CPT Coding questions

[ratched]

Quick questions for those of you knowledgeable about the E&M codes:

-in the "Medical Decision Making" section, you need to tally points for "Problem Points." What exactly counts as a problem? A symptom or a diagnosis? For example, let's say you are treating a pt with diagnosed PTSD, alcohol abuse, and panic disorder, and let's say that he is asymptomatic in follow-up. Are the "problems" considered to be these 3 diagnoses (which would yield 3 points -- 1 point for each established problem being stable or improved)? Or, are the problems nightmares, flashbacks, alcohol ingestion, hypervigilance, episodes lasting >10 min of SOB, tachycardia, sweating, impending doom (which would yield 4+ points, thus satisfying the highest complexity of Medical Decision Making, assuming either Data Points or Level of Risk is at the highest level)?

-a follow-up question: since essentially all psych d/o's can pose "a threat to life or bodily function" (via increased risk of suicide attempt), do essentially all of our patients meet the highest level of risk? If audited, would that be adequate justification, even if the above pt (as described) were stable during the visit that you are coding/billing for?


Thanks....

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[michaelrack]

Quick questions for those of you knowledgeable about the E&M codes:

-in the "Medical Decision Making" section, you need to tally points for "Problem Points." What exactly counts as a problem? A symptom or a diagnosis? For example, let's say you are treating a pt with diagnosed PTSD, alcohol abuse, and panic disorder, and let's say that he is asymptomatic in follow-up. Are the "problems" considered to be these 3 diagnoses (which would yield 3 points -- 1 point for each established problem being stable or improved)? Or, are the problems nightmares, flashbacks, alcohol ingestion, hypervigilance, episodes lasting >10 min of SOB, tachycardia, sweating, impending doom (which would yield 4+ points, thus satisfying the highest complexity of Medical Decision Making, assuming either Data Points or Level of Risk is at the highest level)?

-a follow-up question: since essentially all psych d/o's can pose "a threat to life or bodily function" (via increased risk of suicide attempt), do essentially all of our patients meet the highest level of risk? If audited, would that be adequate justification, even if the above pt (as described) were stable during the visit that you are coding/billing for?


Thanks....

The answer to your follow up question is NO.

 

[honsano]

Points for problems are just that, for problems not symptoms. I think you still can count them toward problem points if the pt is asymptomatic because you are successfully treating for those problems. A minor problem on the other hand....not sure what to tell you about that but that can only account for 2 points max.

What I want to know is assessing risk. If I have my pt on prescription meds would that be enough to satisfy the moderate risk category?

 

[ratched]

honsano - my understanding is that prescribing a med(s) does satisfy the "moderate" risk on the Table of Risk, but that either Data Points or Problem Points would also need to be at the "moderate" level in order to count Medical Decision-Making as Moderate Complexity.

Anyone else wanna weigh in on what constitutes a "problem" in the Problem Points section? How about if a pt has a history of hypothyroidism..... does documenting that he/she has no current symptoms of hypothyroidism (e.g., no changes in wt, no cold insensitivity, no hair changes) mean that this established problem is stable, thereby earning a point? Does it matter that this is not a psychiatric diagnosis to begin with?

 

[michaelrack]

How about if a pt has a history of hypothyroidism..... does documenting that he/she has no current symptoms of hypothyroidism (e.g., no changes in wt, no cold insensitivity, no hair changes) mean that this established problem is stable, thereby earning a point? Does it matter that this is not a psychiatric diagnosis to begin with?

doesn't matter if is a psychiatric disorder- as long as it is relevant (and a pt's thyroid status is usually relevant to psych illness)

 

[TexasPhysician]

honsano - my understanding is that prescribing a med(s) does satisfy the "moderate" risk on the Table of Risk, but that either Data Points or Problem Points would also need to be at the "moderate" level in order to count Medical Decision-Making as Moderate Complexity.

Anyone else wanna weigh in on what constitutes a "problem" in the Problem Points section? How about if a pt has a history of hypothyroidism..... does documenting that he/she has no current symptoms of hypothyroidism (e.g., no changes in wt, no cold insensitivity, no hair changes) mean that this established problem is stable, thereby earning a point? Does it matter that this is not a psychiatric diagnosis to begin with?

FYI - different states have slightly different coding systems. I use Trailblazer.

My coders basically stated that if we were treating something, it should be a problem. For instance with MDD, I could prescribe an SSRI, but lets say the patient also has trouble sleeping. This insomnia which I need to document may be related to MDD or maybe not. Say I prescribe Ambien for the insomnia. I now have 2 problem points even if I just put MDD as the diagnosis. This is what the coders tell me anyways.

