Billing for Med management & Psychotherapy - 99214 + 90833

[Merely]

Who is arguing this?

I would imagine the many docs seeing 50 patients a day lol

---

Members don't see this ad.

 

[splik]

i think you miss the point. If you are billing 5x level 4 visits an hour you're committing fraud. if you're seeing 50 pts a day, these would likely mostly all be stable pts (one would hope) in which case they would not qualify for level 4 coding.

 

[clausewitz2]

i think you miss the point. If you are billing 5x level 4 visits an hour you're committing fraud. if you're seeing 50 pts a day, these would likely mostly all be stable pts (one would hope) in which case they would not qualify for level 4 coding.

Or you could just be one of those docs that will tell you all about how they just love Latuda/Vraylar/Trintellix/Fatiza and gives the latest samples the rep dropped off in a transdiagnostic fashion. Just like their mentors gave everyone Depakote back when they were training...

 

[Merely]

i think you miss the point. If you are billing 5x level 4 visits an hour you're committing fraud. if you're seeing 50 pts a day, these would likely mostly all be stable pts (one would hope) in which case they would not qualify for level 4 coding.

Oh well that's what I was asking, the other people are saying it's not fraud just maybe bad patient care, you're actually saying fraud meaning potential jail time...

 

[Amygdarya]

It really bugs me to see in this and some other money-related threads how some medical students are eager to provide crappy psychiatric care (without even quite knowing yet what psychiatric care entails) in order to maximize their earnings
Oh, and don’t tell me about medical school loans; (almost) everyone has them.

 

[Amygdarya]

Oh well that's what I was asking, the other people are saying it's not fraud just maybe bad patient care, you're actually saying fraud meaning potential jail time...

So “just maybe bad patient care” is ok as long as you stay out of jail?

 

[hamstergang]

If you are billing 5x level 4 visits an hour you're committing fraud. if you're seeing 50 pts a day, these would likely mostly all be stable pts (one would hope) in which case they would not qualify for level 4 coding.

This is not true. If the patients are stable but on meds and have multiple issues to address, then the visits can qualify for 99214. You don't have to stay in the room long to get the criteria met.

 

[Attending1985]

It really bugs me to see in this and some other money-related threads how some medical students are eager to provide crappy psychiatric care (without even quite knowing yet what psychiatric care entails) in order to maximize their earnings
Oh, and don’t tell me about medical school loans; (almost) everyone has them.

I second this you’re basically exploiting mentally ill people for financial gain how can you live with that

 

[Merely]

It really bugs me to see in this and some other money-related threads how some medical students are eager to provide crappy psychiatric care (without even quite knowing yet what psychiatric care entails) in order to maximize their earnings
Oh, and don’t tell me about medical school loans; (almost) everyone has them.

I really appreciate this post and agree with you completely. I would never talk about loans or even try to justify my previous posts. I am a student and am simply reflecting on what I see around me, and trying to learn as much as I can. I don't plan on seeing even close to that many patients but am reflecting on what the legal and financial possibilities are in this field. I am seeing people talk about bill 50 pts a day 99214. I am trying to learn about this and see is this legal or what's going on, posters are disagreeing because some are saying legal since no time requirement while splik disagrees.

Tldr: just because I ask a question about something doesn't mean I will do it, learning about things doesn't make you a bad prrson/doctor.

 

[nexus73]

Oh well that's what I was asking, the other people are saying it's not fraud just maybe bad patient care, you're actually saying fraud meaning potential jail time...

Thus could also be called negligence, and may end up cutting into profit margins

 

[sweetlenovo88]

Is is necessary to have a practice address to get contracted insurance rates? Can one call say they want to practice in the area to get said rates without having to sign a lease first to obtain a practice address?

