Experience billing +90833 when patient already has a therapist

[clausewitz2]

So of course I am asking people locally as well, but I wanted to get a sense from the hive mind about how much pushback you get when using the +90833 add on code to 99213/4/5. Any advice or wisdom appreciated.

As I mentioned in another thread I am looking at a position with a specialized therapy group and so probably the majority of the people I see will have a concurrent therapist. The idea of billing an E+M code with add-on psychotherapy twice an hour us much more consistent with my approach and how I work then trying to hustle through 3+ appointments an hour. I would not be seeing these folks weekly or anything, probably once a month, though in this setting there are elements of the therapy I might be uniquely qualified to deliver for a subset.

Do you all think this is going to be a huge problem or trigger an audit? I feel pretty confident about how to document but any less obvious points I should make sure to take into account to minimize chance of non-payment?

---

Members don't see this ad.

 

[splik]

No it isn’t an issue unless the DOS is the same as the therapist. Hell some patients see more than one therapist at the same and their insurance may cover it if the reason is different. It should be clear why what you are providing is medically necessary tho.

 

[Taddy Mason]

Just a resident, but that’s how I bill a majority of my outpatients, even ones who are seeing a separate therapist and I’ve never run into an issue. My spouse does claims reviews for a CMS contractor and per her there’s nothing questionable about this and by itself wouldn’t trigger an audit. Were there an issue you’d likely be notified about “appropriate” billing and receive “education” before a formal audit.

 

[TexasPhysician]

No it isn’t an issue unless the DOS is the same as the therapist. Hell some patients see more than one therapist at the same and their insurance may cover it if the reason is different. It should be clear why what you are providing is medically necessary tho.

This. Don’t double up on the same day.

 

[downwithDTB]

No it isn’t an issue unless the DOS is the same as the therapist. Hell some patients see more than one therapist at the same and their insurance may cover it if the reason is different. It should be clear why what you are providing is medically necessary tho.

Has this been challenged in court as a violation of mental health parity laws?

I'd love to see a good test case where a psychiatist and other therapist billed for seperate and distinct empirically supported individual therapy treatments on the same day (i.e. IPT for an MDE from one and CBT-E for bulimia nervosa from the other).

I'm not doubting the validity of your good advice.

 

[TexasPhysician]

Has this been challenged in court as a violation of mental health parity laws?

I'd love to see a good test case where a psychiatist and other therapist billed for seperate and distinct empirically supported individual therapy treatments on the same day (i.e. IPT for an MDE from one and CBT-E for bulimia nervosa from the other).

I'm not doubting the validity of your good advice.

It is parity. Say you are a FM doc. You can’t see a patient billing 99214 and then have the same patient return to same clinic same day and bill another 99214 seeing your partner.

Counseling is the same. It can be covered once/day at the same clinic. Psychiatrist can bill med management and counselor bill counseling same day same clinic.

 

[downwithDTB]

Perhaps we need more specific therapy codes then... CBT for OCD and IPT are about as similar as an endoscopy and a colonoscopy... you can bill both of those in the same day.

Also, are you saying that if I see my PCP in the AM for CAP and then go back for an abx rxn or for stitches after I cut my hand, they can't bill e/m the second visit? That's seriously messed up. This country ...

 

[TexasPhysician]

Also, are you saying that if I see my PCP in the AM for CAP and then go back for an abx rxn or for stitches after I cut my hand, they can't bill e/m the second visit? That's seriously messed up. This country ...

Correct. Otherwise PCP’s could tell patients that they can only address 1 issue per visit. Then sign up patients for 3-4 visits/day when they have multiple issues. Insurance companies want us to address everything in 1 visit to keep costs low.

 

[Sushirolls]

Same clinic, under same corporation and Tax ID, cannot bill for same specialty services on the same date of service. This is why Big Box Shops make sure therapists and psychiatrists see patients on different days.

Community private practice I bill 90833 with no issue for patients who happen to have their own therapists. If they see their therapist on the same day it won't be an issue, because those are different tax ID numbers with different corporations and also different locations for place of service.

