Over a year of the new coding rules -- what do you think?

[Doctor Bagel]

I just got a call from a patient asking why she received two bills, and I'm reminded why I as a resident preferred the old system. What are you guys experiences? I feel like people interpret the two different codes as me potentially ripping them off.

Are you making more money? I guess that was the goal. Any good explanations for the two codes?

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[vistaril]

I just got a call from a patient asking why she received two bills, and I'm reminded why I as a resident preferred the old system. What are you guys experiences? I feel like people interpret the two different codes as me potentially ripping them off.

Are you making more money? I guess that was the goal. Any good explanations for the two codes?

I only fill them out when attendings staff my outpts, but in looking at them and talking to people who it impacts more I'd say it's a negative. Most people seem to be making somewhat less money at it. More hassle, more paperwork, more bull**** overall.

Many of my patients still have copays that make up the vast majority of their 90823. When that's the case, wtf is the point?

 

[Addiction]

I just got a call from a patient asking why she received two bills, and I'm reminded why I as a resident preferred the old system. What are you guys experiences? I feel like people interpret the two different codes as me potentially ripping them off.

Are you making more money? I guess that was the goal. Any good explanations for the two codes?

This is not based on a market analysis but just based on one psychiatrist I have spoken to in private practice in an affluent area of a northeast city. He is of the older generation and sees every patient for one hour. He takes cash but also bills out of network for patients who have PPO insurance. Prior to E&M changes he used to bill 90807 and get paid $140 not including co-insurance. After the E&M coding changes the same service (but now billed as E&M with add on psychotherapy was ~$170). Recently, with the increase in reimbursement for psychotherapy add on by psychiatrists, he now gets ~$220 for a one hour visit including medication management and therapy. So overall, $140->$220 for the same service.

 

[Shikima]

Interesting.....
So, my understanding for a 1 hour visit is 99213/4 + 90836 rider?

Is anyone billing for telephone calls using;
99441 for 5-10 minutes?
99442 for 11-20 minutes?
99443 for 21-30 minutes?

 

[PikminOC]

Still confused. I have a new appointment at 99205, but it was well over an hour, so I added a 90838, is this even possible?

 

[PikminOC]

Interesting.....
So, my understanding for a 1 hour visit is 99213/4 + 90836 rider?

Is anyone billing for telephone calls using;
99441 for 5-10 minutes?
99442 for 11-20 minutes?
99443 for 21-30 minutes?

More importantly, is anyone getting reimbursed for the calls?

 

[Shikima]

More importantly, is anyone getting reimbursed for the calls?

Technically, if there is a CPT code for phone calls, you ought to be reimbursed for them.

 

[Shikima]

Still confused. I have a new appointment at 99205, but it was well over an hour, so I added a 90838, is this even possible?

That would be almost a 2 hour appointment. As long as you documented clearly that psychotherapy existed for greater than 45 mins with a clear demarkated start/stop. I guess it would be feasible. Just not sure if it is adventageous.

 

[EEGNeurofeedback]

Interesting.....
So, my understanding for a 1 hour visit is 99213/4 + 90836 rider?

Is anyone billing for telephone calls using;
99441 for 5-10 minutes?
99442 for 11-20 minutes?
99443 for 21-30 minutes?

In my area, the majority of psychiatrists (in fact I have never heard of one) don't even take crisis calls. Most refer to the suicide and crisis center.

 

[Shikima]

In my area, the majority of psychiatrists (in fact I have never heard of one) don't even take crisis calls. Most refer to the suicide and crisis center.

You bring up a good point. Telephone calls could be about medication changes and reactions that are occuring. Not all billable phone calls are crisis related.

 

[EEGNeurofeedback]

You bring up a good point. Telephone calls could be about medication changes and reactions that are occuring. Not all billable phone calls are crisis related.

You know for medication problems a lot of psychiatrists in my area do email with patients. Both parties find it easier. It is good in the sense that everyone has a record of what was being said without any misunderstanding. You can create a business address and share it with clients.

 

[Shikima]

You know for medication problems a lot of psychiatrists in my area do email with patients. Both parties find it easier. It is good in the sense that everyone has a record of what was being said without any misunderstanding. You can create a business address and share it with clients.

