99214 vs 99215 questions/frustrations

[nexus73]

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 frustration lies in the fact if I see someone with depression, anxiety, and suicidality, I'm dealing with a potentially severe situation. The suicide risk assessment takes time and carries risk, and a decision about whether someone needs to be in the hospital or not. Is there a way to justify a 99215 in the current rules given the increased risk of treating an outpatient with SI?

Versus a PCP visit where someone is seen for HTN and HLD is also a 99214 and requires a lot less work and less risk. Or a recent note I saw from an ENT in our system treating a TMJ patient, and he diagnosed both TMJ and obesity (with plan for obesity documented as "counseled patient about healthy diet and exercise), where obesity clearly seemed like it was tacked on to make 2 diagnoses and justify a 99214, when really that ENT doctor isn't treating obesity. Or just a straight psych visit with a worried well patient with mild depression and anxiety, is also a 99214 but clearly much less work and risk.

So can a 99215 be justified if patient is suicidal but not meeting criteria for inpatient care? My coders tell me 99215 should only be if I'm admitting them to the hospital.

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[adiradirim]

My understanding is that if a person is suicidal that meats level 5 for both complexity and risk. When a person is suicidal and you treat outpatient, you are making a "decision regarding hospitalization" which is that you will not admit at this time because you have a safety plan, etc. Your decision regarding admission is not to admit at this time. I believe you just have to put in your note that you considered admission but decided to continue outpatient with safety planning.

 

[Stagg737]

Is there a way to justify a 99215 in the current rules given the increased risk of treating an outpatient with SI?

If you're considering admission then it meets criteria for high-complexity decision making, which I'd argue is true in your case if you're doing a full suicide risk assessment. SI leading to consideration for admission is also very likely a "severe" exacerbation of one of their conditions, so just with those two factors you should meet criteria for 99215 with proper documentation.

 

[calvnandhobbs68]

My understanding is that if a person is suicidal that meats level 5 for both complexity and risk. When a person is suicidal and you treat outpatient, you are making a "decision regarding hospitalization" which is that you will not admit at this time because you have a safety plan, etc. Your decision regarding admission is not to admit at this time. I believe you just have to put in your note that you considered admission but decided to continue outpatient with safety planning.

Agree. This isn’t for SI only either. For instance, if someone is psychotic and I’m seriously considering referral for hospitalization or crisis unit referral but decided against it, I clearly state all of this in the note and then submit it as a 99215.

You could even throw in the required wording “severe exacerbation” or “threat to life or bodily functioning”. I would definitely justify deciding not to admit someone but changing around medical management and following closely as ways to address a possible “threat to life or bodily functioning”.

 

[NickNaylor]

As others have mentioned, SI is pretty much a slam dunk 99215, assuming you document your decision-making rationale, as suggested. Perhaps for more chronically suicidal patients that are stable a 99215 wouldn’t be appropriate, but for most other circumstances I would consider that high-complexity.

 

[liquidshadow22]

It's rare where a telehatlh outpt visit leads to a psych hospitalization.

My experience has been more often referring patients to partial hospitalizations for passive si or si with plans in recent past, but nothing imminent.

Would this definitely qualify for a 99215?

 

[splik]

It's rare where a telehatlh outpt visit leads to a psych hospitalization.

My experience has been more often referring patients to partial hospitalizations for passive si or si with plans in recent past, but nothing imminent.

Would this definitely qualify for a 99215?

No

SI isn't an automatic 99215. It depends on the patient and the plan. If the patient doesn't meet criteria for hospitalization, it won't count. They do need to meet criteria for admission. They don't need to be admitted to the hospital, if you carefully document why and what you are doing instead. For example, you could have a patient who definitely meets criteria for hospitalization but cites a reason for not wanting to be admitted and you determine that admission would be more harmful and instead refer them for admission to PHP that would count. Or if you had a patient who had financial problesm and the cost of the hospitalization would make them more suicidal, and instead you increase the frequency of sessions, then you could justify 99215. You also should not exaggerate the patient's clinical condition to justify 99215 as that could have serious consequences for the patient and open you up to liability, not only for negligent diagnosis and assessment, but also fraudulent upcoding.

I rarely bill 99215 on MDM, it would typically based on time. 99214 does cover a wide range in complexity now, but it is deliberate, as 99215 is supposed to have a high bar and be used infrequently.

Another common misunderstanding is people seem to think if you have a pt on lithium or clozapine they would automatically qualify. that is not true. They only qualify if their illness is also severe or unstable.
For example, patient with bipolar I disorder, currently moderately depressed on lithium would not qualify not 99215.
a patient with schizophrenia, stable but symptomatic on clozapine would not qualify for 99215.
A patient who is acutely manic and on lithium would qualify for 99215.
a patient with psychosis hearing voices to harm others on clozapine would qualify for 99215

 

[liquidshadow22]

No

And alcohol use disorder with acute withdrawal does not qualify for 99215 either? It falls under acute illness with systemic side effects which is moderate but not under a severe exacerbation of chronic illness with threat to life?? Sounds so arbritary and idiotic. Oh wait it is.

 

[hamstergang]

Unlike the ENT, you can at least also add in a 90833 to the 99214, assuming the visit went long enough and you did something the insurance company would consider to be psychotherapy (which I think would be likely with a suicidal patient).

 

[clausewitz2]

a patient with schizophrenia, stable but symptomatic on clozapine would not qualify for 99215.

