99214 vs 99213 vs 92215

[edieb1]

Although I know it varies from practice to practice, I was just curious which E&M code is most commonly used by everybody. I have difficulty understanding when to use 9911`3 vs 99214. However, for a myriad of reasons, including the fact that 99213 pays $32, I typically utilize 99214 with the 90833.

I would estimate I use 99213 with extremely easy cases which is approximately .10 of the time. 99214 I use with most cases that are moderately complex cases, even if I do not change the medicines (.89 of the time). Finally I use the 99215 only in the most severe cases .01 of the time.

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[Sushirolls]

99214 documentation

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...

forums.studentdoctor.net

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

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

forums.studentdoctor.net

99214 vs 99215 questions/frustrations

I may not be fully up to speed on the new billing code criteria for 2021. My basic understanding is that billing on complexity, the subjective and objective don't matter anymore, it's all about the medical decision making. And basically 2+ diagnoses of chronic conditions is a 99214. My...

forums.studentdoctor.net

E&M coding changes for 2021

Ok, does anyone have a good resource where we can check out how this affects psychiatrists and how we document? Also, before these changes, I've lived by and worked off of the attachment i linked below. Does anything change in there for us then? I really don't want to learn a whole bunch of...

forums.studentdoctor.net

 

[robellis]

99214 should pretty much be used in 95 percent of cases and add 90833 the majority of the time, if they are on lithium or clozapine then it gets bumped to a 99215

 

[NickNaylor]

Sounds like your billing is about what I expect, assuming you're not primarily seeing patients that are stable over the long-term and pretty straightforward diagnostically.

 

[jbomba]

99214 should pretty much be used in 95 percent of cases and add 90833 the majority of the time, if they are on lithium or clozapine then it gets bumped to a 99215

Any (very) rough estimate of what a 99214 + 90833 may pay?

 

[Sushirolls]

Medicaid, you can look that up.
Medicare, you can look that up.

Some places in the country pay less than medicare or at best match medicare for Psychiatry.

Some places like the odd pocket I'm in have a handful of insurance that pay in excess of medicare. To the big box shops they pay WAY in excess of medicare.
99214 could be from medicaid to private insurance that I've seen, $50-225
90833 could be from medicaid to private insurance that I've seen, $45-140

I've heard of other non-psychiatry specialists who are using 90833 getting more contractually then I as a Psychiatrist... go figure.

My own medical EOBs, I've seen Big Box shops locally get $292 and $305 for a 99214 from 2 separate insurance companies - but my rates are much, much lower for those same 2 companies.

In summary, it varies widely by location and that matters most, secondly assume its poor for psychiatry and you'll be disappointed.

 

[robellis]

Medicaid, you can look that up.
Medicare, you can look that up.

Some places in the country pay less than medicare or at best match medicare for Psychiatry.

Some places like the odd pocket I'm in have a handful of insurance that pay in excess of medicare. To the big box shops they pay WAY in excess of medicare.
99214 could be from medicaid to private insurance that I've seen, $50-225
90833 could be from medicaid to private insurance that I've seen, $45-140

I've heard of other non-psychiatry specialists who are using 90833 getting more contractually then I as a Psychiatrist... go figure.

My own medical EOBs, I've seen Big Box shops locally get $292 and $305 for a 99214 from 2 separate insurance companies - but my rates are much, much lower for those same 2 companies.

In summary, it varies widely by location and that matters most, secondly assume its poor for psychiatry and you'll be disappointed.

Think about this if we see 14 patients per day at $250 per patient we’re making the hospital 3500 per day, that equals 840k per year working 5 days a week, then people come on here and ask if they should accept 280k per year to see 18 patients per day…look at the numbers people and know your worth….

 

[trixter888]

Important to note that 99215s and correlating 99205 can be billed based off of time alone (depending on complexity) but cannot be combined with add on code. I did notice that when looking at billing a 99205 billed higher than 99214 + 90833.

Separate question: What do you think about billing a 99204 + 90833 in only 30 minutes? I feel with a new evaluation that would be hard to justify 16 minutes for therapy. 99214 + 90833 can be done in 30 minutes reasonably, but what do you think about in a 20 minute evaluation?

 

[robellis]

Important to note that 99215s and correlating 99205 can be billed based off of time alone (depending on complexity) but cannot be combined with add on code. I did notice that when looking at billing a 99205 billed higher than 99214 + 90833.

Separate question: What do you think about billing a 99204 + 90833 in only 30 minutes? I feel with a new evaluation that would be hard to justify 16 minutes for therapy. 99214 + 90833 can be done in 30 minutes reasonably, but what do you think about in a 20 minute evaluation?

99214+90833 is very standard for a 30min appointment…now if you start doing it for 20 minutes that becomes less standard and a bit more sketchy although people definitely still do it..remember that means you did 16 minutes of therapy as well as completed the E+M portion in 4 minutes..just depends on your comfort level

 

[jbomba]

So by these numbers, one should be able to do 2.5, 99214 + 90833 per hour and generate (as a rough floor) $250/hr?

