2021 Changes to E/M Office Visit Codes & Psychiatry

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I was looking over the 2021 changes to outpatient codes here:


www.aapc.com

Evaluation and Management (E/M) Code Changes 2021

Stay updated with E&M coding and documentation guidelines 2021. E/M codes define the terms used in the code descriptors and provide instructions.
www.aapc.com www.aapc.com

From my understanding, it seems billing based on time is harder (e.g. 99213 will be 20 - 29 minutes) while billing based on elements got easier (based on MDM only). RVUs overall are increased for each code.

Will the 2021 changes negatively impact psychiatry? Will we still have add-on therapy codes? What impact will the changes have?
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It should be noted that the time based billing is now time spent on the overall encounter and not just patient to patient face time.

Regardless if you want/wanted to be as efficient as possible with your billing you should probably have been basing on elements from the start and I don't see anything changing in this regard with the new billing guidelines. This is assuming you don't just consistently see patients where you only refill their 100mg of Zoloft
 
Really appreciate you posting these, pretty big changes I was not aware of yet. Very interested if there are any changes to psychotherapy add-on codes.
 
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oldiebutgoodie1211 said:
If overall the RVUs increased that’s overall a good thing for us right?
Click to expand...

It's a good thing if your productivity measures are RVU-based, whether or not that will translate to increased reimbursement from payers - we'll see...
 
There's as of right now no proposed change that I can see with add-on therapy codes. However, at many facilities, MDs are *not allowed* to bill add on therapy codes due to the nature of the carve outs anyway (i.e. through private contracting between insurance and the facility, the insurance dictates that only therapists are providing therapy.)

In fact, few that I know in insurance-based practices do add-ons. Add-on therapy codes (esp. 45-min) seem to be a very OON-centric thing.
 
sluox said:
There's as of right now no proposed change that I can see with add-on therapy codes. However, at many facilities, MDs are *not allowed* to bill add on therapy codes due to the nature of the carve outs anyway (i.e. through private contracting between insurance and the facility, the insurance dictates that only therapists are providing therapy.)

In fact, few that I know in insurance-based practices do add-ons. Add-on therapy codes (esp. 45-min) seem to be a very OON-centric thing.
Click to expand...

This is ridiculous. Another push to have psychiatrists just push meds only. Sigh.
 
PistolPete said:
This is ridiculous. Another push to have psychiatrists just push meds only. Sigh.
Click to expand...

Eh I mean in those situations it'd be like an inpatient ortho billing for PT or inpatient ENT trying to bill for speech therapy (if they knew how to do this...didn't say they actually do) when they're already seeing those specialities for the allowable billable time per week. For most therapy services you can't bill for the same service too close together with insurance.

I wonder more if people don't do the add-ons in outpatient because they're just not aware of them/think they're going to reimburse too poorly to be worth their time or don't know how to document them. I see few attendings and/or residents billing therapy add-ons and they didn't seem aware it was even a thing. Also there are definitely EMRs which are not very conducive to trying to organize the note to even document and bill the add-on without it being a pain. We just had a whole billing lecture talking about the therapy add-on and it didn't seem that many people had been utilizing them.
 
sluox said:
There's as of right now no proposed change that I can see with add-on therapy codes. However, at many facilities, MDs are *not allowed* to bill add on therapy codes due to the nature of the carve outs anyway (i.e. through private contracting between insurance and the facility, the insurance dictates that only therapists are providing therapy.)

In fact, few that I know in insurance-based practices do add-ons. Add-on therapy codes (esp. 45-min) seem to be a very OON-centric thing.
Click to expand...
This might be geographical but this is definitely not a thing on the west coast. Most counties won't reimburse MDs for therapy for medi-cal patients but medicare always pays for therapy codes and commercial insurance does too. It is pretty standard for people to use these codes. I consult regarding behavioral health coding and billing etc and am unaware of any institutions where MDs are not allowed to bill for therapy codes. Now, if a patient sees a therapist on the *same day* sure, you're unlikely to be reimbursed but it's not a problem otherwise.
 
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splik said:
This might be geographical but this is definitely not a thing on the west coast. Most counties won't reimburse MDs for therapy for medi-cal patients but medicare always pays for therapy codes and commercial insurance does too. It is pretty standard for people to use these codes. I consult regarding behavioral health coding and billing etc and am unaware of any institutions where MDs are not allowed to bill for therapy codes. Now, if a patient sees a therapist on the *same day* sure, you're unlikely to be reimbursed but it's not a problem otherwise.
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Makes sense. How does the insurer decide whom to reimburse for therapy that day... psychiatrist or MFT/psychologist? Or is it neither?
 
splik said:
Now, if a patient sees a therapist on the *same day* sure, you're unlikely to be reimbursed but it's not a problem otherwise.
Click to expand...

I thought this pertains if the therapist and psychiatrist are in the same organization but doesn't pertain if they are in different organizations. Correct me if I'm wrong.
 
splik said:
This might be geographical but this is definitely not a thing on the west coast. Most counties won't reimburse MDs for therapy for medi-cal patients but medicare always pays for therapy codes and commercial insurance does too. It is pretty standard for people to use these codes. I consult regarding behavioral health coding and billing etc and am unaware of any institutions where MDs are not allowed to bill for therapy codes. Now, if a patient sees a therapist on the *same day* sure, you're unlikely to be reimbursed but it's not a problem otherwise.
Click to expand...

