99214 + 90836 for weekly 45 min therapy/combined med mgnylt

[liquidshadow22]

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99214 + 90836 for weekly 45 min therapy/combined med mgmt visits. Anyone do this, is it kosher? Just took an insurance based job and really need to make sure I get that coding down pat now

 

[calvnandhobbs68]

For weekly visits? So you're basically saying you're taking 7 minutes to achieve a 99214 level of medical decision making weekly and then spending a minimum of 38 minutes on therapy (minimum time for 90836). Remember there is a level of medical necessity that warrants that level of coding as well. PCPs can't just bring patients in with HTN and HLD every week to tell them they're still doing fine, keep doin what you're doin and code it as a 99214 every week for 2 months straight.

You can certainly try it and see what happens but I'd be very concerned about an audit and sooner rather than later if you're seeing this person weekly for some prolonged period of time. You're gonna get quickly flagged as an outlier because I doubt many people are billing these together that frequently.

Most people who see patients for truly weekly therapy visits just take cash or leave the therapy to a person's psychotherapist. If you want to try to bill insurance, 99213 + 90836 would make you less prone to get audited for this, since requirements for 99213 are pretty low. Or you could just bill 99214 + 90836 like once a month and then just do therapy codes the other 3 weeks, so you could reasonably say you're assessing the medical conditions once a month.

 

[SmallBird]

99214 + 90836 for weekly 45 min therapy/combined med mgmt visits. Anyone do this, is it kosher? Just took an insurance based job and really need to make sure I get that coding down pat now

If you're seeing weekly I think the best is 99214 + 90836 once a month and then just the therapy codes for the other visits. Of course its different if they have a side-effect or something you need to address.

 

[splik]

Not a problem. I see pts for twice weekly as well as weekly therapy and have had no issues with 99214+90836 or 90838 for either and that includes pts I have seen for yrs using these codes. Just make sure your documentation supports it

 

[clausewitz2]

Not a problem. I see pts for twice weekly as well as weekly therapy and have had no issues with 99214+90836 or 90838 for either and that includes pts I have seen for yrs using these codes. Just make sure your documentation supports it

I have 4-5 patients who I see for weekly therapy who I bill 99214+ 90838 (90636 if the appointment is shorter than normal for some reason). I have another one who is usually 99213+90838 but recently has been 99214 due to some recent developments and re-orientation of our work on a more acute problem. It helps that a couple of them are on lithium or are not infrequently suicidal. I agree with @splik ; if the documentation is good and you are hitting the criteria in a justifiable way, what exactly is an audit going to be able to say to you? I've not yet had a problem getting this paid.

You're probably not going to get away with saying it's an hour of supportive psychotherapy in the long run, though, so I'd definitely be documenting an established modality of some kind.

 

[calvnandhobbs68]

Not a problem. I see pts for twice weekly as well as weekly therapy and have had no issues with 99214+90836 or 90838 for either and that includes pts I have seen for yrs using these codes. Just make sure your documentation supports it

I have 4-5 patients who I see for weekly therapy who I bill 99214+ 90838 (90636 if the appointment is shorter than normal for some reason). I have another one who is usually 99213+90838 but recently has been 99214 due to some recent developments and re-orientation of our work on a more acute problem. It helps that a couple of them are on lithium or are not infrequently suicidal. I agree with @splik ; if the documentation is good and you are hitting the criteria in a justifiable way, what exactly is an audit going to be able to say to you? I've not yet had a problem getting this paid.

You're probably not going to get away with saying it's an hour of supportive psychotherapy in the long run, though, so I'd definitely be documenting an established modality of some kind.

Which is interesting because there's people getting audited using 99214 + 90833 (not even 90836/90838) regularly and seems like they're getting targeted for audits due to this. Either of you two gotten audited on any of those patients yet?

My main concern with billing 99214 weekly would be that I think it'd be easy for insurance to say, in what way are you addressing these stable chronic problems WEEKLY outside of the psychotherapy? Which is what you're billing the psychotherapy codes for. The E+M codes are supposed to be an entirely separate evaluation portion. Again, I think back to the PCP example above where I highly doubt it would fly in an audit if a FM doc was seeing someone on a ACEi and statin back every week to manage their HTN and HLD just to tell them they're still stable and billing a 99214 every week for months. That's more like a nursing BP check-in level of care. Not really standard of care. Now if their BP suddenly shot up or they were having hypertensive urgency symptoms on a visit or SE from meds, that could definitely get converted into a 99214 but for someone fairly stable you're just seeing for weekly therapy? Eh.

@clausewitz2 the fact that the patients are on lithium or have fluctuating SI actually would be pretty helpful in justifying a 99214, since they're on a high toxicity med or at higher risk that you could justifying evaluating outside of the psychotherapy portion.

Since documentation requirements are so minimal for a 99213, I personally think that would be a safer option than 99214 weekly. Sounds like there could be situations where the above coding works though.

 

[clausewitz2]

My main concern with billing 99214 weekly would be that I think it'd be easy for insurance to say, in what way are you addressing these stable chronic problems WEEKLY outside of the psychotherapy?

I make sure to ask and document questions systematically reviewing relevant symptoms, medication side effects, and track progress. Most of my patients end up completing a standardized self-report rating scale prior to their session depending on their issue (PHQ9, GAD7, IRLS, ESS, OCI-R, etc) , and monitoring response to treatment is certainly a part of treating something. My notes also always discuss my reasoning for why I am or am not changing medications to show that there is clearly MDM going on. I have not in fact been audited.