It is an interesting idea, but the bottom line, how do you bill for it with shrinking reimbursement rates and increased practice costs?

 

[mgdsh]

My concerns with email interaction are:
1) Potential for abuse on the patients part (ie emailing too frequently or at inappropriate length). I have no problems speaking with them about whatever, but prefer for important subjects to be brought up in session whenever possible.
2.) Statements of harm to self or others.

Would love to hear how others deal with that.

For my private practice, I don't have an email address on my card nor my website. I have given it out to a few patients if they specifically ask to communicate in that way.

 

[EEGNeurofeedback]

It is an interesting idea, but the bottom line, how do you bill for it with shrinking reimbursement rates and increased practice costs?

The doctors that I know don't bill for this. If it gets too complex some providers just tell their patients to come in for another visit.

 

[Shikima]

The VA uses myhealthyvet to do written correspondence and have a dedicated nursing offical who is responsible for risky patients and can coordinate care for those who have intented to harm themselves. The nice piece is that you have written proof when calling PD to go pick someone up as they've demonstrated they're gravely disabled and at risk for self harm - but still a significant PITA in coordinating between the office and outside agencies in doing welfare checks.

 

[vistaril]

It is an interesting idea, but the bottom line, how do you bill for it with shrinking reimbursement rates and increased practice costs?

in an insurance based practice though, the patients that are going to email you are going to require a ton of work to do with when they come in as well....to the point that their united or blue cross reimbursed 98023 isn't even worth it. It may just be better to knock it out by email and give up the code in exchange for scheduling some patients who are going to be easier and more stackable.

I spoke with a PA yesterday who works in South Alabama in a high volume general medicine IM outpt clinic(doing lots of medicare), and she states she saw 19 patients yesterday. By herself. In the morning. Her boss saw 30. By himself. In the morning. between the two of them they must have seen 90 patients that day, and I don't get the sense it was an atypical day. mostly 98023's Im guessing. That's the way to make money. I told her what I see in my clinic now when I do it(about 8 medmgt followups scheduled in the afternoon with 1 or 2 no shows likely).....it doesn't take a genius to figure out that if they are seeing an average of 45-50 in a half day and I'm scheduling 8...and we are using pretty much the same codes....well, do the math.

 

[EEGNeurofeedback]

in an insurance based practice though, the patients that are going to email you are going to require a ton of work to do with when they come in as well....to the point that their united or blue cross reimbursed 98023 isn't even worth it. It may just be better to knock it out by email and give up the code in exchange for scheduling some patients who are going to be easier and more stackable.

I spoke with a PA yesterday who works in South Alabama in a high volume general medicine IM outpt clinic(doing lots of medicare), and she states she saw 19 patients yesterday. By herself. In the morning. Her boss saw 30. By himself. In the morning. between the two of them they must have seen 90 patients that day, and I don't get the sense it was an atypical day. mostly 98023's Im guessing. That's the way to make money. I told her what I see in my clinic now when I do it(about 8 medmgt followups scheduled in the afternoon with 1 or 2 no shows likely).....it doesn't take a genius to figure out that if they are seeing an average of 45-50 in a half day and I'm scheduling 8...and we are using pretty much the same codes....well, do the math.

Just curious, how long are your med management followups? Do you also do psychotherapy?

 

[EEGNeurofeedback]

If a patient complained that she/he felt rushed during 15 minute med follow ups (complaining to you and receptionist) and would often state, "you are not listening to me," would you consider referring this patient out eventually?

thanks

 

[vistaril]

Just curious, how long are your med management followups? Do you also do psychotherapy?

we schedule 2 pts per hour...comes out to about 25 minutes each. And no not for this clinic I don't do psychotherapy.

 

[vistaril]

If a patient complained that she/he felt rushed during 15 minute med follow ups (complaining to you and receptionist) and would often state, "you are not listening to me," would you consider referring this patient out eventually?

thanks

sure....if it conflicted with my model. What I would do is say "I'm doing the med mgt. I will refer you to a therapist so you have more time to talk about these things and work through them". In many communities this is the standard.

