99212+90838

[roastedcapers]

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Hello. I have gotten very mixed feedback on the best way to code for weekly hour long psychotherapy visits with patients for whom I am also managing medications.

I've decided, though still wanting feedback if anyone has any, that the best way to generally code these sessions is 99212+90838. A 99213 every single week seems way beyond medical necessity for most people. This makes sense because 99212=you are acknowledging your role as their med provider and 90838 because you are spending >53 mins on therapy. This pays about 20% better than a 90837 and just prescribing meds probably requires on average 20% more time than just doing therapy for 60 mins.

My goal: get paid the most while avoiding audits and generally following ethics/sensical/fair guidelines around MDM and medical necessity.

 

[Stagg737]

The more experienced can correct me, but if you're titrating meds or changing them I'd think you could bill 99213 multiple weeks in a row. You could also probably do multiple 99213's if your patients are walking disasters requiring high levels of attention to multiple diagnoses. Would be interested in other's thoughts as well though.

 

[clozareal]

I agree with Stagg737. I've been doing mostly 99214+90836 for my 45 minute therapy appointments. I don't think I'd be doing therapy for patients who would fit the bill for 99213 as they'd probably do okay with monthly med management visits or less. Don't sell yourself short as every therapy appointment you have with a patient, you are keeping in the back of your mind an evaluation about what to do about medications. This is what I was taught to do anyways.

For 99214, I usually document based on history and medical complexity, not exam.
- History requires a chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS. This comes out naturally as part of the therapy process.
- Medical complexity (3 problem points + moderate complexity, data points is tougher to get): problem points include 2 minor/self-limited problems and one main diagnosis which is pretty simple and moderate complexity risk is being documented with two stable chronic illnesses which is the easiest.

For 90836, I make sure to document how much time I spent doing therapy (somewhere between 38-52 minutes) with the patient. I usually just put 40 minutes.

 

[Attending1985]

I agree with Stagg737. I've been doing mostly 99214+90836 for my 45 minute therapy appointments. I don't think I'd be doing therapy for patients who would fit the bill for 99213 as they'd probably do okay with monthly med management visits or less. Don't sell yourself short as every therapy appointment you have with a patient, you are keeping in the back of your mind an evaluation about what to do about medications. This is what I was taught to do anyways.

For 99214, I usually document based on history and medical complexity, not exam.
- History requires a chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS. This comes out naturally as part of the therapy process.
- Medical complexity (3 problem points + moderate complexity, data points is tougher to get): problem points include 2 minor/self-limited problems and one main diagnosis which is pretty simple and moderate complexity risk is being documented with two stable chronic illnesses which is the easiest.

For 90836, I make sure to document how much time I spent doing therapy (somewhere between 38-52 minutes) with the patient. I usually just put 40 minutes.

So you’re billing for 40 minutes of therapy with 5 minutes dedicated to the 99214?

 

[roastedcapers]

I don't think I'd be doing therapy for patients who would fit the bill for 99213 as they'd probably do okay with monthly med management visits or less.

The issue is that I work with "worried well"--people who really could live without weekly therapy. Like, people who are having anxiety at work and we are doing CBT, and they might be on 50 of sertraline and we're just leaving it there for a few weeks. Yes I guess I am in the back of my mind always considering changes.

So, for you long-time private practice folks, how have you billed these sessions over the years and managed to avoid audits and feel good about how you are billing? I've only been billing insurance since Nov. which is why I feel like I'm still kind of feeling around on this topic.

Edit: I suppose, if they came in in crisis, I would up to 99214 and probably decrease therapy time to 90836 if we spend 25 mins talking about medication changes instead of doing therapy. But I'm talking for standard weekly low risk therapy sessions where meds aren't really mentioned much. Also, cool username! Sounds like it could be your rapper name.

 

[romanticscience]

The issue is that I work with "worried well"--people who really could live without weekly therapy. Like, people who are having anxiety at work and we are doing CBT, and they might be on 50 of sertraline and we're just leaving it there for a few weeks. Yes I guess I am in the back of my mind always considering changes.

So, for you long-time private practice folks, how have you billed these sessions over the years and managed to avoid audits and feel good about how you are billing? I've only been billing insurance since Nov. which is why I feel like I'm still kind of feeling around on this topic.

Edit: I suppose, if they came in in crisis, I would up to 99214 and probably decrease therapy time to 90836 if we spend 25 mins talking about medication changes instead of doing therapy. But I'm talking for standard weekly low risk therapy sessions where meds aren't really mentioned much. Also, cool username! Sounds like it could be your rapper name.

Hope this helps. For people who began in acute exacerbation and stabilized with medication + therapy (60-min), I move them to every 2 week (60-min), monthly (mostly 30-min, few 60-min), or every 3-months (30-min). That's how I justify the 99213 (continue meds) or 99214 (change meds). I have a few people who I do 99213 every week but it's usually a complex case of trauma+mood disorder +/- substance use. The easy, stable, "worried well" soon move to every other week or month, once the work is done. I have a hard time with pure psychodynamic therapy without much symptom focus. Now, I do see some people for transference-focused therapy or chronic interpersonal sensitivity, at 2-3x per week. In these cases, I bill 99212+90838, maybe a 99213 here and there, with a symptom check-in.

 

[roastedcapers]

Hope this helps. For people who began in acute exacerbation and stabilized with medication + therapy (60-min), I move them to every 2 week (60-min), monthly (mostly 30-min, few 60-min), or every 3-months (30-min). That's how I justify the 99213 (continue meds) or 99214 (change meds). I have a few people who I do 99213 every week but it's usually a complex case of trauma+mood disorder +/- substance use. The easy, stable, "worried well" soon move to every other week or month, once the work is done. I have a hard time with pure psychodynamic therapy without much symptom focus. Now, I do see some people for transference-focused therapy or chronic interpersonal sensitivity, at 2-3x per week. In these cases, I bill 99212+90838, maybe a 99213 here and there, with a symptom check-in.

That makes a lot of sense, thank you. I guess this is where making sure the therapy is as efficient as possible comes in.

 

[splik]

the E&M code is determined by elements you include and medical necessity. I have a patient I see for twice weekly therapy and used 99214+90838 for all visits. This is the beginning of treatment, the patient is unstable and needs frequent review of meds even if med changes arent being made each session. If you have a patient with 3 or more problems that's a 99214. If they have one acute/unstable problem that's a 99214.

My patients are complicated but it is unlikely most psychiatrists would be doing 99212 unless the patient is so straightforward.

Also note than most HMO plans and some PPO plans (e.g. united) wont pay for 90838 without prior authorization (typically for things like PE or ERP).

 

[clozareal]

So you’re billing for 40 minutes of therapy with 5 minutes dedicated to the 99214?

The E/M codes (e.g., 99214) are based on medical necessity, not time. Determining medical necessity can come out during the therapy session and overlap without an issue with billing.

 

[splik]

The E/M codes (e.g., 99214) are based on medical necessity, not time. Determining medical necessity can come out during the therapy session and overlap without an issue with billing.

This is not quite correct. E&M services must be separately identifiable from psychotherapy services. So yes you are saying if you had a 45 minute session with 40minutes of therapy than only 5 minutes of that was E&M. However, there is nothing to stop your work in therapy informing the E&M. Think of it like this. Imagine a hypothetical patient saw a therapist before your session and you were privy to all the information and documentation from that session. You would be able to spend much less time gathering additional historical, MSE information and medication issues. Under such conditions you may well be able to do a level 4 visit in 5 minutes.