Billing for Med management & Psychotherapy - 99214 + 90833

[Information Underload]

I see my follow-ups for 30-minutes, and I'm having a hard time seeing in my mind how I don't end up billing most of my follow-up visits as level 4 (99214) visits with a psychotherapy add-on code (90833). I am doing psychotherapy for more than 16 minutes with most of my patients, and if you look at the criteria for a level 4, it's hard not to hit that threshold.

Legitimately, any patient with 3 chronic illnesses (e.g, MDD, Anxiety NOS, Insomnia) is a level 4 visit:

E.g.,
3 stable illnesses = 3 problem points = moderate complexity (AND)
2 stable chronic illnesses with meds = moderate risk/ medical decision making ultimately
___________________________________________________
= 2/3 categories for moderate complexity (level4) and simply ignore data points

That said, the recommended time for a level 4 visit is 25 -minutes, which seems more fitting of a PCP office where you may see the patient once every 3-6 months and not when you know your patient extremely well--not that CMS or Medicaid may care.

I am trying to decide whether I should be concerned for a potential audit in billing in this fashion, which seems justified based upon medical decision making criteria and by time spent in psychotherapy. My documentation is fine. The only variable out there that concerns me is the recommended time for a level 4 visit, which is 25-minutes, noting that I am NOT typically billing based upon time alone, and then I would not be using an add-on code.

I do bill level 3s, and I do have no-shows. I don't do therapy with everyone. Still, the idea of an audit scares me in concept alone, though I have no doubt my documentation would be fine.

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[PistolPete]

The Medicare manual explicitly states that 25 minutes is only a recommended time for a level 4, not a required time. If you can do it in 15 minutes, great. The only code that is time-dependent is the therapy add-on code. So, as long as you do at least 16 minutes of therapy, you should be fine with both. Now, will an insurance company actually reimburse you for 99214+90833 for most of your patients once they see the pattern is another story.

 

[F0nzie]

Psychotherapy add ons... Let's be real. Three 99214s an hour. 😉

 

[TexasPhysician]

I see no problem with the coding levels detailed here thus far.

 

[heyjack70]

Has anyone run into insurance hassles with the add on code? I think if you were seeing someone weekly and billing 99214+90836 for an hour session insurance would definitely try to stop that. But if visits are spaced out by a month or more and you add 90833 does insurance give you much grief? I thought the whole point of the codes was to pay psychiatrists for the therapy that is inherent to the work we do day in and day out. A med management visit is not just asking checklist questions and prescribing a pill. At least it shouldn't be.

 

[PistolPete]

Psychotherapy add ons... Let's be real. Three 99214s an hour. 😉

Not sure if facetious... 2 99214's+90833 per hour equals about $380 per hour in my state... 3 99214's per hour is about $360 per hour... which one's better? 😉

 

[F0nzie]

Not sure if facetious... 2 99214's+90833 per hour equals about $380 per hour in my state... 3 99214's per hour is about $360 per hour... which one's better? 😉

Ok four 99214s. The 15 min med check is back! 😛

 

[F0nzie]

These reimbursement codes are much better than they were and they are certainly bringing in some healthy competition to the private practice world.

 

[Shikima]

Not sure if facetious... 2 99214's+90833 per hour equals about $380 per hour in my state... 3 99214's per hour is about $360 per hour... which one's better? 😉

Depends on the type of insurance carrier the Pt has and if they are seeing a therapist too.

Good discussion going on here.

I'm curious, what are most people putting down for a chief complaint?

 

[Bartelby]

Very interesting, I had assumed that brief psychotherapeutic interventions (supportive, encouraging non-pharm strategies like exercise / behavioral activation, challenging distorted thoughts, etc) would be considered "built in" to seeing the patient for a 99213/4 visit. As heyjack puts it "A med management visit is not just asking checklist questions and prescribing a pill. At least it shouldn't be." Is the shortest psychotherapy add on meant to compensate for this beyond what is built into the 99213/4, or do people think it amounts to double dipping (especially if you are doing, say 12 minutes of "CBT" every six weeks during med management visits)?

 

[Shikima]

908xx visits have a time code attached to them and needs to be documented as such in the note.