 

[sweetlenovo88]

I can tell you that if you were billing 5x level 4s every hour you'd be clearing >1million a year and would be audited and if they're medicare pts could be done for medicare fraud. level 4s still have to be a) medically necessary and b) they have to believe you have reasonably addressed everything in the allotted time. it's not possible to address every issue for every pt in 10-12 minutes if they have multiple problems to addressed... of course there are some pt visits that one could address the issues briefly and code a level 4, but for the majority... im gonna call it fraud. if anyone would like to try billing 5+ level 4 visits each hour, please let me know how it goes from your minimum security prison cell

I agree. Any thoughts on billing like this in an hour: (99214+90833, 16 min of therapy), (99214+90833, 16 min of therapy), 99213. This should generate right above $400 an hour with medicare rates.

 

[SeniorWrangler]

Ok so could you then do 5 in an hour still and generate 500/hr? Or is that unreasonable?

You would stick out like a sore thumb in the claims data. You know the old saying, "pigs get fed, hogs get slaughtered?" Yeah.

 

[Merely]

You would stick out like a sore thumb in the claims data. You know the old saying, "pigs get fed, hogs get slaughtered?" Yeah.

i don't see how it's fraud if you're actually seeing the patients and meeting all requirements for the service...

 

[clausewitz2]

i don't see how it's fraud if you're actually seeing the patients and meeting all requirements for the service...

They're saying that you can't do this in a credible way and would have to spend quite a lot of your life arguing with auditors who might be similarly dubious of your claims. Better document the hell out of every encounter just to make sure aaaaaand you're no longer effectively making 500 an hour.

 

[Armadillos]

I'm sure I'm going to be writing more sparse notes as an attending, but it's so obvious these folks saying your going to see 50 pts a day have never done any opt psychiatry. It takes a decent junk of time just to write 5 notes after a half day of resident clinic. Heck even the prospect of writing notes on 16 pts a day for 30 min followups seems super daunting to me and that would be a super cushy attending job.

 

[Merely]

its fraud because i say it is. which is essentially how this works. if you are billing disproportionate to anyone it raises red flags. if experts then testify to your fraudulent activity (i would personally be very happy to see rogue docs removed from practice) you're toast. a jury is not going to be happy with you raking in millions of tax payer money for being a drug dealer.

and if everyone bills disproportionate to what the insurance companies expect they will simply dramatically reduce the compensation to account for it or stop paying for said codes entirely.

Very interesting point, however what gives you the authority to call someone rogue? a doc has to make 300k and if he makes 700k all of a sudden he's rogue? Maybe he actually is doing a good job with his 50 patients a day, how could you know that? Also so it's not government and taxpayer related one could just see only private insurance to remove the taxpayer aspect of it

 

[clausewitz2]

Very interesting point, however what gives you the authority to call someone rogue?

"Counsel for the defendant, do you stipulate to [Dr. Splik's] qualifications?"

"Yes, your Honor."

Boom, authority.

Also so it's not government and taxpayer related one could just see only private insurance to remove the taxpayer aspect of it

Oh so the jury instead thinks you're stealing more directly from them because the name of that private insurance is likely to be one their employer contracts with to provide them health insurance. So they'll definitely favor you if they feel you're not increasing your taxes but just increasing their insurance premiums.

 

[tr]

i don't see how it's fraud if you're actually seeing the patients and meeting all requirements for the service...

If your objective is to enrich yourself, overbilling Medicare or insurance is the dumbest way to go about it. Medicare reimbursement is horrible and yes they will audit you for egregious billing practices. The billing codes are structured so as to add up to about 3 RVU per hour for outpatient care, with *slight* bumps for new or very complex patients. Even getting the correct reimbursement for work you actually did out of an insurance company is a side job in itself - what you bill and what you collect are likely to be quite different.

If you want to make $400/h then move to a rich area and charge cash, skipping the insurance headache altogether. Or learn to do a procedure like ECT, TMS, or ketamine. Or go take a look at White Coat Investor for other ideas on goosing your income stream. Just don't do Medicare fraud, it's plain stupid.

