E&M coding changes for 2021

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randomdoc1

randomdoc1

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Ok, does anyone have a good resource where we can check out how this affects psychiatrists and how we document? Also, before these changes, I've lived by and worked off of the attachment i linked below. Does anything change in there for us then? I really don't want to learn a whole bunch of stuff all over again....
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TexasPhysician said:
Time based coding for evals is requiring increased amounts of time which is a negative on income. I haven’t tried to determine how this would all play out in an insurance based practice yet.
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But the new changes make it so much easier to qualify for complexity based on MDM. Obviously if you were relying on 3 99214s per hour billing on time this isn't great, but it is so much less burdensome to document now for those of us doing 30 minute f/u slots.
 
@clausewitz2 @TexasPhysician Do you have any links in terms of where I can read up about how we need to be documenting now? I'm not even sure where to look. I would look myself but I'm pretty deep in trying to sort out which cost share waives will continue and how telehealth will be covered into 2021 with all these payors we are contracted with. Thanks in advance! It's a nightmare! But insurance is what allowed us to grow so fast.
 
The APA has some great info on their site about this as directly related to psych. The AMA has more generic info.

I do expect teething problems. For those in wRVUs positions who do outpatient this is good. I do not expect it to impact those who only see patients with commercial insurance or cash pay. it was always easy to hit 99214 for the majority of follow ups for most psychiatrists imho. 99215 will be more difficult depending on your practice setting, but may be easier for those who prescribe lithium, VPA and clozapine regularly. Routine antipsychotic lab monitoring wouldn’t qualify.

90792 has gone up from 3.25 wRVUs to 4.16 which is a game changer for those in productivity positions. If you are eat what you kill it won’t affect you unless you see a lot of Medicare. Currently I never use 90792 outpatient now I may ocasiónally.

it will be harder for those of us doing 99205 for new visits not based on time. I usually do 99205 + 90838 for my initial visits and I won’t be able to do this for most of my visits (typically 2 hrs) anymore. These are complex patients but if they’re not unstable or you aren’t starting complex meds like Ali or clozapine you won’t qualify on MDM.

those of us that do long visits like me (I do 2-3hr initial evals as is customary in neuropsychiatry) will lose out in because the new prolonged services codes aren’t as good as the old ones and it will be hard to get reimbursed and will trigger an audit if you routinely use them.

the expectation with the new system is more level 4 billing and less level 5 so if you significantly increase level 5 expect an audit.

again this is not likely to affect commercial insurance reimbursement any time soon. I’ve also heard some hospitals and practices refusing to institute these changes for wRVU based staff trying to have it both ways!
 
How are you guys documenting time based encounters now that specifying face to face time isn't required? Can you just put "Total Time: 25 minutes."
 
clausewitz2 said:
Start time and end time
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I get that for back when face to face time mattered, but how would that apply to the new changes? What if you chart review from 730a-740a, see the patient from 845a-915a, then don't get to your note until 2pm. How would you document a start and stop time for that? All those times chunks are applicable to billing now.
 
hebel said:
I get that for back when face to face time mattered, but how would that apply to the new changes? What if you chart review from 730a-740a, see the patient from 845a-915a, then don't get to your note until 2pm. How would you document a start and stop time for that? All those times chunks are applicable to billing now.
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Good point. My inclination would be to just record times for everything. You're going to be glad you did if you ever get audited over this sort of thing anyway, and my guess is insurance companies are definitely going to get their auditing pens out when people suddenly become the slowest documenters in the world and everything's a 992*5
 
clausewitz2 said:
Good point. My inclination would be to just record times for everything. You're going to be glad you did if you ever get audited over this sort of thing anyway, and my guess is insurance companies are definitely going to get their auditing pens out when people suddenly become the slowest documenters in the world and everything's a 992*5
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Haha, I think insurers may be shocked by how long all the work associated with a visit can actually take. My clinic uses Epic, and IT showed us a really neat feature that tracks how long I spent in the patients chart during each phase of care which I can access when choosing a billing code. I actually vastly underestimated how much time I took, and I consider myself on the more efficient side.
 
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Is there a good reference for wRVU multipliers? I see that 90792 increased to 4.16 RVUs. Have there been changes to other common codes?

99203-205 outpatient new
99213-99214 outpatient established

99221-223 inpatient new
99231-233 inpatient established?

90833-838 psychotherapy.
 
nexus73 said:
Is there a good reference for wRVU multipliers? I see that 90792 increased to 4.16 RVUs. Have there been changes to other common codes?