 

[hamstergang]

Very interesting, I had assumed that brief psychotherapeutic interventions (supportive, encouraging non-pharm strategies like exercise / behavioral activation, challenging distorted thoughts, etc) would be considered "built in" to seeing the patient for a 99213/4 visit.

These are the same codes used by primary care, right? Do you think they're doing brief psychotherapy (beyond medication counseling which is different)? If not, then it's reasonable to me that we sometimes bill for the add-ons.

 

[MLT2MT2DO]

These are the same codes used by primary care, right? Do you think they're doing brief psychotherapy (beyond medication counseling which is different)? If not, then it's reasonable to me that we sometimes bill for the add-ons.

Their version should include diet and exercise as well as preventative care counseling...to be fair

 

[MLT2MT2DO]

A

 

[daru1]

I too see my PP patients for 30 minute follow ups and bill 99214+90833 for most of them. I document the time (and obviously the things needed for E&M), and since psychotherapy notes are privileged, I don't think the insurance has had a problem with it (no audits).

 

[PistolPete]

I too see my PP patients for 30 minute follow ups and bill 99214+90833 for most of them. I document the time (and obviously the things needed for E&M), and since psychotherapy notes are privileged, I don't think the insurance has had a problem with it (no audits).

Psychotherapy notes are privileged, but when you use the add on code, you document the psychotherapy performed during the visit (and how long the psychotherapy was) on the same note as the 99213/99214, so I think the insurances still see it. But I'm not sure.

I wonder if practicing attendings can actually attest to how the changes have translated in the real world? Are the insurance companies using other frivolous excuses to deny payment due to the higher (and MORE REASONABLE) fees?

 

[splik]

Psychotherapy notes are privileged, but when you use the add on code, you document the psychotherapy performed during the visit (and how long the psychotherapy was) on the same note as the 99213/99214, so I think the insurances still see it. But I'm not sure.

yes this is not a psychotherapy note. even if you were doing a 90837 the note in the medical record is not a psychotherapy note. psychotherapy notes per HIPAA are not paet of the medical record, they are personal notes for the therapist's eyes only that might transcribe what happens in the session, transference, countertransference, resistance, even formulation. none of this should be in the patient's medical record.

a note saying "This was a 60 minute psychodynamic psychotherapy visit. Patient talked about his past. Provided empathic validation, confrontation, clarification, interpretation, naming emotions. Dx: adjustment disorder with depression and anxiety. Plan: continue weekly therapy" is NOT a psychotherapy note.

 

[Shikima]

What ought to be documented when you have the following headings to complete for a psychotherapy note?
Current Clinical Status
Focus of the Therapeutic Encounter
Intervention Type

 

[heyjack70]

What ought to be documented when you have the following headings to complete for a psychotherapy note?
Current Clinical Status
Focus of the Therapeutic Encounter
Intervention Type

I would try to keep it as brief as possible. Eg. 45 minutes of cbt addressing cognitive distortions of negative filter and catastrophizing.

 

[Shikima]

I would try to keep it as brief as possible. Eg. 45 minutes of cbt addressing cognitive distortions of negative filter and catastrophizing.

I wonder how many ways you can say this each week? heh..

 

[smalltownpsych]

My notes are more of the DAIP variety
Data:
Patient reported decrease in frequency and intensity of suicidal thoughts, has no intent to act on thoughts, and readily identified children and family as reasons to live. Reported that journaling has been helpful for coping with distress. Also reported that medication appears to be helping with mood lability.
Assessment:
Mood appeared dysphoric, affect congruent
Intervention:
45 minutes individual psychotherapy
Plan:
Continue I 2x per week and monitor suicidality
That is what they were like when I typed them myself. Often they would be even shorter if I had no significant risk issue. At my current position I dictate them so they have gotten quite a bit longer and even tangential at times.

 

[nexus73]

Is insurance paying for this billing combo without much hassle?

 

[finalpsychyear]

Is insurance paying for this billing combo without much hassle?

I spoke to an attending of mine who always is coding based on rules and regulations. He said he had been audited for the 99214+ therapy code but was able to justify it. So even if he sees the pt for 25-30 he won't always do an add on code. Said has run into trouble when patient has a therapist as well and if they both saw the patient the same week. Some insurances will red flag it he said. Also, he said you have to always have a variety in your coding as the vast majority of doctors just do 99213. Even if your doing it correctly the insurance companies will flag you and likely audit you for deviating from the norm. Even if this norm is incorrectly skewed. Also said u can be dinged for under coding. I'd like to hear of an insurance doing that though... i call bs on that.

