Employer Pushing for Psychotherapy Addons

[VeryOldSpice]

Hi all.

I just started with a telepsych company and they are asking me to do follow up appointments as a 20 minute slot 99214 with a 16 minute 90833 add-on for most or all patients. I asked for an extended follow up for one patient due to her complexity and they said to do a 40 minute appointment 99214 with a 38 minute therapy add on. To me it seems hard to justify that the patient showed up perfectly on time, we didn't end a single minute early, and I did 2 minutes of med management with 38 minutes of therapy / 4 minutes of med management with 16 minutes of therapy. Is this a standard billing practice? Are most people billing these codes without issue? I really need this job from a financial perspective so there is a lot of pressure to conform.

Thank you for your guidance.

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[comp1]

Standard billing practice and legal might be two different things. I know of some places that got audited for too many psychotherapy codes, but I'm definitely not saying it's uncommon or that if you go to a new employer they won't push the same thing.

 

[wolfvgang22]

I bill these codes all the time, but I do actually provide the services I am billing.

 

[Stagg737]

Tell them you want 30 minute f/ups if they’re going to push the add-on or no add-on. You could probably do it, but one report to the state board is all it would take to get censured. What’s more important to you, your job or your license?

 

[mistafab]

Not a surprise at all.

Is this talkiatry? Their business model, like other health startups, is to break into the market and defraud millions before anyone stops them. At that point, they will close up shop and walk away with anything they can, as well as a few white collar crime sentences (slaps on the wrist).

Cost of doing business.

 

[allantois]

Also just because the appointment is booked for 20 mins, does not mean it is automatically a 99214. Are appointments even lasting 16 mins? The employer is going to be on the hook for clawbacks but check your contract for any clause that they may also try to recoup those from you

 

[nexus73]

Hi all.

I just started with a telepsych company and they are asking me to do follow up appointments as a 20 minute slot 99214 with a 16 minute 90833 add-on for most or all patients. I asked for an extended follow up for one patient due to her complexity and they said to do a 40 minute appointment 99214 with a 38 minute therapy add on. To me it seems hard to justify that the patient showed up perfectly on time, we didn't end a single minute early, and I did 2 minutes of med management with 38 minutes of therapy / 4 minutes of med management with 16 minutes of therapy. Is this a standard billing practice? Are most people billing these codes without issue? I really need this job from a financial perspective so there is a lot of pressure to conform.

Thank you for your guidance.

Herein lies the biggest problem for any job. This is how the local for profit mega psych unit keeps staffed with docs (hint, they don't stay staffed by retaining docs). Four D's: dumb, desperate, divorced, or in debt.

All work done should be billed. You should never bill for work not done. 16 minutes of therapy plus e/m for meds in a 20-minute appointments is extremely suspicious. If you are billing 3 therapy codes extra per hour, that could be covering your compensated hourly rate, then the company is getting off with all the regular e/m reimbursement. MBAs are destroying healthcare.

I'd look for a different job honestly.

Check out this company out of Montana. 100% telepsych. From what I've heard they are pretty reasonable to work with. Psychiatrist

 

[Psychresy]

Tell them you want 30 minute f/ups if they’re going to push the add-on or no add-on. You could probably do it, but one report to the state board is all it would take to get censured. What’s more important to you, your job or your license?

Are you really going to lose a license if you are doing 16 min therapy add on and 4 minutes med mgmt in a 20 min follow up appt?

 

[TexasPhysician]

Are you really going to lose a license if you are doing 16 min therapy add on and 4 minutes med mgmt in a 20 min follow up appt?

It’s more likely that you would get hit with fraud charges. Over-billing Medicare/Medicaid gets the government involved. Charges that stick can affect licensing.

 

[ObsequiousAplomb]

Herein lies the biggest problem for any job. This is how the local for profit mega psych unit keeps staffed with docs (hint, they don't stay staffed by retaining docs). Four D's: dumb, desperate, divorced, or in debt.

All work done should be billed. You should never bill for work not done. 16 minutes of therapy plus e/m for meds in a 20-minute appointments is extremely suspicious. If you are billing 3 therapy codes extra per hour, that could be covering your compensated hourly rate, then the company is getting off with all the regular e/m reimbursement. MBAs are destroying healthcare.

I'd look for a different job honestly.

