Coding question

[DD214_DOC]

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I'm new to this coding stuff, and my training program wasn't very helpful -- I just found out I have been taught to use the CPT code for prescribing psychologists for straight med management. Ugh.

Anyway, if I'm not doing therapy with a patient and it's just med management, what CPT code do I use? The E&M codes in our EMR system do not show up and have a separate section. Do I still need a CPT code?

If I am doing therapy, would I use both a CPT code and the E&M code?

 

[nitemagi]

E&M is a CPT code.

 

[DD214_DOC]

E&M is a CPT code.

Yeah, that's what I thought, which is the problem. None of them are an option to select for a procedure code

 

[medium rare]

Yes, E&M code is a CPT code.

To the OP, you would use the E&M code and the psychotherapy add-on code, both of which are CPT codes.

I'm new to this coding stuff, and my training program wasn't very helpful -- I just found out I have been taught to use the CPT code for prescribing psychologists for straight med management. Ugh.

Anyway, if I'm not doing therapy with a patient and it's just med management, what CPT code do I use? The E&M codes in our EMR system do not show up and have a separate section. Do I still need a CPT code?

If I am doing therapy, would I use both a CPT code and the E&M code?

 

[nitemagi]

Is it an EMR that you have control over (local vendor)? If so, talk to them about adding the codes.

 

[DD214_DOC]

But what if you're not doing therapy? What if it's just med management?

 

[PistolPete]

Med management only would follow the same CPT codes as all other physicians: generally a 99213, 99214 or 99215 for f/u. Sounds like you need the vendor to input these codes into your system because the psychologists do not use these codes, as they are not physicians.

 

[Information Underload]

Watch the videos on the AACAP site for help with coding. They are very helpful.

http://www.aacap.org/AACAP/Clinical...spx?hkey=e53bd2fa-d1f9-4db5-bbfa-17f48bec4e35

It's the second video down.

For most psychiatric outpatient follow-up visits, you're looking at 99213, 99214, and 99215. If you're using a psychotherapy add-on code, you use the e/m code AND the psychotherapy add-on code, which is:

90833 - 16-37 minutes of therapy
90836 - 38-52 minutes of therapy
90838 - 53+ minutes of therapy.

If it's just med management, you don't add the add-on code.

I use almost exclusively 99204 for my outpatient initial evals unless I run into a 99205 in a suicidal patient.

 

[nexus73]

The simplest way to bill is based on time:

99213: greater than 15 minutes
99214: greater than 25 minutes
99215: greater than 35 minutes

You must document that "more than 50% of the time was spent in counseling or coordination of care." But, if you see someone for 24 minutes you can only bill a 99213 based on time.

However, if the complexity of the visit is sufficient you could actually bill a 99214 or 99215 based on the following linked summary guide. Study this: http://www.aacap.org/App_Themes/AAC...f_practice/cpt/EM_Coding_SUmmary_Guide_v2.pdf

If you want to add on therapy to the visit, you must bill based on complexity and cannot utilize the time requirements.

 

[PistolPete]

The simplest way to bill is based on time:

99213: greater than 15 minutes
99214: greater than 25 minutes
99215: greater than 35 minutes

You must document that "more than 50% of the time was spent in counseling or coordination of care." But, if you see someone for 24 minutes you can only bill a 99213 based on time.

However, if the complexity of the visit is sufficient you could actually bill a 99214 or 99215 based on the following linked summary guide. Study this: http://www.aacap.org/App_Themes/AAC...f_practice/cpt/EM_Coding_SUmmary_Guide_v2.pdf

If you want to add on therapy to the visit, you must bill based on complexity and cannot utilize the time requirements.

For medical decision making of moderate complexity, one must document 3 problem points and 3 data points. For data points, 1 point can be for "decision to obtain old records and/or obtain history from someone other than the patient" and 2 points for "review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider." Can I:

decide to obtain history from someone other than the patient
and
actually obtain the history from someone other than the patient

for a total of 3 points? Or can it only be one or the other?

And for "review and summarization of old records" are those records from other providers, or can they be review of my own progress notes about the patient from the last 2-3 months?

 

[splik]

Just to clarify there did used to be med management codes for psychiatrists but these have died. (Good) Psychiatrists don't do med management and we should retire the term, hence we use these evaluation and management codes. This is an important distinction because the role of the psychiatrist is to provide ongoing psychiatric evaluation and risk assessment of the patient including consideration of biological, psychological, social, cultural, ethical, and medicolegal factors to develop a comprehensive formulation of the patient to guide management, which may or may not involve prescribing of medications not just fling as many drugs at the patient as possible without evaluating them (sort of implied by the term "med management" which no other field of medicine uses it is used to describe what pharmacists do)

I have heard some psychiatrists argue that we shouldn't even use the psychotherapy alone codes, because even if we are doing straight psychotherapy we are providing psychiatric evaluation and management and should still use the E&M + psychotherapy add ons. However in reality these codes are kind of BS because they are predicated on their being clearly distinguishable portions of the visit that are "E&M" and "psychotherapy" which is of course impossible (or would be weird). I have heard some argue that we should always being using psychotherapy add-on codes because we should always be providing some sort of psychotherapy. Again that is kind of BS in theory, but there isn't anything stopping you from using the psychotherapy add-on codes (I almost always do).

