COBGC flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

CPT 90853

Group psychotherapy (other than multiple-family group) code, billed once per patient per group session, typically 45-50 minutes, requiring a trained therapist and 2+ unrelated patients.

CPT 90849

Multiple-family group psychotherapy code, billed per patient per session, requiring the presence of multiple families and a therapist leading the group.

CPT 90857

Interactive group psychotherapy code for patients using interactive techniques, often in partial hospitalization or intensive outpatient programs, with specific documentation requirements.

HBAI group codes

Health and Behavior Assessment/Intervention group codes (96153-96155) used for health and behavior services in groups, not psychotherapy, requiring different training and documentation.

Group psychotherapy minimum time

Group psychotherapy sessions must meet a minimum time threshold, typically 45 minutes for 90853, to be billed; shorter sessions may require modifier 52 and documentation.

Medical necessity group therapy

Requires a DSM-5/ICD-10-CM diagnosis, functional impairment, and an individualized treatment plan specifying group therapy as appropriate, with documented progress toward goals.

Treatment plan elements

Must be individualized, include measurable goals, objectives, timeframes, and be signed and dated by the treating provider; reviewed and revised as needed.

Progress note content

Must describe the patient's response to group intervention, progress toward goals, changes in treatment plan, and include date, start/stop times, group type, and therapist credentials.

Group size documentation

Group composition and size should be documented; psychotherapy groups typically have 2-12 patients, ensuring each receives individualized attention.

Record retention

Medicare requires 7 years; many states require 7-10 years; retention must comply with state and federal laws and payer contracts.

ICD-10-CM Chapter 5

Contains mental disorders codes F01-F99; primary diagnosis for group psychotherapy must be the most specific code describing the patient's mental health condition.

Primary diagnosis selection

Sequence the most specific mental health diagnosis first (e.g., F33.1), followed by secondary diagnoses that affect treatment; avoid coding symptoms when a definitive diagnosis exists.

Z codes in behavioral health

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

Laterality and episode

ICD-10-CM requires specifying episode of care for recurrent disorders (e.g., F33.1 for recurrent major depressive disorder, moderate) and laterality where applicable.

Modifier 95

Used for synchronous telemedicine group psychotherapy; place of service 02 (telehealth) or 10 (patient's home) may apply depending on payer rules.

Modifier 25

Used when a significant, separately identifiable E/M service is provided on the same day as group psychotherapy; must be documented separately.

Place of service 52

Psychiatric partial hospitalization facility; group psychotherapy in PHP is billed with POS 52 and revenue code 0914 on UB-04, not CMS-1500.

CMS-1500 Box 24D

Used for CPT/HCPCS codes and modifiers; Box 24E for diagnosis pointer; Box 21 for ICD-10-CM codes; Box 24J for rendering provider NPI.

Modifier 52

Reduced services modifier; may be used if a group session is significantly shorter than typical time, but documentation must support the reduced service.

Modifier 76

Repeat procedure by same physician; not appropriate for group therapy because each session is distinct and not a repeat of a prior procedure.

Audit targets group therapy

Verify medical necessity, start/stop times, group size, treatment plan, and that units billed match sessions; ensure rendering provider NPI is correct.

LCD L33617

Medicare Local Coverage Determination for psychiatric services, specifying coverage criteria for group psychotherapy, including documentation and medical necessity requirements.

Prior authorization

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

False Claims Act

Imposes liability for knowingly submitting false claims; accurate documentation and coding are essential to avoid penalties for group therapy billing.

Rendering provider NPI

Group therapy must be billed under the NPI of the therapist who rendered the service; billing under a supervisor's NPI when not present is fraudulent.

Payer-specific modifier rules

Some payers require specific modifiers (e.g., 95 for telehealth) or place of service matching the location; verify payer policies before billing group therapy.

Audit sampling

Random sample of claims reviewed for documentation sufficiency, code accuracy, and medical necessity; errors corrected and overpayments refunded.

Compliance plan elements

Include training on group therapy coding, regular audits, and a process for reporting and correcting billing errors to ensure adherence to payer rules.

42 CFR §410.155

Defines outpatient mental health services, including group therapy, and specifies conditions for coverage under Medicare Part B.

Group psychotherapy per session

CPT 90853 is reported per group session, not per patient; each participant's claim includes the same code, but only one unit per patient per session.

State licensure scope

Determines which providers may furnish and bill for group psychotherapy, e.g., clinical social workers, psychologists, psychiatric nurses, and psychiatrists.

MPFS group psychotherapy

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