99214 documentation

[hebel]

In order to bill 99214, you need 2/3 of either a detailed history, detailed exam, or moderate complexity MDM.

In my opinion, it's a lot simpler to document in order to meet the history and exam criteria than the MDM complexity. Are you allowed to just always document the history and exam sections at a detailed level, or does the MDM complexity need to be what dictates everything else?

For the MDM, how do you typically document the 'problems?" Would you ever consider a medication side effect or a single symptom ("irritability") a problem, or only actual diagnoses?

I prefer my A/P formatted like below, but wonder if that's a bad way to do it for billing:

DSM Diagnoses:
xxx
xxx

Assessment/Plan
[Paragraph assessment]

- [medication related stuff]
- [miscellaneous interventions as indicated, like therapy, lab work, etc ]

---

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[TexasPhysician]

In order to bill 99214, you need 2/3 of either a detailed history, detailed exam, or moderate complexity MDM.

In my opinion, it's a lot simpler to document in order to meet the history and exam criteria than the MDM complexity. Are you allowed to just always document the history and exam sections at a detailed level, or does the MDM complexity need to be what dictates everything else?

For the MDM, how do you typically document the 'problems?" Would you ever consider a medication side effect or a single symptom ("irritability") a problem, or only actual diagnoses?

I prefer my A/P formatted like below, but wonder if that's a bad way to do it for billing:

DSM Diagnoses:
xxx
xxx

Assessment/Plan
[Paragraph assessment]

- [medication related stuff]
- [miscellaneous interventions as indicated, like therapy, lab work, etc ]

Every time that I’ve talked to a biller, MDM must be 1 of the 2

 

[nexus73]

I think technically MDM (medical decision making) is not required to be 1 of the 2 currently, but that will change for Medicare starting January 2021.

I've heard from billers that MDM is a requirement...when really it's "Medical Necessity" that is the driving force. But the billers see the word medical in both medical decision making and medical necessity and the two get conflated.

I also think coders are ever fearful of the Medicare audit and clawback of 100s of thousands of dollars. They don't care if you make $61 for a 99213 and $98 for a 99214. That $37 doesn't affect them and is ultimately chump change in comparison to Medicare refunds and fines, so better to err on the side of caution and require MDM as 1 of the 2 just in case.

 

[splik]

I actually think its hard to have history consistently be the item because its not always necessary to have an ROS or to have PSFH in progress notes. History is rarely one of the 2 elements for me for 99214. if you have a patient with 3 or more stable problems or 1 stable problem and 1 worsening problem that is enough for moderate complexity MDM.

 

[calvnandhobbs68]

I actually think its hard to have history consistently be the item because its not always necessary to have an ROS or to have PSFH in progress notes. History is rarely one of the 2 elements for me for 99214. if you have a patient with 3 or more stable problems or 1 stable problem and 1 worsening problem that is enough for moderate complexity MDM.

And I always find it very easy to hit a 99214 (and honestly you shouldn’t need to see a 99213 in more than 20 minutes...so if you’re billing 99213s they should be in 20 min slots). If you’re changing a med, they should be a 99214 if you can pull out one more problem you can “consider”. If you’re not changing anything I’m willing to bet the vast majority of our patients have 3 or more problems. Nicotine use disorder, MDD, GAD, bam. Autism spectrum disorder, ADHD, other specified anxiety disorder. ADHD, ODD, other specified anxiety disorder. Bipolar 1 disorder, nicotine use disorder, obesity (if you take their weight, you can say you’re monitoring their obesity since they’re very likely on some weight affecting med).

So basically if you’re working with anything that’s more than a pretty stable population that you could knock out 3 an hour anyway with 20 minute visits and get 3x99213s anyway, you should be able to hit 99214s in MDM.

remember though you can also bill a 99214 based on TIME (and I think billers forget this all the time for some reason). So if you had a 30min followup but ended up being a 99213 based on complexity you could still bill it as a 99214 as long as you put a blurb that you spent at least 25 minutes on the encounter, at least half of which was patient “counseling or coordination of care”. Also say that the patient has 20 questions and now the 30 min visit turned into 40 minutes or they have a caregiver that you had to talk to as well to coordinate care. You can bill THAT as a 99215 as long as you spent 50 percent of the time counseling/coordinating care. You just have to explicitly say this somewhere in the note.

So say I have a kid with just Autism and ADHD who was put in for a 30 min followup slot, parents both come with him, don’t make any med changes but they want to talk to me about what to expect with his medication, his eating patterns on the meds and some sleeping problems he’s been having that then makes me run over into 40 minutes. If I just billed that based on complexity, it’d be a 99213 and I’m leaving a lot of relative money on the table. If I bill it based on time and include the blurb about time spent, it’s now a 99215.

 

[reca]

And I always find it very easy to hit a 99214 (and honestly you shouldn’t need to see a 99213 in more than 20 minutes...so if you’re billing 99213s they should be in 20 min slots). If you’re changing a med, they should be a 99214 if you can pull out one more problem you can “consider”. If you’re not changing anything I’m willing to bet the vast majority of our patients have 3 or more problems. Nicotine use disorder, MDD, GAD, bam. Autism spectrum disorder, ADHD, other specified anxiety disorder. ADHD, ODD, other specified anxiety disorder. Bipolar 1 disorder, nicotine use disorder, obesity (if you take their weight, you can say you’re monitoring their obesity since they’re very likely on some weight affecting med).