Check out this company out of Montana. 100% telepsych. From what I've heard they are pretty reasonable to work with. Psychiatrist

Plus they have a nice theme song

 

[forchinet121]

Hi all.

I just started with a telepsych company and they are asking me to do follow up appointments as a 20 minute slot 99214 with a 16 minute 90833 add-on for most or all patients. I asked for an extended follow up for one patient due to her complexity and they said to do a 40 minute appointment 99214 with a 38 minute therapy add on. To me it seems hard to justify that the patient showed up perfectly on time, we didn't end a single minute early, and I did 2 minutes of med management with 38 minutes of therapy / 4 minutes of med management with 16 minutes of therapy. Is this a standard billing practice? Are most people billing these codes without issue? I really need this job from a financial perspective so there is a lot of pressure to conform.

Thank you for your guidance.

I mean it’s probably fraud if you’re billing this for the majority, I would say for every 3 20 minute slots 1 or max 2 would have psychotherapy add ons…

 

[TheRightMedication]

I would write back "I will do my best to bill for my services appropriately."

Are they so bold as to put "we need more of these codes" in writing? If they are directly ordering you to commit fraud you gotta get outta there.

If they are not crooked you can negotiate and say you could probably provide services at a 99214 and 90833 level more often if it was 2 patients per hour, not 3.

 

[splik]

Are you really going to lose a license if you are doing 16 min therapy add on and 4 minutes med mgmt in a 20 min follow up appt?

medical boards do not get involved in billing issues. however if CMS came after you then the medical board might sanction you. But doing 16 min therapy add on in a 20min appt is not an absolute no-no as it may be justified occassionally, but if you are consistently doing it, then that is definitely overbilling and might get flagged for audit.

 

[Bartelby]

I agree with others here, don't do this. It's unrealistic to consistently have 20-minute visits where you do evaluation and management and then do at least 16 minutes of therapy. If you document that you are doing so consistently even though you aren't, the consequences will fall on you. The company would probably claim they never encouraged you to bill inappropriately, and even if you have it in writing that they did then basically you are both facing serious problems (it doesn't get you off the hook).

 

[Sushirolls]

Run away.
Don't walk.
Giant Red Flag
LIKE HUGE its waving, and the weather says no wind....

 

[Psychresy]

medical boards do not get involved in billing issues. however if CMS came after you then the medical board might sanction you. But doing 16 min therapy add on in a 20min appt is not an absolute no-no as it may be justified occassionally, but if you are consistently doing it, then that is definitely overbilling and might get flagged for audit.

I'm imagining not doing this with medicare/medicaid would be a bit of a diff story as in at worst you'd have to pay back in an audit... although if you are documenting appropriately I'm not sure how you would lose that audit. I can see how running afoul with the govt could be a different story.

I'm asking because I definitely have some follow ups where they are stable on meds and we end up chatting for 16-20 minutes about their life, recurrent problem areas and I bill a 90833 add on for a 20 or so minute visit.

 

[allantois]

I'm imagining not doing this with medicare/medicaid would be a bit of a diff story as in at worst you'd have to pay back in an audit... although if you are documenting appropriately I'm not sure how you would lose that audit. I can see how running afoul with the govt could be a different story.

I'm asking because I definitely have some follow ups where they are stable on meds and we end up chatting for 16-20 minutes about their life, recurrent problem areas and I bill a 90833 add on for a 20 or so minute visit.

I have heard of insurances requesting time logs from virtual meetings

 

[Psychresy]

I have heard of insurances requesting time logs from virtual meetings

Yeah I mean I never lie about time or things I didn't do. But if a meeting log is 20 minutes and I documented 16 minutes of supportive psychotherapy who is to say I didn't do a med check in four minutes which is totally reasonable for some patients imo.

 

[dieABRdie]

Hi all.

I just started with a telepsych company and they are asking me to do follow up appointments as a 20 minute slot 99214 with a 16 minute 90833 add-on for most or all patients. I asked for an extended follow up for one patient due to her complexity and they said to do a 40 minute appointment 99214 with a 38 minute therapy add on. To me it seems hard to justify that the patient showed up perfectly on time, we didn't end a single minute early, and I did 2 minutes of med management with 38 minutes of therapy / 4 minutes of med management with 16 minutes of therapy. Is this a standard billing practice? Are most people billing these codes without issue? I really need this job from a financial perspective so there is a lot of pressure to conform.

Thank you for your guidance.