99203-205 outpatient new
99213-99214 outpatient established

99221-223 inpatient new
99231-233 inpatient established?

90833-838 psychotherapy.
Click to expand...

I did some googling and came across this. Not sure if accurate, but it looks correct to me.
 

Attachments

99417 (additional 15 minutes) is a new CPT code that you can use as many times as you want, but doesn't have an wRVU associated with it yet. Anyone have a guess on how much this might be?
 
clozareal said:
99417 (additional 15 minutes) is a new CPT code that you can use as many times as you want, but doesn't have an wRVU associated with it yet. Anyone have a guess on how much this might be?
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I have to double check the form I have in my office, but I believe it was either .61 or .67
 
splik said:
The APA has some great info on their site about this as directly related to psych. The AMA has more generic info.

I do expect teething problems. For those in wRVUs positions who do outpatient this is good. I do not expect it to impact those who only see patients with commercial insurance or cash pay. it was always easy to hit 99214 for the majority of follow ups for most psychiatrists imho. 99215 will be more difficult depending on your practice setting, but may be easier for those who prescribe lithium, VPA and clozapine regularly. Routine antipsychotic lab monitoring wouldn’t qualify.

90792 has gone up from 3.25 wRVUs to 4.16 which is a game changer for those in productivity positions. If you are eat what you kill it won’t affect you unless you see a lot of Medicare. Currently I never use 90792 outpatient now I may ocasiónally.

it will be harder for those of us doing 99205 for new visits not based on time. I usually do 99205 + 90838 for my initial visits and I won’t be able to do this for most of my visits (typically 2 hrs) anymore. These are complex patients but if they’re not unstable or you aren’t starting complex meds like Ali or clozapine you won’t qualify on MDM.

those of us that do long visits like me (I do 2-3hr initial evals as is customary in neuropsychiatry) will lose out in because the new prolonged services codes aren’t as good as the old ones and it will be hard to get reimbursed and will trigger an audit if you routinely use them.

the expectation with the new system is more level 4 billing and less level 5 so if you significantly increase level 5 expect an audit.

again this is not likely to affect commercial insurance reimbursement any time soon. I’ve also heard some hospitals and practices refusing to institute these changes for wRVU based staff trying to have it both ways!
Click to expand...

Can't you do 99205 + 90838 + 99417 x4 for your 2 hour appointments? You'll meet MDM because you're going to be fulfilling category 1 (reviewing 1-2 unnique charts from 1-2 unique sources, reviewing lab results) and category 2 (reviewing neurologist test results, overreading the MRI) or category 3 (talking to referring physician). 1 chronic illness with severe impairment is what the neurpsych/complex patients are likely seeing you for so you'll meet the complexity there.
 
clozareal said:
Can't you do 99205 + 90838 + 99417 x4 for your 2 hour appointments? You'll meet MDM because you're going to be fulfilling category 1 (reviewing 1-2 unnique charts from 1-2 unique sources, reviewing lab results) and category 2 (reviewing neurologist test results, overreading the MRI) or category 3 (talking to referring physician). 1 chronic illness with severe impairment is what the neurpsych/complex patients are likely seeing you for so you'll meet the complexity there.
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Do you mean 99205+99417x4? You can’t use 99417 with psychotherapy add ons.

in general I don’t use the prolonged service codes because I have not got reimbursed with them with the exception of Medicare. Interestingly when I do work in a neurology clinic, the prolonged service codes get reimbursed by insurance but for psych I haven’t had much luck and I document perfectly to justify it. So there is definitely a parity issue.

I also suspect if you use more than a few 99417 in an encounter it won’t get reimbursed but it’s too early for me to know that for certain.
 
clozareal said:
Can't you do 99205 + 90838 + 99417 x4 for your 2 hour appointments?
Click to expand...
To add on to splik's response, you still can't use the psychotherapy add-ons if you bill the E&M portion on time. If you use 99417, then you are billing the 99205 portion based on time, not MDM elements. If you bill 99205 based on the MDM, then I don't believe you can use 99417 as the time becomes irrelevant.
 
hebel said:
I did some googling and came across this. Not sure if accurate, but it looks correct to me.
Click to expand...

So for outpatient positions that use RVU-based compensation models - in theory, are these encounters going to pay more? Will it take less total encounters to meet an RVU threshold?