So basically if you’re working with anything that’s more than a pretty stable population that you could knock out 3 an hour anyway with 20 minute visits and get 3x99213s anyway, you should be able to hit 99214s in MDM.

remember though you can also bill a 99214 based on TIME (and I think billers forget this all the time for some reason). So if you had a 30min followup but ended up being a 99213 based on complexity you could still bill it as a 99214 as long as you put a blurb that you spent at least 25 minutes on the encounter, at least half of which was patient “counseling or coordination of care”. Also say that the patient has 20 questions and now the 30 min visit turned into 40 minutes or they have a caregiver that you had to talk to as well to coordinate care. You can bill THAT as a 99215 as long as you spent 50 percent of the time counseling/coordinating care. You just have to explicitly say this somewhere in the note.

So say I have a kid with just Autism and ADHD who was put in for a 30 min followup slot, parents both come with him, don’t make any med changes but they want to talk to me about what to expect with his medication, his eating patterns on the meds and some sleeping problems he’s been having that then makes me run over into 40 minutes. If I just billed that based on complexity, it’d be a 99213 and I’m leaving a lot of relative money on the table. If I bill it based on time and include the blurb about time spent, it’s now a 99215.

But then you can’t bill a therapy add on code

 

[calvnandhobbs68]

But then you can’t bill a therapy add on code

Correct but then you kinda have to make that decision partway through the encounter. Am I going to be able to do some basic therapy and bill this as a 99213 + add on code or bill it as a 99214 based on time?

 

[J ROD]

I have always been told the MDM is implied as the driving factor. Technically, the way it is written you can do it in actual practice you will not get away with that. It really is not that hard to have 3 chronic problems. Depression, Anxiety, Insomnia. Or a worsening problem

 

[clausewitz2]

In case you needed more reason to be thorough in asking people about sleep problems and substance use, it is if nothing else a very quick way to expand that problem list.

Also, you know, clinically useful and sensible, but at least one place where you can do well by doing good.

 

[VA Hopeful Dr]

I actually think its hard to have history consistently be the item because its not always necessary to have an ROS or to have PSFH in progress notes. History is rarely one of the 2 elements for me for 99214. if you have a patient with 3 or more stable problems or 1 stable problem and 1 worsening problem that is enough for moderate complexity MDM.

It's actually super easy.

Ask if they smoke/drink. There's your social history.

Asking about medication side effect symptoms will get your ROS: anorgasmia in GU, lack of appetite in Constitution, dry mouth for HEENT. Done.

 

[clausewitz2]

It's actually super easy.

Ask if they smoke/drink. There's your social history.

Asking about medication side effect symptoms will get your ROS: anorgasmia in GU, lack of appetite in Constitution, dry mouth for HEENT. Done.

Negative for akathisia (MSK), diarrhea/nausea (GI), headaches (neuro), bam. Most mood stabilizers asking about new rashes is reasonable too. I try not not to double count lack of appetite because that's in my psych ROS but weight gain/loss is a perfectly legitimate CON thing to ask about.

 

[hebel]

Thanks for the responses so far. For ease of billing how do you document your assessment and plan section typically?

 

[Candidate2017]

For patients who are chronically stable, just want refills in 10 minutes, and don't want supportive therapy, it seems like a waste of time to reserve them a full 20 or 30 minute slot. Would it be economically more efficient to dedicate one day a week solely for 15 minute appointments to slot these quick patients? Second, even if they have 3 stable problems but are out in 10 minutes, can we still code a 99214 on complexity?

 

[clausewitz2]

For patients who are chronically stable, just want refills in 10 minutes, and don't want supportive therapy, it seems like a waste of time to reserve them a full 20 or 30 minute slot. Would it be economically more efficient to dedicate one day a week solely for 15 minute appointments to slot these quick patients? Second, even if they have 3 stable problems but are out in 10 minutes, can we still code a 99214 on complexity?

Trouble is if even one of these folks shows up and against expectations everything is -not- copacetic this time, you might end up taking 30-40 minutes dealing with the situation. At that point you are an -entire- patient behind. Tightly clustered appointments leave very little room for error or miscalculation. Also, what do you do with people who are, say, six minutes late to their appointment? Tell them they have to reschedule?

The people who are stable enough that seeing them for ten minutes q 3 months is reasonable also tend not to put up with being told that being a few minutes late means they don't get a refill this week.

 

[splik]

It's actually super easy.

Ask if they smoke/drink. There's your social history.

Asking about medication side effect symptoms will get your ROS: anorgasmia in GU, lack of appetite in Constitution, dry mouth for HEENT. Done.

Well it depends on how frequently you see pts. I see pts one to two times per week mostly so this is not going to fly. However the pts need to be seen frequently and thus the MDM is sufficient to justify 99214 for my pts

 

[VA Hopeful Dr]

Well it depends on how frequently you see pts. I see pts one to two times per week mostly so this is not going to fly. However the pts need to be seen frequently and thus the MDM is sufficient to justify 99214 for my pts

Why does frequency of visit mean these questions don't need to be asked?

