Billing E/M or therapy codes with ECT?

[Hash Slinging Slasher]

Hey everyone, I'm a PGY-4 on an ECT rotation and had a question about billing.

Bit of a preamble first: Our service starts at 7am with pre-evaluations including interval H&P, medication reconciliation, assessment of side effects from ECT, and evaluation for adjustment of dose or electrode placement. 6-10 patients per morning until about 11am-12pm depending on anesthesia. We then perform the procedures and end up having to write both (1) an Interval HPI note (indicating history assessments, medication reconciliation/evaluation of conflicting meds, psychoeducation, supportive psychotherapy, etc) AND (2) a procedure note indicating the ECT machine settings, electrode placement, dosage, and anesthetics etc. We finally placed a billing code of 90870 for the ECT.

Question is: given that there's both a procedure as well as HPI / evaluation, is it permissible to bill E/M or therapy codes (e.g. 99213, 90833) along with the 90870 ECT code? My attendings weren't sure if we could or not but said that it was a reasonable question to at least ask, so here I am. Any direction or guidance would be greatly appreciated!

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[Sushirolls]

ISEN-ECT society has an email list serv.
One of your attendings at minimum needs to be a member of the society and could drop a query there to get such answers.

The answer is no.

For instance, inpatients where a 99232? would be billed on the floor/unit, can't also be billed for 90870 on the same day. So what I did in the past for patients where I overlapped with a different attending, I would do the 90870, and the day's progress note for the patient. Essentially unbilled time.

It's a fine act for providing all the extra services beyond the procedure and not detracting for what the procedure morning is meant to be - a procedure morning. This can be accomplished by having patients come once a week on a non-treatment day, to have an appointment, and the bill routine E&M.

Or have a stellar ECT RN, who can provide much of the extra bits and conversations. But in some ways, it is quite the experience for many patients, and "customer service" and simply spending the time with patients does help to make the experience a much more therapeutic aligned procedure and not just a mill.

 

[joshmir]

Anesthesiologist here that does some psych stuff (ketamine infusions, stellates, anesthesia for ECT)

I interact frequently with patients who are about to have antero/retrograde amnesia, because of stress, or meds, etc


Forgive my ignorance if this is a strange question(s)

1) do you have confidence a patient will remember any pre-ECT counseling , motivation, encouragement, etc?

2) what is your basis for your confidence in opinion?

 

[ObsequiousAplomb]

Anesthesiologist here that does some psych stuff (ketamine infusions, stellates, anesthesia for ECT)

I interact frequently with patients who are about to have antero/retrograde amnesia, because of stress, or meds, etc


Forgive my ignorance if this is a strange question(s)

1) do you have confidence a patient will remember any pre-ECT counseling , motivation, encouragement, etc?

2) what is your basis for your confidence in opinion?

I was planning on asking a similar question, because I don't really see the benefit for a therapy add-on the day of (or even really the one before or the one after as well) someone getting anesthesia / ECT.

Obviously you would know this better than any of us, since you're constantly interacting with people who aren't expected to remember things. I do remember the anesthesiologists I have spoken to before the procedures that I have had, but little else. Usually the pre-anesthesia counseling conversation is the last thing I clearly recall before going in for surgery.

I certainly wouldn't be doing any counseling the morning of ECT other than calming someone down and helping them relax before the anesthesiologist comes in.

I could see some of these codes being useful for the parts of the medical services related to care that day. I mean, if they're on a unit they're still going to be going to group therapy that afternoon, since it's all there is to do the rest of the day. The family may need extensive talking to, and there may be extensive coordination of care efforts.

 

[Stagg737]

1) do you have confidence a patient will remember any pre-ECT counseling , motivation, encouragement, etc?

2) what is your basis for your confidence in opinion?

1) Minimal.
2) Most of my ECT patients recognize me and can recall that we talked but don't have a clue about specifics we discussed. They may remember a general tone (you seemed calm/nice) but sometimes they don't even recognize me.