@clausewitz2 the fact that the patients are on lithium or have fluctuating SI actually would be pretty helpful in justifying a 99214, since they're on a high toxicity med or at higher risk that you could justifying evaluating outside of the psychotherapy portion.

Since documentation requirements are so minimal for a 99213, I personally think that would be a safer option than 99214 weekly. Sounds like there could be situations where the above coding works though.

I am sure a lot of this is payor specific. I have not heard of anyone in this neck of the woods having trouble getting 99214 reimbursed from the insurance that I accept, but then there's a reason I don't accept, say, Cigna.

 

[splik]

Which is interesting because there's people getting audited using 99214 + 90833 (not even 90836/90838) regularly and seems like they're getting targeted for audits due to this. Either of you two gotten audited on any of those patients yet?

My main concern with billing 99214 weekly would be that I think it'd be easy for insurance to say, in what way are you addressing these stable chronic problems WEEKLY outside of the psychotherapy?

Anyone can be audited. Hell you can even be audited if you're CASH ONLY and provide super bills for pts to use their OON benefits. Some of it is random. I would not let fear of being audited affect my practice if you are not doing something shady. My pts ask their insurance about this and they get told they can have unlimited E&M visits. With MH parity, they aren't supposed to put a limit on those visits. I am a physician. If I am seeing someone for psychotherapy who also is on meds or has complex medical issues, you better believe I am going to be using E&M + psychotherapy add on and not psychotherapy stand alone, because as a physician I am absolutely thinking about the medical aspects of care (including reviewing medical records, ordering and interpreting labs, and prescribing meds where indicated) in addition to doing psychotherapy every time I see the pt. There is a reason the RVUs for using the therapy standalone codes are similar for the E&M+psychotherapy add on.

I am an expert in psych coding and documentation and consult to healthcare organizations and do reviews/audits including for insurance companies so I am quite confident that I would survive an audit as my practice is within the standard of care. I am aware of all the pitfalls that trip people up.

 

[calvnandhobbs68]

Anyone can be audited. Hell you can even be audited if you're CASH ONLY and provide super bills for pts to use their OON benefits. Some of it is random. I would not let fear of being audited affect my practice if you are not doing something shady. My pts ask their insurance about this and they get told they can have unlimited E&M visits. With MH parity, they aren't supposed to put a limit on those visits. I am a physician. If I am seeing someone for psychotherapy who also is on meds or has complex medical issues, you better believe I am going to be using E&M + psychotherapy add on and not psychotherapy stand alone, because as a physician I am absolutely thinking about the medical aspects of care (including reviewing medical records, ordering and interpreting labs, and prescribing meds where indicated) in addition to doing psychotherapy every time I see the pt. There is a reason the RVUs for using the therapy standalone codes are similar for the E&M+psychotherapy add on.

I am an expert in psych coding and documentation and consult to healthcare organizations and do reviews/audits including for insurance companies so I am quite confident that I would survive an audit as my practice is within the standard of care. I am aware of all the pitfalls that trip people up.

Sure sure and I totally agree that’s the point of the psychotherapy add ons for E+M. However, the RVUs may be the same but the actual reimbursement structure is significantly higher for E+M + add on code rather than psychotherapy code alone.

I mean I don’t think they’d put a “limit” on these visits per se but I think the medical utility of these visits would start getting questioned. Kind of like the FM example I gave above. Just like it would seem pretty fishy for a FM doctor to see someone back every week to f/u on a couple stable chronic medical conditions with no change for months for 10 minutes and call it a 99214 every time. Which is essentially what you’re doing here technically since you’re billing the 99214 based on 7 minutes max of eval time in 45 minutes.

 

[Psych19]

Which is essentially what you’re doing here technically since you’re billing the 99214 based on 7 minutes max of eval time in 45 minutes.

This is not really a true statement. Psychotherapy time does need to be a separately identifiable service based on time. However, all of the time during the appointment (including the time spent on psychotherapy) can be used to inform the E&M service that you're providing.

 

[hallowmann]

... I am aware of all the pitfalls that trip people up.

Can you delve into this a bit more? I'm curious what the biggest pitfalls you've seen are.

 

[Mad Jack]

I have 4-5 patients who I see for weekly therapy who I bill 99214+ 90838 (90636 if the appointment is shorter than normal for some reason). I have another one who is usually 99213+90838 but recently has been 99214 due to some recent developments and re-orientation of our work on a more acute problem. It helps that a couple of them are on lithium or are not infrequently suicidal. I agree with @splik ; if the documentation is good and you are hitting the criteria in a justifiable way, what exactly is an audit going to be able to say to you? I've not yet had a problem getting this paid.

You're probably not going to get away with saying it's an hour of supportive psychotherapy in the long run, though, so I'd definitely be documenting an established modality of some kind.

I had a situation that merited this billing before, but this was a case of frequent medication changes, chronic suicidal ideation, and a substantial history of inpatient admissions and suicide attempts. Basically was spending an hour to an hour and 15 minutes a week with this individual much of the time and made great progress which was not always linear. When they were more stable, would drop the 99214 to a 99213, but on any visit with significant suicide risk assessment, medication changes, or labs being ordered I would use a 99214. Therapy was CBT and supportive, depending on the situation, and would bill 90833/90836/90838 as appropriate, noting exact therapy start and end times.