Examples of documentation for psychotherapy add on?

[StayOnTop]

Anyone have any examples or could provide an example of the proper way to document a 90833, for example?

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[TexasPhysician]

https://www.psychnews.org/pdfs/Guidance-to-Help-Ensure-You-Are-Coding-Patient-Visits-Correctly-11-36.pdf

 

[ObsequiousAplomb]

https://www.psychnews.org/pdfs/Guidance-to-Help-Ensure-You-Are-Coding-Patient-Visits-Correctly-11-36.pdf

Aww, that's sad. They're recommending weekly therapy with otherwise stable patients be a 99212+90833 instead of 99213 or 99214. Now I feel like I maybe should throw in some 2s.

 

[calvnandhobbs68]

Aww, that's sad. They're recommending weekly therapy with otherwise stable patients be a 99212+90833 instead of 99213 or 99214. Now I feel like I maybe should throw in some 2s.

Meh, IMO that's dumb. You're still meeting criteria for a 99213 and you can argue it another way, if someone is still needing weekly psychotherapy, aren't they at least a 99213? How could you say they have a totally "stable chronic" illness but still justify weekly psychotherapy?

99212 is underbilling, 99212 is literally "URI, no meds" in primary care or like contact dermatitis, take some OTC steroid cream. If someone's 99212, you should probably have a hard time even justifying regular psychotherapy for them.

 

[Psych19]

Lots of folks on this forum seem to be billing 99214+90833 pretty regularly with varying degrees of frequency. I know a common complaint/annoyance is receiving implicitly threatening letters from insurance companies or their hired minions contractors showing graphs of how frequently we bill 99214 vs 99213 compared to our 'peers.' I've received such letters myself and right into the shredder they usually go. I'm curious to hear of actual first-hand or second-hand accounts of individuals being audited and having to pay back money for being found to have upcoded E/M codes or billed medically unnecessary 90833 codes. Or perhaps insurers are mainly going after large employers because that's where the biggest ROI could happen for such audits. I do wonder if this action from an insurance company would hazard causing providers to drop the insurance.

 

[clozareal]

Psychotherapy time: approx. 20 minutes
Type: CBT
Focus: Reviewed prior plan and walked through steps to take when he first notices mood getting worse. Identified context for anxiety and developed plan. Provided workbook handout to complete and bring to next session.
Patient response: Improvement in insight into environmental and interpersonal factors contributing to anxiety.

 

[PsyDr]

Meh, IMO that's dumb. You're still meeting criteria for a 99213 and you can argue it another way, if someone is still needing weekly psychotherapy, aren't they at least a 99213? How could you say they have a totally "stable chronic" illness but still justify weekly psychotherapy?

99212 is underbilling, 99212 is literally "URI, no meds" in primary care or like contact dermatitis, take some OTC steroid cream. If someone's 99212, you should probably have a hard time even justifying regular psychotherapy for them.

IIRC, assessing side effects moves the MDM up to 99214.

 

[tr]

IIRC, assessing side effects moves the MDM up to 99214.

I think there has to actually *be* a side effect for 99214. If you assess and there aren't any, I think it's still 99213 (assuming the patient has a single diagnosis).

 

[hippopotamusoath]

Lots of folks on this forum seem to be billing 99214+90833 pretty regularly with varying degrees of frequency. I know a common complaint/annoyance is receiving implicitly threatening letters from insurance companies or their hired minions contractors showing graphs of how frequently we bill 99214 vs 99213 compared to our 'peers.' I've received such letters myself and right into the shredder they usually go. I'm curious to hear of actual first-hand or second-hand accounts of individuals being audited and having to pay back money for being found to have upcoded E/M codes or billed medically unnecessary 90833 codes. Or perhaps insurers are mainly going after large employers because that's where the biggest ROI could happen for such audits. I do wonder if this action from an insurance company would hazard causing providers to drop the insurance.

99214 + 90833 is my most common follow-up visit. The people with one problem seem to often be ADHD. Everyone else has more than one stable (or unstable), chronic illness, which gets assessed at each visit and I'm always making a decision to maintain/taper/increase their prescription drugs. I'm not sure how I code anything but 99214 for that, regardless of whether we do therapy as well. Are other people doing 99213 in these situations? Why?