Any diagnosis psych or not that you address works.

 

[psychiatrist20]

I was wondering what other psychiatrists are finding their billing patterns are regarding 99213s vs 99214s. I know it could vary based on the type of practice and difficulty of the patients but am intersted if there are any trends. For this first month I am seeing roughly 75% as 99213s vs 25% for 99214s.

 

[vistaril]

I was wondering what other psychiatrists are finding their billing patterns are regarding 99213s vs 99214s. I know it could vary based on the type of practice and difficulty of the patients but am intersted if there are any trends. For this first month I am seeing roughly 75% as 99213s vs 25% for 99214s.

There are a few practical problems(in real world practices) out there with 'upgrading' the billing code.....

One is except for the ultimate grinding code(the lowest level medmgt code) aren't the others based to some degree on time spent? For example, even if I document a bazillion medical and psych issues to be addressed with the pt, don't I need to spend at least 17-20+ minutes or whatever to get the code above the lowest? A lot of people out there doing serious grind work are seeing 8-9+ pts an hour.....if time mandates are an issue, you aren't going to be able to move that sort of volume and code at higher levels.

More importantly, a lot of patients have deductibles and stuff. If they haven't reached their deductible yet, they are going to wonder why it was 145 dollars instead of 90 dollars this visit...when you didn't spend anymore time with them or do anything different in their eyes. And telling them "well the extra 55 dollars is because I documented that you still take blood pressure meds and your blood sugars have been a bit high lately" really isn't going to go over well or build therapeutic rapport.

 

[michaelrack]

There are a few practical problems(in real world practices) out there with 'upgrading' the billing code.....

One is except for the ultimate grinding code(the lowest level medmgt code) aren't the others based to some degree on time spent? For example, even if I document a bazillion medical and psych issues to be addressed with the pt, don't I need to spend at least 17-20+ minutes or whatever to get the code above the lowest? A lot of people out there doing serious grind work are seeing 8-9+ pts an hour.....if time mandates are an issue, you aren't going to be able to move that sort of volume and code at higher levels.

More importantly, a lot of patients have deductibles and stuff. If they haven't reached their deductible yet, they are going to wonder why it was 145 dollars instead of 90 dollars this visit...when you didn't spend anymore time with them or do anything different in their eyes. And telling them "well the extra 55 dollars is because I documented that you still take blood pressure meds and your blood sugars have been a bit high lately" really isn't going to go over well or build therapeutic rapport.

I bill as an internist, usually 99213 or 99214 for a return visit. Although technically you can bill for counseling time; 99% of the time, time spent has absolutely nothing to do with billing for E and M.

 

[BS81]

Therapy requires strict timing. The E&M codes do not. If you can accomplish what you need for billing purposes for a Level 4 in 5 minutes, more power to you.

 

[psychiatrist20]

I was wondering if anyone else was having major problems with insurance companies handling the new CPT codes. A number of the panels I work with are not prepared for the changes and are delaying processing claims. One has not determined their reimbursement rates and I can't even tell patients what to expect to pay with their deductibles. The one that has started to process the claims had made a number of errors. The panels are not treating the 992- and 908- portions together and they are subjecting both to different deductibles and copayment systems. It has been a mess so far.

 

[vistaril]

I was wondering if anyone else was having major problems with insurance companies handling the new CPT codes. A number of the panels I work with are not prepared for the changes and are delaying processing claims. One has not determined their reimbursement rates and I can't even tell patients what to expect to pay with their deductibles. The one that has started to process the claims had made a number of errors. The panels are not treating the 992- and 908- portions together and they are subjecting both to different deductibles and copayment systems. It has been a mess so far.

that is what I am anticipating as well...the insurance are going to most likely screw us.

Another of my biggest fears is copay systems that the pt doesn't understand and isn't consistent. I don't really give a crap what Humana thinks of me, but pts are different.

 

[psychiatrist20]

I just found out that a number of my Blue Cross/Blue Shield patients will have to pay two deductibles/co-payments to be seen for an E/M(99213,etc) and add-on code(90833,etc). Each service is treated under a different benefit section of their plan. It seemed too good to be true to be able to see patients and do both services with increased reimbursement. My patients are not going to understand the reason that they have to pay two co-payments for one appointment. If this is a trend with other insurances this will discourage psychiatrists from doing therapy as part of their treatment. Has anyone else noticed a similar issue?

 

[Dapplegrey]

The insurance companies are trying to figure out how to deal with the new coding system more than we are. I've seen it done three different ways:

BC/BS--Two full copays
Aetna--Full copay for one, then no copay for the other
UBH--One full copay split between the two CPT codes

 

[ratched]

Thanks for the responses thus far.

