), according to the AMA guidelines. Documentation must support medical necessity for the extended time, indicating face-to-face time was spent with the patient.

Psychotherapy with E/M Services

When psychotherapy services are provided with medical evaluation and management services on the same day by the same provider, add-on codes 90833, 90836, and 90838 are reported with E/M codes, the primary service.

  • 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 patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure

You will note that the guidelines indicate that the above codes should be reported in conjunction with 99201-99255, 99304-99337, 99341-99350. These are E/M service codes.

Be sure to read all the parenthetical notes associated with each code before making final code assignment.


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