99214 documentation

[clausewitz2]

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?



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.

If it is not an appointment in which I am ordering the labs or interpreting a given set of results for the first time, generally I am billing 99214. If it's something like clozapine or the initiation phase of lithium than yes it is often a 5.

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[Stagg737]

If it is not an appointment in which I am ordering the labs or interpreting a given set of results for the first time, generally I am billing 99214. If it's something like clozapine or the initiation phase of lithium than yes it is often a 5.

What about Lithium monitoring where you're not drawing labs or interpreting new labs but are drawing labs 3 months within last draw. Example:

Two months ago, a patient with bipolar I has hypomanic exacerbation and you increased Li dose at the time. At that same appointment, you also drew labs and got results back same day showing level of 0.8. Patient had repeat labs drawn a week later and level was 1.0. A month later you saw them, interpreted that lab and left lithium at that dose. You're now seeing him for the second f/up 2 months after you increased Lithium. You are not changing the dose at todays appointment and plan to order repeat lithium level in 1 month so you will be doing intensive drug monitoring. You also note that he has a slight tremor which has developed since increasing the Lithium dose but is otherwise stable (99215 criteria for complexity of problem met). You don't meet 99215 criteria for complexity of data. How do you bill this situation? 99214 or 215?

In this case, the patient is requiring intensive drug monitoring at this time even if later appointments when lab draws become less frequent don't meet that criteria. So this still meets criteria for 99215, no? I realize this is a pretty specific example and probably not very common, but I do wonder how those who bill 99215 for patients with drug monitoring are billing the "in between" appointments where labs aren't ordered. Imo, even if you're not drawing labs at that appointment, you're still meeting criteria for "intensive drug monitoring" in the risk category for billing, so as long as you're hitting 99215 criteria in the CoP or CoD categories, you can still bill 99215 for the encounter.

 

[clausewitz2]

What about Lithium monitoring where you're not drawing labs or interpreting new labs but are drawing labs 3 months within last draw. Example:

Two months ago, a patient with bipolar I has hypomanic exacerbation and you increased Li dose at the time. At that same appointment, you also drew labs and got results back same day showing level of 0.8. Patient had repeat labs drawn a week later and level was 1.0. A month later you saw them, interpreted that lab and left lithium at that dose. You're now seeing him for the second f/up 2 months after you increased Lithium. You are not changing the dose at todays appointment and plan to order repeat lithium level in 1 month so you will be doing intensive drug monitoring. You also note that he has a slight tremor which has developed since increasing the Lithium dose but is otherwise stable (99215 criteria for complexity of problem met). You don't meet 99215 criteria for complexity of data. How do you bill this situation? 99214 or 215?

In this case, the patient is requiring intensive drug monitoring at this time even if later appointments when lab draws become less frequent don't meet that criteria. So this still meets criteria for 99215, no? I realize this is a pretty specific example and probably not very common, but I do wonder how those who bill 99215 for patients with drug monitoring are billing the "in between" appointments where labs aren't ordered. Imo, even if you're not drawing labs at that appointment, you're still meeting criteria for "intensive drug monitoring" in the risk category for billing, so as long as you're hitting 99215 criteria in the CoP or CoD categories, you can still bill 99215 for the encounter.

Do you feel comfortable justifying 'severe side effect of treatment' based on a mild tremor?

 

[Stagg737]

Do you feel comfortable justifying 'severe side effect of treatment' based on a mild tremor?

Not really relevant to my question, but I'll play. Let's say it's a severe tremor that causes the patient to be embarrassed in public or causes difficulties performing some tasks. Meeting criteria for the CoP isn't really what I'm interested in, let's just say they meet that criteria for 99215. I'm more curious about how people are interpreting the "Drug therapy requiring intensive monitoring for toxicity" criteria to meet the 99215 criteria for the risk category.

 

[hamstergang]

but I do wonder how those who bill 99215 for patients with drug monitoring are billing the "in between" appointments where labs aren't ordered.

I would generally bill a 99214 for the visits where the labs aren't being ordered or interpreted as I don't think I'm doing what an insurance company would consider "intensive drug monitoring" at those visits. Based on other responses in this thread, it seems I'm not alone in saying this.

 

[calvnandhobbs68]

I mean the real kicker for all this isn’t “is this what we think” it’s “what do the insurance companies/Medicare” think. Guidelines ar published by CMS but as we can see above there’s pretty wide ranges in how to interpret some of these guidelines.

