2013 CPT code changes

[beezley]

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I was speaking with one of my attendings the other day who is quite efficient and does 15 minute med checks. Says being busy like that one could make 300,000$/year (midwest). However, this person found out that with the new CPT codes doing 2 patients per hour meds + psychotherapy nets the same # of RVUs as 4 patients/hour meds only. They are planning on slowing down their schedule and looking forward to it.

If that is true I think it pretty much awesome but has anyone else heard this?

 

[BS81]

I was speaking with one of my attendings the other day who is quite efficient and does 15 minute med checks. Says being busy like that one could make 300,000$/year (midwest). However, this person found out that with the new CPT codes doing 2 patients per hour meds + psychotherapy nets the same # of RVUs as 4 patients/hour meds only. They are planning on slowing down their schedule and looking forward to it.

If that is true I think it pretty much awesome but has anyone else heard this?

Yes, it's true. 1.72 RVUs for med management. Its about 3.0 RVUs for a 25 minute E&M, plus whatever the addon psychotherapy code will be worth

 

[F0nzie]

Started a thread on this a while back. Psychiatry will likely see a very handsome raise. Though it may take several years for salaried positions to raise our pay accordingly.

Shifting to private will steal some thunder from the public sector. The increased competition will inevitably raise wages to fair market value. Everybody go private! And only work halftime!

 

[billypilgrim37]

A raise, or we will actually be paid to do our job in a reasonable way? Because in 15 minutes, plenty of times I'm not sure I'm adding much more value than a fairly experienced PA would add. But with 30 minutes, that's enough time to utilize the sort of skills we learn in our training to do some real good.

 

[PistolPete]

Looking forward to this... by the time I'm done with residency, hopefully the reimbursement and salaries will be such that you no longer have to do 15 min med checks at lightning speed to make 250k+. 30 min, appropriate visits, with med management and some therapy, where this will really make more of an impact and a difference to the patient, so that they don't feel swindled. Hopefully both private practices and salaried positions will be better off.

 

[michaelrack]

Looking forward to this... by the time I'm done with residency, hopefully the reimbursement and salaries will be such that you no longer have to do 15 min med checks at lightning speed to make 250k+. 30 min, appropriate visits, with med management and some therapy, where this will really make more of an impact and a difference to the patient, so that they don't feel swindled. Hopefully both private practices and salaried positions will be better off.

My prediction is that by the time you are done with residency, you will need to do 15 minute med checks at lightning speed to make 225k+

 

[michaelrack]

I expect a gradual decline in the reimbursement per RVU

 

[PistolPete]

Sad panda... 🙁

 

[F0nzie]

Here's an interesting point of view that contradicts the optimism: http://www.kevinmd.com/blog/2012/11/medicare-devalue-work-psychiatrists.html

 

[vistaril]

My prediction is that by the time you are done with residency, you will need to do 15 minute med checks at lightning speed to make 225k+

yep....agreed

 

[beezley]

15 minute med checks at lightning speed for 225+, isn't that where we are now?

I thought the whole purpose of this, spurred by the APA was to have our work valued appropriately. Sounds like no one is sure what the future holds.

 

[digitlnoize]

15 minute med checks at lightning speed for 225+, isn't that where we are now?

I thought the whole purpose of this, spurred by the APA was to have our work valued appropriately. Sounds like no one is sure what the future holds.

Anyone care to revise their doomsday predictions in light of Obama's comments that he's going to work to improve mental health care?

I can see Medicare continuing to suck. As far as private practice general adult, and especially child, I see the future as pretty darn bright. Especially in shortage areas.

 

[shan564]

I really don't think the math adds up if you're suggesting that the CPT code changes will mean less money for psychiatrists. The system may be a bit more complex than it used to be, but unless you suck at math, it's not that hard to understand.

The billing system is somewhat similar to how family doctors bill in Australia. After a short while, all of the doctors get a simple feel for which code goes where. At the end of a consultation, they just tell their assistant which code to bill (i.e. "put it under code C"), and that's it.

 

[honsano]

How's everyones experience with this today? We were not even close to ready to implement this.

I wanted to ask specifically on the outpt f/u visits. I am hoping to bill 99214 regularly but had a question on the documentation. I get there are 3 portions History, Physical and MDM and a threshold that needs to be reached in 2 of the 3 portions above. I am wondering if one of those portions MUST be the MDM section or can I just document my pts history and physical well enough to bill a 99214 even though the MDM is subthreshold? I'm assuming I can't just do that.