 

[Candidate2017]

Trouble is if even one of these folks shows up and against expectations everything is -not- copacetic this time, you might end up taking 30-40 minutes dealing with the situation. At that point you are an -entire- patient behind. Tightly clustered appointments leave very little room for error or miscalculation. Also, what do you do with people who are, say, six minutes late to their appointment? Tell them they have to reschedule?

The people who are stable enough that seeing them for ten minutes q 3 months is reasonable also tend not to put up with being told that being a few minutes late means they don't get a refill this week.

Yeah, I don't currently mind these 10 minute patients because they give me free time. In private practice, if there were too many 10 minute 99213s, I think I'd send them back to their PCP as they don't need anything from me, and the practice would run a loss to see two of them an hour.

 

[Stagg737]

Correct but then you kinda have to make that decision partway through the encounter. Am I going to be able to do some basic therapy and bill this as a 99213 + add on code or bill it as a 99214 based on time?

How much more do the therapy add-on codes typically add to the encounter? I realize it varies geographically, but is there a significant difference between the two situations you listed above?

Thanks for the responses so far. For ease of billing how do you document your assessment and plan section typically?

Most residents in my program do something like the following:

A/P: (paragraph, length obviously varies based on stability and complexity)

DSM-V diagnoses:

Other factors/diagnoses:

Medications/Plan: (in bullet format)

RTC in X time

Disclaimers (safety plan discussed, side effects discussed, etc)

Trouble is if even one of these folks shows up and against expectations everything is -not- copacetic this time, you might end up taking 30-40 minutes dealing with the situation. At that point you are an -entire- patient behind. Tightly clustered appointments leave very little room for error or miscalculation. Also, what do you do with people who are, say, six minutes late to their appointment? Tell them they have to reschedule?

The people who are stable enough that seeing them for ten minutes q 3 months is reasonable also tend not to put up with being told that being a few minutes late means they don't get a refill this week.

Then you see that person in 5 minutes. I did a rotation in med school with a doc whose outpatient panel was 80%+ stable and were basically there for refills. I found that a lot of these patients mostly just wanted to get in and out and appreciated the rapid-fire type questions. One could easily copy/paste previous notes, update minor changes, and write a brief subjective and finish the whole encounter and charting in <10 minutes and meet billing standards. Whether that meets ethical standards is a separate issue, but I've certainly seen patients who were stable who would be more than happy to be in and out in 10 minutes, and I could only imagine that becoming more common with the advent of telehealth.

Why does frequency of visit mean these questions don't need to be asked?

If you're seeing a patient twice per week are you really asking for an updated substance history every time? If you got audited by Medicare and that was your only SH at every appt for weeks at a time, would that be valid or would you get hit for billing fraud? The first question is more rhetorical, the second I'm legitimately curious about.

 

[clausewitz2]

How much more do the therapy add-on codes typically add to the encounter? I realize it varies geographically, but is there a significant difference between the two situations you listed above?



Most residents in my program do something like the following:

A/P: (paragraph, length obviously varies based on stability and complexity)

DSM-V diagnoses:

Other factors/diagnoses:

Medications/Plan: (in bullet format)

RTC in X time

Disclaimers (safety plan discussed, side effects discussed, etc)




Then you see that person in 5 minutes. I did a rotation in med school with a doc whose outpatient panel was 80%+ stable and were basically there for refills. I found that a lot of these patients mostly just wanted to get in and out and appreciated the rapid-fire type questions. One could easily copy/paste previous notes, update minor changes, and write a brief subjective and finish the whole encounter and charting in <10 minutes and meet billing standards. Whether that meets ethical standards is a separate issue, but I've certainly seen patients who were stable who would be more than happy to be in and out in 10 minutes, and I could only imagine that becoming more common with the advent of telehealth.



If you're seeing a patient twice per week are you really asking for an updated substance history every time? If you got audited by Medicare and that was your only SH at every appt for weeks at a time, would that be valid or would you get hit for billing fraud? The first question is more rhetorical, the second I'm legitimately curious about.

In reverse order:
There are patients I would definitely ask for recent substance history every single time, but point taken that that is probably not normative. Probably it is not the only thing you should care about. Someone who has a significant alcohol use disorder or is on MAT, this is pretty critical to keep track of.

Right, but if you only had a ten minute slot to begin with, and they turn up six minutes late, assuming you immediately transition into rapid fire questions without even pausing to take a breath, seeing them in ten minutes means you are now running half an appointment behind. I don't see how you don't end up making the people at the end of the day wait a significant amount of time.

In terms of therapy add-on codes, in my area Medicare pays 79.73 for a 99213, 116.93 for a 99214, and 76.65 for a 90833. That means that doing 99213 + 90833 nets you about 40 dollars more than 99214 by itself on average. Even if you crank out the 99214s 3 an hour (I am not going to touch doing this six times an hour) gets you 350.79 v. taking your time with 2 99213 + 90833s in the same time netting you 312.76. However, I would suggest that if you are actually taking 30 minutes for the later, you almost certainly are collecting enough information to meet billing requirements for 99214, so really you are looking at 350.79 v 387.16.

Again, you can do well by doing good, at least in this area. If you are so desperate for revenue that you are trying to grind out 6 patients an hour you should just bite the bullet and start hiring NPs.