I'd like to give a particular example and see if I'm understanding things properly. Let's say I have a gentleman whom I've diagnosed with MDD, Panic D/O, GAD, and EtOH Dependence (in early remission). I'm prescribing him Effexor, and I see him in follow-up and all symptoms are under control. I document enough in the "History" section of his note to satisfy the "detailed" (or 99214) level; I document enough in the "Exam" section for a "detailed" note (a fairly complete MSE should cover this).

Does this alone allow me to bill 99214 (since the median component of History, Exam, and Med Decision-making is at the "detailed" or higher level)? Let's say the answer to that question is "no" and that Med Decision-making needs to be "moderate" or higher.... then, since I'm prescribing for him that would argue for "moderate" complexity of MDM. If I also document as follows, would I have 4 data points (for 4 stable problems): "Mood stable. Panic d/o stable. EtOH Dependence stable. Generalized anxiety stable."

Am I missing something? Shouldn't it be rather easy to bill 99214 for nearly every pt we see (unless it's a really pure case of MDD that's in full remission; even so, we can make the history and exam sufficiently detailed, right?)?

 

[TexasPhysician]

Thanks for the responses thus far.

I'd like to give a particular example and see if I'm understanding things properly. Let's say I have a gentleman whom I've diagnosed with MDD, Panic D/O, GAD, and EtOH Dependence (in early remission). I'm prescribing him Effexor, and I see him in follow-up and all symptoms are under control. I document enough in the "History" section of his note to satisfy the "detailed" (or 99214) level; I document enough in the "Exam" section for a "detailed" note (a fairly complete MSE should cover this).

Does this alone allow me to bill 99214 (since the median component of History, Exam, and Med Decision-making is at the "detailed" or higher level)? Let's say the answer to that question is "no" and that Med Decision-making needs to be "moderate" or higher.... then, since I'm prescribing for him that would argue for "moderate" complexity of MDM. If I also document as follows, would I have 4 data points (for 4 stable problems): "Mood stable. Panic d/o stable. EtOH Dependence stable. Generalized anxiety stable."

Am I missing something? Shouldn't it be rather easy to bill 99214 for nearly every pt we see (unless it's a really pure case of MDD that's in full remission; even so, we can make the history and exam sufficiently detailed, right?)?

Your example with a thorough history, 3+ diagnoses, and prescribing a med would qualify as 99214.

All the coders I talk to say that you NEED MDM to make the code. It says 2 of 3 needed of history, physical, and MDM but you really have to use MDM as 1. The E&M book says that you can use history + physical, but you must still demonstrate the "need" to document for a lower MDM as a higher level of care. I'm not sure how you could justify that and my coders tell me not to try.

My clinic is probably 10% 99212, 30% 99213, 50% 99214, and 10% 99215 recently.

A stable ADHD patient with no side effects on the same dosage of stimulant for 2 years is no higher than 99212.

A patient on Clozapine with problems requiring education, etc. can hit 99215.

Once a faculty, you can also bill based on time, add complexity codes, psychotherapy codes, etc. Now whether insurance will pay for them, who knows.

 

[ratched]

Great, thanks! That was very helpful, both the explanation and the percentage breakdowns of what your clinic is coding.

 

[michaelrack]

A stable ADHD patient with no side effects on the same dosage of stimulant for 2 years is no higher than 99212.

.

Documenting that you are taking steps to prevent diversion (verifying that the patient always uses the same pharmacy for all of his meds, etc) of a DEA schedule 2 substance merits 99213, unless perhaps you are seeing the patient once a month- that is the only circumstance in which I would consider billing 99212.

 

[TexasPhysician]

Documenting that you are taking steps to prevent diversion (verifying that the patient always uses the same pharmacy for all of his meds, etc) of a DEA schedule 2 substance merits 99213, unless perhaps you are seeing the patient once a month- that is the only circumstance in which I would consider billing 99212.

True. Initially I intersperse this with medication education, eating/weight education, etc. to increase to a 99213-4 initially with ADHD. After a period of exceptional compliance and understanding of all info, I drop to 99212.

For instance: College student taking average dose of Adderall only on weekdays who has been on the same dose for 2 years now making all A's who never needs early refills, uses the same pharmacy, etc. gets a 90212 from me on some visits.

Other ADHD patients can fluctuate from 90213-4 for a couple years and more due to side effects, poor compliance, early refills, etc.