Now my job next year is extremely low volume med mgt(relative to what most insurance based people are doing in the community), so I will have time to be supporitive and listen to pts. At least that's the goal. I also won't make much money, but oh well.

 

[deleted314290]

Is anyone using 99444 with any success?

 

[EEGNeurofeedback]

sure....if it conflicted with my model. What I would do is say "I'm doing the med mgt. I will refer you to a therapist so you have more time to talk about these things and work through them". In many communities this is the standard.

Now my job next year is extremely low volume med mgt(relative to what most insurance based people are doing in the community), so I will have time to be supporitive and listen to pts. At least that's the goal. I also won't make much money, but oh well.

It's actually my patient that does this. He has a therapist. I think he is one of those that just loves to talk.

 

[Shikima]

If a patient complained that she/he felt rushed during 15 minute med follow ups (complaining to you and receptionist) and would often state, "you are not listening to me," would you consider referring this patient out eventually?

thanks

Currently one of my employers has 15 min med checks to move the meat. I basically shrug and tell them I'm sorry, but that I'll do the best I can for them.... as we're walking to the door.... Kinda hypocritical but I do make quick changes and stabilize them well.

 

[Doctor Bagel]

My concerns with email interaction are:
1) Potential for abuse on the patients part (ie emailing too frequently or at inappropriate length). I have no problems speaking with them about whatever, but prefer for important subjects to be brought up in session whenever possible.
2.) Statements of harm to self or others.

Would love to hear how others deal with that.

For my private practice, I don't have an email address on my card nor my website. I have given it out to a few patients if they specifically ask to communicate in that way.

Yeah, this is where I'm at. I like the convenience of email, but it's got a lot of logistical issues. Things like myhealthyvet get around that, but I suspect in private practice, I'll stick with voicemail as my primary contact.

Speaking of horror stories with the new coding system, my supervisor was seeing a patient weekly, billing for medication management level 2 and psychotherapy for each visit (psychodynamic work). He was paid by the insurance company, but they then asked him to return a bunch of money, saying he could only do the medication management stuff once a month for this patient, even though like all psychiatrists he was thinking about and assessing the medications at each visit.

 

[notdeadyet]

Speaking of horror stories with the new coding system, my supervisor was seeing a patient weekly, billing for medication management level 2 and psychotherapy for each visit (psychodynamic work). He was paid by the insurance company, but they then asked him to return a bunch of money, saying he could only do the medication management stuff once a month for this patient, even though like all psychiatrists he was thinking about and assessing the medications at each visit.

I think I'd tend to side with the insurance company on this one (probably the first time those words have passed through these lips). I think you'd be hard pressed to need to see a patient weekly to do medication management. If you are seeing a therapy patient weekly, billing them weekly for "medication management" for asking "how are the meds treating you?" seems a bit off.

If we do this kind of thing, we're basically demanding that medication management and therapy be split amongst providers to prevent this kind of abuse (so that the patient is only billed weekly for therapy and q4 weeks for med management visits). And this split is exactly what most of us psychiatrists are fighting against.

 

[vistaril]

Yeah, this is where I'm at. I like the convenience of email, but it's got a lot of logistical issues. Things like myhealthyvet get around that, but I suspect in private practice, I'll stick with voicemail as my primary contact.

Speaking of horror stories with the new coding system, my supervisor was seeing a patient weekly, billing for medication management level 2 and psychotherapy for each visit (psychodynamic work). He was paid by the insurance company, but they then asked him to return a bunch of money, saying he could only do the medication management stuff once a month for this patient, even though like all psychiatrists he was thinking about and assessing the medications at each visit.

the only horror story there is it took the insurance company as long as it did to call bs and do the right thing. Billing weekly med mgt codes for the same pt week after week after week after week after week is at best unethical and a poor use of resources and at worst outright fraud.

 

[Doctor Bagel]

I think I'd tend to side with the insurance company on this one (probably the first time those words have passed through these lips). I think you'd be hard pressed to need to see a patient weekly to do medication management. If you are seeing a therapy patient weekly, billing them weekly for "medication management" for asking "how are the meds treating you?" seems a bit off.