If you see a PCP for pneumonia and ABX in the AM, then get bitten by the Emotional Support Animal in the waiting room when checking out, you could be seen again by the PCP for stitches 40 minutes later on their lunch hour. They would not attempt to bill a 99213 and 99214 on the same day, instead, they would bill the 99213 and then do some other variant of prolonged services 99354. My understanding is these codes do not need to be consecutive, but simply clearly illustrate the increased time and reasoning behind its use. I also believe a colleague PCP could be the one to do the stitches and evaluation, and they could be the one enter the 99354. [clarify these facts before applying them yourself...]

 

[Sushirolls]

Perhaps we need more specific therapy codes then... CBT for OCD and IPT are about as similar as an endoscopy and a colonoscopy... you can bill both of those in the same day.

Please no. Don't ever mention such thing again. I have no desire to be like ortho or the other fields with ICD-10 and having a CPT code for every random detail, 'fracture, tibia, distal 1/3, quadruple sideways reversed twist, reduced in the vacuum of space, anesthesia provided by genetically engineered lizard' only to learn that insurance only pays for 'fracture, tibia, distal 1/3, quadruple sideways reversed twist, reduced in the vacuum of space, anesthesia provided by Space Cadet 1st Class, DNP, CRNA, ARNP, FNP, RN, BSN' or that they only pay if it was in the proximal 1/3.

Less is best when it comes to bureaucracy of billing CPT codes.

 

[SpongeBob DoctorPants]

I wanted to get a sense from the hive mind about how much pushback you get when using the +90833 add on code to 99213/4/5.

The idea of billing an E+M code with add-on psychotherapy twice an hour us much more consistent with my approach and how I work then trying to hustle through 3+ appointments an hour.

I don't do a lot of add on codes, but one of my colleagues who left our practice a few months ago said he would sometimes be asked by the insurance company why he was billing for therapy, when the patient already sees a therapist (whether or not the therapist was part of our group). This has caused me to be avoid billing for therapy when a patient of mine already has a therapist. But reading some of the responses here makes me think I don't really need to worry about that.

I'm interested in knowing how you manage to bill 90833 twice an hour. Whenever I do therapy in conjunction with medication management, I always book an hour for those appointments, so I have enough time for the med management and the therapy. Med management alone tends to eat up most the appointment time for the majority of my patients who come in for 30-minute follow ups, so doing an extra 16-37 minutes of therapy means I'd better have that time available. Also, assuming I could work efficiently enough, I wonder if I'd get any pushback from the insurance company for billing E+M plus a 30-minute therapy code all within 30 minutes.

 

[FlowRate]

I don't do a lot of add on codes, but one of my colleagues who left our practice a few months ago said he would sometimes be asked by the insurance company why he was billing for therapy, when the patient already sees a therapist (whether or not the therapist was part of our group). This has caused me to be avoid billing for therapy when a patient of mine already has a therapist. But reading some of the responses here makes me think I don't really need to worry about that.

I'm interested in knowing how you manage to bill 90833 twice an hour. Whenever I do therapy in conjunction with medication management, I always book an hour for those appointments, so I have enough time for the med management and the therapy. Med management alone tends to eat up most the appointment time for the majority of my patients who come in for 30-minute follow ups, so doing an extra 16-37 minutes of therapy means I'd better have that time available. Also, assuming I could work efficiently enough, I wonder if I'd get any pushback from the insurance company for billing E+M plus a 30-minute therapy code all within 30 minutes.

90833 is more practically 16-20 minutes of psychotherapy with 5-9 minutes of med management which leaves you with 5 minutes to do your documentation.

 

[Taddy Mason]

90833 is more practically 16-20 minutes of psychotherapy with 5-9 minutes of med management which leaves you with 5 minutes to do your documentation.

16-37min specifically. Also, was literally just visiting with our outpatient billing staff and per their experience this is more of an issue if people incorrectly use psychotherapy + E&M codes v. straight psychotherapy codes.