 

[rjs2131]

Another question re: coding - considering joining a company that exclusively does 30 min follow-ups and 1 hr news (which is what I prefer anyway) but compensation will eventually be RVU based. I've been told most folks are billing 99214 + 90833 for 30-min follow-ups to maximize RVUs - is this legit? Seems easy enough to get to a 99214 if you're spending 30 min with a patient but not sure if people are regularly billing 99214 + 90833 (vs 99213 + 90833) and if insurance is reimbursing for 99214 + 90833 on a regular basis.

 

[liquidshadow22]

Another question re: coding - considering joining a company that exclusively does 30 min follow-ups and 1 hr news (which is what I prefer anyway) but compensation will eventually be RVU based. I've been told most folks are billing 99214 + 90833 for 30-min follow-ups to maximize RVUs - is this legit? Seems easy enough to get to a 99214 if you're spending 30 min with a patient but not sure if people are regularly billing 99214 + 90833 (vs 99213 + 90833) and if insurance is reimbursing for 99214 + 90833 on a regular basis.

is it possible to bill 99214+ 90833 for a 20 minute visit, or is that likely cheating?

 

[hamstergang]

is it possible to bill 99214+ 90833 for a 20 minute visit, or is that likely cheating?

You'd have to claim that you spent at least 16 minutes doing therapy and therefore at most 4 minutes establishing the criteria for the 99214 and talking about medications. That would make for quite a rapid E&M portion that is supposed to be moderately complex. I don't bill 99214+90833 for less than 25 minutes, but I don't think there are strict guidelines written down for this. I've never been told that any insurance company rejected my billing but I might not have been audited ever.

 

[liquidshadow22]

While I personally would raise my eyebrows about this, if you genuinely believe you are providing 16+ mins of psychotherapy in the visit that is separately identifiable from the E&M component, and document the modality, techniques, goals, frequency, and measurement of progress, and are not conflating counseling and motivational interviewing with "psychotherapy" then technically this is defensible.

I often do 58 minute visits using 99214+90838 which means the E&M portion is 5 minutes. The difference is I am typically seeing the patients frequently for the expressed purpose of psychotherapy and really am only spending a v brief amount of time on issues related to medication, diagnosis etc that would count as E&M. However, the same principles would still apply in the 99214+90833 situation even though the purpose of the visit is difference. Also, while the E&M portion must be separately identifiable from the psychotherapy portion (which is a tall order), there is no rule that you cannot use information gleaned from the therapy portion to inform the E&M portion. Under those circumstances it makes more sense that the 99214 could be 4-5 mins if you are using information from the other part of the session to inform your E&M (which is inevitable). I find it hard to conceptualize 16 mins as "therapy" unless it's Lacanian analysis, but the codes allow you to bill for 16 mins of psychotherapy so as long as it is credible in your mind nothing would prohibit this.

I mean I try to incorporate "supportive psychotherapy" into med check visits, so technically I could make the argument I provided 16 min of psychotherapy. I guess it really just depends on whether or not you have a patient that wants to discuss medications the entire length of a 20 minute visit or are they willing to discuss their life stressors. When you refer to "counseling and motivational interviewing"- are you referring to discussions about lifestyle and compliance with meds? I would consider motivational interviewing for a SUD patient to be billable for psychotherapy, no?

 

[robellis]

I mean I try to incorporate "supportive psychotherapy" into med check visits, so technically I could make the argument I provided 16 min of psychotherapy. I guess it really just depends on whether or not you have a patient that wants to discuss medications the entire length of a 20 minute visit or are they willing to discuss their life stressors. When you refer to "counseling and motivational interviewing"- are you referring to discussions about lifestyle and compliance with meds? I would consider motivational interviewing for a SUD patient to be billable for psychotherapy, no?

Yes this is appropriate

 

[romanticscience]

While I personally would raise my eyebrows about this, if you genuinely believe you are providing 16+ mins of psychotherapy in the visit that is separately identifiable from the E&M component, and document the modality, techniques, goals, frequency, and measurement of progress, and are not conflating counseling and motivational interviewing with "psychotherapy" then technically this is defensible.

I often do 58 minute visits using 99214+90838 which means the E&M portion is 5 minutes. The difference is I am typically seeing the patients frequently for the expressed purpose of psychotherapy and really am only spending a v brief amount of time on issues related to medication, diagnosis etc that would count as E&M. However, the same principles would still apply in the 99214+90833 situation even though the purpose of the visit is difference. Also, while the E&M portion must be separately identifiable from the psychotherapy portion (which is a tall order), there is no rule that you cannot use information gleaned from the therapy portion to inform the E&M portion. Under those circumstances it makes more sense that the 99214 could be 4-5 mins if you are using information from the other part of the session to inform your E&M (which is inevitable). I find it hard to conceptualize 16 mins as "therapy" unless it's Lacanian analysis, but the codes allow you to bill for 16 mins of psychotherapy so as long as it is credible in your mind nothing would prohibit this.

I have some patients who are 99214 medically complex and I see them some months for weekly therapy. I've been just randomly using 99213 (or 99212 for biweekly visits) and 99214s, because of this fear of using them "too frequently." I think to myself, "If this person wasn't in a course of psychotherapy, at what frequency would I bill a 99214 or have a medication follow up?"

