99213 vs 99214 with add on code for therapy?

[tr]

lol I'm gonna be real and go out on a limb and say I consider myself providing much more value doing 20 minutes of introducing the principles of automatic thinking, reviewing an automatic thought worksheet and giving the patient homework to identify automatic thoughts to discuss at our followup visit than I see some therapists doing in 50 minute visits

I have somebody coming in for ERP right now who invariably finishes her sessions in 30 minutes. She has an outside therapist for supportive/whatever they are doing in there so she doesn't spend a single minute talking about her parents, her dog, or whatever. She comes in, we review her homework (which she always does), maybe do a YBOCS, refer to her SUDS scale and arrange homework for next time, she does a therapist eval, it's always good, and we're done in 30 min. She's made a ton of progress in four sessions so far. I always block an hour for therapy sessions but I'm seriously thinking about booking her for 30 minute slots going forward.

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[WisNeuro]

I have somebody coming in for ERP right now who invariably finishes her sessions in 30 minutes. She has an outside therapist for supportive/whatever they are doing in there so she doesn't spend a single minute talking about her parents, her dog, or whatever. She comes in, we review her homework (which she always does), maybe do a YBOCS, refer to her SUDS scale and arrange homework for next time, she does a therapist eval, it's always good, and we're done in 30 min. She's made a ton of progress in four sessions so far. I always block an hour for therapy sessions but I'm seriously thinking about booking her for 30 minute slots going forward.

There are definitely the outlier patients. For example, traditional PE sessions are generally 90 minutes. But, some patients can grasp concepts and move through things at a good clip and get it slightly under an hour. Those were the exception rather than the rule IME, and at least for the first several sessions, we were still generally going full time as we laid the groundwork for the treatment.

 

[rjs2131]

From someone who has a pretty extensive therapy training background. The thought of considering 16 minutes of something to be actual therapy and being able to bill for it seems almost criminal to me.

You're probably right when you consider formal therapeutic modalities, how they should be done, how much time is usually needed to incorporate structured therapy, etc. That said (and like others have mentioned), I think psychiatrists are uniquely suited to use therapy add-on codes and I view them as an opportunity to spend more time with patients. It may not be formal therapy, but I see a lot of benefit in this extra time and it's pretty easy to incorporate principles of CBT, MI, PMT, etc during a visit. This can often help patients begin to think about "non-medication" approaches to their treatment before they can get into weekly-biweekly therapy. I also think if you took a look at the patient panel of a psychiatrist who spends 30 min with each patient vs 15-20 min, there's a good chance the former has a higher treatment success rate.

All of that aside - these codes are really just a game insurance companies created anyway, so I think it's a win-win to play the game, spend more time with patients and get reimbursed for your time vs hesitating to use 90833/90836 because you worry "is what I actually did therapy".

 

[WisNeuro]

You're probably right when you consider formal therapeutic modalities, how they should be done, how much time is usually needed to incorporate structured therapy, etc. That said (and like others have mentioned), I think psychiatrists are uniquely suited to use therapy add-on codes and I view them as an opportunity to spend more time with patients. It may not be formal therapy, but I see a lot of benefit in this extra time and it's pretty easy to incorporate principles of CBT, MI, PMT, etc during a visit. This can often help patients begin to think about "non-medication" approaches to their treatment before they can get into weekly-biweekly therapy. I also think if you took a look at the patient panel of a psychiatrist who spends 30 min with each patient vs 15-20 min, there's a good chance the former has a higher treatment success rate.

All of that aside - these codes are really just a game insurance companies created anyway, so I think it's a win-win to play the game, spend more time with patients and get reimbursed for your time vs hesitating to use 90833/90836 because you worry "is what I actually did therapy".

I think it's more of a win-neutral in actual practice, generally speaking, favoring the provider. Just look at the number of threads asking how to use the least amount of time to maximize billing. I think there are some good psychiatrists there doing some actual 30 min chunks of therapy. Id bet there are far more providers out there killing time to get to the 16 minute mark and shuffling people out the door.

 

[nexus73]

I think it's more of a win-neutral in actual practice, generally speaking, favoring the provider. Just look at the number of threads asking how to use the least amount of time to maximize billing. I think there are some good psychiatrists there doing some actual 30 min chunks of therapy. Id bet there are far more providers out there killing time to get to the 16 minute mark and shuffling people out the door.

You sound pretty biased against psychiatrists based on some web forum threads.

 

[tr]

I think it's more of a win-neutral in actual practice, generally speaking, favoring the provider. Just look at the number of threads asking how to use the least amount of time to maximize billing. I think there are some good psychiatrists there doing some actual 30 min chunks of therapy. Id bet there are far more providers out there killing time to get to the 16 minute mark and shuffling people out the door.

I have to say I agree with this. 90833 is not '16 minutes,' it's an add-on code for a psychotherapeutic intervention that could take anywhere from 16-37 minutes. The intent seems to be to reimburse for approximately half an hour of psychotherapy in addition to med management, presumably in a visit that might have lasted anywhere from 30-60 minutes, with wiggle room for understanding that the med management portion of the visit could have taken a variable period of time.

