What is the differecne between 90806 and H0004?

Answer 1

This is an excellent question. As a clinician who contracts in the public sector where this code is used, I have been confused as well.

I stumbled across something online from Oregon that describes CPT's and it helps differentiate these. Clearly, 90806 is:

Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient.

Here are the parameters for H0004:

No upper time limit per day. If more than 15 minutes of service are provided in the same day, bill one line and the number of 15 minute units that comes closest to the total service time - DO NOT use multiple lines, 1 unit each. Treatment plan must specify behavioral health counseling to use this code. Example: Telephone counseling / intervention SMI client requesting counseling or help structuring their day. Clinical note needs to be able to show that counseling occurred versus case management in any code that may be used with a telephone contact. Code and 15 minute increments addresses telephone calls made by prescribers. Do not use to replace 908 codes for planned face-to-face therapy.

The important thing here is that it clearly states H0004 is not intended to replace 90806. This still leaves some unanswered questions. For example, if I see a client for more than the 50 minute 90806 hour, can I bill both 90806 AND H004 (for the extra 15 minutes I spent)?

I have seen individuals use H0004 (4 15 minute units) because it reimburses higher than 90806 but my read on the specific definition of the service is that this is not OK.