COBGC cheat sheet

Group psychotherapy (CPT 90853) requires a trained therapist leading a group of 2 or more unrelated patients; the session must be documented with start/stop times and total minutes.

Outpatient behavioral health group services are covered under Medicare Part B when medically necessary and furnished by a qualified provider; the service must be prescribed and documented in the treatment plan.

The Code of Federal Regulations (42 CFR §410.155) defines outpatient mental health services, including group therapy, and specifies the conditions for coverage.

CPT 90853 is reported per group session, not per patient; the same code is billed for each participant, but only one unit per patient per session.

Group counseling (e.g., 90849, 90853) must be distinguished from group health and behavior assessment/intervention (HBAI) codes (96150-96155) and from educational or support groups that are non-billable.

Medicare requires that group psychotherapy be provided under an individualized treatment plan that includes measurable goals and objectives, and the plan must be reviewed and revised as needed.

The 2023 Medicare Physician Fee Schedule (MPFS) established separate payment for group psychotherapy (90853) and group counseling (90849) with specific relative value units (RVUs).

State licensure and scope-of-practice laws determine which providers may furnish and bill for group psychotherapy; e.g., clinical social workers, psychologists, psychiatric nurses, and psychiatrists.

CPT 90853: Group psychotherapy (other than of a multiple-family group) – reported once per group session per patient, typically 45-50 minutes.

CPT 90849: Multiple-family group psychotherapy – billed per patient per session; requires multiple families present and a therapist leading the group.

CPT 90857: Interactive group psychotherapy – for patients who use interactive techniques, often in partial hospitalization or intensive outpatient programs; requires specific documentation.

Group counseling codes (e.g., 90832-90834 for individual, 90846-90847 for family) are not used for group; group counseling is typically reported with 90853 or 90849 when the focus is psychotherapy.

HBAI group codes (96153-96155) are used for health and behavior assessment/intervention in groups, not for psychotherapy; they require a different training and documentation.

Add-on code 90863 (pharmacologic management with psychotherapy) is not used with group psychotherapy; it is for individual sessions.

Time-based codes: group psychotherapy codes are not time-based for billing; they are per session. However, the session must meet the minimum time threshold (e.g., 45 minutes for 90853).

When a group session is shorter than the typical time, the code may still be billed if the therapeutic content is complete; documentation must support the medical necessity and the session's duration.

Documentation must include: date, start and stop times, group type, therapist name and credentials, participants (or group size), and the therapeutic interventions provided.

Medical necessity for group psychotherapy requires a DSM-5 or ICD-10-CM diagnosis, functional impairment, and a treatment plan that specifies group therapy as an appropriate modality.

Progress notes must describe the patient's response to the group intervention, progress toward goals, and any changes in the treatment plan.

The treatment plan must be individualized and include measurable goals, objectives, and timeframes; it must be signed and dated by the treating provider.

Group size and composition should be documented; for psychotherapy groups, typically 2-12 patients, but the therapist must ensure each patient receives individualized attention.

Documentation must support the medical necessity of group therapy over individual therapy, e.g., interpersonal learning, social support, or cost-effectiveness.

For Medicare, the certifying physician must document the need for group therapy and review the plan of care every 60 days (for partial hospitalization) or as required by the payer.

Records must be retained according to state and federal laws (e.g., Medicare requires 7 years; many states require 7-10 years).

ICD-10-CM codes for mental disorders are found in Chapter 5 (F01-F99); the primary diagnosis must be the most specific code describing the patient's condition.

For group psychotherapy, the primary diagnosis should be the mental health disorder being treated; codes such as F41.1 (generalized anxiety disorder) or F33.1 (major depressive disorder, recurrent, moderate) are common.

Use additional codes to identify alcohol or drug use (F10-F19), intellectual disabilities (F70-F79), and other factors that may affect treatment.

Do not code symptoms (e.g., R45.1 restlessness) when a definitive diagnosis exists; code the highest level of specificity.

For Medicare, the diagnosis must be on the covered list for mental health services; some diagnoses (e.g., V codes or Z codes) may be used as secondary but not primary.

When a patient has multiple diagnoses, sequence the primary diagnosis first, followed by secondary diagnoses that affect the treatment and management.

ICD-10-CM requires laterality and episode of care for some disorders; e.g., F33.1 for recurrent major depressive disorder requires specifying the episode (mild, moderate, severe).

Z codes (e.g., Z60.2 living alone) may be used to document social factors, but they are not sufficient as a primary diagnosis for group psychotherapy.

Modifier 95 (synchronous telemedicine) is used for group psychotherapy provided via telehealth; place of service (POS) 02 (telehealth) or 10 (patient's home) may be used depending on payer rules.

Modifier 59 or XE/XS/XU is not typically used for group therapy; however, modifier 25 may be used if a significant, separately identifiable E/M service is provided on the same day.

Place of service codes: 11 (office), 12 (home), 22 (outpatient hospital), 49 (independent clinic), 50 (federally qualified health center), 51 (inpatient psychiatric facility), 52 (psychiatric partial hospitalization), 53 (community mental health center).

CMS-1500 claim form: Box 24D for CPT/HCPCS and modifiers; Box 24E for diagnosis pointer; Box 21 for ICD-10-CM diagnosis codes; Box 32 for facility location if different from billing.

Group therapy is billed per patient, so each patient's claim must include the appropriate diagnosis and the same procedure code; the rendering provider NPI goes in Box 24J.

For Medicare, group psychotherapy in a partial hospitalization program (PHP) is billed with POS 52 and revenue code 0914 (psychiatric partial hospitalization) on the UB-04, not CMS-1500.

Modifier 52 (reduced services) may be used if the group session is significantly shorter than the typical time, but documentation must support the reduced service.

Modifier 76 (repeat procedure by same physician) is not appropriate for group therapy because each session is distinct and not a repeat of a prior procedure.

Audit targets: verify medical necessity, documentation of start/stop times, group size, treatment plan, and that the number of units billed matches the number of sessions.

Medicare's Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) specify coverage criteria for group psychotherapy; e.g., LCD L33617 for psychiatric services.

Commercial payers may require prior authorization for group psychotherapy; verify eligibility and benefits before billing.

The False Claims Act imposes liability for knowingly submitting false claims; accurate documentation and coding are essential to avoid penalties.

Group therapy sessions must be billed under the rendering provider's NPI; billing under a supervisor's NPI when not present is fraudulent.

Payer-specific rules: some payers require the group therapy code to be billed with a specific modifier (e.g., 95 for telehealth) or with a place of service that matches the location.

Audit sampling: a random sample of claims should be reviewed for documentation sufficiency, code accuracy, and medical necessity; errors should be corrected and refunded if overpayment.

Compliance plans should include training on group therapy coding, regular audits, and a process for reporting and correcting billing errors.