99214 + 90833 getting rejected by UHC due to insufficient visit length

[sighchiatry]

I am out of network in private practice.
My patients submit their superbills to their carrier for reimbursement.

Recently, UnitedHealthCare requested clinical notes for one of my patients to process reimbursement.
I just got off the phone with a rep from UnitedHealthCare who told me that all of my patients notes and reimbursement has been declined.
The specific reason was that my 99214 + 90833 visits took 30 minutes and, according to them, should take at least 45 minutes.

I explained that this is incorrect, I am billing 99214 based on complexity and not based on time, etc
But the rep from UHC told me that I am wrong and that the AMA and other CPT organizations have required minimum time amounts.

I then asked if the time I spend outside of the visit on patient care counts towards hitting their disputed time based metrics and the rep did not believe so.

99214 being time based and work outside the appointment not counting both seem wrong to me.
What is the correct answer?
Is there anything official from CMS or other sources that UHC would accept that I can provide to them to show that they are incorrect so that this goes away?

Thank you.

---

Members don't see this ad.

 

[Sushirolls]

To bill 90833, 99214 must be on complexity.
99214 complexity can be accomplished in 5 minutes or 40 minutes.

90833 is time based.

99214 can be time based after an appointment, and before the appointment, but then if billing on time, it prevents 90833.

The real issue, is this is UHC AND an OON claim submission. They don't want to pay. I remember seeing OON UHC EOBs say patient owes nothing, out of network and doctor is paid nothing. Therefore this helped me to understand I won't submit any claims to any insurance that I am OON with because, no, that is wrong, you can't tell me that I am owed nothing...

UHC is a pain to work with when in network, I'm not surprised they are difficult OON.

I dropped UHC long again, and haven't looked back. But to their credit, there is a reason they are a publicly traded company that also issues dividends and is the biggest of the companied. They also own change healthcare... which hit the news in the past 12 months, for more reasons than being contested in court of UHC could purchase them.

*You should never have even called UHC. After you give the superbill to the patient, that is between them and the patient. Embrace the joy of being OON. If you are OON, be OON. Not your rodeo.

 

[Attending1985]

So they want you to resubmit for a 99214 only in order to pay?

 

[TexasPhysician]

Have the patient or yourself file a claim with the state insurance commission.

United has no contract with you. They are incentivized to deny for any reason. They know the odds of someone appealing or filing a state complaint is low (punishments are also weak).

The medical field doesn’t follow reason. A NP hastily diagnosed bipolar in the past for my patient with TRD. Insurance now refusing to cover Spravato despite meeting all criteria because NP said Bipolar a year ago. Makes no sense.

 

[calvnandhobbs68]

Have the patient or yourself file a claim with the state insurance commission.

United has no contract with you. They are incentivized to deny for any reason. They know the odds of someone appealing or filing a state complaint is low (punishments are also weak).

The medical field doesn’t follow reason. A NP hastily diagnosed bipolar in the past for my patient with TRD. Insurance now refusing to cover Spravato despite meeting all criteria because NP said Bipolar a year ago. Makes no sense.

They also realize that the rules around psychotherapy add on codes are convoluted enough that most doctors don't know the rules, much less a patient trying to figure it out.

Anyway, how about themselves? This is literally from an Optum subsidiary OP....just send a cut of the winnings my way 😉

https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/adminResourcesMain/fwae/emDocumentation.pdf

"Note: Per CPT guidelines, E/M services that are billed with a psychotherapy add-on code (90833,90836, 90838) cannot be billed by time and must be based on MDM components."

But, just pay attention because if you don't meet all their other documentation requirements they may just deny the 90833 anyway so who knows if it's worth your time.

 

[sighchiatry]

To bill 90833, 99214 must be on complexity.
99214 complexity can be accomplished in 5 minutes or 40 minutes.

90833 is time based.

99214 can be time based after an appointment, and before the appointment, but then if billing on time, it prevents 90833.

The real issue, is this is UHC AND an OON claim submission. They don't want to pay. I remember seeing OON UHC EOBs say patient owes nothing, out of network and doctor is paid nothing. Therefore this helped me to understand I won't submit any claims to any insurance that I am OON with because, no, that is wrong, you can't tell me that I am owed nothing...

