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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

2013 Current Procedural Terminology (CPT) Code Changes for OMH–Licensed Clinics
FAQs received as result of December 13, 2012 Webinar (January 2, 2013)

  1. Are the new codes to be used in billing for inpatient mental health units (Article 28)?

    Providers should use the codes required by their payers.  For OMH-licensed outpatient clinics, the codes presented in the webinar and OMH CPT Crosswalk PDF Document (154kb) are the only codes Medicaid fee-for-service and Medicaid Managed Care plans will reimburse.  

  2. Does the Evaluation and Management (E&M) code affect the weight of the visit?  For example, will we be reimbursed at a higher rate for a psychiatric assessment with an E&M of 99215 as compared to 99212, with the same diagnosis?  

    For OMH-licensed outpatient clinics, the E&M code does not affect the weight of the visit when billing for Medicaid.  A 99212 will pay the same as a 99215 with the same diagnosis.

  3. What is the difference between a new patient and an established patient?  If the patient is transferred from one doctor to another in the same clinic, are they considered a new patient for the new doctor?

    From the American Medical Association (AMA) manual page 11: A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. 

    An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

    OMH considers the “same group practice” to mean the same clinic site.

  4. Is there a limit to the Initial Assessment, 90792 service?

    Yes.  There is a limit of three initial assessments per client, per episode of care.  90791 and 90792 are both Initial Assessments; there is a limit of three combined.   For definition of episode of care and billing limitations, see page 33 of the
    Part 599 guidance document.PDF Document (369kb)

  5. With regard to the number of pre-admission visits allowed before an admission determination must be completed, do crisis services count toward the three allowed?

    Yes.  A crisis service would be counted as one of the three pre-admission services.

  6. Are the Medicaid Managed Care Plans also required to change to the new CPT codes, effective January 1, 2013?

    Yes.  Medicaid managed care companies are required to convert to the new CPT codes effective on January 1, 2013.  The Department of Health recently provided guidance to managed care companies PDF Document (154kb) on the new CPT codes and Medicaid Ambulatory Patient Groups (APG) payment requirements for Article 31 clinics.

  7. Can you tell me if OMH or Medicaid requires a separate progress note by the Medical Doctor/Nurse Practitioner in Psychiatry (MD/NPP) when the Physician add-on service is provided and added to a procedure performed by a non-MD/NPP provider?

    In all cases the psychiatrist/NPP participation must be documented separately.  However, a separate progress note is not required; documentation of MD/NPP involvement may be included on the same note. 

  8. On those services which are for physicians and NPPs, should physician’s assistants also be included?

    No, physician's assistants are not included for services that must be provided by a doctor/NPP.  The staffing requirements have not changed. Please see page 51 of the Part 599 guidance document. PDF Document (154kb)

  9. Do you know if the changes also affect New York State Office of Alcoholism and Substance Abuse Services (OASAS) Clinics?

    CPT code changes are being implemented nationwide on January 1, 2013.  OASAS guidance regarding the CPT changes PDF DocumentLeaving OMH site

  10. Under what circumstances would CPT code 90792 be used by a psychiatrist/NPP as opposed to an E&M code?

    CPT 90792 is to be used for Initial Assessments with medical services only.  There is a limit of three Initial Assessments (combination of both 90791 & 90792) per client per episode of care.  Clinics will only use E&M codes for Psychotropic Medication Treatment or Psychiatric Assessment services.  Additionally, clinics must use the physician modifier to get the bump in payment.

  11. If a 90792 is claimed, can a psychotherapy code of 90833 or 90836 be combined with it?

    No.  90833 and 90836 are only to be used with an E&M code for a Psychiatric Assessment.

  12. Does the requirement of the use of the E&M codes mean that the 90805 and 90807 can no longer be used?

    Yes.  CPT codes 90805 and 90807 have been eliminated by the AMA for date of services on or after January 1, 2013.

