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?

---

Members don't see this ad.

 

[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.

 

[Psychferlyfe3000]

Anyone have any sense of what percent of the time 90833 is added on to 99214 by the average psychiatrist? Or into 99213?

 

[annoyedpsychiatrist]

Anyone have any sense of what percent of the time 90833 is added on to 99214 by the average psychiatrist? Or into 99213?

probably 30% of my follow ups if i had to guess. Could probably argue for 40-50% though.

 

[TexasPhysician]

Anyone have any sense of what percent of the time 90833 is added on to 99214 by the average psychiatrist? Or into 99213?

I know practices in which it is 0% and those where it is 100%. Some do no counseling ever, and some psychiatrists refer out patients that don’t need or want counseling.

 

[Stagg737]

Anyone have any sense of what percent of the time 90833 is added on to 99214 by the average psychiatrist? Or into 99213?

It's whatever percent of the time you're doing 16+ minutes of psychotherapy. I can't imagine every doing a psychotherapy add-on for a 99213 as the only patients I bill a 99213 for are the super stable ADHD only patients or the unicorn that truly only has MDD with no other relevant diagnosis.

 

[splik]

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.

Just to update - I've just had insurance approve year 3 of twice weekly 99214+90838 for a patient (technically they approved unlimited sessions). This is a complicated patient but yes it can be medically necessary and justified to bill 99214 multiple times per week -sometimes for years.

 

[rjs2131]

Anyone have any sense of what percent of the time 90833 is added on to 99214 by the average psychiatrist? Or into 99213?

I use 90833 for 100% of my follow-ups, though I'm CAP + young adults. I document accordingly (not just time spent and goals, but more subjective stuff that we're discussing). I highly doubt most psychiatrists are tracking every minute of psychotherapy they do because...what a waste of our energy and time. Someone arbitrarily decided 15 is too little for psychotherapy, 16 min is "just enough". I've never received any training on "16 min psychotherapy", has anyone else? Most residency programs aren't training psychiatrists in supportive/insight-oriented psychotherapy (and I went to a therapy heavy residency program...lots of family therapy, MI, CBT, other therapeutic modalities), and yet this is the only way to combine med management and therapy as a psychiatrist and be reimbursed for it via insurance. If someone is following these rules verbatim, they're basically setting themselves up to be underpaid unless they have negotiated exceptional rates for a stand-alone 99213/99214.

Doing well for yourself/playing the game + providing great patient care don't have to be mutually exclusive!

 

[clausewitz2]

I would say 90833 gets added on to 90-95% of my follow-ups. I don't seen anyone for less than 30 minutes typically and if someone is genuinely 99213 and basically fine I am pretty aggressive about discontinuing treatment and letting them know they can come back later if something changes. Stable rocks are boring to me and also hurt my bottom-line. I reckon this is incentives working they way they ought to.

Can confirm what @splik was saying about repetitively billing 99214+90838. I have never done it twice weekly with anyone but have had some long-term therapy patients who were rather complicated who I've done this weekly for a year+. I don't have many proper therapy clients so the ones I take are always rather complicated, like, on Parnate + Elavil or lithium complicated.

 

[sloh]

I use 90833 for 100% of my follow-ups, though I'm CAP + young adults. I document accordingly (not just time spent and goals, but more subjective stuff that we're discussing). I highly doubt most psychiatrists are tracking every minute of psychotherapy they do because...what a waste of our energy and time. Someone arbitrarily decided 15 is too little for psychotherapy, 16 min is "just enough". I've never received any training on "16 min psychotherapy", has anyone else? Most residency programs aren't training psychiatrists in supportive/insight-oriented psychotherapy (and I went to a therapy heavy residency program...lots of family therapy, MI, CBT, other therapeutic modalities), and yet this is the only way to combine med management and therapy as a psychiatrist and be reimbursed for it via insurance. If someone is following these rules verbatim, they're basically setting themselves up to be underpaid unless they have negotiated exceptional rates for a stand-alone 99213/99214.

Doing well for yourself/playing the game + providing great patient care don't have to be mutually exclusive!

So are you doing less than 16 minutes of therapy but still coding 90833?

 

[rjs2131]

So are you doing less than 16 minutes of therapy but still coding 90833?

