Coding Question 99205

[sometimespants]

I've read some coding threads, however, still have questions on coding a 99205 for a new outpatient visit. I recently started a solo practice, and have never had to code for myself and then rely on myself with definitive certainty that I am coding correctly. I easily spend over 60+ minutes with the patient, whether it be through review of documentation or just the initial eval-often with multiple complaints with sleep/anxiety/etc. I have heard from different sources I can code this way if I list that I am spending 60 min in the visit.
I do ask them comprehensive questions related to ROS in the subjective portion, "Do you have any chest pain, trouble breathing, etc", but do not do a comprehensive physical exam on the patient (I get height, weight, BMI, VS) . I really don't have an interest in coding a 99702, it requires a PA. Am I safe to code with a 99205?

---

Members don't see this ad.

 

[splik]

You can either code on time OR you can code based on elements.
If you are coding on time, for a 99205 you must spend at least 53 minutes* in the physical presence of the patient, with at least 50% (it is better to specify the time than just put >50% of time) of that time spent in counseling and coordination of care (e.g. discussion of diagnosis, discussion of treatment options, psychoeducation regarding risk factors, counseling re: driving etc). You should specify what constituted counseling and coordination of care.

If you are billing on elements, you must have a 4 point HPI, a complete review of systems, must have 3 of following (height, weight, BMI, heart rate, respiratory rate, temperature, BP), a past medical, family, social history, an an MSE with all elements including recent and remote memory, orientation, fund of knowledge) and a comprehensive assessment.

99205 tends to pay better than 90792 but it is much easier to meet the documentation requirements for 90792. Also for those who are on an wRVU system, 90792 actually is worth more wRVUs even though it pays less overall! Another reason why RVUs don't make any sense in psychiatry...

I am confused about 90792 requiring a prior authorization - if that is the case, it is likely that any psychiatric services require prior authorization as I fail to see why an insurance company would pay the higher price of a 99205 without PA. You should look into this.

*codes are rounded up to when billing on time, as long as the midpoint of the time for the lower code (in this case 99204 of 45 mins) has been surpassed, otherwise you round down to the lower code.

 

[sometimespants]

So I lack the physical assessment component (minus the constitutional VS), all the other elements I have gotten(PMH/Family and Social Hx and the MSE). This is great advice on what I should specify for counseling/Coordination of care! Thank you so much!
In this case, should I code on time alone? I have been worried about getting dinged for coding like this for each visit-so I already have also asked Healthicity to see if they can audit my charts-I haven't gone through with it yet, because even with them it appears you have to have the working knowledge of what to do, and/or how to fix it after they audit your charts.

You are correct about all psychiatric services requiring a PA. I'm in CT. I haven't even messed with modifiers or codes for psychotherapy for this reason. If I had a billing person, I'd have them do the legwork for me, but my practice is so small, I can't justify hiring one at this point. (although with the anxiety of billing a 99205, maybe it's worth my peace of mind. haha)

 

[Merely]

you don't need a physical exam. In psychiatry, the MSE counts as the physical exam, it just has to have all of the elements. If you get height, weight, VS that is sufficient. One of the things I do is behavioral health consulting regarding coding and documentation which includes not just doing an audit, but helping practices to maximize revenue by documenting and coding appropriately including helping them develop appropriate templates so they capture the revenue for all the work done.

How did you learn how to code so well?

 

[sometimespants]

you don't need a physical exam. In psychiatry, the MSE counts as the physical exam, it just has to have all of the elements. If you get height, weight, VS that is sufficient. One of the things I do is behavioral health consulting regarding coding and documentation which includes not just doing an audit, but helping practices to maximize revenue by documenting and coding appropriately including helping them develop appropriate templates so they capture the revenue for all the work done.

That is awesome! Wow, if you are accepting new clients please PM me! I could so use the help! Thanks again!

 

[NickNaylor]

For those interested, I created a quick billing cheat sheet as the information that we got from our billing staff sucked. It doesn't include every code but includes commonly used codes in inpatient, outpatient, and ED settings (since I work in all of these settings). I keep it with me as a reference.

