Diagnostic Codes

When psychologists bill Medicare, they must use appropriate diagnostic and procedure codes on the claim form. The diagnostic code represents the reason why the patient is seeking services from the psychologist (i.e., depression), while the procedure code represents the service the psychologist is providing (i.e., psychotherapy). For purposes of Medicare payment, psychologists must use a diagnostic code from the International Classification of Diseases - 9th Revision (ICD-9). Conveniently, nearly all of the mental health ICD-9 codes crosswalk exactly to the DSM-IV diagnoses, and many psychologists, knowingly or not, list the DMS-IV diagnoses on their claim form. The problem with that practice comes when ICD-9 has a higher level of specificity that is not reflected in the DSM-IV version. There have been some instances of claim denials due to a lack of specificity in the diagnosis. It is best to get a current version of the ICD-9 coding manual so that there is no question about using the proper diagnostic code.

CPT Codes

Current Procedural Terminology (CPT) codes are used to represent services provided by psychologists and other Health Care Professionals. For example, if a psychologist were to provide a 45-50 minute "insight-oriented" individual psychotherapy session in their private practice office, the CPT code for that service would be 90806. This code is put on the HCFA 1500 claim form and tells the carrier what service was provided to the beneficiary.

The AMA, who owns the CPT coding system, does not specifically restrict usage of certain codes, however coverage of certain CPT codes is often restricted by insurance entities. Often times, these coverage policies vary depending upon the payor. For example, although Medicare will not cover Evaluation and Management services provided by psychologists, some other payors will. Again, this restriction is not based upon the code itself, but reflects a coverage policy that utilizes the CPT coding scheme.

Psychology Specific CPT Codes

Both CPT and ICD-9 manuals are reproduced and updated each year (though not all sections) by the American Medical Association (AMA) and can also be found in most medical libraries. A CPT coding manual dated 1998 or later reflects the most comprehensive update to the "Psychiatry" section , and would contain the bulk of codes used by psychologists. The codes used for testing/assessment (96100-96117) are actually in a separate section of the CPT manual entitled, "Central Nervous System Assessments/Tests." Members often ask for a list of "just the psychology codes," rather than having to buy the entire CPT manual. The National office of the American Psychological Association (APA) is not authorized to reproduce any of these codes without prior written approval from AMA, and unfortunately at the present time, copyright laws prohibit us from reproducing the entire list. We have managed to reproduce short lists of coding changes that are available on our website at: http://www.apa.org/practice/cpt.html and http://www.apa.org/practice/pointer1295.html. You can also obtain copies of these documents through our Government Relations office by calling (202) 336-5889. Again, purchasing the most current CPT code book is a good investment. There are many codes in the book that members may not be aware of and thus, when only a limited list of codes is available to them, they try to "make the service fit the code." This type of erroneous coding can cause problems down the road if ever faced with an audit. To purchase either a current CPT or ICD-9 manual, contact the AMA at 1-800-621-8335.

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