Also, do you guys try documenting Psychotherapy 30minute add-on to a 99214 for a 30 minute visit or is that cutting it too close for timing?

hm

 

[toothless rufus]

How's everyones experience with this today? We were not even close to ready to implement this.

I wanted to ask specifically on the outpt f/u visits. I am hoping to bill 99214 regularly but had a question on the documentation. I get there are 3 portions History, Physical and MDM and a threshold that needs to be reached in 2 of the 3 portions above. I am wondering if one of those portions MUST be the MDM section or can I just document my pts history and physical well enough to bill a 99214 even though the MDM is subthreshold? I'm assuming I can't just do that.

Also, do you guys try documenting Psychotherapy 30minute add-on to a 99214 for a 30 minute visit or is that cutting it too close for timing?

hm

Do they not conveniently provide a book that thoroughly defines and describes what exactly is necessary to understand these changes to billing and how to effectively implement them into practice? 😕 I can't imagine they want people making mistakes.

 

[toothless rufus]

BTW are CPT codes ever discussed or considered by residents routinely in any programs? I have never heard anything about billing, beyond a very brief superficial overview.

 

[TexasPhysician]

How's everyones experience with this today? We were not even close to ready to implement this.

I wanted to ask specifically on the outpt f/u visits. I am hoping to bill 99214 regularly but had a question on the documentation. I get there are 3 portions History, Physical and MDM and a threshold that needs to be reached in 2 of the 3 portions above. I am wondering if one of those portions MUST be the MDM section or can I just document my pts history and physical well enough to bill a 99214 even though the MDM is subthreshold? I'm assuming I can't just do that.

Also, do you guys try documenting Psychotherapy 30minute add-on to a 99214 for a 30 minute visit or is that cutting it too close for timing?

hm

As I understand it, you document based on MDM qualifications. In other words, you must reach the correct MDM as 1 of the 3 required.

Psychotherapy add ons should only be for specific time utilized for therapy - not documenting or med management. It would thus be impossible for a 30 min visit for a therapy add on. You would use a specific psychotherapy only code.

I'm new to this as well, so I apologize if I get anything wrong. Based on a PowerPoint and reading the 1997 E&M rules, this is what I've gathered.

 

[TexasPhysician]

Do they not conveniently provide a book that thoroughly defines and describes what exactly is necessary to understand these changes to billing and how to effectively implement them into practice? 😕 I can't imagine they want people making mistakes.

The rules have been around since 1997. Many psychiatrists have been using E&M for years. There are rule books and power points and classes online for this.

As I understand it, only a small psych specific area has changed, but E&M is not new to psych.

 

[cherryalmond]

Can someone give me a quick overview about the new cpt codes. Or a link or a pdf that explains them. I am supposed to start billing using them on Mon and am a bit confused. If it's an outpt med mgmt visit, like say 20-30min, what is the code for that. I would like to understand this fully but I do not know where to look. o and i'd prefer no initials of something in case i don't know what it refers to
thanks!

 

[Chrismander]

👎

As I understand it, you document based on MDM qualifications. In other words, you must reach the correct MDM as 1 of the 3 required.

Psychotherapy add ons should only be for specific time utilized for therapy - not documenting or med management. It would thus be impossible for a 30 min visit for a therapy add on. You would use a specific psychotherapy only code.

I'm new to this as well, so I apologize if I get anything wrong. Based on a PowerPoint and reading the 1997 E&M rules, this is what I've gathered.

Wrong...

This is obviously arcane stuff (thanks gov't!) so make sure to get some good background from a professional coder before you go out into practice... I'm amazed at how much I've had to learn in only 1 months, and grateful that I'm at a larger organization and not solo right now. If you're solo or don't have that kind of support, go to psych.org ASAP and do all their learning activities on it. They even have some coded notes for you to look to as examples, and templates and stuff.

1) For "new patient E&M" (99201-5)--WHICH YOU WILL PROBABLY NEVER USE--all 3 elements are required--i.e., the "lowest of the 3". So the MDM needs to be there.

For established E&M (99211-5), it's 2/3--and can be any combination, per my coders. Some of the charts of mine they audited this week as we went live reached it by History + Physical, some reached by Physical + MDM.

I say you'll never use the 99201-5 because psychiatrists have 99791-2 at our disposal, which in RVU terms (2.8 and 2.92) is greater than a Level 4 new E&M, only slightly less than level 5, and has significantly less acuity requirements / documentation requirements / billing restrictions (the 3 year practice rule for instance).

