Billing and coding questions!

[mathrap22]

I'm an attending in an 18 bed inpatient adult psychiatric unit in the midwest. I had some questions about billing and appreciate anyone's input:

1) Do you think it's reasonable to add on 90833 therapy code to most every 99233 and 99232 follow ups in the inpatient unit? Most of my patients seem to benefit from therapy, and our length of stay is short (2-4 days) I think in part because of engaging in good therapy and med management, in addition to a strong milieu and group system, so I've been using the add on 90833 code for most patients. I also bill 99233 and document appropriately, as if they are improving and at a 99232 level and want to discharge, I'll probably lean towards discharge. Most of our patients are depression as well and amenable to therapy, so not a lot of psychosis, mania, etc. on my unit. I'm not performing psychotherapy and billing 90833 on the rare catatonic, totally psychotic, or manic and aggressive patients that we get haha. I will do therapy on patients who are refusing care though to try and improve reality testing, improve therapeutic rapport, and improve compliance with treatment plan if they are amenable to at least talking with me to discuss risks/benefits/alternatives/etc. though.

TLDR: is billing an add on 90833 every day and mostly 99233 appropriate for short length of stays in a psychiatric hospital as long as severe/life threatening symptoms are noted and active med management is occuring? If they get to a 99232 type level, I mostly am thinking "if they want to leave, then why keep them in the hospital at all? Do they need to be in a 24 hour monitored lockdown psychiatric unit with only moderate symptoms and level of risk if they otherwise want to leave?"


2) For discharges, it seems like all discharges take at LEAST 30 minutes to prepare, so I find myself using 99239 only for discharges and not 99238. I'll often also engage the patient in therapy the day of discharge as well to review all of the lessons learned and establish good safety plans for when they leave, so usually add on 90833 to 99239 as well. Does that sound reasonable?

TLDR: do you mostly bill 99239 and NOT 99238 for discharges, and do you think it's reasonable to add on 90833 to discharge day note if documented and performed appropriately as separate services?


3) Is it reasonable to bill one 90846 or 90847 during the patient's stay on a day a 99233 and 90833 is also billed, if they are performed and documented appropriately as separate services? I try and engage family as much as possible as it leads to better outcomes and facilitates safety plans, which leads to faster clinical improvements and decreased hospital length stays!

TLDR: if you spent 26+ minutes with a patient's family member with or without the patient once during the patient's stay, and if this was performed and documented separately from the 99233 and 90833 for that day, would it be unreasonable to add on 90846/90847 to the 99233 and 90833 for that day?


I want to be earning as many RVUs as I deserve for the significant work I'm doing with the patients and long hours at work, but of course don't want to be breaking any rules accidentally or anything. I work 7 on 7 off, so I work really hard on my weeks on and do the best I can to provide the best care I can for my patients, and then relax on my week off. I try and do everything I can for the patient to get them better as soon as possible if they are amenable, including med management, psychotherapy and family therapy, so they can get out of the hospital quickly and back to their lives functioning at a high level. Thank you for sharing your thoughts and wisdom!

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[Stagg737]

is billing an add on 90833 every day and mostly 99233 appropriate for short length of stays in a psychiatric hospital as long as severe/life threatening symptoms are noted and active med management is occuring?

If you are legitimately doing at least 16 minutes of therapy, patients are meeting 99233 criteria, and you are documenting appropriately, then of course. Though I can see you getting significant pushback about this. Side question, if you're legit seeing 18 patients per day and doing billable therapy with almost all of them, how long are your days? What you're talking about is an extra 4+ hours of face to face time with patients per day.

TLDR: do you mostly bill 99239 and NOT 99238 for discharges, and do you think it's reasonable to add on 90833 to discharge day note if documented and performed appropriately as separate services?

You cannot use psychotherapy add-ons (like 90833) when you're billing your E/M based on time. Maybe you could get away with it for a 99238 (I've never tried it), but pretty sure billing 99239 + 90833 is a big no-no. Others can correct me if I'm wrong there and I'd be interested to know if you can add-on therapy codes to a 99238.