 

[Sushirolls]

So by these numbers, one should be able to do 2.5, 99214 + 90833 per hour and generate (as a rough floor) $250/hr?

Nah, change it to per hour:
99214 + 99214 +90833 if you want to project out conservative numbers.

Using Medicare numbers, sure, $250/hr is doable. But don't forget to subtract your overhead from that!

I do about 85% 99214
13% 99213
I maybe add 90833 to 20-25% - which others have keenly pointed out needs drastic correction

If you review over the private practice thread I started, I calculate out a 'blended payor mix' which is a blend of the % of each insurance I have in my panel, and % ratio of 99213/99214 I billed out for that quarter to get a magic number per 30 minute follow up encounter.

 

[Sushirolls]

Think about this if we see 14 patients per day at $250 per patient we’re making the hospital 3500 per day, that equals 840k per year working 5 days a week, then people come on here and ask if they should accept 280k per year to see 18 patients per day…look at the numbers people and know your worth….

My blended payor mix formula isn't approaching that $250 mark... But perhaps if I were doing 90833 every patient, it might,
I'd drop that number down for conservative estimates to $130-150.
But even with that number, it still proves your point - know your worth. And those Big Box shops are clearly getting better rates, too.

 

[jbomba]

My blended payor mix formula isn't approaching that $250 mark... But perhaps if I were doing 90833 every patient, it might,
I'd drop that number down for conservative estimates to $130-150.
But even with that number, it still proves your point - know your worth. And those Big Box shops are clearly getting better rates, too.

2.5 x 90833 +99214 = $130/hr??? That's like 50 bucks for a 90833+99214 if I'm reading this correctly..

 

[clausewitz2]

So by these numbers, one should be able to do 2.5, 99214 + 90833 per hour and generate (as a rough floor) $250/hr?

I'll put it this way. I have a couple private pay therapy patients who i charge $300 per hour. I lose money on them compared to doing two 30 minutes 99214+90833's in that time. So it's probably never going to be more than a couple at a time.

 

[Sushirolls]

2.5 x 90833 +99214 = $130/hr??? That's like 50 bucks for a 90833+99214 if I'm reading this correctly..

Robellis and I were referencing per patient (encounter). Not a total hourly rate.
So $130 per encounter, typically 30 minute block. So double that, equals $260/hr

To Clausewitz2 point, I recently dropped a low paying insurance, well below medicare rates, and also raised my out of pocket cash rate. Only one insurance is lower than my cash rate. At some point I'll drop that one too. In summary, I do better with insurance than doing cash. **This is not the experience for many places in the country** I also don't expect this cash vs insurance equilibrium to continue moving forward years to come, and anticipate insurance companies making the decision for me to drop them all, one by one.

 

[sighchiatry]

Medicaid, you can look that up.
Medicare, you can look that up.

Some places in the country pay less than medicare or at best match medicare for Psychiatry.

Some places like the odd pocket I'm in have a handful of insurance that pay in excess of medicare. To the big box shops they pay WAY in excess of medicare.
99214 could be from medicaid to private insurance that I've seen, $50-225
90833 could be from medicaid to private insurance that I've seen, $45-140

I've heard of other non-psychiatry specialists who are using 90833 getting more contractually then I as a Psychiatrist... go figure.

My own medical EOBs, I've seen Big Box shops locally get $292 and $305 for a 99214 from 2 separate insurance companies - but my rates are much, much lower for those same 2 companies.

In summary, it varies widely by location and that matters most, secondly assume its poor for psychiatry and you'll be disappointed.

I wasn't aware that non-psychiatrist physicians could use psychotherapy add on codes such as 90833.

 

[jbomba]

I'll put it this way. I have a couple private pay therapy patients who i charge $300 per hour. I lose money on them compared to doing two 30 minutes 99214+90833's in that time. So it's probably never going to be more than a couple at a time.

Why the heck are attendings in my program telling us to expect 250k a year if we are doing pp full-time after residency then?

 

[trixter888]

Interestingly my biller informed be that 90792 bills more than my 99204. During a 30 minute eval I am not feeling comfortable enough to do a 99204 + 90833 (which would be more than 90792). This is medicare by the way

 

[calvnandhobbs68]

Why the heck are attendings in my program telling us to expect 250k a year if we are doing pp full-time after residency then?

1) Because it's gonna take some time until you have a full patient load of 14 half hour evals a day. For instance, I'm just starting out within a larger therapist group paneled on a couple insurances (will be paneled on like 5 total I think when all the credentialling comes through) and I'm doing about 4-5 new evals a day. Even if you accept insurance (which means you either need the time or infrastructure for this) you don't automatically start with a completely full panel. These numbers are projecting a completely full panel with minimal no show rate, things that you either need to 1) Hire people to do (bill insurance, remind patients, bill patients for no shows) or 2) Pay a larger group a percentage of your revenue/flat fee to handle for you (which is what I'm doing). Both of these eat into your gross.

