Billing question

[futuredo32]

I am soooooooo confused about billing. I have a small private practice. I do mostly therapy with meds and a few med appointments only.
Everyone else seems to bill 90834 for the therapy and then 99212-99215 for med management. My biller says this is wrong and I can't use any 99212-15 but instead use 90836. What do you use to code? I'm just trying to make it thru about the next two years and then pray to God I match into FP but kinda need to pay the bills in the meantime. I don't hate psychiatry, I like a little therapy, find writing prescriptions all day BORING and I miss medicine. But I only work part time because that is truly all I can stand of it I'm not looking for advice on that part just the billing.

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[Shikima]

If it's a simple med refill with 30 mins psychotherapy, then 99213+90834. 1 hour psychotherapy, 90836. If you make a med change, review labs, etc 99214+psychotherapy add on code. If you hospitalize a person, 99215 without psychotherapy add-on code.

 

[futuredo32]

If it's a simple med refill with 30 mins psychotherapy, then 99213+90834. 1 hour psychotherapy, 90836. If you make a med change, review labs, etc 99214+psychotherapy add on code. If you hospitalize a person, 99215 without psychotherapy add-on code.

90834 is 45 minutes I think

 

[hamstergang]

The full answer to this probably requires a link to something that draws this all out. That said, 90832 is 30 minutes therapy, 90834 is 45 minutes therapy, and 90837 is 60 minutes of therapy. You bill whichever code is closest to the time you spent. So 16-37 minutes is 90832, 38-52 minutes is 90835, and 53+ is 90837.

If you do something with meds, then you should bill the E&M codes (99211 - 99215, with the majority being 99213 and 99214, with a few 99215s most likely). You can choose the correct E&M code based on the elements you do (there's a chart that explains each piece of this including history, mental status exam, and medical decision making, it takes some thinking) or based on time.

If you do meds AND therapy in 1 visit, then use the appropriate E&M code based on elements but not time, and also use the psychotherapy add-on codes 90833, 90836, and 90838 based on time (same time limits as the psychotherapy alone codes above). The time of the visit that counts towards the psychotherapy add-on code must be separate from the time you spent gathering the necessary elements for the E&M portion.

 

[hamstergang]

Also be aware that if you look this up somewhere, it will likely give the guidelines for a full physical exam. However, there are specialty specific physical exams that can be used as well. In psychiatry, for example, you just have to do certain elements of the mental status exam instead of hitting up different organ systems.

 

[Merely]

What is the theoretical and legal amount someone could bill per hour if they were just trying to make the most money possible? Could they reach 500/hr using insurance? Just out of curiosity.

 

[futuredo32]

What is the theoretical and legal amount someone could bill per hour if they were just trying to make the most money possible? Could they reach 500/hr using insurance? Just out of curiosity.

NOT IN MICHIGAN............

 

[futuredo32]

If you do meds AND therapy in 1 visit, then use the appropriate E&M code based on elements but not time, and also use the psychotherapy add-on codes 90833, 90836, and 90838 based on time (same time limits as the psychotherapy alone codes above). The time of the visit that counts towards the psychotherapy add-on code must be separate from the time you spent gathering the necessary elements for the E&M portion.

This is the confusing part.

 

[futuredo32]

90834 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes)
+90836 - Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes) when performed with an evaluation and management service. So I would have to see the patient for at least 76 minutes?

 

[Armadillos]

What is the theoretical and legal amount someone could bill per hour if they were just trying to make the most money possible? Could they reach 500/hr using insurance? Just out of curiosity.

Not sure the numbers, but my understanding is if you have enough elements and some documentation to justify complexity there is no specific time requirement for a 99214 and it really isn't hard to hit the requirements so technically you could do as many as you want in an hour.

 

[hamstergang]

90834 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes)
+90836 - Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes) when performed with an evaluation and management service. So I would have to see the patient for at least 76 minutes?

No. You would need to see the patient for 38-52 minutes of psychotherapy, and then some additional time for the 99213-99215. There is no required amount of time for that E&M component, but it probably takes at least/around 5 minutes.

You can not use 90834 with 90836. That would be adding on psychotherapy to psychotherapy. The psychotherapy add-on codes (90833, 90836, and 90838) are used only with E&M codes (99211-99215 for follow up and 99201-99205 for new patients). It says that right in your post -- "when performed with evaluation and management service."

If you do solely psychotherapy in a visit, then you bill only the therapy code that corresponds to how much time you took: 90832, 90834, or 90837.

 

[futuredo32]

No. You would need to see the patient for 38-52 minutes of psychotherapy, and then some additional time for the 99213-99215. There is no required amount of time for that E&M component, but it probably takes at least/around 5 minutes.

You can not use 90834 with 90836. That would be adding on psychotherapy to psychotherapy. The psychotherapy add-on codes (90833, 90836, and 90838) are used only with E&M codes (99211-99215 for follow up and 99201-99205 for new patients). It says that right in your post -- "when performed with evaluation and management service."

If you do solely psychotherapy in a visit, then you bill only the therapy code that corresponds to how much time you took: 90832, 90834, or 90837.

But didn't you say
90834 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes)
+90836 - Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes) when performed with an evaluation and management service.

