CPT® Code 90824

Deleted

1. Indications

The indications for utilizing CPT® Code 90824 include scenarios where individual psychotherapy is necessary for patients who may have difficulty expressing themselves verbally. This is particularly relevant for:

• Small Children Patients who are young and may not have developed the verbal skills necessary for traditional psychotherapy.
• Non-Verbal Communication Needs Individuals who are unable to communicate effectively through spoken or written language due to various conditions.
• Inpatient Care Requirements Situations where patients require therapeutic intervention while being treated in an inpatient hospital, partial hospital, or residential care setting.

2. Procedure

The procedure for CPT® Code 90824 involves several key steps that ensure effective engagement with the patient. Each step is designed to facilitate communication and therapeutic interaction.

• Step 1: Preparation Prior to the session, the therapist prepares the environment by gathering appropriate play equipment and physical devices that can aid in non-verbal communication. This preparation is crucial for creating a comfortable and engaging atmosphere for the patient.
• Step 2: Initial Interaction The therapist initiates the session by establishing rapport with the patient. This may involve using toys or other interactive tools to encourage the patient to express themselves in a non-verbal manner, allowing the therapist to gauge the patient's emotional state and needs.
• Step 3: Therapeutic Engagement During the 20 to 30-minute session, the therapist actively engages with the patient using the selected play equipment and devices. The focus is on facilitating communication through play, which can help the patient express feelings and thoughts that may be difficult to articulate verbally.
• Step 4: Medical Evaluation and Management If applicable, the therapist incorporates medical evaluation and management services into the session. This may involve assessing the patient's overall mental health status and addressing any medical concerns that arise during the interaction.
• Step 5: Conclusion and Documentation At the end of the session, the therapist concludes the interaction, ensuring that the patient feels secure and understood. Documentation of the session is completed, noting the techniques used, the patient's responses, and any medical evaluations conducted.

3. Post-Procedure

Post-procedure care following the use of CPT® Code 90824 involves monitoring the patient's emotional and psychological state after the session. It is essential to provide a supportive environment where the patient can process their experiences. Additionally, follow-up sessions may be scheduled to continue therapeutic engagement and address any ongoing needs. Documentation of the session outcomes and any recommendations for further treatment or evaluation should be maintained to ensure continuity of care.