As a psychiatrist-psychotherapist, I'm in an odd spot with these combo codes. I know the non-MD therapists are all doing 90837s straight and the psychopharmacologists are doing 99214s +/- 90833 every month.

Any help with this, "what is the complexity addressed" each visit? For example, would it be reasonable to bill 99214 throughout the course of a CBT trial (8-12)?

 

[romanticscience]

I mean I try to incorporate "supportive psychotherapy" into med check visits, so technically I could make the argument I provided 16 min of psychotherapy. I guess it really just depends on whether or not you have a patient that wants to discuss medications the entire length of a 20 minute visit or are they willing to discuss their life stressors. When you refer to "counseling and motivational interviewing"- are you referring to discussions about lifestyle and compliance with meds? I would consider motivational interviewing for a SUD patient to be billable for psychotherapy, no?

I'm always perplexed by this motivational interviewing is or is not psychotherapy thing. I get that there are these administrative/technical definitions but clinically the differences in MI v. supportive PDPT v. existential (Yalom) therapy v. patient centered (Rogerian) therapy are hard to notice.

Also, the begining portions of IPT and CBT include sections on medication review and symptom checks, do you not count that as psychotherapy? Or, can psychologists bill that part as E/M? OK, I won't open that can of worms!

 

[clausewitz2]

I have some patients who are 99214 medically complex and I see them some months for weekly therapy. I've been just randomly using 99213 (or 99212 for biweekly visits) and 99214s, because of this fear of using them "too frequently." I think to myself, "If this person wasn't in a course of psychotherapy, at what frequency would I bill a 99214 or have a medication follow up?"

As a psychiatrist-psychotherapist, I'm in an odd spot with these combo codes. I know the non-MD therapists are all doing 90837s straight and the psychopharmacologists are doing 99214s +/- 90833 every month.

Any help with this, "what is the complexity addressed" each visit? For example, would it be reasonable to bill 99214 throughout the course of a CBT trial (8-12)?

I try to be extremely literal about this question. If I am meaningfully addressing two chronic and stable disorders that the patient legitimately can be diagnosed with, and I am making decisions about pharmacotherapy/monitoring adverse effects/discussing alternatives, I do not see how you cannot meet the MDM criteria for 99214 with the current guidelines as written. I agree that 4 minutes is not very much time to do this and you might struggle to explain in what way you meaningfully addressed two problems separately but it's not at all impossible.

The 16 minute add-on psychotherapy thing seems like a trickier issue, but there are definitely decomposable therapy approaches out there in which you can implement some part of the therapeutic approach in that amount of time. If you are doing E/RP, you can do good work identifying a fear hierarchy in 16 minutes. Why shouldn't that count?

 

[tr]

I have some patients who are 99214 medically complex and I see them some months for weekly therapy. I've been just randomly using 99213 (or 99212 for biweekly visits) and 99214s, because of this fear of using them "too frequently." I think to myself, "If this person wasn't in a course of psychotherapy, at what frequency would I bill a 99214 or have a medication follow up?"

As a psychiatrist-psychotherapist, I'm in an odd spot with these combo codes. I know the non-MD therapists are all doing 90837s straight and the psychopharmacologists are doing 99214s +/- 90833 every month.

Any help with this, "what is the complexity addressed" each visit? For example, would it be reasonable to bill 99214 throughout the course of a CBT trial (8-12)?

I bill 90837 for visits that were strictly psychotherapy, either because the patient is not on meds or because their meds are stable and were not addressed during the visit. Reimbursement seems similar to 2x99214 actually. I don't see a reason to use an E&M code for a visit that included no E&M.

 

[AD04]

I try to be extremely literal about this question. If I am meaningfully addressing two chronic and stable disorders that the patient legitimately can be diagnosed with, and I am making decisions about pharmacotherapy/monitoring adverse effects/discussing alternatives, I do not see how you cannot meet the MDM criteria for 99214 with the current guidelines as written. I agree that 4 minutes is not very much time to do this and you might struggle to explain in what way you meaningfully addressed two problems separately but it's not at all impossible.

The 16 minute add-on psychotherapy thing seems like a trickier issue, but there are definitely decomposable therapy approaches out there in which you can implement some part of the therapeutic approach in that amount of time. If you are doing E/RP, you can do good work identifying a fear hierarchy in 16 minutes. Why shouldn't that count?

I think more physicians lose out on under-billing than on audits. The criteria for billing is clearly labeled and if you meet the criteria, then you meet the criteria. If you are not billing by time, then why even consider how much time you spend?

How is an auditor supposed to say you didn't treat 2 stable chronic conditions or spend x minutes in psychotherapy if it is documented in your notes and you schedule enough time for patients for medication management and psychotherapy?

The more people under-bill out of fear, the more they are skewing the median billing, the more they increase audit chance of people who are properly billing.