UHC is a pain to work with when in network, I'm not surprised they are difficult OON.

I dropped UHC long again, and haven't looked back. But to their credit, there is a reason they are a publicly traded company that also issues dividends and is the biggest of the companied. They also own change healthcare... which hit the news in the past 12 months, for more reasons than being contested in court of UHC could purchase them.

*You should never have even called UHC. After you give the superbill to the patient, that is between them and the patient. Embrace the joy of being OON. If you are OON, be OON. Not your rodeo.

UHC is terrible. It is a competition to the be the worst. Agreed that they intentionally make the process painful.
I am going to educate my patient specifically about how UHC is wrong and let the patient handle the appeal and arguing.
Thank you

 

[sighchiatry]

So they want you to resubmit for a 99214 only in order to pay?

They want my 30 minute visit to be a 45 minute visit to substantiate my 99214+90833
They refused to see it any other way besides length of visit.

 

[sighchiatry]

Have the patient or yourself file a claim with the state insurance commission.

United has no contract with you. They are incentivized to deny for any reason. They know the odds of someone appealing or filing a state complaint is low (punishments are also weak).

The medical field doesn’t follow reason. A NP hastily diagnosed bipolar in the past for my patient with TRD. Insurance now refusing to cover Spravato despite meeting all criteria because NP said Bipolar a year ago. Makes no sense.

I love filing with the state. When it works, it is great. A lot of times they can't or won't accept the case if the insurance is provided through the employer. But when they do accept it, smooth sailing. Magically the problem vanishes.
Thank you

 

[sighchiatry]

They also realize that the rules around psychotherapy add on codes are convoluted enough that most doctors don't know the rules, much less a patient trying to figure it out.

Anyway, how about themselves? This is literally from an Optum subsidiary OP....just send a cut of the winnings my way 😉

https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/adminResourcesMain/fwae/emDocumentation.pdf

"Note: Per CPT guidelines, E/M services that are billed with a psychotherapy add-on code (90833,90836, 90838) cannot be billed by time and must be based on MDM components."

But, just pay attention because if you don't meet all their other documentation requirements they may just deny the 90833 anyway so who knows if it's worth your time.

Incredible
This is very helpful and also makes me want to retire
Thank you

 

[DOswag]

Have the patient or yourself file a claim with the state insurance commission.

United has no contract with you. They are incentivized to deny for any reason. They know the odds of someone appealing or filing a state complaint is low (punishments are also weak).

The medical field doesn’t follow reason. A NP hastily diagnosed bipolar in the past for my patient with TRD. Insurance now refusing to cover Spravato despite meeting all criteria because NP said Bipolar a year ago. Makes no sense.

I see this pretty frequently in my clinic when trying to get a patient approved for TMS. No hx of manic symptoms but were diagnosed with bipolar from a brief inpatient stay when they were 14 after throwing a fit at their parent. Haven't been treated with mood stabilizer for 2 decades and come to me as a mid-late 30yr old with clear hx of depression, likely trauma and/or BPD symptoms. TMS gets denied because of their bipolar diagnosis from 20+ years ago...

 

[Jules A]

As an out of network practice I don’t understand the need for multi-tier billing codes especially if it’s going to cause grief. It’s fairly rare that my clients even ask for superbill.

 

[Bartelby]

As an out of network practice I don’t understand the need for multi-tier billing codes especially if it’s going to cause grief. It’s fairly rare that my clients even ask for superbill.

Yeah, so far I code 30-min visits as 99214 for reimbursement for my out of network evals, even though most such encounters could be 99214+90833.

In my employed role where we bill insurance I mainly bill 99214+90833 for 30-min follow ups and have never had any pushback.

 

[sighchiatry]

As an out of network practice I don’t understand the need for multi-tier billing codes especially if it’s going to cause grief. It’s fairly rare that my clients even ask for superbill.