 

[Shikima]

I spoke to an attending of mine who always is coding based on rules and regulations. He said he had been audited for the 99214+ therapy code but was able to justify it. So even if he sees the pt for 25-30 he won't always do an add on code. Said has run into trouble when patient has a therapist as well and if they both saw the patient the same week. Some insurances will red flag it he said. Also, he said you have to always have a variety in your coding as the vast majority of doctors just do 99213. Even if your doing it correctly the insurance companies will flag you and likely audit you for deviating from the norm. Even if this norm is incorrectly skewed. Also said u can be dinged for under coding. I'd like to hear of an insurance doing that though... i call bs on that.

Alternating between 99214 and 99213 is the best. No flags get raised and nothing ever comes back from audits.

 

[PistolPete]

Alternating between 99214 and 99213 is the best. No flags get raised and nothing ever comes back from audits.

With or without 90833?

 

[TexasPhysician]

I wouldn't change your billing based on fear of an audit. Audits happen anyway.

Document and bill appropriately based on complexity.

 

[tr]

Really, you can bill 99214 for complexity regardless of time? So if a complex patient (for the sake of argument let's say substance use disorder, PTSD, ocd, childhood trauma, not seen in clinic for 2 years) shows up 20 min late for a 30 min appt, and I have to figure out what to do with her in 10 min (and consequently do a bad job), are you saying I could still bill the full 99214 based on complexity? Not 99212 based on the fact that I only saw her for 10 min?

 

[splik]

all E&M codes are either billed on elements or time. you can only bill time if >50% of the time was spent on counseling and coordination of care. it is unlikely, but possible that you could provide service for a 99214 in 10 mins as presumably if things were complicated you would be spending more than 10 mins with the patient. but yes it would be at least a 99213. It is unlikely that you would ever be using 99212 in psychiatry unless you were seeing people with self-limiting problems or not prescribing meds. if you're prescribing meds it goes up to at least a level 3 by virtue of mx being "moderate risk". Btw sometimes I will see pts for only 5 mins if they are really late but I still want to see them and correctly code 99213. Please see the APA or AACAP guidelines on this. We have qs on this regularly here and I'm always amazed at how much confusion there is about this.

 

[Shikima]

With or without 90833?

If you want to do that sort of thing.

 

[Shikima]

Really, you can bill 99214 for complexity regardless of time? So if a complex patient (for the sake of argument let's say substance use disorder, PTSD, ocd, childhood trauma, not seen in clinic for 2 years) shows up 20 min late for a 30 min appt, and I have to figure out what to do with her in 10 min (and consequently do a bad job), are you saying I could still bill the full 99214 based on complexity? Not 99212 based on the fact that I only saw her for 10 min?

Yes. It's not on time alone. Also document that they were 20 minutes late for their appointment. And document a comprehensive plan to address all of the ongoing issues.

 

[romanticscience]

Does anyone use the psychotherapy add-on code (90838) with E/M? If so, how long are your appointments. Thanks!

 

[futuredo32]

What about 90834 with med management? I do 45 min therapy with meds.

 

[romanticscience]

You would have to use 90836. 90834 is what the non-MDs use. I use that for my 45-min appointments.


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[Shikima]

What about 90834 with med management? I do 45 min therapy with meds.

No change in meds? 99213 + 90836

Changed meds and/or blood work? 99214 + 90836

 

[futuredo32]

No change in meds? 99213 + 90836

Changed meds and/or blood work? 99214 + 90836

TY. all for 45 min total? HATE billing. I googled and bleh.

 

[Shikima]

TY. all for 45 min total? HATE billing. I googled and bleh.

This would be for 45 mins of work, yes. You need to document the time start/stop for therapy. Separate from the med eval.
Hint: Therapy with 836 doesn't need to be for a full 45 mins.

 

[hamstergang]

You would have to use 90836. 90834 is what the non-MDs use. I use that for my 45-min appointments.