I guess places could just increase their organization's RVU threshold but it seems like a 99213/99214 in 2021 will pay more than the same code in 2020. I'm mainly curious about if people are bringing this up in contract/negotiation discussions and how this is playing out.
 
rjs2131 said:
So for outpatient positions that use RVU-based compensation models - in theory, are these encounters going to pay more? Will it take less total encounters to meet an RVU threshold?

I guess places could just increase their organization's RVU threshold but it seems like a 99213/99214 in 2021 will pay more than the same code in 2020. I'm mainly curious about if people are bringing this up in contract/negotiation discussions and how this is playing out.
Click to expand...
Medicare will pay more commercial insurance likely no real difference. It should be easier to hit rvu targets and make more money but I anticipate a correction because the whole rvu system of payment was meant to depress physician compensation. Already hearing of clinics moving the goal posts or refusing to move to 2021 rvu system
 
hebel said:
I did some googling and came across this. Not sure if accurate, but it looks correct to me.
Click to expand...
rjs2131 said:
So for outpatient positions that use RVU-based compensation models - in theory, are these encounters going to pay more? Will it take less total encounters to meet an RVU threshold?

I guess places could just increase their organization's RVU threshold but it seems like a 99213/99214 in 2021 will pay more than the same code in 2020. I'm mainly curious about if people are bringing this up in contract/negotiation discussions and how this is playing out.
Click to expand...
splik said:
Medicare will pay more commercial insurance likely no real difference. It should be easier to hit rvu targets and make more money but I anticipate a correction because the whole rvu system of payment was meant to depress physician compensation. Already hearing of clinics moving the goal posts or refusing to move to 2021 rvu system
Click to expand...

Per @hebel 's document psych is going to be reimbursed 3% less per wRVU: "This article has reviewed estimated increases to both wRVUs and clinical compensation. However, because the expected change in wRVU values exceeds the expected change in clinical compensation, compensation per wRVU ratios are expected to decrease in future surveys. See Column C in Table 4 for the estimated impact on specific specialties. Overall, our study indicated a 3% decrease in the TCC/wRVU rate, but significant variability by specialty. "

I have no idea how to tell if this will actually occur overall, but I'd imagine it would only be beneficial for EWYK models.
 
randomdoc1 said:
@clausewitz2 @TexasPhysician Do you have any links in terms of where I can read up about how we need to be documenting now? I'm not even sure where to look. I would look myself but I'm pretty deep in trying to sort out which cost share waives will continue and how telehealth will be covered into 2021 with all these payors we are contracted with. Thanks in advance! It's a nightmare! But insurance is what allowed us to grow so fast.
Click to expand...

www.aacap.org

CPT & Reimbursement

www.aacap.org www.aacap.org
 
Are there any differences in reimbursement when using the time vs MDM when using same code?
I can't get straight answers from insurers.
 
I finally blocked out the time to watch the AMA videos on their website and really look at the tables of how to classify the note.

Pinch me. Is this for real? I feel like its a win, which doesn't happen to us. Is some one hiding behind a bush ready to pop out and kick us? I think I can actually finally stop asking stupid questions only pertinent to billing.

I predict I'll from my 80ish percent 99214 to 90% or more. I do 90 minute consults so all mine are now 99205, and the only question is do I drop the prolonged code?

Is the new 15min prolonged code still 99354 for outpatient or is some new number 99417?
 
Sushirolls said:
I finally blocked out the time to watch the AMA videos on their website and really look at the tables of how to classify the note.

Pinch me. Is this for real? I feel like its a win, which doesn't happen to us. Is some one hiding behind a bush ready to pop out and kick us? I think I can actually finally stop asking stupid questions only pertinent to billing.

I predict I'll from my 80ish percent 99214 to 90% or more. I do 90 minute consults so all mine are now 99205, and the only question is do I drop the prolonged code?

Is the new 15min prolonged code still 99354 for outpatient or is some new number 99417?
Click to expand...
417 q 15 minutes
 
But if all doctors are billing more 99214 will reimbursement drop for this code? That’s my concern. If you were billing 80% 99214 and now it’s 90% but reimbursement is cut it may not help. Whereas a PCP (or nephrologist or pulmonologist or oncologist etc) going from 40% to 80% 99214 will could be better even if reimbursement drops. A lot of non psych specialists see patients in 10 minutes and cover 2 chronic problems which used to be 99213 but will now all be 99214.
 