 

[rjs2131]

Personal belief: If you spent the time, effort and money to go through psychiatry residency +/- fellowship, you should be able to decide if you're doing "16+ minutes of psychotherapy" - not the insurance company. There are so many different therapy modalities out there...I think we're just shooting ourselves in the foot if we try and overanalyze whether or not something is "actually therapy" and undercode as a result. If you're a psychiatrist seeing a follow-up patient for 30 minutes, there is almost always a way to justify that more than half of that session was spent doing therapy. I probably wouldn't feel comfortable consistently coding 99214+90833 for a 20 min visit, but 30 minute visits? All day.

 

[robellis]

Personal belief: If you spent the time, effort and money to go through psychiatry residency +/- fellowship, you should be able to decide if you're doing "16+ minutes of psychotherapy" - not the insurance company. There are so many different therapy modalities out there...I think we're just shooting ourselves in the foot if we try and overanalyze whether or not something is "actually therapy" and undercode as a result. If you're a psychiatrist seeing a follow-up patient for 30 minutes, there is almost always a way to justify that more than half of that session was spent doing therapy. I probably wouldn't feel comfortable consistently coding 99214+90833 for a 20 min visit, but 30 minute visits? All day.

Agreed 30 minute visits are almost always automatic 99214+90833

 

[Merovinge]

I bill 90837 for visits that were strictly psychotherapy, either because the patient is not on meds or because their meds are stable and were not addressed during the visit. Reimbursement seems similar to 2x99214 actually. I don't see a reason to use an E&M code for a visit that included no E&M.

Reimbursement like RVU generation or reimbursement like payment from insurance company? I'd be very interested to know where 90837s pay cash about equal to 2x 99214 (unless the later is billing something like Medicaid prices and is already comically low)

 

[tr]

Reimbursement like RVU generation or reimbursement like payment from insurance company? I'd be very interested to know where 90837s pay cash about equal to 2x 99214 (unless the later is billing something like Medicaid prices and is already comically low)

Current institution is on a billing model not an RVU model. Looking at billing summaries, Aetna and/or Cigna seem to be paying $160 for a 30-minute 99214 and $329 for a 60-minute 90837.

Previous institution was on an RVU model and a 99214 was 1.5 RVU while a 90837 was 3.0 RVU.

 

[calvnandhobbs68]

Current institution is on a billing model not an RVU model. Looking at billing summaries, Aetna and/or Cigna seem to be paying $160 for a 30-minute 99214 and $329 for a 60-minute 90837.

Previous institution was on an RVU model and a 99214 was 1.5 RVU while a 90837 was 3.0 RVU.

might just be me but I feel like $329 is outstanding for a 90837...

 

[tr]

might just be me but I feel like $329 is outstanding for a 90837...

I'm at a large AMC in a high COL area, and presumably the institution, being large, has good leverage to bargain with insurance. Additionally these are the only two outside insurances the dept lets us take so I assume the rates offered by the others were not acceptable.

 

[Merovinge]

I'm at a large AMC in a high COL area, and presumably the institution, being large, has good leverage to bargain with insurance. Additionally these are the only two outside insurances the dept lets us take so I assume the rates offered by the others were not acceptable.

Very interesting, thanks for the actual figures!

 

[Sushirolls]

Any y'all still getting those letters from a certain 3rd party company the insurance companies have outsourced to for review billing numbers?

I'm getting the same letter every 3-6 months saying the percent of 99213 & 99214 are not reflective of specialty norms.

I'm ~85% 99214 even before the 2021 E&M changes. I've run the mental exercise gauntlet in my mind and as I'm coding but don't see any room for improvement.

So the curiosity question is what percent 99214 y'all billing?

Part of me is like, whatever, bring on the audits get it over with and leave me alone.

 

[splik]

Any y'all still getting those letters from a certain 3rd party company the insurance companies have outsourced to for review billing numbers?

I'm getting the same letter every 3-6 months saying the percent of 99213 & 99214 are not reflective of specialty norms.

I'm ~85% 99214 even before the 2021 E&M changes. I've run the mental exercise gauntlet in my mind and as I'm coding but don't see any room for improvement.

So the curiosity question is what percent 99214 y'all billing?

Part of me is like, whatever, bring on the audits get it over with and leave me alone.

Im 98% 99214, 2% 99215. 0% 99213 for follow ups. I most often see follows ups 1-2 times per week (with therapy using 90838 or 90836) and no issues with using 99214 that frequently. The bar is low.

 

[Psych19]

Any y'all still getting those letters from a certain 3rd party company the insurance companies have outsourced to for review billing numbers?

I'm getting the same letter every 3-6 months saying the percent of 99213 & 99214 are not reflective of specialty norms.

I'm ~85% 99214 even before the 2021 E&M changes. I've run the mental exercise gauntlet in my mind and as I'm coding but don't see any room for improvement.

So the curiosity question is what percent 99214 y'all billing?

Part of me is like, whatever, bring on the audits get it over with and leave me alone.

I've been in practice since 2019. Paneled with a bunch of commercial insurances.

I got my first letter like this a few weeks ago.

The information they sent is not inaccurate. I just know most psychiatrists are under-billing and it makes those of us who are billing appropriately look like outliers. There's a guy in my group who just always bills 99213 for every encounter. He's paid straight salary by our organization and I think he just doesn't care about RVU targets or bonuses--so I imagine he doesn't care whether his coding is appropriate.