No? Yes? How would you measure this?

All of my visits are 30 min with therapy incorporated. I'm not sure how to turn therapy "on" and "off" when I'm working with patients/families, and I don't really care to have a stopwatch to attempt to do this. For the foreseeable future, 16+ min of therapy is what I'm doing during all of my visits.

 

[sloh]

No? Yes? How would you measure this?

All of my visits are 30 min with therapy incorporated. I'm not sure how to turn therapy "on" and "off" when I'm working with patients/families, and I don't really care to have a stopwatch to attempt to do this. For the foreseeable future, 16+ min of therapy is what I'm doing during all of my visits.

Gotcha. Yeah I was asking not as a veiled criticism. Billing and coding guidelines are often inconsistently applied, vague, and sell all of us physicians short. Kudos to you for playing and winning the game.

 

[rjs2131]

Gotcha. Yeah I was asking not as a veiled criticism. Billing and coding guidelines are often inconsistently applied, vague, and sell all of us physicians short. Kudos to you for playing and winning the game.

Totally - the system is frustrating but I do what I can to be a good doctor to my patients and do well financially. The game will probably change with time, so might as well make the most of this current system while we can.

I always encourage psychiatrists with 30-min visits to regularly use the 90833 add-on, because otherwise it's pretty obvious we're being underpaid by insurance relative to other specialties (still recall seeing the $300+ charge for a 99214 for a friend's 15-20 min OBGYN visit...where the same code from the same insurer paid psychiatrists around half of that).

 

[jbomba]

I would say 90833 gets added on to 90-95% of my follow-ups. I don't seen anyone for less than 30 minutes typically and if someone is genuinely 99213 and basically fine I am pretty aggressive about discontinuing treatment and letting them know they can come back later if something changes. Stable rocks are boring to me and also hurt my bottom-line. I reckon this is incentives working they way they ought to.

Can confirm what @splik was saying about repetitively billing 99214+90838. I have never done it twice weekly with anyone but have had some long-term therapy patients who were rather complicated who I've done this weekly for a year+. I don't have many proper therapy clients so the ones I take are always rather complicated, like, on Parnate + Elavil or lithium complicated.

I have one patient I do hourly psychodynamic, med mgmt sessions with once a week. We do 99214+90838. We have been doing this for 3 years. No issue so far.

 

[ObsequiousAplomb]

I would say 90833 gets added on to 90-95% of my follow-ups. I don't seen anyone for less than 30 minutes typically and if someone is genuinely 99213 and basically fine I am pretty aggressive about discontinuing treatment and letting them know they can come back later if something changes. Stable rocks are boring to me and also hurt my bottom-line. I reckon this is incentives working they way they ought to.

Can confirm what @splik was saying about repetitively billing 99214+90838. I have never done it twice weekly with anyone but have had some long-term therapy patients who were rather complicated who I've done this weekly for a year+. I don't have many proper therapy clients so the ones I take are always rather complicated, like, on Parnate + Elavil or lithium complicated.

Do you often bill a 99215+9083X if you're seeing Elavil+ Parnate or lithium patients who either have a side effect or are experiencing an acute emotional crisis? Because those sound pretty high complexity to me.

 

[clausewitz2]

Do you often bill a 99215+9083X if you're seeing Elavil+ Parnate or lithium patients who either have a side effect or are experiencing an acute emotional crisis? Because those sound pretty high complexity to me.

I wouldn't say often, but yes, I definitely do that sometimes

 

[ObsequiousAplomb]

I wouldn't say often, but yes, I definitely do that sometimes

I've never prescribed an MAO-i, mostly because my TRD patients come to me naive from a TCA and they usually respond well to the TCA +/- Rexulti or Latuda or lithium. I've always been curious about MAO-i or even the MAO-i + TCA.

What are some good sources to read up on this combo beyond Stahls?

Do you do what Stahl suggests and start both at lowest dose and stepwise increase one then the other by the smallest amounts?

Did you prescribe MAO-i or MAO-i + TCA in residency?

 

[clausewitz2]

I've never prescribed an MAO-i, mostly because my TRD patients come to me naive from a TCA and they usually respond well to the TCA +/- Rexulti or Latuda or lithium. I've always been curious about MAO-i or even the MAO-i + TCA.