My understanding is hospital stays, LTACs, SNFs, dialysis, ICU etc burn more insurance money than the bulk of outpatient medicine. That really won't make much of an issue.

For instance if I some one ~6x in a year lets say, and the contracted reimbursement is $700 - only from the insurance, and the rest is patient out of pocket, $700 just doesn't compare to that $17k bill for OB/GYN labor and delivery, etc.

However, I suspect insurance companies, and other Big Box Shops will use this change as an excuse to kick us yet again. As a consolation prize we might have gained more streamlined charting though I hope.
 
nexus73 said:
But if all doctors are billing more 99214 will reimbursement drop for this code? That’s my concern. If you were billing 80% 99214 and now it’s 90% but reimbursement is cut it may not help. Whereas a PCP (or nephrologist or pulmonologist or oncologist etc) going from 40% to 80% 99214 will could be better even if reimbursement drops. A lot of non psych specialists see patients in 10 minutes and cover 2 chronic problems which used to be 99213 but will now all be 99214.
Click to expand...

Eh doubt it. Like @Sushirolls said, inpatient and/or procedures cost WAY more than general outpatient office codes. That was actually part of the whole point of this outpatient E+M revision push. Medicare fully anticipated that outpatient specialities would have more revenue coming in and as part of that anticipated change, cut reimbursement for certain inpatient codes this year (go to the rads, anesthesia, crit care, etc forums to see the complaints there). It's part of a push overall by Medicare to reimburse more for outpatient services and less for high billing inpatient services which overall is budget neutral or perhaps even saves money for them. At least that's the idea.

Sure individual insurance companies may deviate from this but they usually don't too much.
 
I'm wondering if we can drop the Chief Complaint in progress notes. Completely useless in Psychiatry more than 95% of the time. No patient ever walks in saying, "I'm here to follow up for my depression and see if my recent initiation of sertraline 25mg was a good plan or not."

I intend to use it still for intake/consults, but progress notes I can't help but think I'm going to drop it.
 
Sushirolls said:
I'm wondering if we can drop the Chief Complaint in progress notes. Completely useless in Psychiatry more than 95% of the time. No patient ever walks in saying, "I'm here to follow up for my depression and see if my recent initiation of sertraline 25mg was a good plan or not."

I intend to use it still for intake/consults, but progress notes I can't help but think I'm going to drop it.
Click to expand...

My progress notes are strictly SOAP format, no CC in sight, and i haven't had any pushback
 
Thoughts on 99205 + 90833? A few practices I've talked to seem to utilize this for new 60 min intakes but my understanding is you would need to bill 99205 based on MDM. Looking at the definition of high complexity via AACAP, "1 or more chronic illnesses with severe exacerbation, progression or side effects from treatment" OR "1 acute or chronic illness that poses a threat to life/bodily function"

How are people defining the above...or I guess more importantly, how are insurance companies defining the above?

In theory I could see how a new intake for depression, for example, could be defined as an acute/chronic illness that poses a threat to life depending on symptoms (i.e. SI as the most obvious, but also amotivation/sleep disturbances/etc that if untreated would post a threat to function). I could also see anxiety, ADHD, etc falling into this category. It seems like it depends on how 'threat to function' is defined.

Thoughts?
 
Anyone know what code is used for a nurse (RN) who gives an injection in an outpatient office (Consta, haldol dec, etc.)? No other visit will be done the same day, no contact with the psychiatrist.
 
rjs2131 said:
Thoughts on 99205 + 90833? A few practices I've talked to seem to utilize this for new 60 min intakes but my understanding is you would need to bill 99205 based on MDM. Looking at the definition of high complexity via AACAP, "1 or more chronic illnesses with severe exacerbation, progression or side effects from treatment" OR "1 acute or chronic illness that poses a threat to life/bodily function"

How are people defining the above...or I guess more importantly, how are insurance companies defining the above?

In theory I could see how a new intake for depression, for example, could be defined as an acute/chronic illness that poses a threat to life depending on symptoms (i.e. SI as the most obvious, but also amotivation/sleep disturbances/etc that if untreated would post a threat to function). I could also see anxiety, ADHD, etc falling into this category. It seems like it depends on how 'threat to function' is defined.