I assume these letters are just a scare tactic. I imagine it's really cheap and easy to identify these coding habits using a database and send letters to the outliers. If it results in a few of these providers deciding to downcode their services going forward for fear of an audit, then mission-accomplished by the insurance company. It would be more tedious and expensive for the insurance company to actually request and send notes for an audit. Perhaps it will eventually come to that for me, but I feel pretty good about my documentation supporting the level of service that I purport to offer. Our organization sends their own internal audits for a randomly selected small sample of my notes 1-2 times per year and each time I've done pretty well in my documentation.

 

[nexus73]

I've been in practice since 2019. Paneled with a bunch of commercial insurances.

I got my first letter like this a few weeks ago.

The information they sent is not inaccurate. I just know most psychiatrists are under-billing and it makes those of us who are billing appropriately look like outliers. There's a guy in my group who just always bills 99213 for every encounter. He's paid straight salary by our organization and I think he just doesn't care about RVU targets or bonuses--so I imagine he doesn't care whether his coding is appropriate.

I assume these letters are just a scare tactic. I imagine it's really cheap and easy to identify these coding habits using a database and send letters to the outliers. If it results in a few of these providers deciding to downcode their services going forward for fear of an audit, then mission-accomplished by the insurance company. It would be more tedious and expensive for the insurance company to actually request and send notes for an audit. Perhaps it will eventually come to that for me, but I feel pretty good about my documentation supporting the level of service that I purport to offer. Our organization sends their own internal audits for a randomly selected small sample of my notes 1-2 times per year and each time I've done pretty well in my documentation.

I agree. These letters are a load of bull****. It’s either fabricated or based on doctors in employed settings who under bill. Even before the coding changes, a 99214 for psych patients was very common giving multiple conditions being managed.

 

[Merovinge]

Im 98% 99214, 2% 99215. 0% 99213 for follow ups. I most often see follows ups 1-2 times per week (with therapy using 90838 or 90836) and no issues with using 99214 that frequently. The bar is low.

Were you mentioning that patients on lithium are billable at 99215 from a risk standpoint?

 

[splik]

Were you mentioning that patients on lithium are billable at 99215 from a risk standpoint?

being on lithium does not de facto qualify for 99215, but requiring intensive drug monitoring (i.e. q3monthly or more) due to risk of toxicity is one point for level 5 MDM. you would need another point. So for example, if you have a pt with stable bipolar I, no other dx on lithium, they wouldn't qualify for 99215. but if you have a pt with bipolar I, currently depressed (or manic etc) on lithium they would.

 

[luckrules]

I'm just a resident, but we learn criminally little about the billing portion of medicine so I'm reading this thread and others to expand my knowledge base. Looking at this link to get a sense of some of the changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

I noticed with the time piece it includes time spent documenting and time spent reviewing the patients records. With most patients I have to spend at least 3-10 minutes looking at the last note and any other notes that may be in the system from other doctors (for example, saw endocrinology, orthopedics, neurology, had surgery). Can you just include a little blurb at the beginning saying "spent 5 minutes reviewing EHR to aid in E&M"?

Looking more over the document, it seems hard that most psych visits would not be at least a 99214 and anyone who has been or is at risk of hospitalization due a psychiatric illness would be 99215, and/or anyone with any sort of medical comorbidity. Does anyone have any other useful documents I might look at to get a greater sense of what actually changed in 2021?

 

[clausewitz2]

Remember it is not just severity of condition alone that is going to get out to 99215, you need the lab/consulting other providers/reviewing medical record piece (and make sure you can justify it is necessary), or the intensive monitoring of significant adverse medication effects/making active decision about hospitalization.

So for most chronically suicidal folks you probably aren't getting to a 99215 unless you can explain and back up in your documentation exactly what you were doing at each one of those regular visits to assess for hospitalization. A dot phrase of risk and protective factors probably isn't going to cut it in an audit. If it's a crisis, though? Yeah, that could happen very easily.

The file you linked is the changes.

 

[sloh]

Remember it is not just severity of condition alone that is going to get out to 99215, you need the lab/consulting other providers/reviewing medical record piece (and make sure you can justify it is necessary), or the intensive monitoring of significant adverse medication effects/making active decision about hospitalization.

So for most chronically suicidal folks you probably aren't getting to a 99215 unless you can explain and back up in your documentation exactly what you were doing at each one of those regular visits to assess for hospitalization. A dot phrase of risk and protective factors probably isn't going to cut it in an audit. If it's a crisis, though? Yeah, that could happen very easily.

The file you linked is the changes.

Do you think reviewing medical records and intensive monitoring of significant adverse medication effects leaves a lot of wiggle room to justify a 99215? For example, can "intensifying monitoring of significant adverse effects" simply be asking the patient if they are having "X" symptoms/problems?

 

[clausewitz2]

Do you think reviewing medical records and intensive monitoring of significant adverse medication effects leaves a lot of wiggle room to justify a 99215? For example, can "intensifying monitoring of significant adverse effects" simply be asking the patient if they are having "X" symptoms/problems?

To hit 99215 on complexity of data you have to be reviewing at least 3 external notes each from a unique source, review results of unique tests, ordering a test, or getting collateral IN ADDITION TO either independent interpretation of tests someone else ordered or discussing management/test interpretation with another qualified professional. It's actually not easy.