It's not really about whether you're an MD or not. If you're doing therapy only regardless of title, then you'd do 90834. If you are also billing an E&M code for the visit, then the therapy piece would be billed with the 90836 add-on code.

 

[futuredo32]

Thank you. I have a biller who said to do 90834 90836. I KNEW that was wrong and have only been doing a therapy code for a therapy patient or 9921.... for a med patient even if they got some therapy.

 

[Madden007]

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?

 

[Merely]

If you have stable patients and you're very efficient, could you do 5 99214s in an hour and be generating 600/hr?

 

[Shikima]

If you have stable patients and you're very efficient, could you do 5 99214s in an hour and be generating 600/hr?

Depending, yes.....

Depends on what? If they all show up, what your contract is for with the insurers, and if you meet the bench marks for a 99214. You also need time for documentation.

 

[finalpsychyear]

If you have stable patients and you're very efficient, could you do 5 99214s in an hour and be generating 600/hr?

Medicare in my area pays 105 for a level 4 and i only have one insurance that pays above that. Pretty much for a strict EM med check and no therapy most of the insurers in my area pay 90 ish for a level 4.

 

[Merely]

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

 

[hamstergang]

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

12 minutes visits, with patients that have enough issues to qualify for 99214, would be bad care. Some do it, but it seems like no fun for the psychiatrist keeping up with this pace and no good for the patients. Especially as you couldn't keep this flowing smoothly without making patients show up rather early -- otherwise they'd be late here and there and that would throw the whole flow off.

 

[Merely]

12 minutes visits, with patients that have enough issues to qualify for 99214, would be bad care. Some do it, but it seems like no fun for the psychiatrist keeping up with this pace and no good for the patients. Especially as you couldn't keep this flowing smoothly without making patients show up rather early -- otherwise they'd be late here and there and that would throw the whole flow off.

Agreed but at least it can be done, nice to know there's such a variation for people that wanna work hard to earn more and people who wanna take more time with patients and earn less but enjoy their work more

 

[SteinUmStein]

Agreed but at least it can be done, nice to know there's such a variation for people that wanna work hard to earn more and people who wanna take more time with patients and earn less but enjoy their work more

Hmm this is missing a crucial part of the interaction: the patient experience, and patient outcomes (i.e. are we really doing our job well?) I would argue that 10-15 minute med checks (versus more reasonable 20-30 minutes minimum for complex patients warranting 99214 or therapy + 99213) is affecting more than just the quality of life of the psychiatrist. Patient care looks very different at 10-12 minute visits versus a 20-30 minute visit. At 10-12 minute RVs, you will have patients who feel (deservedly in most cases) they are being rushed out the door with random prescriptions in hand. I would argue you are running a higher risk of missing something important with 10-12 minute med checks versus 20-30 minutes or more. Examples of things I've picked up at minute 20 or 25 that I probably would have missed with only 12-15 minutes with the patient: sleep apnea in a thin, healthy person, parent-child interactions that changed my entire understanding of the family, patients opening up about substance abuse with no hint of past sub abuse, time to perform a MoCA in clinic revealing significant and unexpected cognitive changes, time to review medical history in more detail revealing important, treatment-altering info, etc etc.

And good luck fitting in any kind of rapport building in less than 15 minutes, you'll barely have time to meet your minimum check boxes for a 99213 or 99214 in 10 minutes let alone meeting the person in front of you. And no, it's not enough to stock up rapport at an initial 45-60 minute visit and assume the person wants checkbox psychiatry q3 months ad infinitum. It's great that most psychiatrists make a healthy financial living, but it's misleading to think that just by "working harder" we can all make huge money from high-volume, conveyor belt med check practices without some real clinical downsides. I've seen patients and families negatively affected by this and it's sad to see. If you decide to go this route, at least practice evidence-based psychiatry - most practices churning out 4-5 med checks an hour send patients out on bizarre, near-random polypharm combinations that literally kill people. Don't be that person. Primum non nocere - corny but worth repeating.

 

[PistolPete]

Medicare in my area pays 105 for a level 4 and i only have one insurance that pays above that. Pretty much for a strict EM med check and no therapy most of the insurers in my area pay 90 ish for a level 4.

Ouch... only one insurer paying above Medicare in your area for a level 4 at that rate? Dang. How much does the top insurer reimburse for 90833?