  13. The Psychiatric Assessment process is the same regardless of the clinical diagnosis at its conclusion, yet, the APG weights vary.  Also, the weight ascribed to childhood behavioral disorders is particularly low even though children can have many more factors that need to be taken into account during an assessment. How were the weights determined and can these be revisited?

    The diagnosis-based weights were developed by the Department of Health (DOH) based on average cost.  OMH and DOH will be discussing possible changes to those weights in early 2013.

  14. In a National Council webinar regarding E&M codes, they described levels of exams that applied to E&M codes ranging from "problem focused" to "comprehensive." Is OMH adopting this tiered application of the E&M codes?

    We require that clinics use the appropriate E&M code based on the service provided.  However, according to Part 599 regulations, in order to be reimbursed by Medicaid, clinics must spend at least 30 minutes for a Psychiatric Assessment and at least 15 minutes for a Psychotropic Medication Treatment.

  15. Can CPT 90792 with AF (psychiatrist) modifier be used for the Initial Assessment in an episode of care? If yes, are there any restrictions or rules that apply?

    The AF modifier (add-on for psychiatrist) can be used for the Initial Assessment in an episode as long as the psychiatrist/NPP provided the service.  Clinics are allowed up to three initial assessments (combination of 90791 & 90792) per episode.  CPT 90792 can only be provided by a doctor/NPP so the entire session has to be provided by the doctor.

    CPT 90791 is an alternative to 90792.  In addition to MD/NPP, the eligible staff for 90791 allows for Licensed Master Social Worker (LMSW), Licensed Clinical Social Worker (LCSW), Licensed Psychologist, Registered Nurse (RN), Licensed Mental Health Counselor (LMHC), Licensed Marriage and Family Therapist (LMFT), and Licensed Creative Arts Therapist (LCAT), Licensed Psychoanalysts and appropriate non-licensed staff.  The MD/NPP modifiers are allowed for CPT 90791 as long as the MD/NPP either provides the entire session or spends at least 15 minutes with the client in the session being provided by another professional.   

  16. Is it permissible to apply the Psychotherapy add-on (90833 or 90836) to a Health Physical procedure if an Nurse Practitioner (NP) (Primary Care) performs the service?  With the broader definition of psychotherapy, we thought it might apply.

    No.  Clinics will only use 90833 or 90836 with an E&M (office visit) code to indicate that a psychiatric assessment has taken place.  Please Note: When providing a health physical and a psychotherapy service, clinics will bill the appropriate health services rate code (i.e., 1474, 1477, 1588, or 1591) with the appropriate health physical E&M code.  The psychotherapy session will be claimed using 90832 or 90834 with the appropriate rate code (e.g., 1504, 1516).   

  17. Where do I find the Rate/Revenue & Weights for the E&M codes (e.g., 99212, 99213, etc.)?

    The E&M weights are diagnosis-based and can be found on page 8 of the OMH CPT Crosswalk.PDF Document (154kb)  

  18. Will the new codes be automatically added to our other codes with DOH or do we have to check with them?

    DOH will add the codes to the APG grouper automatically. 

  19. Will clinics be reimbursed by Medicaid if all services provided by a doctor/NPP are claimed using E&M codes?

    Clinics may only use E&M codes for Psychotropic Medication Treatment and Psychiatric Assessments.  Psychotropic Medication Treatment requires a minimum time spent of 15 minutes regardless of the E&M code you use.  A Psychiatric Assessment requires a minimum of 30 minutes + the appropriate psychotherapy add-on code. 

  20. Will the code changes affect Personalized Recovery Oriented Services (PROS) billing for Clinical Treatment (CT) services?

    Yes.  The CPT code changes are effective nationwide beginning January 1, 2013.  However, the definitions of the services and the reimbursements have not changed for PROS clinics. PROS clinics will continue to claim Medicaid using rate code 4525.  PROS clinics must replace the deleted CPT codes with the new CPT codes according to the OMH CPT Crosswalk.PDF Document (154kb) OMH Financial Planning will be sending out specialized guidance for PROS providers soon.

Comments or questions about the information on this page can be directed to the Bureau of Financial Planning.