2) In a truly bizarre move, you only have to do 16 minutes of psychotherapy to bill for 30 minutes. It's called the "50% rule". They wanted clear guidelines as to what number of minutes counted for which level, for the "in betweens". So you know whether to round up or down. I don't have the exact numbers in front of me but it's like 16-37 mins bill 30 mins, 38-52 bill 45, 53+ bill 60. So yes you can bill an E&M code plus a 30 min psychotherapy code for a 30 minute visit, provided you actually did and then subsequently document that 16+ minutes of it was psychotherapy, and met the appropriate E&M level for what you coded. Totally goofy. 👎

Hope this helps. Folks in my group are ranging from nonplussed to totally freaking right now.

 

[Chrismander]

Can someone give me a quick overview about the new cpt codes. Or a link or a pdf that explains them. I am supposed to start billing using them on Mon and am a bit confused. If it's an outpt med mgmt visit, like say 20-30min, what is the code for that. I would like to understand this fully but I do not know where to look. o and i'd prefer no initials of something in case i don't know what it refers to
thanks!

Are you a resident? You need way more help right now than can be given in a single reply. There's no single code anymore... you might have used 90862 or 90805 before exclusively... now it depends on condition of patient, acuity, thoroughness of documentation. You might bill 99213 for a straightforward followup, 99214 for a complex followup, and a 99215 for someone so suicidal you call the police or direct admit threm to the hospital from your practice. But that's a really rough draft of it. You can have a severely complex patient but only be able to bill 99213 because your documentation sucks. In which case just winging it and writing 99214 or 99215 is fraud.

Now's a great time to use your APA membership since they have a huge database on how to do this transition. Read up on "E&M" coding, the 3 elements of it, the 2/3 rule, find a grid that shows which combinatinon of elements results in which code. You'll be using a "single system exam" in which your mental status exam plus some constitutional & musculoskeletal exam bullet points will count in place of a comprehensive exam.

Call your higher ups and get some back up on this... i've been working like 2 months getting up to speed on this--won't take that long (i just like to be prepared) but it takes more than an hour or two to understand it, and more than that to become "fluent" in it. You don't want to be spending 10 minutes between each patient consulting your grid to find the level, and getting behind...

Sorry... hope that helps....

 

[TexasPhysician]

1) For "new patient E&M" (99201-5)--WHICH YOU WILL PROBABLY NEVER USE--all 3 elements are required--i.e., the "lowest of the 3". So the MDM needs to be there.

For established E&M (99211-5), it's 2/3--and can be any combination, per my coders. Some of the charts of mine they audited this week as we went live reached it by History + Physical, some reached by Physical + MDM.

By that reasoning, I can see a simple ADHD - stable patient and bill 99214 if my documentation is excellent for History + Physical? If true, it makes no sense for insurance companies to pay us for that. MDM isn't required at all for follow-ups?

Is there requirements for 90792? I couldnt find them on the APA site. We are told to use this but the PowerPoint didn't provide specifics.

For psychotherapy add-ons, 16 minutes of supportive therapy lets us up-code? That's nice.

Our lecture on this new coding system is later this month. In the meantime, our coding team is double-checking us. I'd still like to know as much as possible to ask better questions at the lecture.

 

[Chrismander]

By that reasoning, I can see a simple ADHD - stable patient and bill 99214 if my documentation is excellent for History + Physical? If true, it makes no sense for insurance companies to pay us for that. MDM isn't required at all for follow-ups?

Is there requirements for 90792? I couldnt find them on the APA site. We are told to use this but the PowerPoint didn't provide specifics.

For psychotherapy add-ons, 16 minutes of supportive therapy lets us up-code? That's nice.

Our lecture on this new coding system is later this month. In the meantime, our coding team is double-checking us. I'd still like to know as much as possible to ask better questions at the lecture.

Someone who's truly stable and at goal is a 99213. You need 4 elements of HPI for an active problem not at goal to justify a Detailed history, which would be a prereq for 99214 if you do History plus Physical.

What constitutes "at goal" is obviously up in the air... it seems tawdry to say the patient is only 99.9% at goal and then just describe in excruciating detail the remaining mini-symptoms and bill a level 4. I'm sure some folks will try it, and there will probably be some additional "clarifications" about what constitutes "at goal" issued down the road at some point as a result...

No published requirements for 792 that I've found... we've been told the doc requirements are the same as a 90801...