What are some good sources to read up on this combo beyond Stahls?

Do you do what Stahl suggests and start both at lowest dose and stepwise increase one then the other by the smallest amounts?

Did you prescribe MAO-i or MAO-i + TCA in residency?

I did get experience with MAOIs in residency for sure, I think I had one MAOI + TCA patient while still a resident. I was lucky to have a supervisor who was old-school enough that they had seen this before and didn't clutch their pearls when I proposed this.

This is a great place to start for info:

PsychoTropical Research by Dr Ken Gillman

Critical independent evaluations in psycho-pharmacology - Expert commentary on Monoamine Oxidase Inhibitors and Serotonin toxicity

www.psychotropical.com

For what it's worth Stahl is one of the people who contributes to the expert group who worked on the guidelines they recently put out and contributes to ongoing discussions of the finer points of using these medications in the specialist group mentioned on that website.

 

[Psychferlyfe3000]

Totally - the system is frustrating but I do what I can to be a good doctor to my patients and do well financially. The game will probably change with time, so might as well make the most of this current system while we can.

I always encourage psychiatrists with 30-min visits to regularly use the 90833 add-on, because otherwise it's pretty obvious we're being underpaid by insurance relative to other specialties (still recall seeing the $300+ charge for a 99214 for a friend's 15-20 min OBGYN visit...where the same code from the same insurer paid psychiatrists around half of that).

Whaaaaaat. I guess I'm naive but I thought we had parity laws that prevented that sort of thing.

 

[splik]

Whaaaaaat. I guess I'm naive but I thought we had parity laws that prevented that sort of thing.

1. parity laws do not address payment just coverage. parity laws did not even require insurances to cover mental health, just that if they do they have to provide the same coverage (e.g. same number of appointments. same type of prior authorization process) as physical health.
2. parity laws are still not very well enforced.

 

[jbomba]

100% should be doing 90833 with every single med appt if hitting 16 min imo. Insurance woefully underpays us comparatively. Call it supportive therapy if you must and move on. It's a game, so play by the ridiculous rules.

 

[rjs2131]

Whaaaaaat. I guess I'm naive but I thought we had parity laws that prevented that sort of thing.

Nope - it's a system that doesn't value us unfortunately, so we have to do what we can to maximize our worth. Grateful for PP!

 

[Merovinge]

1. parity laws do not address payment just coverage. parity laws did not even require insurances to cover mental health, just that if they do they have to provide the same coverage (e.g. same number of appointments. same type of prior authorization process) as physical health.
2. parity laws are still not very well enforced.

Do you find the parity laws had any tangible effect? What would need to be different in the upcoming policy changes to make them actual get to (or closer to) parity? Everything legal/policy washes straight over my head but I feel like I need to be more educated on this all.

 

[calvnandhobbs68]

Totally - the system is frustrating but I do what I can to be a good doctor to my patients and do well financially. The game will probably change with time, so might as well make the most of this current system while we can.

I always encourage psychiatrists with 30-min visits to regularly use the 90833 add-on, because otherwise it's pretty obvious we're being underpaid by insurance relative to other specialties (still recall seeing the $300+ charge for a 99214 for a friend's 15-20 min OBGYN visit...where the same code from the same insurer paid psychiatrists around half of that).

Yes in my mind at least 90833 is basically there so I can actually get paid similar to other specialists or with practices that shuttle people through 15 minute appts if I'm actually spending time with a patient. Fine, in and out in <15 minutes even if you were scheduled for a 30 min f/u, sure just 99214. If I'm actually spending around 30 minutes with a patient, I'm generally billing for a psychotherapy add on. I do have some 99213s because there are a lot of kids who are just here for ADHD or GAD or something whose parents don't want to go back to a PCP.

Insurance companies have come up with all the ridiculous rules about "start/stop" times for psychotherapy. The actual CPT code says nothing about having to have a specific discrete continuous "psychotherapy" time vs "E+M" time.

This is the actual language:
"Use add-on code for Individual psychotherapy, insight oriented,behavior modifying and/or supportive, 30 minutes with the patient and/or familymember (time range 16-37 minutes), when performed with an evaluation and management service."