If we do this kind of thing, we're basically demanding that medication management and therapy be split amongst providers to prevent this kind of abuse (so that the patient is only billed weekly for therapy and q4 weeks for med management visits). And this split is exactly what most of us psychiatrists are fighting against.

But I think we're always functioning in an E&M capacity when we see patients because we are physicians, and that is part of what we're thinking about. I think the old coding system most accurately reflected that. Not coding for E&M aside from some arbitrary once monthly type of thing seems like undercharging to me.

Now I'm curious about how most providers who do lots of psychotherapy work bill? Do you rarely bill for E&M? With that, I'm guessing you would see a pay cut with the new codes.

 

[Doctor Bagel]

Interesting -- super preliminary but less billing for psychotherapy so far.

http://blog.carepaths.com/2013/10/29/impact-of-2013-cpt-code-changes-on-psychiatrists-income/

 

[vistaril]

But I think we're always functioning in an E&M capacity when we see patients because we are physicians, and that is part of what we're thinking about.

but the service, by any reasonable standard, simply *isn't* needed/useful that frequently. By this definition you could see a pt literally everyday and function 'in an E/M capacity'. That sort of stuff isn't going to help us.

Around here(and where I am headed) all the largest/most common payers have visit limits/year. There isn't some open ended carte blanche that I can just run up any way I see fit. 16-20 visits/year seems to be common, and for some of those plans a visit where E/M and psychotherapy are billed count for 2. So if I was practicing with that guys model(weekly E/M + therapy codes) the pt would be out of outpt mental health coverage by the end of February.

Insurance reimburse continues to go into the sh*****. Our outpt clinic just dropped all school teachers/public education employees plans(an offshoot of blue cross here called Phipp). They kept on ratcheting down rates to the point that our clinic said we couldn't see them anymore. They now have to go to one of two extremely large high volume outpt stack and whack places, who still take that insurance but that's only because they are going to make it up with volume.

 

[Doctor Bagel]

More interesting thoughts --

http://www.kevinmd.com/blog/2012/11/medicare-devalue-work-psychiatrists.html

The thing about the confusion of the bill for the patient seems particularly spot on and played into my recent conversation with the patient I mentioned above. This patient has a large deductible and has to pay out of pocket for a while before insurance kicks in, and I can't tell them how much a session will be in advance because it depends on what we do. If the treatment gets more complex, I'll bill a higher E&M code.

I am biased, but I get increasingly suspicious that all these changes are pushing us to adopt traditional medication management types of practices. Don't get me started on the ROS. I think I preferred the old coding system just for not having to document that.

 

[vistaril]

I am biased, but I get increasingly suspicious that all these changes are pushing us to adopt traditional medication management types of practices.

hasn't that ship sailed 2 or 3 decades ago for outpt insurance based psychiatrists though?

I mean I'm scheduled to do what would be considered a nontraditional medication management type of practice that is insurance based, but tha choice is costing me a lot of income.

 

[Doctor Bagel]

hasn't that ship sailed 2 or 3 decades ago for outpt insurance based psychiatrists though?

I mean I'm scheduled to do what would be considered a nontraditional medication management type of practice that is insurance based, but tha choice is costing me a lot of income.

Maybe I live in a weird community, but I know a decent amount of people in private practice who take insurance, do lots of psychotherapy (generally psychodynamic/analytic stuff) and seem to do just fine. Maybe there's an income cut compared to what you could make having some medication management mill type of practice, but I've heard the pay is at the very least comparable to what you would make working for a bigger system.

 

[OldPsychDoc]

Maybe I live in a weird community, but I know a decent amount of people in private practice who take insurance, do lots of psychotherapy (generally psychodynamic/analytic stuff) and seem to do just fine. Maybe there's an income cut compared to what you could make having some medication management mill type of practice, but I've heard the pay is at the very least comparable to what you would make working for a bigger system.

I've always heard the city where you live being referred to as the quintessential "weird community".

 

[hamstergang]

it doesn't take a genius to figure out that if they are seeing an average of 45-50 in a half day and I'm scheduling 8...and we are using pretty much the same codes....well, do the math.

Yeah, but there's no way that seeing patients for that short of time can be good for the patients. It's not something anyone should strive for.