 

[billypilgrim37]

Our advisers have emphasized that it is the patient, and not how much documentation, that determines the level for billing. They say to determine the complexity based on the patient, then document to match that level of complexity. I'm not sure what actually happens if you bill stable patients as fours with documentation that matches the four if you get audited (probably nothing), but over-documenting to get paid for a higher level of complexity is regarded as a big no-no around here, and I can't imagine the folks I work for leaving any money on the table on purpose.

 

[michaelrack]

http://www.tricare.mil/ocfo/_docs/P...ialty_Coding_Guidelines_05.16.2012. Final.doc MDM is a mandatory component of e and m billing for tricare (see page 3-5).

For other insurers, you can't bill for more than justified by the complexity of the patient, which is basically the same as mdm

 

[TexasPhysician]

Spoke to my university coders, MDM is basically required for follow-ups.

99204 pays roughly $10 more than 90792 but has a much higher cash/insurance co-price or something. To make it easier on patients, we are asked to bill 90792. It can also be used repeatedly for new problems on separate days.

I'm in a state with Trailblazer so realize things may be a bit different elsewhere.

 

[trophyhusband]

Spoke to my university coders, MDM is basically required for follow-ups.

99204 pays roughly $10 more than 90792 but has a much higher cash/insurance co-price or something. To make it easier on patients, we are asked to bill 90792. It can also be used repeatedly for new problems on separate days.

I'm in a state with Trailblazer so realize things may be a bit different elsewhere.

As of November 2012 the MAC for Texas is Novitas. And all MAC's are equally bad so I wouldn't blame it on that... ha.

 

[toothless rufus]

What's the reason behind the code changes? Just seems to make things unnecessarily cumbersome, especially versus the prior system mentioned above with just two codes. Can we vote and go back?

 

[priorities2]

I thought it was designed by psychiatrists to increase reimbursement.

 

[beezley]

That was also my understanding. In speaking with one of our clinic managers today he agrees that powering through 15 minute med checks all day has been disincentivised (if that is a word) and that you can do equally well seeing 2/hr meds+psychotherapy for 16 minutes versus 4/hr e & m only.

 

[toothless rufus]

I thought it was designed by psychiatrists to increase reimbursement.

Really?! Well then I LOVE it!! $$$👍$$$

 

[Doctor Bagel]

Can I just say argh about this even though I know in the long run it will be a good thing. We've had no talks about how to implement the new codes and instead got this ridiculously long powerpoint that I don't really have time to look through to explain stuff. We also have a new template for our regular office visits that is seriously twice as long as our old template, so it's taking me way more time to write notes so far. I'm probably doing it wrong, but I'm feeling a little overwhelmed and frustrated with these changes. I'm hoping our billing office will catch it if I screw up in any big way, and I guess I'll get through that powerpoint when I have a chance.

I already hate documentation as it is.

 

[digitlnoize]

That was also my understanding. In speaking with one of our clinic managers today he agrees that powering through 15 minute med checks all day has been disincentivised (if that is a word) and that you can do equally well seeing 2/hr meds+psychotherapy for 16 minutes versus 4/hr e & m only.

If that's the case, didn't they just effectively double the shortage of psychiatrists, since we will all now be seeing 2 patient per hour instead of 4?

Arguably, it might be better care, but still...the shortage is already BAD in many places.

I know it won't really be doubled, because not everyone will change from 4 to 2 per hour, but it still could worsen access pretty badly. But money! Yay!

 

[F0nzie]

Recently heard from a private practice psychiatrist who just made the switch that the codes changed but the rates essentially remain the same as the previous codes. If that isn't discrimination I don't know what is.

 

[TexasPhysician]

Recently heard from a private practice psychiatrist who just made the switch that the codes changed but the rates essentially remain the same as the previous codes. If that isn't discrimination I don't know what is.

Our rates are higher. In not sure how anyone can say they are exactly the same. There was one code for follow-ups. Now there are multi-levels with therapy and complexity add-ons. Patient to patient could be a big difference in itself.

A practice with mostly stable ADHD may pay much less. One with more difficult patients that includes therapy may be much better.

 

[snarfer]

Recently heard from a private practice psychiatrist who just made the switch that the codes changed but the rates essentially remain the same as the previous codes. If that isn't discrimination I don't know what is.

it may take a while for certain insurance companies to make the adjustment depending on where you are. I've noticed increased in reimbursement and will start scheduling more pts for both psychotherapy and med mgt.