90833 add on

[Sushirolls]

I'm curious if any FM have billed the therapy add on code 90833 to the usual E&M 9921(3-5)? Has insurance reimbursed you for it?

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[VA Hopeful Dr]

No, since we don't tend to do therapy.

Wouldn't this question be better suited to the Psychiatry forum?

 

[Mad Jack]

Potential pitfall in Medicare billing: psychotherapy in conjunction with an evaluation and management service

Potential pitfall in Medicare billing: psychotherapy in conjunction with an evaluation and management service

www.aafp.org

In psych we do it all the time but it's easy to justify in our documentation. Here's a link that discusses the basics in FM. I'd imagine one must be very careful outside of psych if you're billing these regularly to ensure that you document the type of therapy provided, duration of therapy, and subject matter addressed to ensure you're not getting rejections or audits left and right

 

[deleted87716]

Most FPs just use time-based billing for that stuff. I've been told therapy codes won't be reimbursed unless you're psych.

https://tinyurl.com/yb3frpa5

 

[vistaril]

I'm curious if any FM have billed the therapy add on code 90833 to the usual E&M 9921(3-5)? Has insurance reimbursed you for it?

this doesn't make any sense. Im a psych, and this is something(when I did outpt) I would just tack on for every med mgt visit to make the compensation more appropriate. But I don't see how a non-psych could do it. it is used just for psych.

This would be like me trying to throw in a code for an I and D, I'm a psych; what the hell do I know about an I and D? (even if I did one during the visit.....and if I did do well, why the hell did I do one?)

 

[Sushirolls]

No, since we don't tend to do therapy.

Wouldn't this question be better suited to the Psychiatry forum?

No this question wouldn't be more appropriate for psych. With intention, I posted it here for the real world experience of FM. I am specifically trying to ascertain if non-Psychiatry based taxonomic physicians have attempted to bill and been successful with this add on code. An FM could drop this code for numerous reasons.

 

[Sushirolls]

this doesn't make any sense. Im a psych, and this is something(when I did outpt) I would just tack on for every med mgt visit to make the compensation more appropriate. But I don't see how a non-psych could do it. it is used just for psych.

This would be like me trying to throw in a code for an I and D, I'm a psych; what the hell do I know about an I and D? (even if I did one during the visit.....and if I did do well, why the hell did I do one?)

It makes perfect sense when you realize that Psychiatrists aren't the only ones doing therapy. Just tacking it on is sloppy, and likely rife with billing fraud. Pointedly adding it on, and documenting the necessary metrics is something that not every visit meets. I've seen enough collateral records cross my eyes to know that simply checking 90833 or dropping the code on a billing sheet is insufficient.

It is an E&M code, and thus far I have not read anything that clearly states it is only for Psych. My understanding is any E&M code is billable by any physician, but it is the insurance contracts that dictate the compensation. So my question again, have any FM billed for this and been paid?

 

[Sushirolls]

Most FPs just use time-based billing for that stuff. I've been told therapy codes won't be reimbursed unless you're psych.

https://tinyurl.com/yb3frpa5

Thanks for that. Seems a bit dated with the ICD-9 and DSM-IV-TR tossed in there. I did note the comment about advising against PCPs from billing psych codes but it didn't necessarily say why.

I could understand perhaps a psych new eval code 90872, but I'm still not buying why an FM couldn't appropriately document and submit for 90833 add on.

 

[deleted87716]

Thanks for that. Seems a bit dated with the ICD-9 and DSM-IV-TR tossed in there. I did note the comment about advising against PCPs from billing psych codes but it didn't necessarily say why.

I could understand perhaps a psych new eval code 90872, but I'm still not buying why an FM couldn't appropriately document and submit for 90833 add on.

 

[vistaril]

Thanks for that. Seems a bit dated with the ICD-9 and DSM-IV-TR tossed in there. I did note the comment about advising against PCPs from billing psych codes but it didn't necessarily say why.

I could understand perhaps a psych new eval code 90872, but I'm still not buying why an FM couldn't appropriately document and submit for 90833 add on.

ummm....because an FM doesn't have training in psychiatry and is not a psychiatrist?

I don't try to bill for things a lot of the things a family medicine is trained to do and does.