 

[downwithDTB]

That document is nice, but states that you need all three elements for codes where my understanding is that you only need 2/3. Also, for history, I thought it was only 2/3 elements. The documentation of therapy also seems excessive.

The biggest ambiguities in my mind are risk... I can imagine many patients whose acute risk in a visit is higher than the risks of being prescribed a bland drug, but who may not be prescribed a medication.

 

[romanticscience]

This has been my main resource for coding while in private practice. I still use it from time to time.

 

[sometimespants]

Wow! Thanks all! Very helpful info!!!

 

[NickNaylor]

That document is nice, but states that you need all three elements for codes where my understanding is that you only need 2/3. Also, for history, I thought it was only 2/3 elements. The documentation of therapy also seems excessive.

The biggest ambiguities in my mind are risk... I can imagine many patients whose acute risk in a visit is higher than the risks of being prescribed a bland drug, but who may not be prescribed a medication.

I’m not sure what you’re referring to, but “meeting” a specific level of complexity is different in the complexity of the history and the complexity of the MDM. In the history, all three components must meet whatever level you’re attempting to bill for (in addition to including a chief complaint, which is required for all history types and which I didn’t include on that sheet). In MDM, you only need two out of three components.

The documentation for psychotherapy may be excessive but is nevertheless what CMS recommends. Most of the information in that document came from CMS documentation. I would add that what is included there is consistent with what our institution’s billing staff tell us to document for psychotherapy services.

I agree that risk is difficult to assess, though per CMS documentation this is at the discretion of the billing clinician. Obviously trying to say that routine “stress” is a high complexity situation is going to be challenging, but in cases with grey area I imagine you won’t get into hot water by going with a higher level of complexity. It’s difficult though, and I’ll admit that I tend to err on the side of caution and potentially “underbill” if the risk isn’t explicitly obvious.

 

[Stagg737]

How did you learn how to code so well?

Coding is actually not that difficult if you're willing to take a little time and really look into it. You can easily gain a pretty comprehensive understanding of the basics in a weekend, especially if you have something like the charts provided here. There are some intricacies and pearls that are trickier, and I always like reading these threads as some of the more experienced individuals here have some great advice in regards to those.

For those interested, I created a quick billing cheat sheet as the information that we got from our billing staff sucked. It doesn't include every code but includes commonly used codes in inpatient, outpatient, and ED settings (since I work in all of these settings). I keep it with me as a reference.

This is a really nice chart and it's a lot cleaner than the pamphlets we're given for billing. Thank you for sharing!

Small semi-mistake is that for the ROS section, "head", "eyes", and "ENT" can all be considered different systems (though I've head some different opinions as to whether "head" is actually valid) and "HEENT" is actually combining 3 potential systems into 1. I've always separated "Eyes" and "ENT" in the templates I use for notes, as it just makes it easier to hit the 10 systems for full ROS.


Something I'm still trying to really wrap my head around though are the elements for the HPI. On medicine they're pretty easy/self-explanatory, but with psych they get kind of ambiguous for me. Anyone have some examples of how they document the following to meet appropriate criteria?

Location:
Quality:
Severity: (obvious imo)
Duration:
Timing:
Context:
Modifying factors:
Associated signs/symptoms:

Severity, timing, and duration are pretty obvious to me and I think context is pretty straightforward (usually the largest part of my HPI). I usually consider the actual problem (depression, anxiety, mania, psychosis, etc) to fall into the "quality" element, but I'm not sure if that's correct. My real questions are with location, modifying factors, and associated signs/symptoms. I feel like a full Psych ROS with the HPI will hit 4 pretty easily, but if anyone can clarify on those last few it would be appreciated!

 

[splik]

That is awesome! Wow, if you are accepting new clients please PM me! I could so use the help! Thanks again!

Feel free to PM me, busy at the moment but have availability next month.

I feel like a full Psych ROS with the HPI will hit 4 pretty easily, but if anyone can clarify on those last few it would be appreciated!