 

[clausewitz2]

90833 is more practically 16-20 minutes of psychotherapy with 5-9 minutes of med management which leaves you with 5 minutes to do your documentation.

I.e. the modal follow-up visit for someone reasonably high-functioning not in crisis

 

[FlowRate]

16-37min specifically. Also, was literally just visiting with our outpatient billing staff and per their experience this is more of an issue if people incorrectly use psychotherapy + E&M codes v. straight psychotherapy codes.

How do you fit 37 minutes of psychotherapy into a 30 minute visit? (teasing)

 

[Taddy Mason]

How do you fit 37 minutes of psychotherapy into a 30 minute visit? (teasing)

Outside of convenience, basically having a front row seat to the sheer absurdity to our medical reimbursement system is partially why my wife keeps her job. The specific, yet arbitrary time qualifiers of add on psychotherapy E&M codes is honestly pretty rational/logical compared to other billing situations (e.g., the 4 months my wife’s department was delegated to only reviewing ED claims for “appropriate utilization of IV saline” - no electrolyte abnormalities and no documentation of objective signs of dehydration in the PE = no reimbursement for IV fluids).

 

[SpongeBob DoctorPants]

90833 is more practically 16-20 minutes of psychotherapy with 5-9 minutes of med management which leaves you with 5 minutes to do your documentation.

So I'm wondering now what counts as therapy for the purposes of 90833. I only bill this if I am spending at least 16 minutes doing things like introducing the cognitive behavioral model to my patient, assigning therapy homework, following up on therapy homework, discussing strategies for reducing defiance in children, discussing strategies for reducing anxiety in specific situations, etc. I do not include time spent in gathering history or updates to the patient's progress. Most often, however, when I offer recommendations for therapeutic strategies it only takes a minute or two, rather than the minimum of 16. For those who do add-on therapy frequently, I am curious to know what sort of things you discuss each visit in addition to medication management. This is a skill I would like to learn as I never got this experience in training. As a side note, I would also like to see more of my patients arrive on time and I wonder how to encourage this; on average, my patients tend to arrive a few minutes late, so that we are getting started 10-15 minutes after their appointment time, which is frustrating, because it only leaves 15-20 minutes for the encounter.

 

[downwithDTB]

So I'm wondering now what counts as therapy for the purposes of 90833. I only bill this if I am spending at least 16 minutes doing things like introducing the cognitive behavioral model to my patient, assigning therapy homework, following up on therapy homework, discussing strategies for reducing defiance in children, discussing strategies for reducing anxiety in specific situations, etc. I do not include time spent in gathering history or updates to the patient's progress.

I like to think of it as follows: I can do the absolute bare bones e/m. I start my mse in the waiting room, that plus MDM is all you need for billing. If you go by history, your HPI needs a mere 4 elements for a 214, that takes 13 seconds. So do a quick, e/m HPI/MSE, then spend the bulk of my visit doing therapy, which pretty much always includes gathering information that I need to do the therapy and informs the MDM, then I wrap with some MDM. There is no rule that says that you can't use what you learned in the therapy portion of the visit to inform your e/m. Whether you're doing dynamic supportive therapy, CBT, MI, ect. you use the therapy portion to turn a minimally billable e/m session into high quality care.

 

[splik]

I like to think of it as follows: I can do the absolute bare bones e/m. I start my mse in the waiting room, that plus MDM is all you need for billing. If you go by history, your HPI needs a mere 4 elements for a 214, that takes 13 seconds. So do a quick, e/m HPI/MSE, then spend the bulk of my visit doing therapy, which pretty much always includes gathering information that I need to do the therapy and informs the MDM, then I wrap with some MDM. There is no rule that says that you can't use what you learned in the therapy portion of the visit to inform your e/m. Whether you're doing dynamic supportive therapy, CBT, MI, ect. you use the therapy portion to turn a minimally billable e/m session into high quality care.