Make sure that you save every email or other correspondence they send to you.
Record phone calls with admin pressuring you. (if in a "one party" state, of course).
Keep it in your back pocket.
Bill for your services appropriately... but whip it out when they try to fire you for it.

 

[TexasPhysician]

Yeah I mean I never lie about time or things I didn't do. But if a meeting log is 20 minutes and I documented 16 minutes of supportive psychotherapy who is to say I didn't do a med check in four minutes which is totally reasonable for some patients imo.

I agree that it is appropriate for certain patients, but that isn’t a generalization you can make for all patients.

In my insurance practice, I’ll see 3-4 follow-up patients per hour. Typically 2 include therapy and 1-2 don’t. So some are 16 of 20 minutes, some are 17 of 30 minutes, and some are just 5-7 minute visits.

 

[annoyedpsychiatrist]

medical boards do not get involved in billing issues. however if CMS came after you then the medical board might sanction you. But doing 16 min therapy add on in a 20min appt is not an absolute no-no as it may be justified occassionally, but if you are consistently doing it, then that is definitely overbilling and might get flagged for audit.

this. Its very easy to bill for 99214 because most psych patients have two stable diagnosis. Even my ADHD people usually have anxiety or another comorbid issue like sleep.

On that note, ive found myself being objective with my billing. Can i honestly justify i did 16 minutes of CBT with my stable vyvanse patient with no anxiety/depression/sleep issues? It becomes an ethics issue too. What if the patient gets billed for by insurance? What if insurance refuses to cover it?

I would say 30-50% (depending on the day) of my f/us i could justify 90833 easy. The rest would be a reach

 

[calvnandhobbs68]

Yeah I think the biggest thing here is that'd you get flagged for audits if you're burning through 3 PPH and documenting psychotherapy add ons for everyone. As you noted, it's also pretty tough to justify for EVERYONE that you managed to do all your E+M in 4 minutes and exactly 16 minutes of psychotherapy. 30 minute appointments are much more defendable, it's pretty easy to do even 99214 level e+m in 10-14 minutes and call the other 16-20 minutes psychotherapy. I agree that 50% of 25-30min appointments having 90833 add ons is pretty typical...if someone is taking up a whole 30 minutes of your time, you're probably doing something else besides talking about increasing or switching meds.

It's pretty hard to say you AREN'T doing psychotherapy or what is/isn't psychotherapy so if you're documenting appropriately and patients were actually showing up (so you aren't documenting encounters that didn't happen) you are very unlikely to be tagged for any type of fraud. You will likely get tagged by insurance companies as an outlier though and they'll put your notes under a microscope.

 

[Stagg737]

Are you really going to lose a license if you are doing 16 min therapy add on and 4 minutes med mgmt in a 20 min follow up appt?

TP explained it. You likely wouldn't lose your license, but you would be censured by the board. Things like CMS fraud are things you'd have to report to other states if trying to get a license there and are the type of censures which prevent you from obtaining licenses in the future. Depending on how egregious it is or how frequently you do it though, you could potentially lose your license if the state wanted to crack down.

 

[Stagg737]

Yeah I mean I never lie about time or things I didn't do. But if a meeting log is 20 minutes and I documented 16 minutes of supportive psychotherapy who is to say I didn't do a med check in four minutes which is totally reasonable for some patients imo.

Also, "chatting about life for 16-20 minutes" is not supportive psychotherapy despite what people may say. From an ethical standpoint charging patients for psychotherapy when you're not doing actual psychotherapy is pretty questionable, but that's a separate discussion.

 

[annoyedpsychiatrist]

It's pretty hard to say you AREN'T doing psychotherapy or what is/isn't psychotherapy so if you're documenting appropriately and patients were actually showing up (so you aren't documenting encounters that didn't happen) you are very unlikely to be tagged for any type of fraud. You will likely get tagged by insurance companies as an outlier though and they'll put your notes under a microscope.

i agree, itll be hard for them to say youre not doing it but I think that is a very good point, that even if they arent able to prove youre not doing it they may start looking at your notes more closely and ding you for other things. Realistically your employer is encouraging fraudulent billing to be blunt about it. My concern is if they will try to pressure you into fraudulent billing, what else will they try to pressure you into?

 

[calvnandhobbs68]

Also, "chatting about life for 16-20 minutes" is not supportive psychotherapy despite what people may say. From an ethical standpoint charging patients for psychotherapy when you're not doing actual psychotherapy is pretty questionable, but that's a separate discussion.