 

[Attending1985]

Hmm this is missing a crucial part of the interaction: the patient experience, and patient outcomes (i.e. are we really doing our job well?) I would argue that 10-15 minute med checks (versus more reasonable 20-30 minutes minimum for complex patients warranting 99214 or therapy + 99213) is affecting more than just the quality of life of the psychiatrist. Patient care looks very different at 10-12 minute visits versus a 20-30 minute visit. At 10-12 minute RVs, you will have patients who feel (deservedly in most cases) they are being rushed out the door with random prescriptions in hand. I would argue you are running a higher risk of missing something important with 10-12 minute med checks versus 20-30 minutes or more. Examples of things I've picked up at minute 20 or 25 that I probably would have missed with only 12-15 minutes with the patient: sleep apnea in a thin, healthy person, parent-child interactions that changed my entire understanding of the family, patients opening up about substance abuse with no hint of past sub abuse, time to perform a MoCA in clinic revealing significant and unexpected cognitive changes, time to review medical history in more detail revealing important, treatment-altering info, etc etc.

And good luck fitting in any kind of rapport building in less than 15 minutes, you'll barely have time to meet your minimum check boxes for a 99213 or 99214 in 10 minutes let alone meeting the person in front of you. And no, it's not enough to stock up rapport at an initial 45-60 minute visit and assume the person wants checkbox psychiatry q3 months ad infinitum. It's great that most psychiatrists make a healthy financial living, but it's misleading to think that just by "working harder" we can all make huge money from high-volume, conveyor belt med check practices without some real clinical downsides. I've seen patients and families negatively affected by this and it's sad to see. If you decide to go this route, at least practice evidence-based psychiatry - most practices churning out 4-5 med checks an hour send patients out on bizarre, near-random polypharm combinations that literally kill people. Don't be that person. Primum non nocere - corny but worth repeating.

Thank you for this very well said and becoming a public health problem

 

[Merely]

Hmm this is missing a crucial part of the interaction: the patient experience, and patient outcomes (i.e. are we really doing our job well?) I would argue that 10-15 minute med checks (versus more reasonable 20-30 minutes minimum for complex patients warranting 99214 or therapy + 99213) is affecting more than just the quality of life of the psychiatrist. Patient care looks very different at 10-12 minute visits versus a 20-30 minute visit. At 10-12 minute RVs, you will have patients who feel (deservedly in most cases) they are being rushed out the door with random prescriptions in hand. I would argue you are running a higher risk of missing something important with 10-12 minute med checks versus 20-30 minutes or more. Examples of things I've picked up at minute 20 or 25 that I probably would have missed with only 12-15 minutes with the patient: sleep apnea in a thin, healthy person, parent-child interactions that changed my entire understanding of the family, patients opening up about substance abuse with no hint of past sub abuse, time to perform a MoCA in clinic revealing significant and unexpected cognitive changes, time to review medical history in more detail revealing important, treatment-altering info, etc etc.

And good luck fitting in any kind of rapport building in less than 15 minutes, you'll barely have time to meet your minimum check boxes for a 99213 or 99214 in 10 minutes let alone meeting the person in front of you. And no, it's not enough to stock up rapport at an initial 45-60 minute visit and assume the person wants checkbox psychiatry q3 months ad infinitum. It's great that most psychiatrists make a healthy financial living, but it's misleading to think that just by "working harder" we can all make huge money from high-volume, conveyor belt med check practices without some real clinical downsides. I've seen patients and families negatively affected by this and it's sad to see. If you decide to go this route, at least practice evidence-based psychiatry - most practices churning out 4-5 med checks an hour send patients out on bizarre, near-random polypharm combinations that literally kill people. Don't be that person. Primum non nocere - corny but worth repeating.

Thanks for the insight, some argue there is variability in efficiency and some docs are seeing 50 patients a day in clinic while doing a reasonable job since there's a shortage and many need to be seen. Now if 99214 gets changed to have a time requirement then financials would take a big hit

 

[nexus73]

Thanks for the insight, some argue there is variability in efficiency and some docs are seeing 50 patients a day in clinic while doing a reasonable job since there's a shortage and many need to be seen. Now if 99214 gets changed to have a time requirement then financials would take a big hit

Who is arguing this?