2) They don't know how to bill. You'd be surprised how many of your attendings probably just bill straight 99213s or 99214s for their appointments because they just don't care about the revenue since they're salaried. Or how many of them probably still bill 90792s for their intakes without realizing their 60 minute intakes all basically automatically count as 99205s now based on time. Or often times the RVU bonus isn't enough to put the effort into writing decent enough notes to qualify for a 99214 + 90833 (which is why you see all your attendings writing 3 sentence long notes). Academic centers there's very little incentive to maximize coding in general since so much of anything you bill gets skimmed off the top anyway, why would you bother putting in the documentation for the higher level codes when you aren't going to see most of that money? Academic/large hospital systems tend to have a decent floor in terms of salary depending on where you go but a very low ceiling in terms of salary.

 

[calvnandhobbs68]

Interestingly my biller informed be that 90792 bills more than my 99204. During a 30 minute eval I am not feeling comfortable enough to do a 99204 + 90833 (which would be more than 90792). This is medicare by the way

Uh yeah man a 99204 is a new patient eval. I wouldn't feel comfortable trying to code a 99204 + 90833 either for a new eval in 30 minutes.

Most people are talking about 99213s vs 99214s for followups. 99204 + 90833 I wouldn't even try to do in anything less than 45 minutes and all my new intakes are an hour. 99205 now automatically hits 60 minutes of face to face time for new intakes which I've found generally bills more than a 90792 at this point.

 

[AD04]

Why the heck are attendings in my program telling us to expect 250k a year if we are doing pp full-time after residency then?

If these attendings could run a successful private practice, they wouldn't be in academia with their low salaries.

 

[hamstergang]

If these attendings could run a successful private practice, they wouldn't be in academia with their low salaries.

Not everyone prioritizes money above all else.

 

[trixter888]

90792 for 30 minutes bills higher than 99205 at 60 minutes. But I hear yah.

 

[calvnandhobbs68]

90792 for 30 minutes bills higher than 99205 at 60 minutes. But I hear yah.

No duh. It’s a matter of whether you think you’re getting a quality psych new patient visit in 30 minutes. Many of us would say no.

 

[clausewitz2]

No duh. It’s a matter of whether you think you’re getting a quality psych new patient visit in 30 minutes. Many of us would say no.

I can't think of any patients this would be appropriate for who wouldn't also be better served with you concluding by sending them back to their PCP.


Honestly I am considering making my intakes 90 minutes going forward now that I am pretty full. Not always necessary but useful more often than not. Especially for folks who have been around the block MH treatment wise a few times.

 

[NickNaylor]

I can't think of any patients this would be appropriate for who wouldn't also be better served with you concluding by sending them back to their PCP.


Honestly I am considering making my intakes 90 minutes going forward now that I am pretty full. Not always necessary but useful more often than not. Especially for folks who have been around the block MH treatment wise a few times.

Our TRD evaluations are scheduled for 2 hours, and even that amount of time isn't sufficient. Granted this is a different patient population, but 90 minutes seems entirely reasonable to me for a thorough evaluation and plenty of time for discussion of diagnostic impressions and treatment options.

 

[Stagg737]

They don't know how to bill. You'd be surprised how many of your attendings probably just bill straight 99213s or 99214s for their appointments because they just don't care about the revenue since they're salaried.

I'm always shocked at how true this is, and looking back how many of my attendings (pre-residency) could have probably made significantly more if they'd optimized their billing. I've found that physicians as a whole are pretty financially ignorant and that the 'you don't know what you don't know' addage is especially true. On the flip side, the few docs I've worked with who were very financially savvy had very few reservations about sharing their knowledge and offering resources like blogs or books that they've found helpful.

 

[clausewitz2]

On the flip side, the few docs I've worked with who were very financially savvy had very few reservations about sharing their knowledge and offering resources like blogs or books that they've found helpful.

At least when it comes to billing appropriately, disseminating this knowledge widely is still a win-win at the margin. The more people are billing 99214+90833 when they should, the more normal my billing patterns look to insurers and the less likely I am to get hassled about it.

Of course at some point this might mean the costs associated with these codes increase to the point there is a push to revise them downwards, but I don't think that equilibrium is coming any time in the near future.

 

[Sushirolls]

I can't think of any patients this would be appropriate for who wouldn't also be better served with you concluding by sending them back to their PCP.


Honestly I am considering making my intakes 90 minutes going forward now that I am pretty full. Not always necessary but useful more often than not. Especially for folks who have been around the block MH treatment wise a few times.

I do 90 minutes and feel its the right amount of time. Bell curve, 5% on each end for me wrapping up early or wishing I had more time.

When I was doing more of TRD role with an ECT service in past 90 minutes then was a rush and often pushed into 2 hours.