 

[vistaril]

It makes perfect sense when you realize that Psychiatrists aren't the only ones doing therapy. Just tacking it on is sloppy, and likely rife with billing fraud. Pointedly adding it on, and documenting the necessary metrics is something that not every visit meets. I've seen enough collateral records cross my eyes to know that simply checking 90833 or dropping the code on a billing sheet is insufficient.

It is an E&M code, and thus far I have not read anything that clearly states it is only for Psych. My understanding is any E&M code is billable by any physician, but it is the insurance contracts that dictate the compensation. So my question again, have any FM billed for this and been paid?

1) Psychiatrists are the only physician level providers doing therapy(therapy isn't simply talking to people about certain things). Many of the cases where a family medicine physician does spend time talking to a patient about something, that would be more appropriately billed under some sort of patient education I would bet, or a time-based thing.
2) No, it's not sloppy(and certainly not billing fraud) for an outpatient psychiatrist to tack it on most every outpatient visit. The visits are *set up* for that very purpose. I don't do outpatient now, but I incorporated supportive therapy into every appt as there is almost always an opportunity to do this. And in the thousands of times I did this when I did outpatient, it was challenged exactly zero times. So so much for billing fraud. But thanks for education from someone in another specialty on how I should bill in my specialty.
3) You are right that insurance is going to ultimately decide what is paid, and I'm pretty sure they would balk at a family medicine physician throwing down a therapy add on code. Family medicine physician don't have training in this, so there is no reason to bill it. I don't have training in a heck of a lot of things you guys do, so that's why I don't do those codes.

This whole line of thinking/questioning(as the family medicine providers here have pointed out and are equally perplexed by) is bizarre and almost troll-like.

 

[vistaril]

Thanks for that. Seems a bit dated with the ICD-9 and DSM-IV-TR tossed in there. I did note the comment about advising against PCPs from billing psych codes but it didn't necessarily say why.

ummmm...because you don't have training in psych? Just like I don't try submitting codes for a bunch of stuff I don't do and don't have training in.

 

[vistaril]

Note that I was able to do the 90833 for > 95% of patients with full approval from insurers because they knew I wasn't scheduling 5-6 pts an hour or whatever.
You guys are seeing more patients than a typical outpt psych(even one who is considered mostly med mgt outpt), so the numbers arent going to work financially without the add on code.
You guys are seeing 5-6 patients an hour in many cases I believe. When I did outpt, I was seeing 3 patients an hour(for f/us). The 90833 I used was a reflection of that.....billing 99214 + 90833(which was probably the combo on 90% of the patients, there was a very rare 99215 or 99213) at 3 patients an hour probably came out about the same as billing 4.7 or so 99214's an hour.

So it really comes out about the same.
Had I scheduled patients like 5 an hour, I wouldnt have done the 90833(because I wouldnt have done it)

In mental health outpatient a lot of times you dictate what service you are going to provide routinely as opposed to the line of thinking being "the patient is here, what level of service do they need?". It's just the nature of the practice, and insurers know that. If patients wanted to go somewhere where they would get an hour of psychodynamic therapy, they shouldn't go to my practice at the time. Likewise if patients wanted to go somewhere where they would be in and out with their refill in 2 mins without having to talk at all, same.....

it's just the way the practice was set up, and you'll see that most outpt practices are set up in that way. Insurers know and understand that reality.

 

[PikminOC]

Thanks for that. Seems a bit dated with the ICD-9 and DSM-IV-TR tossed in there. I did note the comment about advising against PCPs from billing psych codes but it didn't necessarily say why.

I could understand perhaps a psych new eval code 90872, but I'm still not buying why an FM couldn't appropriately document and submit for 90833 add on.

I thought you were a psychiatrist?

 

[VA Hopeful Dr]

No this question wouldn't be more appropriate for psych. With intention, I posted it here for the real world experience of FM. I am specifically trying to ascertain if non-Psychiatry based taxonomic physicians have attempted to bill and been successful with this add on code. An FM could drop this code for numerous reasons.

Yes it would because non-psych physicians almost never do therapy.

 

[InvestingDoc]

I'm curious if any FM have billed the therapy add on code 90833 to the usual E&M 9921(3-5)? Has insurance reimbursed you for it?

Yes, Since 4/1/2020 I billed for it 26 times and on average it pays me ~$66. This is in addition to my 99214 code.