Main issue of course being that the insurance company comes back and audits these charts and decides that your theoretical patients above don’t meet criteria for 99215 and instead make you pay back all that difference between 99215 and 99214. With your recourse being….an appeal to the insurance company. I think that’s why people tend to be pretty conservative with 99215s.

 

[Stagg737]

I mean the real kicker for all this isn’t “is this what we think” it’s “what do the insurance companies/Medicare” think. Guidelines ar published by CMS but as we can see above there’s pretty wide ranges in how to interpret some of these guidelines.

Main issue of course being that the insurance company comes back and audits these charts and decides that your theoretical patients above don’t meet criteria for 99215 and instead make you pay back all that difference between 99215 and 99214. With your recourse being….an appeal to the insurance company. I think that’s why people tend to be pretty conservative with 99215s.

True, but unless you have a high number of Clozapine patients or a lot of unstable borderline patients, how frequently are we actually going to see 99215's who may/may not meet criteria for intensive drug monitoring. I guess I'm asking this as more of an academic question as for most I'd guess the number of patients sitting on that fence is small enough that losing an audit wouldn't cost all that much anyway.

 

[clausewitz2]

True, but unless you have a high number of Clozapine patients or a lot of unstable borderline patients, how frequently are we actually going to see 99215's who may/may not meet criteria for intensive drug monitoring. I guess I'm asking this as more of an academic question as for most I'd guess the number of patients sitting on that fence is small enough that losing an audit wouldn't cost all that much anyway.

Making it hard to meet criteria for 99215 is definitely by design. Based on how the criteria are set up it seems much easier to get there in a multi-disciplinary kind of setting with regular team meetings. Not a terrible thing.

 

[splik]

The reason audits exist etc is because physicians do shady things like upcoding, which is fraud. (Of course all of the major insurers also do shady things.) The criteria are quite clear, and if you aren't clear on this sort of thing, you need to hire someone to help you understand or do an internal audit of your coding. Facing an audit is stressful particularly if it involves Medicare, as there are both federal civil and criminal penalties you can face in addition to potentially being banned from medicare/medicaid (which can cause problems with credentialing, licensing renewal, working at a hospital etc). Even for commercial insurance, it is just a massive headache to face an audit where money is clawed back. Often they wont just demand the difference (i.e. difference between a level 4 and 5 visit), they may demand it ALL back so you end up losing more money. They may also deny or delay any pending bills, or request you pre-authorize or submit documentation prospectively for future payments. They can also levy fines or remove you from their panel. Often these reviews reveal other unrelated deficiencies which can be used to claw back payments etc.

What about Lithium monitoring where you're not drawing labs or interpreting new labs but are drawing labs 3 months within last draw. Example:

Two months ago, a patient with bipolar I has hypomanic exacerbation and you increased Li dose at the time. At that same appointment, you also drew labs and got results back same day showing level of 0.8. Patient had repeat labs drawn a week later and level was 1.0. A month later you saw them, interpreted that lab and left lithium at that dose. You're now seeing him for the second f/up 2 months after you increased Lithium. You are not changing the dose at todays appointment and plan to order repeat lithium level in 1 month so you will be doing intensive drug monitoring. You also note that he has a slight tremor which has developed since increasing the Lithium dose but is otherwise stable (99215 criteria for complexity of problem met). You don't meet 99215 criteria for complexity of data. How do you bill this situation? 99214 or 215?

In this case, the patient is requiring intensive drug monitoring at this time even if later appointments when lab draws become less frequent don't meet that criteria. So this still meets criteria for 99215, no? I realize this is a pretty specific example and probably not very common, but I do wonder how those who bill 99215 for patients with drug monitoring are billing the "in between" appointments where labs aren't ordered. Imo, even if you're not drawing labs at that appointment, you're still meeting criteria for "intensive drug monitoring" in the risk category for billing, so as long as you're hitting 99215 criteria in the CoP or CoD categories, you can still bill 99215 for the encounter.

This is 99214 because the there isnt a life threatening condition or severe exacerbation of condition. neither hypomania (which is less than mild mania by definition) or mild tremor count would qualify as severe. Now, if the patient was acutely manic then it would be 99215 if the patient was on lithium, regardless if labs were drawn at that visit because lithium is a treatment that requires intensive monitoring for toxicity.