but yeah you should be using 99204/99205/90792 for new evaluations
and 99213/99214 for follow ups with the relevant psychotherapy add on if providing psychotherapy (90833 will be most common)
Remember if seeing family members and using psychotherapy add-on to use the 90875 (interactive complexity) add on in addition

99215 should be used sparingly as this tends to get audited because it should be rarely used in practice. The kind of situation you would use it would be a suicidal patient who needs hospitalization and should be time-based with >50% of time on counseling and coordination of care.

also to clarify if you are using the psychotherapy add on- you cannot use E&M codes based on time, but on elements.

 

[splik]

For medical decision making of moderate complexity, one must document 3 problem points and 3 data points. For data points, 1 point can be for "decision to obtain old records and/or obtain history from someone other than the patient" and 2 points for "review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider." Can I:

decide to obtain history from someone other than the patient
and
actually obtain the history from someone other than the patient

for a total of 3 points? Or can it only be one or the other?

And for "review and summarization of old records" are those records from other providers, or can they be review of my own progress notes about the patient from the last 2-3 months?

you actually do not need 3 data points (and your own records from the past few months do not count as a data point!) as long as the risk is moderate or high (which is typically will be). you only need 2/3 (problem point, data point, risk) to be at or above the level for MDM

 

[psych2009]

Another question: so if all your patients are being billed by psychologist in your office for psychotherapy, could you still bill those add on psychotherapy codes like 90833 ( assuming patient is seen once a month and not more ).

 

[splik]

Another question: so if all your patients are being billed by psychologist in your office for psychotherapy, could you still bill those add on psychotherapy codes like 90833 ( assuming patient is seen once a month and not more ).

yes

 

[smalltownpsych]

Another question: so if all your patients are being billed by psychologist in your office for psychotherapy, could you still bill those add on psychotherapy codes like 90833 ( assuming patient is seen once a month and not more ).

yes

Technically you can use any of these codes as long as you are providing the services; however, it also depends on what the insurance is willing to pay. For example, we have had problems with billing for a PMHNP appointment and for a psychologist the same day. That is a major problem when our patients drive as much as two hours to get here. Our administrative people are not always on top of this type of stuff so there is probably a way to fix that, I am sure.

 

[PistolPete]

you actually do not need 3 data points (and your own records from the past few months do not count as a data point!) as long as the risk is moderate or high (which is typically will be). you only need 2/3 (problem point, data point, risk) to be at or above the level for MDM

Thanks. But it's still not clear to me if I can decide to obtain history from someone other than the patient (1 point) and actually obtain the history from someone other than the patient (2 points) or if these are mutually exclusive?

 

[splik]

they are mutually exclusive as they are different levels. So for example the first would be documenting plan to obtain collateral. 2nd would be calling patients mother during session.

 

[PistolPete]

Awesome thanks guys! Based on what I see it's looking like it should be quite profitable to actually take insurance again for an outpatient practice that sees mostly 99214's and 99213's with some therapy add-on codes thrown in. Anyone have any real-world experience over the last few months with the insurance industry causing any headaches?

 

[Information Underload]

Remember if seeing family members and using psychotherapy add-on to use the 90875 (interactive complexity) add on in addition

The rest of your post was spot-on. I don't think this fits, however, as I would be billing it on every patient as a child psych. Per the AMA, the primary qualifiers are below. I most frequently use it when I have a DCS report to make over abuse or when I have parents/kids blowing up at each other.

• Caregiver emotions or behavior that interferes with the caregiver's understanding and ability to assist in the implementation of the treatment plan

• Evidence or disclosure of a sentinel event and mandated report to a third party with initiation of discussion of the sentinel event and/or report with patient and other visit participants

• Use of play equipment, other physical devices, interpreter, or translator to communicate with the patient to overcome barriers to therapeutic or diagnostic interaction between the physician, or other qualified healthcare professional, and a patient who:
  • Is not fluent in the same language as the physician or other qualified healthcare professional
  • Has not developed, or has lost, the ability to explain his or her symptoms, the ability to understand the physician, or is unable to respond to treatment

 

[Information Underload]

Another question: so if all your patients are being billed by psychologist in your office for psychotherapy, could you still bill those add on psychotherapy codes like 90833 ( assuming patient is seen once a month and not more ).

As long as you are not billing for psychotherapy codes (e.g., 90832) and are billing only psychotherapy add-on codes (e.g., 90833). You can't be using the same codes at the therapist.

 

[romanticscience]

I've heard varying opinions about using E/M codes and psychotherapy add-on codes. Must the time spend doing both be explicitly separated? For instance could you bill a 99214 (2-minutes) and 90838 (53-minutes) for a 55-min appointment?