Thoughts?
Click to expand...
I code some 99205+90833s but making it your standard intake seems a bit cheeky. I think for depression to count the person needs to be actively suicidal, not just in theory at higher risk. The critical part is 'bodily' function, so amotivation isn't going to cut it unless they've stopped attending to ADLs. On the other hand, starting lithium with appropriate labs on someone who endorses current SI - boom, 99205.
 
clausewitz2 said:
I code some 99205+90833s but making it your standard intake seems a bit cheeky. I think for depression to count the person needs to be actively suicidal, not just in theory at higher risk. The critical part is 'bodily' function, so amotivation isn't going to cut it unless they've stopped attending to ADLs. On the other hand, starting lithium with appropriate labs on someone who endorses current SI - boom, 99205.
Click to expand...

Yeah I think 99204+90833 is much more likely to pass audit. I also think if someone was doing 99205+90833 (so not just billing 99205 based on time) for most of their evals, they're gonna trigger an insurance audit pretty quickly. With the new code criteria though, 99205 will be easy to hit by itself as purely time based for us in psych for any new intake that's 60 minutes (probably even 50min since you could justify 10min for the note easy).

Now that I look at it and at the average rates I've gotten from practices for various codes while job searching, 90792 might not even be worth billing anymore (unless in child where you could possibly bill separate 90792 for parent and child interviews), unless they bring the reimbursement up to 99205 levels. 99204 tends to reimburse about the same and if you do some structured therapy in the intake, 99204+90833 will beat a 90792 every time. 99205 definitely beats a 90792.
 
calvnandhobbs68 said:
Yeah I think 99204+90833 is much more likely to pass audit. I also think if someone was doing 99205+90833 (so not just billing 99205 based on time) for most of their evals, they're gonna trigger an insurance audit pretty quickly. With the new code criteria though, 99205 will be easy to hit by itself as purely time based for us in psych for any new intake that's 60 minutes (probably even 50min since you could justify 10min for the note easy).

Now that I look at it and at the average rates I've gotten from practices for various codes while job searching, 90792 might not even be worth billing anymore (unless in child where you could possibly bill separate 90792 for parent and child interviews), unless they bring the reimbursement up to 99205 levels. 99204 tends to reimburse about the same and if you do some structured therapy in the intake, 99204+90833 will beat a 90792 every time. 99205 definitely beats a 90792.
Click to expand...
Does a 99204 + 90833 pay better than a 99205 from what you've seen for a new 60-min intake? It seems like most practices have moved away from 90792 for the reasons you mentioned.
 
So I guess for a new 60 min intake Id be looking at 99204 + 90833 or 99205 + 99417 (time based)
 
splik said:
Do not expect to routinely be reimbursed for 99417.
Click to expand...

Many CAPS spend 90 min on a new eval, and even with a typical 60 min eval there is another 15-30 min (often more) for collateral/other work done outside of the visit. What would you suggest is the best way to bill for this time if 99417 is less likely to be reimbursed?
 
rjs2131 said:
Many CAPS spend 90 min on a new eval, and even with a typical 60 min eval there is another 15-30 min (often more) for collateral/other work done outside of the visit. What would you suggest is the best way to bill for this time if 99417 is less likely to be reimbursed?
Click to expand...
well this is why so many child psychiatrists are cash only. There are several options:
Only accept insurance plans where they agree to pay for 99417
You could also split the intake into two visits with 90792+90785x2
If you are employed an in a wRVU model then you can use the 99417 as you should be paid on work billed, not collected.
accept cash only
have a hybrid model where you accept insurance but have an additional membership fee to provide a premium service that allows you to do the high quality work that is not compensated
 
splik said:
well this is why so many child psychiatrists are cash only. There are several options:
Only accept insurance plans where they agree to pay for 99417
You could also split the intake into two visits with 90792+90785x2
If you are employed an in a wRVU model then you can use the 99417 as you should be paid on work billed, not collected.
accept cash only
have a hybrid model where you accept insurance but have an additional membership fee to provide a premium service that allows you to do the high quality work that is not compensated
Click to expand...

Yeah this is what I was talking about in child. You can split the intake into 2x 45-60 min 90792. That’s probably the only benefit to utilizing 90792 at this point since yes you end up getting paid pretty poorly to do a 99205 for a 90min intake even with good insurances.
 
Last edited:
Inpatient wRVU based folks, are you billing all new intakes at 90792 now since it is more wRVUs than any other new intake code? If not, what would make you choose a different code?
 
splik said:
Exactly. No reason to use 99223 anymore.
Click to expand...
That's what I thought but just wanted to make sure I wasn't missing something. This makes me even more sad I didn't negotiate for a higher salary cap.
 
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