The actual wording is "intensive monitoring for toxicity", and I think you would have a hard time justifying asking questions about symptoms under that heading. However, it would probably go to establishing high complexity in the Problems domain, i.e. establishing that the chronic illness has severe side effects of treatment.

 

[Stagg737]

Do you think reviewing medical records and intensive monitoring of significant adverse medication effects leaves a lot of wiggle room to justify a 99215? For example, can "intensifying monitoring of significant adverse effects" simply be asking the patient if they are having "X" symptoms/problems?

To hit 99215 on complexity of data you have to be reviewing at least 3 external notes each from a unique source, review results of unique tests, ordering a test, or getting collateral IN ADDITION TO either independent interpretation of tests someone else ordered or discussing management/test interpretation with another qualified professional. It's actually not easy.

The actual wording is "intensive monitoring for toxicity", and I think you would have a hard time justifying asking questions about symptoms under that heading. However, it would probably go to establishing high complexity in the Problems domain, i.e. establishing that the chronic illness has severe side effects of treatment.

I don't think that the reviewing 3 external notes is a requirement to hit 99215 in CoD if you're meeting 2 of the other criteria (NEEDING collateral, ordering unique tests, interpreting unique tests). For example, sometimes I'll order a Lithium draw on a patient in the morning and occasionally get results the same day in the afternoon. If I'm ordering and interpreting those results same day then boom, I met 99215 criteria for CoD even without reviewing outside notes. Hitting 99215 in CoD isn't necessary though if you're hitting it in the complexity of problems and patient management categories, which is far more common/easier to meet imo.

The second bolded is something I'd be more curious about. If I'm prescribing a med requiring intensive monitoring (Lithium, Clozapine, etc) it should meet criteria just by continuing the med as the full wording is "Drug therapy requiring intensive monitoring for Toxicity". From what I've been told by admin we don't need to even order/interpret labs or ask questions at an appointment to hit that criteria, we just have to include the most recent results in the note and that the date they were drawn is within recommended guidelines to show ongoing intensive monitoring. From what I understand the point towards 99215 comes from prescribing a drug requiring monitoring, not the monitoring itself. Though if you're not monitoring at the frequency of recommended guidelines, I'd guess they won't approve a 99215 for prescribing that med.

Correct me if I'm wrong about the above, but this is the understanding I have from my discussions with admin and our billing outlines, at least for medicare/medicaid.

 

[clausewitz2]

I don't think that the reviewing 3 external notes is a requirement to hit 99215 in CoD if you're meeting 2 of the other criteria (NEEDING collateral, ordering unique tests, interpreting unique tests). For example, sometimes I'll order a Lithium draw on a patient in the morning and occasionally get results the same day in the afternoon. If I'm ordering and interpreting those results same day then boom, I met 99215 criteria for CoD even without reviewing outside notes. Hitting 99215 in CoD isn't necessary though if you're hitting it in the complexity of problems and patient management categories, which is far more common/easier to meet imo.

The second bolded is something I'd be more curious about. If I'm prescribing a med requiring intensive monitoring (Lithium, Clozapine, etc) it should meet criteria just by continuing the med as the full wording is "Drug therapy requiring intensive monitoring for Toxicity". From what I've been told by admin we don't need to even order/interpret labs or ask questions at an appointment to hit that criteria, we just have to include the most recent results in the note and that the date they were drawn is within recommended guidelines to show ongoing intensive monitoring. From what I understand the point towards 99215 comes from prescribing a drug requiring monitoring, not the monitoring itself. Though if you're not monitoring at the frequency of recommended guidelines, I'd guess they won't approve a 99215 for prescribing that med.

Correct me if I'm wrong about the above, but this is the understanding I have from my discussions with admin and our billing outlines, at least for medicare/medicaid.

The notes/collateral/tests thing is definitely an 'or', but you have to do at least three total things from those categories.

I believe the monitoring needs to be more like quarterly to count as intensive. If you are prescribing the drug but not doing the monitoring, how do you justify it as contributing to medical decision-making complexity?

 

[splik]

The notes/collateral/tests thing is definitely an 'or', but you have to do at least three total things from those categories.

I believe the monitoring needs to be more like quarterly to count as intensive. If you are prescribing the drug but not doing the monitoring, how do you justify it as contributing to medical decision-making complexity?

yup it has to be at least q3monthly.

 

[Stagg737]

yup it has to be at least q3monthly.

Really? Is that stated somewhere in the billing guidelines? I had not heard that.

What would you personally do with those patients you see monthly but draw labs q3months? They should still qualify for 99215 in the patient management category if you’re continuing the med you’re monitoring. Do you just bill 99214 even if they hit 215 in problems also?

The notes/collateral/tests thing is definitely an 'or', but you have to do at least three total things from those categories.

I believe the monitoring needs to be more like quarterly to count as intensive. If you are prescribing the drug but not doing the monitoring, how do you justify it as contributing to medical decision-making complexity?

For q6month monitoring I’ve put “last labs on blah blah with following results” then something saying when next draw should be and why meds are/aren’t being adjusted (no new side effects, ongoing efficacy, appropriate serum level, etc). I’ve billed a couple like this as 99215 and I haven’t been contacted about it yet or talked to by our PD/chair.