I left the military and managed to land a gig as a medical director for a large CMHC, with an integrated state-wide system. I learned billing and such fairly well while it was all on the military's dime in preparation to enter civilian practice, so am quite familiar with add-on codes and the cost/benefit for e/m with and without.

I was very shocked when I started in my new position to learn that psychiatrists aren't, "allowed", do use the add-on codes. In fact, the system doesn't even privilege us to provide therapy. I find this strange in itself, and then pretty ridiculous considering Medicaid and the system puts us into the role of, "physician managed and supervised care", requiring us to direct and ensure the quality and standards of all aspects of treatment -- including therapy. So, we are in a position of being responsible for something we ourselves are not privileged to do or bill for. Naturally, we're doing it anyways as part of patient encounters since that's just part of good psychiatry.

I had to understand why, especially since we're just losing money not billing for things we're all doing anyways. Turns out it's a Medicaid thing and they just don't allow psychiatrists to provide or bill for therapy. So we let unlicensed therapists do it instead, because that's a fantastic idea. (It's super fun supervising and directing their care!)
 
MLT2MT2DO said:
It should be noted that the time based billing is now time spent on the overall encounter and not just patient to patient face time.

Regardless if you want/wanted to be as efficient as possible with your billing you should probably have been basing on elements from the start and I don't see anything changing in this regard with the new billing guidelines. This is assuming you don't just consistently see patients where you only refill their 100mg of Zoloft
Click to expand...

Feeling lazy, any link or quote to the part about it being “total encounter” time? Curious what all that includes, like are we going to get credit for E-scribing/PAs/gathering records/etc?
 
HooahDOc said:
I left the military and managed to land a gig as a medical director for a large CMHC, with an integrated state-wide system. I learned billing and such fairly well while it was all on the military's dime in preparation to enter civilian practice, so am quite familiar with add-on codes and the cost/benefit for e/m with and without.

I was very shocked when I started in my new position to learn that psychiatrists aren't, "allowed", do use the add-on codes. In fact, the system doesn't even privilege us to provide therapy. I find this strange in itself, and then pretty ridiculous considering Medicaid and the system puts us into the role of, "physician managed and supervised care", requiring us to direct and ensure the quality and standards of all aspects of treatment -- including therapy. So, we are in a position of being responsible for something we ourselves are not privileged to do or bill for. Naturally, we're doing it anyways as part of patient encounters since that's just part of good psychiatry.

I had to understand why, especially since we're just losing money not billing for things we're all doing anyways. Turns out it's a Medicaid thing and they just don't allow psychiatrists to provide or bill for therapy. So we let unlicensed therapists do it instead, because that's a fantastic idea. (It's super fun supervising and directing their care!)
Click to expand...

Maybe it’s a Medicaid thing in your state or just in the case of CMHCs because you’re “supervising” therapists who are supposed to be providing the therapy? I’m pretty sure ive billed therapy add on codes for Medicaid patients before and there are specific documents in our states Medicaid contractors that refer to the psychotherapy add on codes as valid codes.
 
With visits being based on TOTAL time now, how would It work if someone was mostly taking time due to documentation? Could a slow documenter bill a bunch of 99215s cause he/she takes a long time to write notes? Will they cap that?
 
hebel said:
With visits being based on TOTAL time now, how would It work if someone was mostly taking time due to documentation? Could a slow documenter bill a bunch of 99215s cause he/she takes a long time to write notes? Will they cap that?
Click to expand...

Read the link up top again. Time documenting does not count towards total time. It all also has to be done on the day of the encounter to count.
 
clausewitz2 said:
Read the link up top again. Time documenting does not count towards total time. It all also has to be done on the day of the encounter to count.
Click to expand...

Hmm, I did read it. I'm reading that it does include documenting into the EMR. And notes are typically done same day as the encounter anyway.
 
hebel said:
Hmm, I did read it. I'm reading that it does include documenting into the EMR. And notes are typically done same day as the encounter anyway.
Click to expand...

I was about to post the list from page 2 but I see you're totally right. You do have to report that separately, though, so better the tracking documentation time. Wouldn't be surprised if insurers start questioning prolonged times for this.

But also, if you do it on MDM, it should be utterly trivial to hit 99214, and anyone on lithium or clozapine is almost immediately a 99215 if you are following monitoring guidelines.
 
How are you guys documenting the MDM portion of your follow-up notes, since it will be ever more important in the future? A lot of guideline examples I see use this format, where problem could be anything from a diagnoses to a side effect (dry mouth) or symptom (irritability):

Problem:
Comment:
Plan:

I personally don't like how this reads and would prefer to simply have a Diagnoses, Assessment, and Plan section. Anyone run into issues with capturing the indicated charges using the latter documentation organization?
 
Medical Decision Making

No obstacles to the treatment agreement/frame.