CMS also wants you to separate them out but also realizes it's incorporate into the visit and you're often estimating time spent:
"For psychotherapy services performed with an E/M service (CPT codes 90833, 90836, and 90838), it is recognized that the psychotherapy time may not be continuous in a combined psychotherapy with an E/M service. However, since psychotherapy is a time-based code, the expectation would be documentation of the start and stop times or total time of the psychotherapy with an E/M service and documentation of the start and stop times or total time devoted to psychotherapy."

 

[splik]

Do you find the parity laws had any tangible effect? What would need to be different in the upcoming policy changes to make them actual get to (or closer to) parity? Everything legal/policy washes straight over my head but I feel like I need to be more educated on this all.

Yes, the ACA and MHPAEA have had a really significant impact despite the ongoing struggle. Additionally, most states have some kind of parity laws and these have been very important. For example, beforehand eating disorders were often excluded from coverage by insurance. Basically, insurance companies felt this was bad behavior and thus not covered. There are now mechanisms to challenge denials or lack of parity but the onus is on vulnerable patients who likely don't have the knowledge, resources, or wellbeing to fight.

These changes have increased demand for psychiatric services, improved reimbursement, and dramatically increased psychiatrist salaries*. Honestly outpatient psych coverage is pretty good these days. Inpatient is still a challenge. Residential care is the area with the most issues with coverage. I think part of the problem with parity laws, is that there isn't really an equivalent for physical health, and medicare does not cover residential care either.

Many people are familiar with Wit v UBH, the case where united health was sued for denying residential care based on their own arbitrary criteria. Most people know the district court judge found in favor of the plaintiffs and ruled that UBH couldn't just make shît up to arbitrarily deny care. Fewer people are aware that this was overturned on appeal - basically we've gone back to insurance companies doing what the hell they want.

Basically, the APA need to come up with some decent guidelines and criteria for residential care (and maybe IOP or PHP too). Right now all there is are ASAM guidelines and AACP's LOCUS guidelines or else the insurance companies make up wither own or use Mckesson interqual.

Few people are also aware than state departments of managed care and insurance commisioner's have zero power to intervene for most patients with commercial insurance. That is because most plans are employed-sponsored and these are regulated by ERISA. ERISA also means that the insurance company can't be held liable for denying care (e.g. won't pay for hospitalization and pt kills themselves or won't pay for residential and pt ODs) unless you have exhausted all levels of appeals. Pro tip - pt's with ERISA plans (any plan from your employer) can call 1-866-444-EBSA or message (EBSA | U.S. Department of Labor) to help enforce parity requirements or fight denied claims etc.

*There are multiple reasons for the dramatic increase in psychiatrist compensation but the ACA and other parity laws are an important part of that.

 

[Merovinge]

Yes, the ACA and MHPAEA have had a really significant impact despite the ongoing struggle. Additionally, most states have some kind of parity laws and these have been very important. For example, beforehand eating disorders were often excluded from coverage by insurance. Basically, insurance companies felt this was bad behavior and thus not covered. There are now mechanisms to challenge denials or lack of parity but the onus is on vulnerable patients who likely don't have the knowledge, resources, or wellbeing to fight.

These changes have increased demand for psychiatric services, improved reimbursement, and dramatically increased psychiatrist salaries*. Honestly outpatient psych coverage is pretty good these days. Inpatient is still a challenge. Residential care is the area with the most issues with coverage. I think part of the problem with parity laws, is that there isn't really an equivalent for physical health, and medicare does not cover residential care either.

Many people are familiar with Wit v UBH, the case where united health was sued for denying residential care based on their own arbitrary criteria. Most people know the district court judge found in favor of the plaintiffs and ruled that UBH couldn't just make shît up to arbitrarily deny care. Fewer people are aware that this was overturned on appeal - basically we've gone back to insurance companies doing what the hell they want.

Basically, the APA need to come up with some decent guidelines and criteria for residential care (and maybe IOP or PHP too). Right now all there is are ASAM guidelines and AACP's LOCUS guidelines or else the insurance companies make up wither own or use Mckesson interqual.