Also, do insurers cap the number of times one can use these codes in a certain amount of time? I'm interested in providing twice, weekly therapy. Info is much appreciated. Thanks!

 

[Doctor Bagel]

Also, do insurers cap the number of times one can use these codes in a certain amount of time? I'm interested in providing twice, weekly therapy. Info is much appreciated. Thanks!

Some do and some don't. I had a supervisor who was asked to refund an insurance company for billing for weekly E&M on top of psychotherapy on the claim that medication management wasn't needed weekly. When I had my residency clinic, I would bill for weekly E&M + psychotherapy add on for my weekly patients and never heard anything. I do know some insurances will cover twice weekly therapy for certain diagnoses, although maybe not indefinitely. The private practice people I know often bill insurance for once weekly sessions and have the patient pay for the extra weekly sessions. Apparently, though, my old insurance in my residency program would cover daily analysis, which is amazing.

 

[nexus73]

Some do and some don't. I had a supervisor who was asked to refund an insurance company for billing for weekly E&M on top of psychotherapy on the claim that medication management wasn't needed weekly. When I had my residency clinic, I would bill for weekly E&M + psychotherapy add on for my weekly patients and never heard anything. I do know some insurances will cover twice weekly therapy for certain diagnoses, although maybe not indefinitely. The private practice people I know often bill insurance for once weekly sessions and have the patient pay for the extra weekly sessions. Apparently, though, my old insurance in my residency program would cover daily analysis, which is amazing.

How long after the fact did this come up I wonder?

 

[splik]

Also, do insurers cap the number of times one can use these codes in a certain amount of time? I'm interested in providing twice, weekly therapy. Info is much appreciated. Thanks!

Depends on the the insurance. my insurance covers 4 times a week therapy and the better ones typically do. Crappier insurance set a limit on how many sessions and then you require prior auth. Technically if the treatment is "medically necessary" then it should be covered. Of course this is where it gets nebulous.

I have seen patients twice weekly for therapy and its been fine.

 

[splik]

I've heard varying opinions about using E/M codes and psychotherapy add-on codes. Must the time spend doing both be explicitly separated? For instance could you bill a 99214 (2-minutes) and 90838 (53-minutes) for a 55-min appointment?

Also, do insurers cap the number of times one can use these codes in a certain amount of time? I'm interested in providing twice, weekly therapy. Info is much appreciated. Thanks!

99214 is not 2 minutes. There is absolutely no way it's not fraud to do that but go ahead and see what happens. I typically bill 99213 + 90836 for those sessions. It would definitely be fraud to do 99214 + 90838 twice a week!

And yes the time theoretically must be clearly separated. Which is why everyone knows the psychtotherapy add ons are BS. Obviously no one actually does it that way.

 

[romanticscience]

OK, that's helpful advice. I'm guessing, to avoid problems, billing 90837 for session #1 and 99213 + 90836 for session #2 would be the way to go. I'm interested in transference-focused psychotherapy, which is ideal twice-weekly.

 

[romanticscience]

I've been reviewing the CPT coding guidelines. I have a questions related to the risk component of medical decision making.

I do risk assessment and management on all my psychiatric patients. Would this satisfy the "Acute or chronic illnesses that pose a threat to life or bodily function?" and thus be considered HIGH risk?

 

[smalltownpsych]

The rest of your post was spot-on. I don't think this fits, however, as I would be billing it on every patient as a child psych. Per the AMA, the primary qualifiers are below. I most frequently use it when I have a DCS report to make over abuse or when I have parents/kids blowing up at each other.

• Caregiver emotions or behavior that interferes with the caregiver's understanding and ability to assist in the implementation of the treatment plan

• Evidence or disclosure of a sentinel event and mandated report to a third party with initiation of discussion of the sentinel event and/or report with patient and other visit participants

• Use of play equipment, other physical devices, interpreter, or translator to communicate with the patient to overcome barriers to therapeutic or diagnostic interaction between the physician, or other qualified healthcare professional, and a patient who:
  • Is not fluent in the same language as the physician or other qualified healthcare professional
  • Has not developed, or has lost, the ability to explain his or her symptoms, the ability to understand the physician, or is unable to respond to treatment

Anytime I have a kid playing with a toy, game, puzzle, coloring, etc. I code this. I think most insurances will pay for it so long as kid is under age of 13. A significant part of my assessment on a kid is based on their ability to play and how they play in addition to how they communicate about other topics. Also, they will answer questions a little more when playing. Otherwise, it's like they are in the principals office being interrogated.

 

[splik]

I've been reviewing the CPT coding guidelines. I have a questions related to the risk component of medical decision making.

I do risk assessment and management on all my psychiatric patients. Would this satisfy the "Acute or chronic illnesses that pose a threat to life or bodily function?" and thus be considered HIGH risk?

high risk would be SI or violence risk necessitating hospitalization or some other change to treatment intensity (for example seeing the patient again the same week). simply documenting a risk assessment does not classify a patient as high risk you should be documenting something about risk on all patients but the vast majority are not going to be high risk.