 

[Jester25]

I reviewed the coding system extensively and talked to coders and people that give lectures on coding. I would say my breakdown is 90% 99214 and 10% 99213

On all my notes I have CC, HPI (detailed), Psych ROS, Substance Use since last visit, Past Medical, Allergies, Past Meds, Vitals (3/7), Gait, MSE (with associations and fund of knowledge), A/P. Most of the things I have on my note are to help me remember the patient's other medical problems and what medications I have used on them before.

Now every single patient I see fits criteria for 99214 based on having the detailed history and 9 ROS from 2 different systems (I have 3 systems because I do vitals/ appearance (constitutional) , gait (MSK), and MSE). There is an idea floating around that MDM NEEDS to be 1 of the 2, but that is not stated anywhere EXCEPT by certain insurance companies like Anthem. Of course you have no way of knowing which insurance companies have changed their policies so if you want to be 100% safe, sure go with the policy that MDM needs to be 1 of the 2, but for the vast majority, there is nothing stated that MDM needs to be 1 of 2.

As far as coding MDM as moderate complexity, you either need 3 data points or 3 problem points as you have already stated. A worsening problem point is worth 2 points. So if I have been prescribing an antipsychotic to a Bipolar patient and they are obese and weight is worsening, well you have 3 problem points now. 1 for Bipolar and 2 for obesity. You have to notate on your notes however how you are working with the patient to address the obesity (diet, exercise, monitoring lipid panels/ A1C, etc..). Anything that is a problem that you are directly addressing is a problem point: insomnia, poor appetite, suicidality, even a drug side effect (e.g. propranolol for tremors 2/2 Zoloft).

If you are in Child Psych, you should be billing 99214 almost 100% of the time since you should be able to get 3 data points on every single visit considering obtaining collateral information from anyone not the patient is worth 2 points and reviewing your previous notes is worth 1 point. So a simple ADHD case can have only 1 problem point, but can have 3 data points.


As far as the thought process "is it medically necessary to obtain a detailed history if the MDM is low complexity". Here is the answer I got. To get to a conclusion about the complexity being low, you can reason you needed to take a detailed history. Just because a patient's depression is stabilized doesn't mean you don't have to ask about neurovegetative symptoms etc..

 

[michaelrack]

I reviewed the coding system extensively and talked to coders and people that give lectures on coding. I would say my breakdown is 90% 99214 and 10% 99213

On all my notes I have CC, HPI (detailed), Psych ROS, Substance Use since last visit, Past Medical, Allergies, Past Meds, Vitals (3/7), Gait, MSE (with associations and fund of knowledge), A/P. Most of the things I have on my note are to help me remember the patient's other medical problems and what medications I have used on them before.

Now every single patient I see fits criteria for 99214 based on having the detailed history and 9 ROS from 2 different systems (I have 3 systems because I do vitals/ appearance (constitutional) , gait (MSK), and MSE). There is an idea floating around that MDM NEEDS to be 1 of the 2, but that is not stated anywhere EXCEPT by certain insurance companies like Anthem. Of course you have no way of knowing which insurance companies have changed their policies so if you want to be 100% safe, sure go with the policy that MDM needs to be 1 of the 2, but for the vast majority, there is nothing stated that MDM needs to be 1 of 2.

As far as coding MDM as moderate complexity, you either need 3 data points or 3 problem points as you have already stated. A worsening problem point is worth 2 points. So if I have been prescribing an antipsychotic to a Bipolar patient and they are obese and weight is worsening, well you have 3 problem points now. 1 for Bipolar and 2 for obesity. You have to notate on your notes however how you are working with the patient to address the obesity (diet, exercise, monitoring lipid panels/ A1C, etc..). Anything that is a problem that you are directly addressing is a problem point: insomnia, poor appetite, suicidality, even a drug side effect (e.g. propranolol for tremors 2/2 Zoloft).

If you are in Child Psych, you should be billing 99214 almost 100% of the time since you should be able to get 3 data points on every single visit considering obtaining collateral information from anyone not the patient is worth 2 points and reviewing your previous notes is worth 1 point. So a simple ADHD case can have only 1 problem point, but can have 3 data points.


As far as the thought process "is it medically necessary to obtain a detailed history if the MDM is low complexity". Here is the answer I got. To get to a conclusion about the complexity being low, you can reason you needed to take a detailed history. Just because a patient's depression is stabilized doesn't mean you don't have to ask about neurovegetative symptoms etc..

What you are describing sounds very reasonable for non-Medicare patients

 

[Jester25]

Why do you say that? What is so different about Medicare?

 

[michaelrack]

Why do you say that? What is so different about Medicare?