 

[TexasPhysician]

99214 + 90833 is my most common follow-up visit. The people with one problem seem to often be ADHD. Everyone else has more than one stable (or unstable), chronic illness, which gets assessed at each visit and I'm always making a decision to maintain/taper/increase their prescription drugs. I'm not sure how I code anything but 99214 for that, regardless of whether we do therapy as well. Are other people doing 99213 in these situations? Why?

Stable ADHD is 99213.

I have a couple therapy patients in which I bill 99213 + 90836. There are 2+ problems, but I usually feel like I focus on 1 each visit when seen weekly. I’m not sure if that is correct, but it is my exception to 99214’s.

 

[jbomba]

99214 + 90833 is my most common follow-up visit. The people with one problem seem to often be ADHD. Everyone else has more than one stable (or unstable), chronic illness, which gets assessed at each visit and I'm always making a decision to maintain/taper/increase their prescription drugs. I'm not sure how I code anything but 99214 for that, regardless of whether we do therapy as well. Are other people doing 99213 in these situations? Why?

I agree. If a patient has two diagnosis I will always ask about them, their symptoms, their experience with these diagnoses and check in about medications or therapy as it relates to these diagnoses. In very stable patients who are doing longer term dynamic work with me these mdm check ins may take 2 minutes or less sometimes. But that's still a 99214.

 

[splik]

Lots of folks on this forum seem to be billing 99214+90833 pretty regularly with varying degrees of frequency. I know a common complaint/annoyance is receiving implicitly threatening letters from insurance companies or their hired minions contractors showing graphs of how frequently we bill 99214 vs 99213 compared to our 'peers.' I've received such letters myself and right into the shredder they usually go. I'm curious to hear of actual first-hand or second-hand accounts of individuals being audited and having to pay back money for being found to have upcoded E/M codes or billed medically unnecessary 90833 codes. Or perhaps insurers are mainly going after large employers because that's where the biggest ROI could happen for such audits. I do wonder if this action from an insurance company would hazard causing providers to drop the insurance.

When I was employed, I had one pt they weren't paying up claims for 6 months. I was seeing the pt twice weekly for 1.5yrs and billing 99214+90838 each time. We submitted all my notes and refiled the claims and they paid up.

Now I'm in private practice I have pts I see twice weekly and use 99214+90838 and two insurance companies have approved this frequency without issue. One of my pts paid $35 per session and got the rest of money back from insurance, and the other pt got 100% of the money back from insurance after meeting their OOPM.

I will add, I'm not like some people who just see people with minor problems multiple times per week. These are challenging pts. My point is that insurance companies do recognize that it can be legitimate to bill 99214 multiple times per week, which is more than most psychiatrists would be doing for the vast majority of their pts. But I do know of colleagues who have been audited and not survived. I provide reviews and audits for practices wanting to avoid this or fight back against insurance companies. Clawbacks are quite rare. It's more common to be downcoded, or to have your reimbursement for codes unilaterally reduced, or placed on prepayment review. Also, some insurance companies punish physicians for leaving their network by auditing them after they leave. That can be a real nuisance.

 

[smalltownpsych]

I am pretty sure that you just document therapy by saying that you did it and for x number of minutes. We don’t have to explain our treatment to insurers. Does a family doc have to explain how she removed a suspicious or problematic mole or does she just say that she did it? Most of our diagnoses have psychotherapy recommended for treatment. The only time we “should” need to justify is extra frequency or duration.

 

[hamstergang]

I am pretty sure that you just document therapy by saying that you did it and for x number of minutes. We don’t have to explain our treatment to insurers. Does a family doc have to explain how she removed a suspicious or problematic mole or does she just say that she did it? Most of our diagnoses have psychotherapy recommended for treatment. The only time we “should” need to justify is extra frequency or duration.

Several have stated (here and in other forums) that they have been audited and that's not been sufficient. It may depend on insurance company, but at least some want modality of therapy, what was addressed, and patient's progress. Some also want start and stop times for therapy (not just total time) even though it's meant to be a service woven into the rest of the visit.