No. You would need to see the patient for 38-52 minutes of psychotherapy, and then some additional time for the 99213-99215. There is no required amount of time for that E&M component, but it probably takes at least/around 5 minutes.

You can not use 90834 with 90836. That would be adding on psychotherapy to psychotherapy. The psychotherapy add-on codes (90833, 90836, and 90838) are used only with E&M codes (99211-99215 for follow up and 99201-99205 for new patients). It says that right in your post -- "when performed with evaluation and management service."

If you do solely psychotherapy in a visit, then you bill only the therapy code that corresponds to how much time you took: 90832, 90834, or 90837.

thank you so much. As soon as my biller catches up, I am getting a new one, she is craptastic.

 

[hamstergang]

But didn't you say
90834 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes)
+90836 - Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes) when performed with an evaluation and management service.

thank you so much. As soon as my biller catches up, I am getting a new one, she is craptastic.

Since you quoted me twice in one post, I'm not sure if you're still confused or not. If you are, I don't fully understand your confusion. Perhaps creating a hypothetical situation that explains your thoughts for billing would help. If not, then great! I would recommend learning the elements needed for E&M billing since it's the same for other fields of medicine too. If you're going into FM you'll need to know this too. (edit: assuming you don't already know it, you might)

 

[futuredo32]

I didn't mean to quote you twice. Long day. So basically I see a patient for therapy 45 minutes 90834 and then 99212-4, correct if meds are discussed or prescribed? This is what I was taught but my biller refuses to bill like this and wants to do 90834 and 90836 for the same patient who has therapy and no 99212-4.

 

[hamstergang]

I didn't mean to quote you twice. Long day. So basically I see a patient for therapy 45 minutes 90834 and then 99212-4, correct if meds are discussed or prescribed? This is what I was taught but my biller refuses to bill like this and wants to do 90834 and 90836 for the same patient who has therapy and no 99212-4.

No, not quite. You can only use 90832, 90834, or 90837 if you do psychotherapy and psychotherapy alone in that visit.

If you do meds (evaluation and management, or E&M) and meds alone, then you bill solely 99211-99215.

If you do meds and therapy, then you bill the E&M code (99211-99215) along with the add-on code (90833, 90836, or 90838). These therapy add-on codes can only be used with E&M codes, not with other therapy codes.

So if you have a 45 minute session, at least 38 minutes of which were spent in therapy and then 7 minutes or so were devoted to gathering the components of the E&M visit (getting the relevant history, doing the parts of the MSE, and meeting criteria for the medical decision making), then you would bill 99211-99215 and 90836.

 

[nexus73]

I didn't mean to quote you twice. Long day. So basically I see a patient for therapy 45 minutes 90834 and then 99212-4, correct if meds are discussed or prescribed? This is what I was taught but my biller refuses to bill like this and wants to do 90834 and 90836 for the same patient who has therapy and no 99212-4.

I'll take a stab at explaining this simply.

1. If you're seeing a patient for med eval (E&M) plus therapy these are the options: 99211-99215 (for the E&M aspect) plus an add on therapy code (90833, 90836, or 90838). If you are using two codes, these are the codes you must use! So 99213+90833 is a perfectly fine combo.

2. If you are doing therapy alone, no med eval/management (no E&M), you use the other codes (90832, 90834, or 90837). These are the codes psychologists use now because they shouldn't be managing meds. You only bill one code here, because you're doing therapy only, so your biller doesn't know what they're doing when they tell you to use 90834 plus another code. 99213+90834 is WRONG.

** option 1 is what most psychiatrists will bill. The situation where you might use #2 is if you're seeing patients for weekly therapy appointments. Insurance probably will not pay for med eval once a week, and you'd have to stick with the therapy alone codes in between med eval appointments.

 

[splik]

** option 1 is what most psychiatrists will bill. The situation where you might use #2 is if you're seeing patients for weekly therapy appointments. Insurance probably will not pay for med eval once a week, and you'd have to stick with the therapy alone codes in between med eval appointments.

I have not had a problem with reimbursement for weekly (or even twice weekly) E&M + psychotherapy coding. You just need to actually be doing that, it needs to medically necessary, and the patient needs to have a parity diagnosis (though even without parity dx I've still managed to get this covered - might depend on insurance). I'm sure if you're doing this for years on end and the pt not getting better then they will dispute it, but for short-term treatment or patients who were getting admitted a lot etc then it's usually fine. Another common misconception is that you need to be rxing meds to use the E&M. You don't, you just need to have considered this and documented accordingly. For instance pt has MDD, you're just doing therapy, but offered or considered meds and pt declined you can still do 99213+90836 etc.

 

[Shikima]

NOT IN MICHIGAN............

Sure it is possible.

 

[Information Underload]

Unless you are seeing the patient multiple times per week, I would argue most psychiatrists should be billling E&M codes (99213-99214) for most appointments with psychotherapy add-on codes (90833, 90836, 90838). You are in essence stating that you are not even evaluating the appropriateness and clinical necessity for medication for a patient if you are billing for only therapy, which I would argue should never be the case for a psychiatrist. Exceptions include family therapy. I also am not a fan of 99212 for psychiatrists, as it implies a self-limited condition, which typically is not the case the with psychiatry.