 

[PistolPete]

I can tell you that if you were billing 5x level 4s every hour you'd be clearing >1million a year and would be audited and if they're medicare pts could be done for medicare fraud. level 4s still have to be a) medically necessary and b) they have to believe you have reasonably addressed everything in the allotted time. it's not possible to address every issue for every pt in 10-12 minutes if they have multiple problems to addressed... of course there are some pt visits that one could address the issues briefly and code a level 4, but for the majority... im gonna call it fraud. if anyone would like to try billing 5+ level 4 visits each hour, please let me know how it goes from your minimum security prison cell

lol! But yea, this pretty much sums it up.

 

[PistolPete]

And agreed. If you want to make boat loads of money, OP, you gotta figure out a side business, outside of medicine. Or just work 12 hour days, 7 days a week.

 

[michaelrack]

its fraud because i say it is. which is essentially how this works. if you are billing disproportionate to anyone it raises red flags. if experts then testify to your fraudulent activity (i would personally be very happy to see rogue docs removed from practice) you're toast. a jury is not going to be happy with you raking in millions of tax payer money for being a drug dealer.

and if everyone bills disproportionate to what the insurance companies expect they will simply dramatically reduce the compensation to account for it or stop paying for said codes entirely.

I don't think proving fraud relies much on expert testimony. However, if you are a significant outlier with medicare, the feds will investigate you. And they will find problems with your billing/coding (probably with the medical decision making component) and you will owe huge fines...

 

[Merely]

I don't think proving fraud relies much on expert testimony. However, if you are a significant outlier with medicare, the feds will investigate you. And they will find problems with your billing/coding (probably with the medical decision making component) and you will owe huge fines...

Fraud that results in jail time needs to be egregious I feel like, seeing 50 patients and actually managing them which is possible in a 10 hour day, should not be considered fraud, just because a doc is very efficient shouldn't mean he goes to jail lol that's silly, however if you're literally just giving meds to people without an assessment or not even seeing people and billing, then that's obviously fraud, I mean there are psych docs seeing tons of people in clinic, I don't see people going to jail left and right...

 

[michaelrack]

Level 4 established office patient 99214 E/M coding, EM evaluation and management coding, e&m documentation, 99214, 99213

If you are billing 99214's, it is pretty easy to make sure your History OR exam meets criteria (only one of these is required); whether it is fraud or not is going to depend on whether your medical decision meets criteria. Time spent makes no difference (except if you are billing codes based on time such as some of the psychotherapy codes)

 

[Merely]

Level 4 established office patient 99214 E/M coding, EM evaluation and management coding, e&m documentation, 99214, 99213

If you are billing 99214's, it is pretty easy to make sure your History OR exam meets criteria (only one of these is required); whether it is fraud or not is going to depend on whether your medical decision meets criteria. Time spent makes no difference (except if you are billing codes based on time such as some of the psychotherapy codes)

Thank you very much for this post, essentially your saying that as long as you follow standard of care, you can bill as many 99214s per hour as you like, what do you mean by medical decision determining fraud? Like decision to prescribe medication vs not?

 

[Armadillos]

Thank you very much for this post, essentially your saying that as long as you follow standard of care, you can bill as many 99214s per hour as you like, what do you mean by medical decision determining fraud? Like decision to prescribe medication vs not?

Where are you in your training?

Medical decision making is a very specific term, look through the link posted by dr rack and click to the medical decision making section which has a bunch of charts.

All that being said your still delusional if you think you can see 50 patients a day.

 

[Merely]

Where are you in your training?

Medical decision making is a very specific term, look through the link posted by dr rack and click to the medical decision making section which has a bunch of charts.

All that being said your still delusional if you think you can see 50 patients a day.

I'm an m3, I am seeing attendings in private practice around me routinely see 50 patients in a day so I guess they must all be delusional. I have also seen other people on here post about attendings they know seeing 50+ in clinic as well so maybe we're all delusional but you..lol

 

[Armadillos]

I'm an m3, I am seeing attendings in private practice around me routinely see 50 patients in a day so I guess they must all be delusional. I have also seen other people on here post about attendings they know seeing 50+ in clinic as well so maybe we're all delusional but you..lol

Guess I can't argue with what your seeing with your own eyes, why not just ask your attending the details?