I mean from what I can tell plenty of therapists seem to charge patients for "chatting about life" for 50 minutes...this has come up before but standard of care for what constitutes "psychotherapy" is pretty low. I don't think that would be the sticking point here rather than the fact that someone is saying they're doing a moderate level of E+M in 4 minutes for almost every patient every day.

 

[Stagg737]

I mean from what I can tell plenty of therapists seem to charge patients for "chatting about life" for 50 minutes...this has come up before but standard of care for what constitutes "psychotherapy" is pretty low. I don't think that would be the sticking point here rather than the fact that someone is saying they're doing a moderate level of E+M in 4 minutes for almost every patient every day.

Right, which was why I said it was a separate ethical issue. Like you said, given the low standard of care for what constitutes "therapy" in the community I don't think that's where legal/licensing issues would arise. As you said, the idea that one is going to justify a 99214 in 4 minutes (or less) of encounter time is where OP would be getting hit as I can't imagine doing that except in the rare occasion would be meeting basic standards of care to bill a 99214.

 

[annoyedpsychiatrist]

Right, which was why I said it was a separate ethical issue. Like you said, given the low standard of care for what constitutes "therapy" in the community I don't think that's where legal/licensing issues would arise. As you said, the idea that one is going to justify a 99214 in 4 minutes (or less) of encounter time is where OP would be getting hit as I can't imagine doing that except in the rare occasion would be meeting basic standards of care to bill a 99214.

well technically you can count it as 99214 if the patient has two stable diagnosis in the outpatient world

 

[Candidate2017]

Most psychiatrists could use a better grip on basic coding. We also need to not devalue our skills. I'm not saying we should race to the bottom, but social workers routinely charge cash pay patients at least twice what insurance 90833 reimburses a psychiatrist.

OP, though you have chosen to take up the yoke of employed work for The Man, your license still dictates that you use independent, professional judgment to practice medicine, including practicing in an ethical, nonfraudulent manner. So, it behooves you to continue the tradition of independent learning and read up on how to bill properly.

I really need this job from a financial perspective so there is a lot of pressure to conform.

It matters not that you need this job because of dire financial straits. You alone are responsible for proper billing and dictating the terms of practice to conform with the standard of care.

p.s. If you're an NP, just ignore what I said and do whatever you want. Because you're an NP, yay!

 

[smalltownpsych]

Most psychiatrists could use a better grip on basic coding. We also need to not devalue our skills. I'm not saying we should race to the bottom, but social workers routinely charge cash pay patients at least twice what insurance 90833 reimburses a psychiatrist.

OP, though you have chosen to take up the yoke of employed work for The Man, your license still dictates that you use independent, professional judgment to practice medicine, including practicing in an ethical, nonfraudulent manner. So, it behooves you to continue the tradition of independent learning and read up on how to bill properly.



It matters not that you need this job because of dire financial straits. You alone are responsible for proper billing and dictating the terms of practice to conform with the standard of care.

p.s. If you're an NP, just ignore what I said and do whatever you want. Because you're an NP, yay!

One caveat to what you said is that the social worker charging more for cash pay is going to be spending more time with the patient than 20 minutes. Cash clients expect better service and for what I do I typically give them a 55 minute hour. It sort of evens out a bit to squeeze the minutes and nickels out of insurance as they squeeze them out of us and clients and then to be more flexible when outside that system. Agree with other posters that pressure to upcode is a huge red flag. I try to maximize the billing based on what seems reasonable and that I feel that I could justify fairly easily in a legal proceeding.

 

[Stagg737]

well technically you can count it as 99214 if the patient has two stable diagnosis in the outpatient world

Yes, but if you’re seeing someone like that in which you only need 4 minutes of E/M, how do you justify doing 16 minutes of psychotherapy with them on a consistent basis? If a patient requires regular psychotherapy, why are they only getting 20 minute appointment slots? Again, not saying you can’t justify a 99214 in 4 minutes if they’ve got 2 chronic stable illnesses and you’re continuing meds. I’m saying that having a panel where you can regularly see them in 4 minutes and still try and bill regular psychotherapy add ons is going to raise a lot of red flags.

 

[nexus73]

4 minutes with me is equivalent to an hour with an average psychiatrist

it's why I bill all 99215s