2022 guidelines for reporting interactive complexity

During a psychotherapy session, specific communication factors may arise that make it difficult to deliver a service or administer treatment to a patient. This type of scenario is known as interactive complexity, and there are specific CPT codes that psychologists should use when billing for these sessions.

Interactive complexity is typically present with patients who have third parties—such as parents, guardians, other family members, agencies, court officers, or schools—involved in their care. Difficult communication with discordant or emotional family members and trying to engage with young and verbally undeveloped or impaired patients are examples of the factors that can complicate service delivery.

When this happens, you may use CPT^® code 90785, the designated add-on code to report interactive complexity, in conjunction with the appropriate psychotherapy service, to report to insurers about the services you’ve provided. You can pair the add-on code with diagnostic evaluation (90791, 90792) or psychotherapy treatment session (90832, 90833, 90834, 90836, 90837, 90838, 90853).

The guidelines for properly reporting interactive complexity have been revised and the new rules became effective on January 1, 2022. Read on for guidance on how to report interactive complexity and some clinical examples of when it applies.

Unlike the add-on codes included in Health Behavior Assessment and Intervention and Psychological or Neuropsychological Testing code sets, interactive complexity is not intended to be used to report increased time to complete the service.

According to CPT guidelines, psychologists can report interactive complexity in conjunction with diagnostic evaluation (CPT code 90791), individual psychotherapy (CPT codes 90832, 90834, 90837) or group psychotherapy (90853) services, if at least one of the following complicating factors are  present and documented in the patient record:

1. The need to manage maladaptive communication (e.g., related to high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.

• Example: The patient is uncooperative and disagrees with the treatment plan as outlined such that the planned therapeutic work cannot continue.

2. Caregiver emotions or behaviors that interfere with the caregiver’s understanding and ability to assist in the implementation of the treatment plan.

• Pediatric patient example: Patient and mother attend the session together. The mother is highly agitated and disagrees with portions of the proposed treatment plan.

3. Evidence or disclosure of a sentinel event and mandated reporting to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with a patient and other visit participants.

• Example: Disclosure of child or elder abuse by the patient or patient’s caregiver.

4. Use of play equipment or other physical devices to communicate with the patient to overcome barriers to therapeutic or diagnostic interaction between the physician or other qualified health care professional; and a patient who has not developed, or has lost, either the expressive language communication skills to explain his or her symptoms and respond to treatment; or a patient who lacks the receptive communication skills to understand the physician or other qualified health care professional if he/she were to use typical language for communication.

• Adult patient example: A patient with ALS loses the capacity for expressive communication and requires assistive technological support devices to continue treatment.

When billing for interactive complexity, keep these points in mind:

• Add-on codes must always be reported in conjunction with an appropriate primary service—it can never be reported as a stand-alone service.
• Practitioners should not assume that they can bill 90785 for each session they have with a “difficult” patient.
• At least one complicating factor identified in the CPT^® Manual must be present for providers to bill the interactive complexity code as an add-on to the primary procedure.
• The amount of time spent providing interactive complexity services should be reflected in the timed service code for psychotherapy.
• Interactive complexity cannot be used in conjunction with: 

• Family psychotherapy codes (90846 and 90847)
• Psychotherapy for crisis codes (90839 and 90840)
• Psychological and Neuropsychological Testing codes (96130, 96131, 96132, 96133, 96134, 96136, 96137, 96138, 96139, 96146)
• Adaptive behavior codes (97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T)

• Do not report 90785 for the purpose of translation or interpretation services.
• 90785 can be reported in conjunction with 90853 for a specified patient when group psychotherapy includes interactive complexity. It should not be reported for every patient participating in the group service.
• Interactive complexity is not applicable to an evaluation and management (E/M) service alone, even when performing an E/M with a psychotherapy service.

Effective for calendar year 2022, revisions to the guidelines for proper reporting for interactive complexity have been implemented. These changes stemmed from the American Medical Association Relative Value Update Committee (RUC) process, and specifically through the Relativity Assessment Workgroup (RAW) which works very closely with the RUC and Centers for Medicaid and Medicare Services (CMS) to ensure that codes are being used properly or reported accurately.

The RAW identified CPT code 90785 as having significantly increased utilization, and there was some concern that the code was being used improperly by reporting it for E/M alone and not when performed with a psychotherapy service or when a psychiatric service was performed in conjunction with E/M.

To correct this, guidance language in the 2022 CPT Manual was revised to explain the intended use for add-on code 90785—that it may be reported for interactive complexity of psychotherapy services whether or not that service is accompanied by an E/M.

The most significant change made was the deletion of the terms “interpreters” or “language translators.” To align with federal and CMS statutory language, CPT guidance no longer lists interpreters or language translators in the very specific situations in which interactive complexity can properly be reported. This, in addition to other minor wording changes, now makes it very clear that there must be “increased complexity of the service due to specific communication factors which can result in barriers to diagnostic or therapeutic interaction with the patient” and specifies that interactive complexity must be reported in conjunction with an appropriate psychiatric diagnostic evaluation.

Clinical example #1

Psychotherapy for an older elementary school-aged child accompanied by divorced parents, reporting declining grades, temper outbursts, and bedtime difficulties. Parents are extremely anxious and repeatedly ask questions about the treatment process. Each parent continually challenges the other’s observations of the patient.

• Report CPT code 90834 with 90785.

Clinical example #2

It is important to recognize situations that require the reporting of interactive complexity in conjunction with diagnostic evaluation or one of the appropriate individual psychotherapy vs. psychotherapy for crisis (90839 and 90840).

A widow who suffers from chronic mild to moderate depression and anxiety is being seen for psychotherapy. She struggles with her increasing physical limitations and has recently been moved into an assisted-living facility. The patient has been receiving psychotherapy for depression

• Scenario A: During the course of the current visit, the daughter of the patient discloses that her mother has recently been the victim of elder abuse by a neighbor. The psychologist’s obligations under state statutes to report this as elder abuse are explained to the patient, and the report process is initiated.
  
  Report 90837 with 90785.
• Scenario B: During the course of the current visit, the patient discloses information that clearly indicates she is now severely depressed and distraught. The patient expresses suicidal ideation with an imminent plan. The psychologist conducts a risk assessment and then takes steps to hospitalize the patient.
  
  Report CPT codes 90839/90840 Psychotherapy for crisis
  
  Report 90839 for the first 60 minutes
  
  Report add-on code 90840 for each additional 30 minutes it takes to complete the service

Both the primary service code and add-on code should be listed on the billing form. This illustration shows how to bill for the add-on interactive complexity code 90785 in connection with the code for a 45-minute psychotherapy session using the CMS 1500 form.