The points needed to hit a comprehensive HPI are minimal. "Pt reports 3weeks depressed mood w/ poor sleep, feels worse in morning, following recent breakup." would be sufficient for billing a Level 5 HPI but is not at all sufficient for your documentation from any other perspective. If you write a decent note, your HPI etc will always meet the threshold. the MSE is the main thing people are going to trip up on if billing on elements.

I don't ask pts ROS typically because it's a waste of time. I have them fill out an ROS as part of the intake. If you use an EMR like EPIC they can do it through that and it will autopopulate in the note. Otherwise, "psych ROS as per HPI, +fatigue (or whatever), all other systems negative" (if they indeed are) is sufficient for a full ROS.

 

[romanticscience]

Coding is actually not that difficult if you're willing to take a little time and really look into it. You can easily gain a pretty comprehensive understanding of the basics in a weekend, especially if you have something like the charts provided here. There are some intricacies and pearls that are trickier, and I always like reading these threads as some of the more experienced individuals here have some great advice in regards to those.



This is a really nice chart and it's a lot cleaner than the pamphlets we're given for billing. Thank you for sharing!

Small semi-mistake is that for the ROS section, "head", "eyes", and "ENT" can all be considered different systems (though I've head some different opinions as to whether "head" is actually valid) and "HEENT" is actually combining 3 potential systems into 1. I've always separated "Eyes" and "ENT" in the templates I use for notes, as it just makes it easier to hit the 10 systems for full ROS.


Something I'm still trying to really wrap my head around though are the elements for the HPI. On medicine they're pretty easy/self-explanatory, but with psych they get kind of ambiguous for me. Anyone have some examples of how they document the following to meet appropriate criteria?

Location:
Quality:
Severity: (obvious imo)
Duration:
Timing:
Context:
Modifying factors:
Associated signs/symptoms:

Severity, timing, and duration are pretty obvious to me and I think context is pretty straightforward (usually the largest part of my HPI). I usually consider the actual problem (depression, anxiety, mania, psychosis, etc) to fall into the "quality" element, but I'm not sure if that's correct. My real questions are with location, modifying factors, and associated signs/symptoms. I feel like a full Psych ROS with the HPI will hit 4 pretty easily, but if anyone can clarify on those last few it would be appreciated!

For the past 1-week [Timing]: Pt reports sustained (lasting most of the day, nearly every day) [duration] mild [severity] depressed [quality] mood exacerbated by marital discord [modifying factors] associated with fatigue, insomnia, and inattention [associated symptoms].

 

[Stagg737]

The points needed to hit a comprehensive HPI are minimal. "Pt reports 3weeks depressed mood w/ poor sleep, feels worse in morning, following recent breakup." would be sufficient for billing a Level 5 HPI but is not at all sufficient for your documentation from any other perspective. If you write a decent note, your HPI etc will always meet the threshold. the MSE is the main thing people are going to trip up on if billing on elements.

I don't ask pts ROS typically because it's a waste of time. I have them fill out an ROS as part of the intake. If you use an EMR like EPIC they can do it through that and it will autopopulate in the note. Otherwise, "psych ROS as per HPI, +fatigue (or whatever), all other systems negative" (if they indeed are) is sufficient for a full ROS.

I realize that it's pretty easy to hit 4 elements in an HPI, I was more curious about how people were actually documenting those elements. Interesting to hear that you can have them fill out their ROS through Epic and have it autopopulate. Would be really nice, but unfortunately at this point in my training it isn't really an option yet.

For the past 1-week [Timing]: Pt reports sustained (lasting most of the day, nearly every day) [duration] mild [severity] depressed [quality] mood exacerbated by marital discord [modifying factors] associated with fatigue, insomnia, and inattention [associated symptoms].

Thank you, this was what I was looking for.

I'm guessing that "location" is moot unless they patient has some form of somatic complaint that goes along with the diagnosis, otherwise I don't see why that element is even included for psychiatry.

 

[downwithDTB]

The psychiatric "location" examples I have seen are: emotional & behavioral. I imagine cognitive would also work. Not saying that I think it makes a great sounding note to say pt co cont behavioral problem of mild hair pulling, worse with stress and associated with a 1" bald spot, but it works for billing so thank cms.