3) Is it reasonable to bill one 90846 or 90847 during the patient's stay on a day a 99233 and 90833 is also billed, if they are performed and documented appropriately as separate services? I try and engage family as much as possible as it leads to better outcomes and facilitates safety plans, which leads to faster clinical improvements and decreased hospital length stays!

TLDR: if you spent 26+ minutes with a patient's family member with or without the patient once during the patient's stay, and if this was performed and documented separately from the 99233 and 90833 for that day, would it be unreasonable to add on 90846/90847 to the 99233 and 90833 for that day?

As far as I know you can't add that on a 90847 to a 90833/826/838. It's either the family code or the individual code. Maybe you could do the individual therapy code plus the 90846, but I honestly don't know. How would that even get billed? The patient gets billed for therapy you're providing to the family? Weird. Would be interested if anyone else actually knows how that works.

Again though, Idk how you can be doing that much individual PLUS taking 50+ minutes to do family therapy at all. How long are your days??

 

[calvnandhobbs68]

3) Is it reasonable to bill one 90846 or 90847 during the patient's stay on a day a 99233 and 90833 is also billed, if they are performed and documented appropriately as separate services? I try and engage family as much as possible as it leads to better outcomes and facilitates safety plans, which leads to faster clinical improvements and decreased hospital length stays!

TLDR: if you spent 26+ minutes with a patient's family member with or without the patient once during the patient's stay, and if this was performed and documented separately from the 99233 and 90833 for that day, would it be unreasonable to add on 90846/90847 to the 99233 and 90833 for that day?

I don't see insurance reimbursing 2 psychotherapy codes of any type from the same physician/therapist on the same day. If you think about it, that's like a therapist trying to bill for an individual therapy session and a family therapy session on the same day...won't get paid. Also, i guess you could pretend you're doing "family therapy" but how much family therapy are you really doing or is this coordinating care and answering questions? That'd be like the hospitalists saying they're doing "family therapy" for all the families they have to talk to about their patients.

And I agree with the idea that if you're billing 90833s on almost every single patient, that means you should be spending 9 hours of face to face time just with the patients. Outpatient regular 90833s on visits that are <25-30min long on a regular basis start getting looked at or you're somehow claiming that you're doing a "moderate" amount of MDM routinely in 4 minutes for every patient every day.

 

[annoyedpsychiatrist]

i agree that is questionable if youre billing 90833 on every patient. Im outpatient and see a lot of depression/anxiety and im not billing 90833 on everyone, probably more like 30-40%. I mean for completely stable patients they dont need 16 minutes of CBT. Also yea if youre seeing 18 patients and spending 30 minutes on all of them then just on patient care alone youd be at 9 hours, not even with charting, orders, treatment team meetings, etc. Doesnt seem practical

 

[clausewitz2]

i agree that is questionable if youre billing 90833 on every patient. Im outpatient and see a lot of depression/anxiety and im not billing 90833 on everyone, probably more like 30-40%. I mean for completely stable patients they dont need 16 minutes of CBT. Also yea if youre seeing 18 patients and spending 30 minutes on all of them then just on patient care alone youd be at 9 hours, not even with charting, orders, treatment team meetings, etc. Doesnt seem practical

I mean, I bill 90833 on almost every patient as an outpatient doc, but I don't schedule anybody for less than 30 minutes. I also wonder how ridiculously long your workdays would be if you are doing this in a way that won't raise eyebrows.

 

[mathrap22]

If you are legitimately doing at least 16 minutes of therapy, patients are meeting 99233 criteria, and you are documenting appropriately, then of course. Though I can see you getting significant pushback about this. Side question, if you're legit seeing 18 patients per day and doing billable therapy with almost all of them, how long are your days? What you're talking about is an extra 4+ hours of face to face time with patients per day.


You cannot use psychotherapy add-ons (like 90833) when you're billing your E/M based on time. Maybe you could get away with it for a 99238 (I've never tried it), but pretty sure billing 99239 + 90833 is a big no-no. Others can correct me if I'm wrong there and I'd be interested to know if you can add-on therapy codes to a 99238.


As far as I know you can't add that on a 90847 to a 90833/826/838. It's either the family code or the individual code. Maybe you could do the individual therapy code plus the 90846, but I honestly don't know. How would that even get billed? The patient gets billed for therapy you're providing to the family? Weird. Would be interested if anyone else actually knows how that works.