Somehow that came to be understood as 'as long as I have spent at least 16 minutes with the patient and asked them about their day I can bill this add-on therapy code.'

 

[WisNeuro]

You sound pretty biased against psychiatrists based on some web forum threads.

Comes from real world experience. I have a handful of excellent ones that I refer out to often, but many more that I wouldn't touch with a ten foot pole. For what it's worth, I'm biased against a lot of psychologists too. You can see that from many threads as well. I'd argue I'm just biased against providers who do more harm than good.

I have to say I agree with this. 90833 is not '16 minutes,' it's an add-on code for a psychotherapeutic intervention that could take anywhere from 16-37 minutes. The intent seems to be to reimburse for approximately half an hour of psychotherapy in addition to med management, presumably in a visit that might have lasted anywhere from 30-60 minutes, with wiggle room for understanding that the med management portion of the visit could have taken a variable period of time.

Somehow that came to be understood as 'as long as I have spent at least 16 minutes with the patient and asked them about their day I can bill this add-on therapy code.'

Exactly. And, I know good providers who will spend the time and do some actual interventions. I just know more who make sure they're getting enough on the clock to bill and couldn't adequately describe how to do an EBT/EST to save their lives. This isn't exclusive to psychiatry, or even MH. Our healthcare system is set up to bill the most you can, for the least amount of effort you can put it. It's only inevitable that a large proportion of providers will fall in line with that mentality.

 

[nexus73]

Comes from real world experience. I have a handful of excellent ones that I refer out to often, but many more that I wouldn't touch with a ten foot pole. For what it's worth, I'm biased against a lot of psychologists too. You can see that from many threads as well. I'd argue I'm just biased against providers who do more harm than good.



Exactly. And, I know good providers who will spend the time and do some actual interventions. I just know more who make sure they're getting enough on the clock to bill and couldn't adequately describe how to do an EBT/EST to save their lives. This isn't exclusive to psychiatry, or even MH. Our healthcare system is set up to bill the most you can, for the least amount of effort you can put it. It's only inevitable that a large proportion of providers will fall in line with that mentality.

I’m curious how many psychologists and masters level therapists are billing 90837 for 53+ minutes when the 45 minute hour has become more the norm. Are they just trying to extend to exactly 53 minutes and rush the client out so they can have 7 minutes before the next client shows up. It seems actually spending 60 minutes with a client would be pretty inconvenient with zero time in between appointments.

 

[nexus73]

Personally I have 40 minute appointments for med mgmt and therapy. Works well for me.

 

[WisNeuro]

I’m curious how many non psychologists and masters level therapists are billing 90837 for 53+ minutes when the 45 minute hour has become more the norm. Are they just trying to extend to exactly 53 minutes and rush the client out so they can have 7 minutes before the next client shows up. It seems actually spending 60 minutes with a client would be pretty inconvenient with zero time in between appointments.

Probably depends on their region and payer sources. Some payers will audit more often, or require more extensive documentation, if the proportion of 837 is high compared to 834.

 

[tr]

I’m curious how many non psychologists and masters level therapists are billing 90837 for 53+ minutes when the 45 minute hour has become more the norm. Are they just trying to extend to exactly 53 minutes and rush the client out so they can have 7 minutes before the next client shows up. It seems actually spending 60 minutes with a client would be pretty inconvenient with zero time in between appointments.

I schedule my patients back to back in 30, 60, or 90 minute (intake) slots. It's just not an efficient use of time to put little blocks of dead time everywhere in my day. If I have room to spare on my RVU/billing target I'd rather take that in a chunk and put it to use at another time.

 

[splik]

I’m curious how many psychologists and masters level therapists are billing 90837 for 53+ minutes when the 45 minute hour has become more the norm. Are they just trying to extend to exactly 53 minutes and rush the client out so they can have 7 minutes before the next client shows up. It seems actually spending 60 minutes with a client would be pretty inconvenient with zero time in between appointments.

in many areas plans either won't pay for 90837 or will pay the same for 90834 as 90837. In some cases they might pay less for 90837 than for 90834!! I actually have thing with Cigna, they pay me more more for 90836 than 90838, presumably because they don't want to cover it or encourage those longer sessions. Like tr, I schedule back to back appts, which are usually 60mins for follow ups though I tend to end at the 57-58 min mark. It would be nice to have some time in between patients, but this is the price I pay for not seeing pts before 10.

 

[rjs2131]

I think it's more of a win-neutral in actual practice, generally speaking, favoring the provider. Just look at the number of threads asking how to use the least amount of time to maximize billing. I think there are some good psychiatrists there doing some actual 30 min chunks of therapy. Id bet there are far more providers out there killing time to get to the 16 minute mark and shuffling people out the door.

Definitely depends on the psychiatrist but I don't doubt this. As others have mentioned, the same logic applies to other physicians, psychologists, therapists, etc - none of us are 100% selfless and compensation matters. I also don't see anything wrong with this if quality care is being provided (vs maximizing volume and shuffling people in and out, which does happen more frequently than it should). At the end of the day we're all individuals that are playing by rules created by insurance companies, so I see no problem maximizing your income as long as you're practicing above the standard of care. Undercoding ultimately benefits the insurance company more than anyone else.