Unless they were having a significant side effect of treatment, of course; if they have gained 80 lbs in the last 6 months, possible seizures, or have substantial constipation, I don't know how you argue it's not a serious side effect of clozapine.

That same patient based on the MDM tables could totally be a 99215 if they are stable but this is the visit where you are ordering a CBC, read their last PCP note, getting collateral from a family member who showed up to the appointment, and also that same day discuss the patient in a team meeting with patient's therapist/case manager/etc. Alternatively, order your CBC, document why you considered but didn't order a cloz/norcloz level, and read the notes from their therapist and case manager plus have that discussion in team and you appear to be hitting it to for someone on clozapine. Admittedly that is not happening in your typical outpatient private practice but it's also not super rare.

 

[liquidshadow22]

Unless they were having a significant side effect of treatment, of course; if they have gained 80 lbs in the last 6 months, possible seizures, or have substantial constipation, I don't know how you argue it's not a serious side effect of clozapine.

That same patient based on the MDM tables could totally be a 99215 if they are stable but this is the visit where you are ordering a CBC, read their last PCP note, getting collateral from a family member who showed up to the appointment, and also that same day discuss the patient in a team meeting with patient's therapist/case manager/etc. Alternatively, order your CBC, document why you considered but didn't order a cloz/norcloz level, and read the notes from their therapist and case manager plus have that discussion in team and you appear to be hitting it to for someone on clozapine. Admittedly that is not happening in your typical outpatient private practice but it's also not super rare.

1)What about TRD on latuda. Develops akasthisia. Tx with propranolol. Does it have to be Severe akasthisia to code as 99215? How do you quantify this, seems so subjective to me

2) another ex. Gad with longstanding benzo dependence. Weaning down and pt having withdrawal sx. "severe" agitation/ anxiety in that setting. Would it be a 99215?

 

[Nudexta]

Can a 99215 be billed with 20 min visit and serve complexity?

 

[liquidshadow22]

Can a 99215 be billed with 20 min visit and serve complexity?

No time requirement if you bill on complexity. If you bill based on time alone then it should be a 40 min visit.

The trick is knowing what would qualify as a severe diagnosis and severe management.

Technically, schizophrenia patient presents with acute dystonia. You stop the antipsychotic and give congentin. If it takes you 20min then you should qualify for a 99215 based on complexity

 

[calvnandhobbs68]

It's rare where a telehatlh outpt visit leads to a psych hospitalization.

My experience has been more often referring patients to partial hospitalizations for passive si or si with plans in recent past, but nothing imminent.

Would this definitely qualify for a 99215?

😆 if I sent everyone with passive SI or SI with a recent plan to PHP or even IOP I’d be sending most of my patients to IOP.

I have a girl who just tried to OD a week ago went to the ED and they sent her back home who I’m still seeing outpatient…don’t even mention half the teenagers I see every day who light up their PHQ-9s with SI.

 

[liquidshadow22]

😆 if I sent everyone with passive SI or SI with a recent plan to PHP or even IOP I’d be sending most of my patients to IOP.

I have a girl who just tried to OD a week ago went to the ED and they sent her back home who I’m still seeing outpatient…don’t even mention half the teenagers I see every day who light up their PHQ-9s with SI.

Yea I honestly don't refer to partial or iop that often. Just if they have some risk factors I am concerned about. I rely mostly on my countertranference.

I have yet to hospitalize an outpt involuntarily during a visit since the pandemic began. My guess is I have done around 2000 visits since then.

Re: partial. there's really no harm in it, if the patient is amenable, why not? I guess perhaps wasting Healthcare dollars or taking spot from someone more severe. But it's CYA at the very least.

 

[clausewitz2]

1)What about TRD on latuda. Develops akasthisia. Tx with propranolol. Does it have to be Severe akasthisia to code as 99215? How do you quantify this, seems so subjective to me

Remember, you need to meet complexity criteria in 2 out of 3 categories. Side effects of treatment alone, even if severe, don't do it.

2) another ex. Gad with longstanding benzo dependence. Weaning down and pt having withdrawal sx. "severe" agitation/ anxiety in that setting. Would it be a 99215?

Anxiety isn't a threat to life or bodily function, so it's not going to work for high complexity of problem. The exception of course would be if they are acutely suicidal as a result. Now if they are having severe GABAergic w/d that's a different question.

 

[liquidshadow22]

Remember, you need to meet complexity criteria in 2 out of 3 categories. Side effects of treatment alone, even if severe, don't do it.



Anxiety isn't a threat to life or bodily function, so it's not going to work for high complexity of problem. The exception of course would be if they are acutely suicidal as a result. Now if they are having severe GABAergic w/d that's a different question.

Guess need to emphasize that the risk of treatment/mgt complications needs to be severe ie. Starting lithium, stopping/switching antipsychotic in a schizophrenic pt due to eps, rx Ativan for etoh withdrawal) in addition to the problem being severe (the definition of severe for means should be taken as threat to life or limb for both the problem and mgmt of said problem)

 

[Dr.MONO]

Any source for good explanation for these codes?

 

[hamstergang]

Any source for good explanation for these codes?

CPT & Reimbursement

www.aacap.org

This is from AACAP, but I think it explains things nicely enough that it won't matter if you treat adults.

 

[calvnandhobbs68]

CPT & Reimbursement

www.aacap.org

This is from AACAP, but I think it explains things nicely enough that it won't matter if you treat adults.

Yeah I think AACAP has some of the best explanations, they even have quite a few specific examples for each type of code in those powerpoint slides.