Excellent point.
I do the multi code in a quixotic attempt to maximize my patient's out of network reimbursement.
I would very happily use just a 99214 if I could confirm it would not negatively impact my patient's reimbursement.
I haven't been able to confirm that 99214 would reimburse the patient as well as 99214 + 90833 yet, but I have looked.

 

[Merovinge]

Excellent point.
I do the multi code in a quixotic attempt to maximize my patient's out of network reimbursement.
I would very happily use just a 99214 if I could confirm it would not negatively impact my patient's reimbursement.
I haven't been able to confirm that 99214 would reimburse the patient as well as 99214 + 90833 yet, but I have looked.

Best use of quixotic I have read in a number of years. Thank you for your dedication to your patients.

 

[ridethecliche]

I see this pretty frequently in my clinic when trying to get a patient approved for TMS. No hx of manic symptoms but were diagnosed with bipolar from a brief inpatient stay when they were 14 after throwing a fit at their parent. Haven't been treated with mood stabilizer for 2 decades and come to me as a mid-late 30yr old with clear hx of depression, likely trauma and/or BPD symptoms. TMS gets denied because of their bipolar diagnosis from 20+ years ago...

The medical field doesn’t follow reason. A NP hastily diagnosed bipolar in the past for my patient with TRD. Insurance now refusing to cover Spravato despite meeting all criteria because NP said Bipolar a year ago. Makes no sense.

This is asinine. I'd counter that insurance doesn't follow reason. The fact that they won't let you 'rule out' a diagnosis after decades of evidence to cover a supported treatment is ridiculous. There's got to be a way to meaningfully push back against such nonsense.

 

[sloh]

You probably can push back but insurance companies make it so cumbersome they tend to win just by war of attrition

 

[Merovinge]

You probably can push back but insurance companies make it so cumbersome they tend to win just by war of attrition

It's so frustrating that the American legal system is now a playbook for corporations.

 

[Sushirolls]

Its a playbook for anybody who wants to play.
We could have cheaper lawyers if they were still LLB degrees and not a graduate JD. Another consequence of degree creep.
We could have a cheaper simpler legal system if we weren't so intent on passing more and more laws every year. The opposite of cutting out laws would be liberating for America.

 

[clausewitz2]

Its a playbook for anybody who wants to play.
We could have cheaper lawyers if they were still LLB degrees and not a graduate JD. Another consequence of degree creep.
We could have a cheaper simpler legal system if we weren't so intent on passing more and more laws every year. The opposite of cutting out laws would be liberating for America.

LLB degrees were always graduate degrees in the US

 

[Sushirolls]

@clausewitz2 You're killing me with this possible 'fact check.' I swore lawyers used to be like pharmacists, a bachelor degree in past, and perhaps had requisite of some other undergrad classes but was structurally cheaper and more akin to what we see with MBBS degrees overseas.

 

[Stagg737]

LLB degrees were always graduate degrees in the US

They actually weren’t. They could have been, but a separate UG degree wasn’t required to obtain an LL.B. degree. Chief justice Warren and J Edgar Hoover both only received LL.B. Degrees without other UG degrees.

 

[sighchiatry]

Best use of quixotic I have read in a number of years. Thank you for your dedication to your patients.

It's very meaningful to get a pat on the back once in a while
Thank you

 

[ridethecliche]

Its a playbook for anybody who wants to play.
We could have cheaper lawyers if they were still LLB degrees and not a graduate JD. Another consequence of degree creep.
We could have a cheaper simpler legal system if we weren't so intent on passing more and more laws every year. The opposite of cutting out laws would be liberating for America.

Another sizzlin' sushi hot take!
Any hotter and we'd have to start calling you yakitori!

 

[Psychferlyfe3000]

My practice manager is concerned that I code 99214+90833 for a half-an-hour visit because he likes to bill based only on time it seems. he considers it "more by the book." Are there any resources that show how often this coding combination is used in half-an-hour visits?

 

[calvnandhobbs68]

My practice manager is concerned that I code 99214+90833 for a half-an-hour visit because he likes to bill based only on time it seems. he considers it "more by the book." Are there any resources that show how often this coding combination is used in half-an-hour visits?