 

[calvnandhobbs68]

I am pretty sure that you just document therapy by saying that you did it and for x number of minutes. We don’t have to explain our treatment to insurers. Does a family doc have to explain how she removed a suspicious or problematic mole or does she just say that she did it? Most of our diagnoses have psychotherapy recommended for treatment. The only time we “should” need to justify is extra frequency or duration.

lol well yes actually they do, are you not familiar with op notes?

But yeah, if you look at insurer guidelines for therapy codes they include more than that

 

[jbomba]

It all just feels like a game. When I have a 30 minute long appt, I may not start therapy exactly at 11:05 and end at 11:21. What's therapy and what's med mgmt? It can blend together at times. I'm certainly not using a stop watch to start/stop every time we verge back into therapy terrority. But nonetheless, I'm going to document supportive therapy framework established, total therapy time 16 minutes, addressing current stressors including x, y, z.

Just play the game and avoid any issues.

 

[smalltownpsych]

lol well yes actually they do, are you not familiar with op notes?

But yeah, if you look at insurer guidelines for therapy codes they include more than that

Hehe. After I posted this yesterday I started thinking about some of the op notes that I have seen where they detailed how they excised this and did some other stuff with that and how surprisingly detailed they were. Thought about deleting my post, but then went on about my day. 🤦‍♂️

 

[ObsequiousAplomb]

I can never remember the nomenclature. Aren't there "op notes" that are like a single sheet of basic things like patient name, procedure, location, etc and then "procedure notes" that are very detailed accounting for steps, akin to our therapy notes?

 

[annoyedpsychiatrist]

Generally my supportive therapy code is something like this

The psychotherapeutic intervention at today's visit was brief supportive therapy. Patient's healthy coping mechanisms were encouraged and unhealthy coping mechanisms were discouraged. The overall goal was aide in improving patient's self esteem and help reinforce the ability to cope with life's stressors. We focused on the skills that the patient possesses and how they have utilized these skills effectively in the past and likely would be able to further utilize them in the future. This was done as an adjunct to medication management and/or review of medical history. Patient was receptive to the information discussed at the time of the encounter. Estimated frequency of adjunct therapy is estimated to be a basis of every 1-3 months, coinciding with the next scheduled follow up (as documented above) unless for any particular reason it is not indicated at that time. The time spent was:

I usually add a few things at the end, depending on what was discussed during the visit so its not always the same paragraph.

 

[hippopotamusoath]

I want to have a generic smart phrase for therapy, but some insurance companies will give you push-back for not "being individualized enough" in your descriptions. Insurance company wants me to waste more time typing, essentially. Okay, the SPECIFIC behavioral change I recommended is going for a jog 3x a week, are we good now?

 

[calvnandhobbs68]

I want to have a generic smart phrase for therapy, but some insurance companies will give you push-back for not "being individualized enough" in your descriptions. Insurance company wants me to waste more time typing, essentially. Okay, the SPECIFIC behavioral change I recommended is going for a jog 3x a week, are we good now?

Yeah it’s just dumb, if you see some of the therapist actual billing notes they’re ridiculously brief or very generic and seem to have no problem billing them every week for years. I do the same thing where I have a template and then edit it a bit.

Just as a real rough example under “interventions” I might put:

CBT/supportive psychotherapy focusing on:
- interpersonal relationships- with boyfriend, peers, decreasing internalization, patient reactions and perspective

 

[annoyedpsychiatrist]

I want to have a generic smart phrase for therapy, but some insurance companies will give you push-back for not "being individualized enough" in your descriptions. Insurance company wants me to waste more time typing, essentially. Okay, the SPECIFIC behavioral change I recommended is going for a jog 3x a week, are we good now?

you can have a generic one and just add a few sentences each time so its different technically

 

[psychmd03]

I want to have a generic smart phrase for therapy, but some insurance companies will give you push-back for not "being individualized enough" in your descriptions. Insurance company wants me to waste more time typing, essentially. Okay, the SPECIFIC behavioral change I recommended is going for a jog 3x a week, are we good now?

I have a handful of generic ones that match to the patient template I am using and then I will toss an extra "specific" example or two depending on how I am feeling about notes that day. But it provides enough variance and everything mentioned in my "therapy" smart phrase is covered with each patient basically no matter what I just have it spread out over various smart phrases to creat the illusion of variety and specificity.