I only bill for it when I talk to patients about non pharm ways extensively to help with their psych symptoms. I have a pretty big focus on mental health and see a lot of anxiety and depression in my office. I'm by no means an expert (psychologist) but love to talk about mindfulness and even did some exposure based therapy where someone was deathly afraid of stairs and we built up to taking the stairs down to the ground level to get a coffee.

The basics for CBT for anxiety are not that hard to talk about. Deep breathing, “I've done this before, just take deep breaths" etc.

I document like crazy what I talked about CBT wise and even if I get audited I've never had a claim reversed.

 

[Sushirolls]

Yes, Since 4/1/2020 I billed for it 26 times and on average it pays me ~$66. This is in addition to my 99214 code.

I only bill for it when I talk to patients about non pharm ways extensively to help with their psych symptoms. I have a pretty big focus on mental health and see a lot of anxiety and depression in my office. I'm by no means an expert (psychologist) but love to talk about mindfulness and even did some exposure based therapy where someone was deathly afraid of stairs and we built up to taking the stairs down to the ground level to get a coffee.

The basics for CBT for anxiety are not that hard to talk about. Deep breathing, “I've done this before, just take deep breaths" etc.

I document like crazy what I talked about CBT wise and even if I get audited I've never had a claim reversed.

Investing Doc, thank you. Thank you for a quality response and positive addition to what the purpose of this thread is.

By chance is this broad spectrum insurance or was this more focused on one or two insurance? I'm trying to gauge if any patterns can be noted from your limited sample.

Contrary to some of the earlier Nay Sayers, I commend you and support your application of this add on code. And for Vistaril's sake, I say this as a Psychiatrist...

 

[Sushirolls]

View attachment 305887

Why? So you get paid for the work and services you perform. That is why enough.

 

[VA Hopeful Dr]

Why? So you get paid for the work and services you perform. That is why enough.

That's why not. It is quite rare for PCPs to do any psychiatric therapy. I'm sure there are some who do (like the above poster) but I would guess that probably 95+% of us don't.

Its the same reason I don't bill for extended ophthalmoscopy (which is also an add-on code to E&M) - because I don't do it.

 

[Sushirolls]

That's why not. It is quite rare for PCPs to do any psychiatric therapy. I'm sure there are some who do (like the above poster) but I would guess that probably 95+% of us don't.

Its the same reason I don't bill for extended ophthalmoscopy (which is also an add-on code to E&M) - because I don't do it.

The very first post was for those who have. You have made it very clear you don't and won't.

 

[InvestingDoc]

Investing Doc, thank you. Thank you for a quality response and positive addition to what the purpose of this thread is.

By chance is this broad spectrum insurance or was this more focused on one or two insurance? I'm trying to gauge if any patterns can be noted from your limited sample.

Contrary to some of the earlier Nay Sayers, I commend you and support your application of this add on code. And for Vistaril's sake, I say this as a Psychiatrist...

Seems like all across the board have paid but some of course went towards high deductible plans and those patients have not paid me yet.

 

[Candidate2017]

Why? So you get paid for the work and services you perform. That is why enough.

90833 requires 16 minutes. FM can finish a 99214 visit and note in 12 minutes or less, and move on to the next COPD, DM, CHF, HTN patient.

 

[Sushirolls]

Seems like all across the board have paid but some of course went towards high deductible plans and those patients have not paid me yet.

Thank you again.

 

[InvestingDoc]

90833 requires 16 minutes. FM can finish a 99214 visit and note in 12 minutes or less, and move on to the next COPD, DM, CHF, HTN patient.

Very true. I only ever bill for it when it encounter takes way longer than I was expecting and it is not can a quite hit that 99215 level. So I done the 99214+ this code.

 

[vistaril]

Yes, Since 4/1/2020 I billed for it 26 times and on average it pays me ~$66. This is in addition to my 99214 code.

I only bill for it when I talk to patients about non pharm ways extensively to help with their psych symptoms. I have a pretty big focus on mental health and see a lot of anxiety and depression in my office. I'm by no means an expert (psychologist) but love to talk about mindfulness and even did some exposure based therapy where someone was deathly afraid of stairs and we built up to taking the stairs down to the ground level to get a coffee.

The basics for CBT for anxiety are not that hard to talk about. Deep breathing, “I've done this before, just take deep breaths" etc.