1. Recurrent-Depression (Unipolar): New/Est chronic/acute condition (description of the overall dx/formulation/course [eg, 3-MDEs +/- hypomania?]) with mild/moderate/severe exacerbation (what is going on now [eg, acute MDE/subsyndromal MDE/euthymia with residual insomnia]. BPAD risk factors or course modifiers. Further work-up planned (HAMD, 5). Cont. lexapro [continuation phase].
2. Secondary anxiety: " " Cont. lorazepam prn.
3. Suicide risk (low): Protective factors (list them) more compelling than risk factors (list them) and justify OP level of care as least restrictive.

Built from attached.
 

Attachments

Last edited:
Can 90833 be used with time based codes now? Previously this was disallowed as 50% of the time had to be counseling/coordination of care, so they considered it already accounted for. Now time based is related to any part of the encounter. I assume still not allowed, but it doesn’t hurt to ask.

Either way it seems easier to meet 99214 + 90833 with less documentation than before.

What codes are y’all using for child evals with this? Could you not use 99204 + 90833 + 90785 + extended time code?
 
TexasPhysician said:
Can 90833 be used with time based codes now? Previously this was disallowed as 50% of the time had to be counseling/coordination of care, so they considered it already accounted for. Now time based is related to any part of the encounter. I assume still not allowed, but it doesn’t hurt to ask.

Either way it seems easier to meet 99214 + 90833 with less documentation than before.

What codes are y’all using for child evals with this? Could you not use 99204 + 90833 + 90785 + extended time code?
Click to expand...

My understanding is that 90833 is still only going to be allowed when billed on medical complexity not time. But yeah should be easier to hit 99214 without having to document as much for complexity.
 
TexasPhysician said:
Can 90833 be used with time based codes now? Previously this was disallowed as 50% of the time had to be counseling/coordination of care, so they considered it already accounted for. Now time based is related to any part of the encounter. I assume still not allowed, but it doesn’t hurt to ask.

Either way it seems easier to meet 99214 + 90833 with less documentation than before.

What codes are y’all using for child evals with this? Could you not use 99204 + 90833 + 90785 + extended time code?
Click to expand...
Regular 99354 extended time code is removed

Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202-99215]) (Use 99354 in conjunction with 90837, 90847, 99241-99245, 99324-99337, 99341- 99350, 99483) (Do not report 99354 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99415, 99416, 99XXX)
 
TexasPhysician said:
Can 90833 be used with time based codes now? Previously this was disallowed as 50% of the time had to be counseling/coordination of care, so they considered it already accounted for. Now time based is related to any part of the encounter. I assume still not allowed, but it doesn’t hurt to ask.

Either way it seems easier to meet 99214 + 90833 with less documentation than before.

What codes are y’all using for child evals with this? Could you not use 99204 + 90833 + 90785 + extended time code?
Click to expand...
I think in order to bill time based service using both 99214+90833 would be 30min minimum for 99214 now + 16 minute for 90833 which means even if they allow using both your appointments has to be scheduled at least for 46 min.
 
RomanticScience said:
Medical Decision Making

No obstacles to the treatment agreement/frame.

1. Recurrent-Depression (Unipolar): New/Est chronic/acute condition (description of the overall dx/formulation/course [eg, 3-MDEs +/- hypomania?]) with mild/moderate/severe exacerbation (what is going on now [eg, acute MDE/subsyndromal MDE/euthymia with residual insomnia]. BPAD risk factors or course modifiers. Further work-up planned (HAMD, 5). Cont. lexapro [continuation phase].
2. Secondary anxiety: " " Cont. lorazepam prn.
3. Suicide risk (low): Protective factors (list them) more compelling than risk factors (list them) and justify OP level of care as least restrictive.

Built from attached.
Click to expand...
If there were an award for excellence in helpful highlighting of a .pdf, I'd nominate this work.
 
calvnandhobbs68 said:
Eh I mean in those situations it'd be like an inpatient ortho billing for PT or inpatient ENT trying to bill for speech therapy (if they knew how to do this...didn't say they actually do) when they're already seeing those specialities for the allowable billable time per week. For most therapy services you can't bill for the same service too close together with insurance.

I wonder more if people don't do the add-ons in outpatient because they're just not aware of them/think they're going to reimburse too poorly to be worth their time or don't know how to document them. I see few attendings and/or residents billing therapy add-ons and they didn't seem aware it was even a thing. Also there are definitely EMRs which are not very conducive to trying to organize the note to even document and bill the add-on without it being a pain. We just had a whole billing lecture talking about the therapy add-on and it didn't seem that many people had been utilizing them.
Click to expand...
For most of my inpatient encounters I think I could very easily bill an add-on therapy code for most patients but I just choose not to. I‘m just too lazy and don’t really have much incentive to do so. I’ll do it for patients that I’m truly doing primary psychotherapeutic work or if an encounter is quite long and psychotherapeutic in nature, but I don’t bother in most circumstances.

In our outpatient clinic, the note template includes, by default, a section documenting psychotherapy. I don’t know what people are actually billing, but I imagine that most of the MDs are utilizing psychotherapy add-on codes for essentially every encounter.
 
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