 

[zolof]

I don't know which part of the country your in but out in the real world of outpatient psychiatry this is not feasible nor sustainable, and private insurance will definitely audit. In addition good luck finding consistently returning patients when they have been seen for a mere 2 minutes. I worked next to a couple of friends of mine who were attempting to see well over 40 patients a day, what really happens? It is inconsistent. Patients do not continue to come. Majority complain. Why do you think so many people are always looking for other psychiatrists?

 

[Merely]

I don't know which part of the country your in but out in the real world of outpatient psychiatry this is not feasible nor sustainable, and private insurance will definitely audit. In addition good luck finding consistently returning patients when they have been seen for a mere 2 minutes. I worked next to a couple of friends of mine who were attempting to see well over 40 patients a day, what really happens? It is inconsistent. Patients do not continue to come. Majority complain. Why do you think so many people are always looking for other psychiatrists?

Very interesting, so one could do inpatient then have 2 clinic days to jam in like 50 patients a day so that you don't need as much volume, 3 days inpt then 2 jam packed clinic days hypothetically

 

[Shikima]

Is that adderall-strawberry or xanax-blueberry flavored psychiatry? That's a lot of jamming.

 

[Merely]

Is that adderall-strawberry or xanax-blueberry flavored psychiatry? That's a lot of jamming.

Dont hate efficiency my friend, it's undeniable some docs are more efficient and others like to chill and bs around, no need to hate on the work horses that wanna get paid

Ps: I appreciate all the insights and at this point I'm just ****ing around

 

[nexus73]

Very interesting, so one could do inpatient then have 2 clinic days to jam in like 50 patients a day so that you don't need as much volume, 3 days inpt then 2 jam packed clinic days hypothetically

I've never heard of a 3 day/week inpatient job. Probably better to work a 5 day week, and jam 25 patients into 2 afternoons/evenings a week.

 

[TexasPhysician]

Ok so could you then do 5 in an hour still and generate 500/hr? Or is that unreasonable?

Possible but then you have an overhead problem. 3 99214’s with 90833 allows time to document and fill a clinic with less needed staff.

If you are filling 5 99214’s per hour, you have significantly more patients and associated calls/problems. There also wouldn’t be time to document. With that volume, you probably need a personal scribe, multiple patient rooms with 1 staff doing vitals/rooming patients constantly, 2+ billing staff, and probably 3-4 answering phones. Staff must be ready to book new patients constantly to keep up that volume.

Overhead from 3 to 5 patients is probably doubling staff/office overhead. Is it worth it? I’m not sure without exact numbers.

 

[hamstergang]

Possible but then you have an overhead problem. 3 99214’s with 90833 allows time to document and fill a clinic with less needed staff.

90833 requires at least 16 minutes spent just on that, so 3 per hour is 48 minutes. Then you need a little bit of time to spend on gathering the elements for 99214 -- how can you do that AND document in the remaining 12 minutes?

 

[michaelrack]

I've never heard of a 3 day/week inpatient job. Probably better to work a 5 day week, and jam 25 patients into 2 afternoons/evenings a week.

I know of psychiatrists who do this, and I have done it in the past on a senior care unit. This typically is not an employed physician (W-2). It typically is a contract job with the doctor being paid a stipend and often billing the patients directly

 

[TexasPhysician]

90833 requires at least 16 minutes spent just on that, so 3 per hour is 48 minutes. Then you need a little bit of time to spend on gathering the elements for 99214 -- how can you do that AND document in the remaining 12 minutes?

Document and therapize simultaneously.

 

[mixolyd]

This is very confusing for early career psychiatrist. Any good resources to learn how to legally and effectively use these codings, as well as what insurances pay out?