I document like crazy what I talked about CBT wise and even if I get audited I've never had a claim reversed.

Im curious- when/how did you get CBT training? I've never met a family medicine physician that ever trained in this....

 

[Sushirolls]

There are CME courses.
There are apps patients can use.
There are books.

Strike up some conversations at CME conferences, you'll realize not all at the APA are Psychiatrists.

 

[vistaril]

There are CME courses.
There are apps patients can use.
There are books.

Strike up some conversations at CME conferences, you'll realize not all at the APA are Psychiatrists.

I guess....but the same could be said for pretty much anything.

I mean I can watch a video on someone draining an abcess. I don't think that means I should then go out and do it and code for it. After all, I've never had any training in that after med school.

I don't think the family medicine docs want us draining abcesses, and I think most psychs wouldn't be keen on most family medicine docs providing therapy based on some books they read or an app or youtube or whatever.

 

[VA Hopeful Dr]

I guess....but the same could be said for pretty much anything.

I mean I can watch a video on someone draining an abcess. I don't think that means I should then go out and do it and code for it. After all, I've never had any training in that after med school.

I don't think the family medicine docs want us draining abcesses, and I think most psychs wouldn't be keen on most family medicine docs providing therapy based on some books they read or an app or youtube or whatever.

And more importantly, we don't even have the proper foundation to learn how to do therapy.

I've done procedures and managed conditions I didn't learn in residency but I had the background to build on so it didn't require a whole new skill set.

 

[hallowmann]

That's why not. It is quite rare for PCPs to do any psychiatric therapy. I'm sure there are some who do (like the above poster) but I would guess that probably 95+% of us don't.

Its the same reason I don't bill for extended ophthalmoscopy (which is also an add-on code to E&M) - because I don't do it.

I think more FM docs practice methods of psychotherapy than you imply, but I do doubt many really hit the time component necessary with that. Brief interventions and abridged MI abound in primary care, but they are not lengthy due to the nature of the primary care visit.

90833 requires 16 minutes. FM can finish a 99214 visit and note in 12 minutes or less, and move on to the next COPD, DM, CHF, HTN patient.

Yup, exactly.

And more importantly, we don't even have the proper foundation to learn how to do therapy.

I've done procedures and managed conditions I didn't learn in residency but I had the background to build on so it didn't require a whole new skill set.

I think this really depends on the individual. You have RNs, BS in Psych, NPs, and obviously plenty of LISWs doing therapy. Many people have worked in the area prior to med school, have other advanced degrees, or just have a sufficient enough interest that they've made it a focus of their training/education. FM programs also emphasize behavioral health to a varied degree - some much more than others.

I agree that the number actually doing formal therapy for a sufficient amount of time with patients is likely very small, but don't sell FM training short. I think if this was something you wanted to pursue you could have developed the foundational training necessary to do it, just like you did with some of those procedures. It would only really be worth it if it was something you were interested in though, like anything else.

 

[deleted87716]

I think more FM docs practice methods of psychotherapy than you imply, but I do doubt many really hit the time component necessary with that. Brief interventions and abridged MI abound in primary care, but they are not lengthy due to the nature of the primary care visit.



Yup, exactly.



I think this really depends on the individual. You have RNs, BS in Psych, NPs, and obviously plenty of LISWs doing therapy. Many people have worked in the area prior to med school, have other advanced degrees, or just have a sufficient enough interest that they've made it a focus of their training/education. FM programs also emphasize behavioral health to a varied degree - some much more than others.

I agree that the number actually doing formal therapy for a sufficient amount of time with patients is likely very small, but don't sell FM training short. I think if this was something you wanted to pursue you could have developed the foundational training necessary to do it, just like you did with some of those procedures. It would only really be worth it if it was something you were interested in though, like anything else.

But, you still probably won't be able to bill/get paid for therapy codes.

 

[hallowmann]

But, you still probably won't be able to bill/get paid for therapy codes.

Haha, fair enough. Probably true except as noted above by @InvestingDoc .

 

[deleted87716]

Haha, fair enough. Probably true except as noted above by @InvestingDoc .

Yeah, but coding for it is one thing. Getting paid is another. Plus, there's a chance that it could flag an audit if you do it often enough. Once an insurance company or (worse) CMS is going through your charts, may God have mercy on your soul.