Again though, Idk how you can be doing that much individual PLUS taking 50+ minutes to do family therapy at all. How long are your days??

I usually work 7am to around 8pm, sometimes a bit later. I try and see any admit that comes in the same day and eat meals at the hospital since the food is cheap.

 

[mathrap22]

i agree that is questionable if youre billing 90833 on every patient. Im outpatient and see a lot of depression/anxiety and im not billing 90833 on everyone, probably more like 30-40%. I mean for completely stable patients they dont need 16 minutes of CBT. Also yea if youre seeing 18 patients and spending 30 minutes on all of them then just on patient care alone youd be at 9 hours, not even with charting, orders, treatment team meetings, etc. Doesnt seem practical

That makes sense. Usually with the severity of symptoms that brought the person to the psychiatric hospital however, most patients are not stable and can benefit from therapy. If they start to become more stable, we try and move towards discharge if the patient is amenable. No reason to keep somebody locked up on a crisis stabilization unit if the crisis is past.

 

[calvnandhobbs68]

I usually work 7am to around 8pm, sometimes a bit later. I try and see any admit that comes in the same day and eat meals at the hospital since the food is cheap.

If you're spending 13 hours at the hospital than psychotherapy away....I'd say you're probably working more than 99% of the psychiatrists out there.

You may not want to necessarily become an extreme outlier in terms of billing though if nobody else who covers this unit is working this way but who knows.

 

[mathrap22]

If you're spending 13 hours at the hospital than psychotherapy away....I'd say you're probably working more than 99% of the psychiatrists out there.

You may not want to necessarily become an extreme outlier in terms of billing though if nobody else who covers this unit is working this way but who knows.

That's understandable... maybe I should cut back... I don't want to get into any trouble with insurance companies or anything, but want to do best by the patients and also earn for myself so I can keep paying back loans.

 

[annoyedpsychiatrist]

That's understandable... maybe I should cut back... I don't want to get into any trouble with insurance companies or anything, but want to do best by the patients and also earn for myself so I can keep paying back loans.

also ive seen this happen before for whatever reason, where the insurance company doesnt cover the add on code and the cost gets transferred to the patient. So then the patient says "wtf, why am I being charged for therapy? i didnt do therapy?" after they call their insurance company to see whats going on. Then that leads to them looking at their note and saying that it didnt actually happen. So it also becomes a bit of an ethical issue.

I would say this, if you cant easily justify it if someone were to question you, then perhaps hesitate doing it. Theres been times where ive decided on going a certain route in terms of medication with a patient, where I had my doubts but decided to do it anyways, but i made sure in my note i could think of multiple reasons to justify that route. Whatever you do, you need to make sure that you can always justify doing it, and have logical reasons, whether its your plan, your billing, etc.

 

[calvnandhobbs68]

also ive seen this happen before for whatever reason, where the insurance company doesnt cover the add on code and the cost gets transferred to the patient. So then the patient says "wtf, why am I being charged for therapy? i didnt do therapy?" after they call their insurance company to see whats going on. Then that leads to them looking at their note and saying that it didnt actually happen. So it also becomes a bit of an ethical issue.

Eh I'm sure that could possibly happen but the number of people who also insist they "never even saw a doctor" the entire time they're in the hospital is absolutely higher than 0. Also like the patients who insist they "never did therapy" in the hospital when they were literally in every group every day. All you'd have to say is "yes I did, here's what we talked about it's right in the note" and that's that basically...if this person is spending 13 hours a day on the inpatient unit I suspect he/she is actually spending plenty of time with patients to justify the codes.

Now if the patient is unexpectedly getting charged hundreds of dollars for services you thought the insurance company should cover, then yes it does become an issue of how much you want to hunt that down. Given that this should not occur with any regular frequency (otherwise whats the point of using the codes), would probably just say to write off the cost to the patient and subtract the RVUs.

There's wayyyy more ridiculous hospital billing things to complain about including when I was once charged 100+ dollars for about 5 dollars worth of dexamethasone in the ER or getting charged for each oxygen probe they used. I suppose one could say "they never changed out my oxygen probe" but how are you gonna prove that either way months later?