Medicare can fine you huge amounts of $. If Medicare thinks you are committing fraud, you can be fined $10,000 per episode. Private insurers can't do much to you other than terminate your contract or withhold payments. The Feds can throw the book at you and bankrupt you and pretty much take away your ability to practice medicine (try getting a job/hospital privileges if you have to check the box on the application saying you aren't allowed to participate in medicare)

Also, there is more wiggle room in the rules for billing a cpt code for private insurers- most don't have clear standards

 

[Shikima]

But also you can shorten that list down to create 99214 when clinic visits are 15-20 mins in length only. The majority you'll see will be 99213 out in practice.

 

[Jester25]

Medicare can fine you huge amounts of $. If Medicare thinks you are committing fraud, you can be fined $10,000 per episode. Private insurers can't do much to you other than terminate your contract or withhold payments. The Feds can throw the book at you and bankrupt you and pretty much take away your ability to practice medicine (try getting a job/hospital privileges if you have to check the box on the application saying you aren't allowed to participate in medicare)

Also, there is more wiggle room in the rules for billing a cpt code for private insurers- most don't have clear standards

Oh gotcha. Well even thou our university coder said MDM doesn't have to be one of the 3, I always use it as 1 of the 3. Essentially all of my 99214s have 3/3 components. I am doing contract work at a community mental health center so the type of clients I see, very often I will get a patient with 3 stable dx, 1 acute, or 1 stable and 1 worsening.

Anytime you prescribe medications (starting new or uptitrating) almost always would qualify for a 99214 (as long as you managing 2 problems). Starting new medication means new acute problem, uptitrating means inadequately controlled which is interchangeable with "worsening". My understanding from reading Medicare coding is that a depression that was 9/10 on Effexor 75mg that requires up titration to 150mg at next visit because the depression is still 9/10 gets you 2 problem points. Correct me if I am mistaken. I can look up my reference and post it here if you disagree.

Shikima - i do 30 min follow ups. Plenty of time to write good detailed notes and form good therapeutic alliances. I will never practice 15 minute psychiatry.

 

[Shikima]

Oh gotcha. Well even thou our university coder said MDM doesn't have to be one of the 3, I always use it as 1 of the 3. Essentially all of my 99214s have 3/3 components. I am doing contract work at a community mental health center so the type of clients I see, very often I will get a patient with 3 stable dx, 1 acute, or 1 stable and 1 worsening.

Anytime you prescribe medications (starting new or uptitrating) almost always would qualify for a 99214 (as long as you managing 2 problems). Starting new medication means new acute problem, uptitrating means inadequately controlled which is interchangeable with "worsening". My understanding from reading Medicare coding is that a depression that was 9/10 on Effexor 75mg that requires up titration to 150mg at next visit because the depression is still 9/10 gets you 2 problem points. Correct me if I am mistaken. I can look up my reference and post it here if you disagree.

Shikima - i do 30 min follow ups. Plenty of time to write good detailed notes and form good therapeutic alliances. I will never practice 15 minute psychiatry.

That's good to hear! I applaud you for this! I will make changes for my way of practicing in the future not to include these practice parameters. I'm not a "move the meat" fan either.

Let me know what you find out about medication titration and billing 3's vs 4's.

 

[Jester25]

It is from 2010, but the same principle applies...

https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

Page 17:

Some important points that should be kept in mind when documenting the number of diagnoses or management options are:

• ❖ For each encounter, an assessment, clinical impression, or diagnosis should be documented which may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation:
  • For a presenting problem with an established diagnosis, the record should reflect whether the problem is:
    • - Improved, well controlled, resolving, or resolved; or
      
      
    • - Inadequately controlled, worsening, or failing to change as expected.

 

[Jester25]

That's good to hear! I applaud you for this! I will make changes for my way of practicing in the future not to include these practice parameters. I'm not a "move the meat" fan either.

Let me know what you find out about medication titration and billing 3's vs 4's.

When I was a 3rd yr med student, my attending psychiatrist saw 4-5 patients per hour. I was dumbfounded. When I was a 4th yr med student, my attending psychiatrist saw 2 per hour and the difference in the therapeutic alliance was evident. When I decided on psychiatry, I told myself that the shortest followup I would do is 20 minutes. Even though the community mental health center wanted me to do 20 min followups at my current gig, I asked for 30 min and they were fine with it.

 

[Shikima]

When I was a 3rd yr med student, my attending psychiatrist saw 4-5 patients per hour. I was dumbfounded. When I was a 4th yr med student, my attending psychiatrist saw 2 per hour and the difference in the therapeutic alliance was evident. When I decided on psychiatry, I told myself that the shortest followup I would do is 20 minutes. Even though the community mental health center wanted me to do 20 min followups at my current gig, I asked for 30 min and they were fine with it.

What's equally interesting is the practioner's comfort level and how that plays a role in delivering care.