Revised NYSPA Documentation Template

OPTUM Issues Provider Alert Addressing Documentation of Psychotherapy Combination Codes

United Behavioral Health (Optum) has issued a Provider Alert addressing documentation of the new psychotherapy combination codes (E/M plus Psychotherapy Add-on Code). You can read the Provider Alert by clicking here.

The Provider Alert reflects extensive feedback and suggestions from both the APA and NYSPA. The NYSPA template for psychotherapy combination codes, currently available in the CPT coding section of the NYSPA website (www.nyspsych.org), includes all the clinical information required in the Optum Provider Alert. The only change is the addition of the requirement to document time spent providing psychotherapy. We have learned now that when CPT first developed the new combination codes, it was CPT’s intention that the time spent providing psychotherapy alone be documented. Therefore, we have modified our combination code template on the NYSPA website to replace “Start and Stop Time” with “Approximate Psychotherapy Time”. For 90833, the minimum psychotherapy time is 16 minutes and for 90836, the minimum psychotherapy time is 38 minutes.

We have elected to retain documentation of total face-to-face time (although not mandatory) to establish that there was sufficient total time to provide both an E/M service and a psychotherapy add-on service.

Optum has advised NYSPA that this new requirement will be enforced prospectively only. We also anticipate that Medicare will issue a similar advisory requiring documentation of psychotherapy time as well. NYSPA will be scheduling a webinar on the new documentation template shortly.

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