CPT® Code 90828

Deleted

1. Indications

Individual psychotherapy using CPT® Code 90828 is indicated for patients who require therapeutic intervention in a structured setting, particularly those who may struggle with verbal communication. The following conditions or situations may warrant the use of this code:

• Children with Communication Difficulties Patients, especially young children, who may not have developed the ability to express their thoughts and feelings verbally can benefit from this interactive approach.
• Non-Verbal Patients Individuals who are unable to communicate effectively through spoken or written language due to various reasons, including developmental disorders or trauma, may require alternative communication methods.
• Inpatient or Residential Care Needs Patients who are in need of intensive therapeutic support within an inpatient hospital, partial hospital, or residential care setting are appropriate candidates for this type of psychotherapy.

2. Procedure

The procedure for individual psychotherapy under CPT® Code 90828 involves several key steps that ensure effective engagement and therapeutic interaction with the patient. Each step is designed to facilitate communication and address the patient's psychological needs.

• Step 1: Initial Assessment The therapist begins with an initial assessment to understand the patient's background, communication abilities, and specific needs. This assessment helps in tailoring the therapeutic approach to the individual.
• Step 2: Setting Up the Environment The therapy session is conducted in a safe and supportive environment, equipped with play equipment and physical devices that encourage non-verbal interaction. This setting is crucial for fostering comfort and openness in the patient.
• Step 3: Engaging the Patient The therapist utilizes various interactive tools, such as toys and other mechanisms of non-verbal communication, to engage the patient. This engagement is essential for building rapport and facilitating expression.
• Step 4: Therapeutic Interaction Throughout the approximately 75 to 80-minute session, the therapist maintains a face-to-face interaction with the patient, guiding them through therapeutic activities that promote emotional expression and psychological healing.
• Step 5: Conclusion and Follow-Up At the end of the session, the therapist summarizes the key points discussed and may outline follow-up steps or additional sessions as needed, ensuring continuity of care.

3. Post-Procedure

After the completion of the psychotherapy session coded under CPT® 90828, it is important to consider the patient's immediate post-procedure care. Patients may require time to process the therapeutic experience, and the therapist should provide a supportive environment for this reflection. Follow-up sessions may be scheduled to continue addressing the patient's needs, and caregivers or family members may be involved in discussions to reinforce the therapeutic goals. Additionally, documentation of the session's content and the patient's response is essential for ongoing treatment planning and compliance with healthcare regulations.