Few people are also aware than state departments of managed care and insurance commisioner's have zero power to intervene for most patients with commercial insurance. That is because most plans are employed-sponsored and these are regulated by ERISA. ERISA also means that the insurance company can't be held liable for denying care (e.g. won't pay for hospitalization and pt kills themselves or won't pay for residential and pt ODs) unless you have exhausted all levels of appeals. Pro tip - pt's with ERISA plans (any plan from your employer) can call 1-866-444-EBSA or message (EBSA | U.S. Department of Labor) to help enforce parity requirements or fight denied claims etc.

*There are multiple reasons for the dramatic increase in psychiatrist compensation but the ACA and other parity laws are an important part of that.

Great response. Few questions/comments:

1) For ERISA plans, can they be held liable if an active appeal has been submitted and the patient dies while awaiting the response?
2) Are physical PMR stays not similar to mental health RTC (or even PHP for people in that level of rehab)? I use this analogy with my patient's/families regularly.
3) We use REDC and ASAM and have pretty good luck as far as authorizations go for RTC. I am not sure if this is more of a geographic issue. People are regularly able to get 4 weeks of RTC covered at my organization and others in the area for EDs and SUDs that one would think warrants RTC. See attached.

 

[Psychferlyfe3000]

gle med appt if hitting 16 min imo. Ins

Yes in my mind at least 90833 is basically there so I can actually get paid similar to other specialists or with practices that shuttle people through 15 minute appts if I'm actually spending time with a patient. Fine, in and out in <15 minutes even if you were scheduled for a 30 min f/u, sure just 99214. If I'm actually spending around 30 minutes with a patient, I'm generally billing for a psychotherapy add on. I do have some 99213s because there are a lot of kids who are just here for ADHD or GAD or something whose parents don't want to go back to a PCP.

Insurance companies have come up with all the ridiculous rules about "start/stop" times for psychotherapy. The actual CPT code says nothing about having to have a specific discrete continuous "psychotherapy" time vs "E+M" time.

This is the actual language:
"Use add-on code for Individual psychotherapy, insight oriented,behavior modifying and/or supportive, 30 minutes with the patient and/or familymember (time range 16-37 minutes), when performed with an evaluation and management service."

CMS also wants you to separate them out but also realizes it's incorporate into the visit and you're often estimating time spent:
"For psychotherapy services performed with an E/M service (CPT codes 90833, 90836, and 90838), it is recognized that the psychotherapy time may not be continuous in a combined psychotherapy with an E/M service. However, since psychotherapy is a time-based code, the expectation would be documentation of the start and stop times or total time of the psychotherapy with an E/M service and documentation of the start and stop times or total time devoted to psychotherapy."

" the expectation would be documentation of the start and stop times or total time of the psychotherapy with an E/M service and documentation of the start and stop times or total time devoted to psychotherapy."

I am a bit confused by this. Are they saying that for 90833 you can add time spent on psychotherapy woven into E/M conversations with time spent on purely psychotherapy?

 

[hamstergang]

" the expectation would be documentation of the start and stop times or total time of the psychotherapy with an E/M service and documentation of the start and stop times or total time devoted to psychotherapy."

I am a bit confused by this. Are they saying that for 90833 you can add time spent on psychotherapy woven into E/M conversations with time spent on purely psychotherapy?

Sort of yes, but they're not even saying that they expect some time dedicated just to psychotherapy. This is called "psychotherapy add-on" but it's not actually required to be any sort of "real" psychotherapy. All of the psychotherapy time can be mixed throughout the E&M time, alternating from one sentence or one minute to the next.

Though I hear some insurances don't agree and require you to document set start and stop times for the psychotherapy portion.

 

[jbomba]

" the expectation would be documentation of the start and stop times or total time of the psychotherapy with an E/M service and documentation of the start and stop times or total time devoted to psychotherapy."

I am a bit confused by this. Are they saying that for 90833 you can add time spent on psychotherapy woven into E/M conversations with time spent on purely psychotherapy?

There are no hard and fast rules. Helping someone better understand their medications, exploring their emotions towards medications, how side effects make them feel, why they think a medicine isn't as effective as we would like, etc. all feel therapeutic to me. So I count it as therapy. No one is going to sit in your visit with you and stop/start a stopwatch so they can play "gotcha!" later. If my visits go a minute or two over 16, I'm billing 90833.