As long as you've spent at least 16 minutes on that appointment and consider that to be psychotherapy, you can bill for it. That can mean in the context of an 18, 25, 30, 45min, whatever appointment. It's up to you how much you want to justify that you did a "moderate" amount of MDM in the remaining time.

I will say that plenty of other specialities bill 99214s for <15 minute face to face appointments all the time. The time criteria for E+M codes have always been more generous than the MDM criteria, even before the 2021 changes. Also, let your practice manager know that you literally cannot bill 90833s when billing based on time, as noted in the link above.

 

[Merovinge]

As long as you've spent at least 16 minutes on that appointment and consider that to be psychotherapy, you can bill for it. That can mean in the context of an 18, 25, 30, 45min, whatever appointment. It's up to you how much you want to justify that you did a "moderate" amount of MDM in the remaining time.

I will say that plenty of other specialities bill 99214s for <15 minute face to face appointments all the time. The time criteria for E+M codes have always been more generous than the MDM criteria, even before the 2021 changes. Also, let your practice manager know that you literally cannot bill 90833s when billing based on time, as noted in the link above.

Most subspecialty surgeons are booked 6/hour f/us of which the majority are 99214s. If your office manager isn't comfortable with this, I would not be comfortable with your office manager.

Edit: whoops replied to the wrong person, clearly calvinnhobbs knows this.

 

[nexus73]

I've never heard anyone billing solely on time outside of psychiatry, primary care, palliative care, maybe some others. And for primary care they are usually dealing with enough it's always a 99214, but they get the time suck of care coordination that pushes them up to 99215s for total time occasionally. At my old job the EMR let you pull up anyone's schedule. Everyone outside of psych, neuro, palliative care...all the other specialties were booked at least 3-4 patients per hour or and when I talked with them 99214 was always billed unless they could hit 99215 on complexity. And in the hospital hardly anybody bills on time. The new time rules are actually really a slap in the face for specialties that need the time. You can bill a 99232 (hospital 99214 equivalent) on a 7 minute follow up. But it takes 35 minutes to hit the same code based on time.

 

[Merovinge]

I've never heard anyone billing solely on time outside of psychiatry, primary care, palliative care, maybe some others. And for primary care they are usually dealing with enough it's always a 99214, but they get the time suck of care coordination that pushes them up to 99215s for total time occasionally. At my old job the EMR let you pull up anyone's schedule. Everyone outside of psych, neuro, palliative care...all the other specialties were booked at least 3-4 patients per hour or and when I talked with them 99214 was always billed unless they could hit 99215 on complexity. And in the hospital hardly anybody bills on time. The new time rules are actually really a slap in the face for specialties that need the time. You can bill a 99232 (hospital 99214 equivalent) on a 7 minute follow up. But it takes 35 minutes to hit the same code based on time.

This is a feature, not a bug, as medicine keeps pushing towards shorter and shorter visits for doctors. I am so grateful for choosing psychiatry where longer visits are standard.

 

[TexasPhysician]

My practice manager is concerned that I code 99214+90833 for a half-an-hour visit because he likes to bill based only on time it seems. he considers it "more by the book." Are there any resources that show how often this coding combination is used in half-an-hour visits?

No good ones. In our field, there is a range of behaviors. I’ve seen an older pp psych that bills every follow-up 99213. 0 exceptions. I’ve seen other pp psych that do 100% 99214 + 90833/36. Done with therapy? Time to transition back to PCP. Arrive too late to code therapy? No-show fee and reschedule.

 

[Psychferlyfe3000]

No good ones. In our field, there is a range of behaviors. I’ve seen an older pp psych that bills every follow-up 99213. 0 exceptions. I’ve seen other pp psych that do 100% 99214 + 90833/36. Done with therapy? Time to transition back to PCP. Arrive too late to code therapy? No-show fee and reschedule.

I requested and received data on this. For Medicare, 50% of 99214s are accompanied by 90833 and 25% of 99213s are accompanied by 90833.

 

[upc]

I am in network and they denied my claim twice because I asked too much, although I used their reimbursement rates. Am stuck!