 

[TableMD]

It seems reasonable to do therapy as an FP, with the right training. With that said, are you seeing them frequently enough for it to work, or is it bridge to creating buy in for working with a more consistent therapist? Like the rest of us, I use supportive language in addressing health issues, but I cant do it on a weekly basis....

 

[Reboa]

Is it possible to offer an upfront cash Model like many psychiatrists currently do maybe? Just avoid insurance completely.

 

[InvestingDoc]

Yeah, but coding for it is one thing. Getting paid is another. Plus, there's a chance that it could flag an audit if you do it often enough. Once an insurance company or (worse) CMS is going through your charts, may God have mercy on your soul.

I would bet that you get audited all the time and just don't know it.

Almost every two weeks, insurance companies request records to audit random records that we have submitted to make sure we are not over billing.

I think once in the last year have I actually had to pay money back to the insurance companies as they felt I over billed. My biller has worked for a surgical office, a sleep medicine office, and another primary care office and she tells me this is very standard. My last biller that I had also tells me the same thing. The biller that I'm friends with who is a biller for surgeon tells me the same thing. They always do these random requests to audit you to make sure you are not overbilling. it is happening all the time.

Unless your biller is having these conversations with you, I can almost guarantee that weekly or at least monthly insurance companies are auditing what you are submitting and just faxing the request for patient records to the insurance company.

I've even billed for Annual physical with a Z00.01 Modifier and an acute care visit code such as a 99213 and its paid out. I get audited almost every time I bill it, every single time that looking my documentation and pay

 

[deleted87716]

I would bet that you get audited all the time and just don't know it.

Dunno. I've never had to pay back anything for overbilling, though. Once that happens, I imagine you're going to get audited more frequently.

 

[InvestingDoc]

Dunno. I've never had to pay back anything for overbilling, though. Once that happens, I imagine you're going to get audited more frequently.

You usually don't have to physically write a check if they ask for you to pay it back. The insurance company sends your biller a notice to "recoup" electronically and they just deduct it from a future payment if you don't write a check within a certain timeframe. If that ever happens to us, we appeal and have won the appeal every time but once.

 

[deleted87716]

You usually don't have to physically write a check if they ask for you to pay it back. The insurance company sends your biller a notice to "recoup" electronically and they just deduct it from a future payment if you don't write a check within a certain timeframe. If that ever happens to us, we appeal and have won the appeal every time but once.

I would still know if it happened.

 

[VA Hopeful Dr]

I would still know if it happened.

No kidding. There is no way my corporate overlords would get a smaller-than-expected check and not let me know that it was my fault.

 

[deleted87716]

No kidding. There is no way my corporate overlords would get a smaller-than-expected check and not let me know that it was my fault.

Yeah, our docs are even charged back for labs performed at our central lab that get denied because of inappropriate coding (lack of medical necessity). The most common ones some people (not me) get nailed for are HgbA1c and vitamin D.

 

[VA Hopeful Dr]

Yeah, our docs are even charged back for labs performed at our central lab that get denied because of inappropriate coding (lack of medical necessity). The most common ones some people (not me) get nailed for are HgbA1c and vitamin D.

Outside of osteoporosis or previously diagnosed vitamin D deficiency, I have given up on ordering Vitamin D for just that reason. It never gets paid for.

 

[hallowmann]

Outside of osteoporosis or previously diagnosed vitamin D deficiency, I have given up on ordering Vitamin D for just that reason. It never gets paid for.

How are people supposed to be diagnosed with Vit D deficiency without it being checked? This is the type of stupid crap that makes people hate our healthcare system. I get that its checked too often, but just put limits on how frequently something can be checked and be done with it. Blanket not covering it is stupid. I didn't know my Vit D was in the single digits until my PCP figured he would check.

/rant

 

[deleted87716]

How are people supposed to be diagnosed with Vit D deficiency without it being checked? This is the type of stupid crap that makes people hate our healthcare system. I get that its checked too often, but just put limits on how frequently something can be checked and be done with it. Blanket not covering it is stupid. I didn't know my Vit D was in the single digits until my PCP figured he would check.

/rant

Well, the benefits of screening for vit. D deficiency have probably been overblown, anyway.

Vitamin D Screening and Supplementation in Primary Care: Time to Curb Our Enthusiasm