When to bill for Interactive Complexity CPT add-on code 90785
Recently, Magellan’s Special Investigations Unit (SIU) and Payment Integrity Unit (PIU) have reported several cases that involved upcoding related to the excessive and improper use of the Interactive Complexity CPT add-on code 90785.
This is a reminder that you should provide and bill only for services to members that are medically necessary and consistent with applicable requirements, regulations, policies, procedures and record-keeping standards required by law and supported by Magellan standards.
The add-on code 90785 refers to communication difficulties during a client’s provider visit. It is meant to reflect increased intensity of service, not increased time, and should only be used in conjunction with primary service codes.
Interactive complexity is often present with clients who:
- Have other individuals legally responsible for their care.
- Request others to be involved in their care during the visit, such as an interpreter or family member.
- Require the involvement of other third parties such as child welfare agencies or parole officers.
Per CPT guidelines, one or more of the following criteria must be present:
- The need to manage maladaptive communication.
- Caregiver emotions or behaviors that interfere with treatment.
- Evidence or disclosure of a client’s sentinel event and required reporting to a third party (e.g., reporting abuse or neglect to a state agency).
- Use of play equipment, physical devices, interpreters, or translators to communicate with a client who has a language barrier.
Your documentation should clearly indicate the type of interactive methods used such as interpreter, use of play, or physical device, and that the client did not have the ability to communicate through normal verbal means.
Lack of provider compliance with documentation standards may result in:
- An audit/investigation initiated by Magellan SIU or review by the Magellan PIU.
- Retraction of payment for services not supported in the documentation (i.e., overpayment). Any overpayment identified will be referred to Magellan's Cost Containment department for recovery by refund check or future claims retractions.
- Magellan completing required reporting to a customer oversight agency.
- Placement of a subset of, or all of, a provider’s claims on a pre-payment review.
- Termination from the Magellan network.
- Review Magellan's policy on examples of fraud, waste, and abuse and HIPAA standard code sets in Section 4 of Magellan's National Provider Network Handbook (PDF).
- If you have additional questions regarding our audit/investigation processes, contact the SIU via email at SIU@MagellanHealth.com or via our hotline 1-800-755-0850 (you can remain anonymous).