 

[Merovinge]

That's understandable... maybe I should cut back... I don't want to get into any trouble with insurance companies or anything, but want to do best by the patients and also earn for myself so I can keep paying back loans.

If you need 13 hours a day to do what's best for your patients that's a problem with the job (or possibly a problem with your expectations). I am confident that <1% of inpatient psychiatrists work 13 hours day whereby they are spending 30+ min with each patient. It's one thing if you are making huge money (certainly north of 500k) and want to grind for a few years to pay back loans. It's another if you somehow think this is standard of care and are making a meager salary in the 3's or low 4's for that work.

 

[comp1]

Concur, a great number of inpatients will report never seeing a doctor, even with camera evidence to the contrary. I'd have a pretty high bar for adding on a therapy code, but I'm salaried without production bonuses so none of this matters nearly as much to me as it does for others.

 

[annoyedpsychiatrist]

Eh I'm sure that could possibly happen but the number of people who also insist they "never even saw a doctor" the entire time they're in the hospital is absolutely higher than 0. Also like the patients who insist they "never did therapy" in the hospital when they were literally in every group every day. All you'd have to say is "yes I did, here's what we talked about it's right in the note" and that's that basically...if this person is spending 13 hours a day on the inpatient unit I suspect he/she is actually spending plenty of time with patients to justify the codes.

Now if the patient is unexpectedly getting charged hundreds of dollars for services you thought the insurance company should cover, then yes it does become an issue of how much you want to hunt that down. Given that this should not occur with any regular frequency (otherwise whats the point of using the codes), would probably just say to write off the cost to the patient and subtract the RVUs.

There's wayyyy more ridiculous hospital billing things to complain about including when I was once charged 100+ dollars for about 5 dollars worth of dexamethasone in the ER or getting charged for each oxygen probe they used. I suppose one could say "they never changed out my oxygen probe" but how are you gonna prove that either way months later?

im talking more of the outpatient setting than inpatient setting for this, where patient sees the provider for 5 mins for med refill and provider somehow documents a 20 minute encounter where they did "16 minutes therapy". Patient gets a bill, asks their insurance company, and then says "but we never did therapy". ive seen that happen a good number of times for outpatient setting

for the inpatient side of things, its likely easier to get away with because they are there 24 hours a day, and who knows how much time someone is really spending with them, to where they actually contest it compared to outpatient setting. Though being there 13 hours a day that would drain the life out of me if thats the case. Tbh i hated 12 hour shifts when I was in residency, i cant imagine doing 13 hours a day, every day, indefinitely.

For outpatient setting i think eyebrows would be raised if youre billing for 30 people a day, and somehow doing adjunct therapy with all 30.

 

[calvnandhobbs68]

im talking more of the outpatient setting than inpatient setting for this, where patient sees the provider for 5 mins for med refill and provider somehow documents a 20 minute encounter where they did "16 minutes therapy". Patient gets a bill, asks their insurance company, and then says "but we never did therapy". ive seen that happen a good number of times for outpatient setting

for the inpatient side of things, its likely easier to get away with because they are there 24 hours a day, and who knows how much time someone is really spending with them, to where they actually contest it compared to outpatient setting. Though being there 13 hours a day that would drain the life out of me if thats the case. Tbh i hated 12 hour shifts when I was in residency, i cant imagine doing 13 hours a day, every day, indefinitely.

For outpatient setting i think eyebrows would be raised if youre billing for 30 people a day, and somehow doing adjunct therapy with all 30.

well yes if you're committing blatant insurance fraud sure....

I thought you meant if OP spent 25-30 min with each of his patients but then people were insisting that OP never did "therapy" with them.

 

[clausewitz2]

If you need 13 hours a day to do what's best for your patients that's a problem with the job (or possibly a problem with your expectations). I am confident that <1% of inpatient psychiatrists work 13 hours day whereby they are spending 30+ min with each patient. It's one thing if you are making huge money (certainly north of 500k) and want to grind for a few years to pay back loans. It's another if you somehow think this is standard of care and are making a meager salary in the 3's or low 4's for that work.

Exactly, I hear about an IP psychiatrist working 13 hours per day, and I assume they are grinding and seeing like 40 patients or something ludicrous.