I can share my coding notes. I can't post a link because it says I need more likes or something, so just like my post or PM me

No change in meds? 99213 + 90836

Changed meds and/or blood work? 99214 + 90836

If you have 3 stable problems then that's 99214. This is fairly easy to meet in psychiatry since most have some combination of depression, generalized anxiety, social phobia, panic disorder, and insomnia. It's the purely ADHD folks that make it difficult to get a 99214. I tend to send those to PCP to handle

 

[TexasPhysician]

I can share my coding notes. I can't post a link because it says I need more likes or something, so just like my post or PM me



If you have 3 stable problems then that's 99214. This is fairly easy to meet in psychiatry since most have some combination of depression, generalized anxiety, social phobia, panic disorder, and insomnia. It's the purely ADHD folks that make it difficult to get a 99214. I tend to send those to PCP to handle

They don’t want them either, so I get plenty at my cash practice. Pure ADHD is a $ loser in the insurance game.

 

[Shikima]

They don’t want them either, so I get plenty at my cash practice. Pure ADHD is a $ loser in the insurance game.

5 mins - 99213

 

[Ahamis]

Can you bill 99214+90833 if the patient already has a therapist?

 

[TexasPhysician]

Can you bill 99214+90833 if the patient already has a therapist?

Yes but not same day if in same group.

 

[TexasPhysician]

5 mins - 99213

Everyone pushes for 99214’s, even PCP’s. Most docs spend 5 min just writing out the scripts. Plus it’s a controlled substance that should prompt database lookup for abuse. It’s a time sink if done right.

 

[hamstergang]

Yes but not same day if in same group.

I do this all the time and have been told it's fine with most insurances. Only Medicaid was a problem but I think that's for other reasons (in NJ, LCSWs can't bill Medicaid directly when working out of a hospital so the bills for their therapy get attached to me).

 

[TexasPhysician]

I do this all the time and have been told it's fine with most insurances. Only Medicaid was a problem but I think that's for other reasons (in NJ, LCSWs can't bill Medicaid directly when working out of a hospital so the bills for their therapy get attached to me).

I could be wrong. When I last talked to a coder, she said that 1 of 2 same facility therapy codes either gets denied or goes to insurance review. Patients were instructed to do visits on separate days. No idea if what the facility was doing actually had a good purpose.

 

[sweetlenovo88]

I am enjoying this thread and wanted to bump my question:

Any thoughts on billing like this in an hour with PRIVATE INSURANCE: (99214+90833, 16 min of therapy), (99214+90833, 16 min of therapy), 99213. This should generate right above $400 an hour. Can this be done on a consistent basis? 24 patients a day, 8 hours day, day in/day out? I wonder if insurance will pay without hassles

 

[boogaaloo]

I am enjoying this thread and wanted to bump my question:

Any thoughts on billing like this in an hour with PRIVATE INSURANCE: (99214+90833, 16 min of therapy), (99214+90833, 16 min of therapy), 99213. This should generate right above $400 an hour. Can this be done on a consistent basis? 24 patients a day, 8 hours day, day in/day out? I wonder if insurance will pay without hassles

Try it and report back to us.

 

[hamstergang]

Can this be done on a consistent basis? 24 patients a day, 8 hours day, day in/day out?

In my opinion, no. Patients aren't that consistent and you need some breaks in that for your sake and for administrative tasks.

 

[TexasPhysician]

I am enjoying this thread and wanted to bump my question:

Any thoughts on billing like this in an hour with PRIVATE INSURANCE: (99214+90833, 16 min of therapy), (99214+90833, 16 min of therapy), 99213. This should generate right above $400 an hour. Can this be done on a consistent basis? 24 patients a day, 8 hours day, day in/day out? I wonder if insurance will pay without hassles

Insurance rates can vary by zip code, size of practice, and negotiation skills. In some areas, those codes pull about $250. Variation can be huge.

 

[Armadillos]

When people are doing the E/M + therapy add on are they actually trying to do a specific course of planned therapy or more just getting paid for the extra time we take compared to an internist and conceptualizing it as supportive therapy?

Wondering because many therapies would recommend weekly visits, but seems tough to justify weekly E/M visits for majority of therapy patients.