 

[sloh]

The criteria are quite clear, and if you aren't clear on this sort of thing, you need to hire someone to help you understand or do an internal audit of your coding. Facing an audit is stressful particularly if it involves Medicare, as there are both federal civil and criminal penalties you can face in addition to potentially being banned from medicare/medicaid (which can cause problems with credentialing, licensing renewal, working at a hospital etc). Even for commercial insurance, it is just a massive headache to face an audit where money is clawed back. Often they wont just demand the difference (i.e. difference between a level 4 and 5 visit), they may demand it ALL back so you end up losing more money. They may also deny or delay any pending bills, or request you pre-authorize or submit documentation prospectively for future payments. They can also levy fines or remove you from their panel. Often these reviews reveal other unrelated deficiencies which can be used to claw back payments etc.

I feel like often the criteria leave a lot of room for interpretation and even those hired in-house to help physicians on coding vary in their answers. It's a headache tbh.

 

[Stagg737]

This is 99214 because the there isnt a life threatening condition or severe exacerbation of condition. neither hypomania (which is less than mild mania by definition) or mild tremor count would qualify as severe. Now, if the patient was acutely manic then it would be 99215 if the patient was on lithium, regardless if labs were drawn at that visit because lithium is a treatment that requires intensive monitoring for toxicity.

So I addressed that aspect in my response to Clause below:

Not really relevant to my question, but I'll play. Let's say it's a severe tremor that causes the patient to be embarrassed in public or causes difficulties performing some tasks. Meeting criteria for the CoP isn't really what I'm interested in, let's just say they meet that criteria for 99215. I'm more curious about how people are interpreting the "Drug therapy requiring intensive monitoring for toxicity" criteria to meet the 99215 criteria for the risk category.

Let's say they meet criteria for 99215 for CoP. I'm just curious how one would interpret the previously mentioned example in regards to the risk category.

 

[hebel]

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.

Do you think an E/M base code is justified for any visit with a psychiatrist, as we are technically always assessing the need for a medication? So even if you don't end up prescribing something, we are generally assessing in some way whether a medication is indicated.

 

[rjs2131]

Do you think an E/M base code is justified for any visit with a psychiatrist, as we are technically always assessing the need for a medication? So even if you don't end up prescribing something, we are generally assessing in some way whether a medication is indicated.

This piece can be subjective but I can't think of a patient visit where I haven't at least considered medication (and then decided after discussion to defer starting) - I think this is what distinguishes us from therapists. I agree with E/M coding being justified for every visit as a psychiatrist, even if you're "only doing therapy".

 

[Stagg737]

Do you think an E/M base code is justified for any visit with a psychiatrist, as we are technically always assessing the need for a medication? So even if you don't end up prescribing something, we are generally assessing in some way whether a medication is indicated.

Interesting though, but are you going to include that assessment in a therapy note? How would you justify making an assessment that a med change would be beneficial/necessary but not making the change because you're "only doing therapy"? Seems like it would be a bad idea to see patients for therapy only if you're going to use an E/M based code.

 

[tr]

Do you think an E/M base code is justified for any visit with a psychiatrist, as we are technically always assessing the need for a medication? So even if you don't end up prescribing something, we are generally assessing in some way whether a medication is indicated.

Uh, no, I think that's a stretch. I would have put an E&M code (99204 or 99205) for the initial visit at which I assessed whether medication was needed. If I'm then seeing them weekly for (say) CBTi I am not assessing meds at every visit. If I did happen to spend time on medication for a given visit I would put an E&M code, but the majority of my therapy visits do not involve any discussion of medication.

 

[clausewitz2]

Uh, no, I think that's a stretch. I would have put an E&M code (99204 or 99205) for the initial visit at which I assessed whether medication was needed. If I'm then seeing them weekly for (say) CBTi I am not assessing meds at every visit. If I did happen to spend time on medication for a given visit I would put an E&M code, but the majority of my therapy visits do not involve any discussion of medication.

I think if you are prescribing them something and do check up about side effects/efficacy at each appointment this can be justified. I agree with you that if you see someone for a strictly psychotherapeutic modality and haven't asked questions or talked about meds in ages, then it is hard to see where the E&M part is.

 

[Dr.MONO]

Does anyone have review resources for codes and documentation for starters?