MI does not count as therapy for the purposes of billing, it counts as counseling which comes under the E&M code
The rules also require that the E&M and psychotherapy services be distinct and separately identifiable. while this is a false distinction in practice, that is what CMS says. sometimes this is easy (e.g. all time discussing medications, asking about psychiatric symptoms, in diagnostic evaluation counts as E&M).
what you are suggesting could be considered fraudulent, i.e. that the E&M part lasts seconds is obviously patently false as you would never spend seconds with a patient for a full visit.
You need to also identify in your documentation the kind of psychotherapy provided (most commonly supportive), the techniques provided, the goals of said treatment and progress
I think most people would agree that the 90833 cpt code has stretched the definition of "psychotherapy" beyond what would traditionally be regarded as "psychotherapy". certainly shooting the shït with the pt isn't psychotherapy. so this has created some confusion of what is and is not psychotherapy. The key thing is that you are providing some kind of intervention that is identifiable as a therapeutic technique in the furtherance of the patient's treatment (e.g. empathic validation, praise, normalizing, naming emotions, encouragement, reflection, clarification, confrontation, interpretation, discussion of transference affect, psychoeducation, goal setting, cognitive reframing, behavior activation, limit setting etc.)

 

[clausewitz2]

MI does not count as therapy for the purposes of billing, it counts as counseling which comes under the E&M code
The rules also require that the E&M and psychotherapy services be distinct and separately identifiable. while this is a false distinction in practice, that is what CMS says. sometimes this is easy (e.g. all time discussing medications, asking about psychiatric symptoms, in diagnostic evaluation counts as E&M).
what you are suggesting could be considered fraudulent, i.e. that the E&M part lasts seconds is obviously patently false as you would never spend seconds with a patient for a full visit.
You need to also identify in your documentation the kind of psychotherapy provided (most commonly supportive), the techniques provided, the goals of said treatment and progress
I think most people would agree that the 90833 cpt code has stretched the definition of "psychotherapy" beyond what would traditionally be regarded as "psychotherapy". certainly shooting the shït with the pt isn't psychotherapy. so this has created some confusion of what is and is not psychotherapy. The key thing is that you are providing some kind of intervention that is identifiable as a therapeutic technique in the furtherance of the patient's treatment (e.g. empathic validation, praise, normalizing, naming emotions, encouragement, reflection, clarification, confrontation, interpretation, discussion of transference affect, psychoeducation, goal setting, cognitive reframing, behavior activation, limit setting etc.)

It strikes me that ACT is actually kind of perfect for this. If you spend a few minutes introducing the basic ideas and intuitions, it's emphasis on brief experiential exercises and metaphors means it would be trivial to throw a couple into a sixteen minute session. There are approximately a millionty published metaphors/exercises in this framework and the better ones tend to be very vivid and thus easy to remember. Given the ubiquity of experiential avoidance and thought fusion in almost anyone who ends up seeking out a psychiatrist many of them are also broadly applicable.

 

[downwithDTB]

what you are suggesting could be considered fraudulent, i.e. that the E&M part lasts seconds is obviously patently false as you would never spend seconds with a patient for a full visit.

I only said that 4 elements of the 214 hpi takes seconds. "How have you been feeling?" "(Implied location: emotional) pretty (quantity) sad (quality) since last week (timing)."

Per AACAP: "
Since 2013, the psychotherapy add-on codes allow psychiatrists to report psychotherapy
with the full range of E/M codes. To report both E/M and psychotherapy, the two services must be significant and separately identifiable. However, the time within the service does not have to be distinctly separated (i.e. elements of psychotherapy may be interwoven with evaluation/ management elements). CPT gives a roadmap for separately identifying the medical and psychotherapeutic components of the service:
1. The type and level of E/M service is selected first based upon the key components of history, examination, and medical decision-making.
2. Time associated with activities used to meet criteria for the E/M service is not included in the time used for reporting the psychotherapy service (i.e., time spent on history, examination, and medical decision making when used for the E/M service is not psychotherapy time).
3. Time may not be used to select the E/M code when psychotherapy add-on codes are used.
4. Prolonged Services may not be reported when E/M and psychotherapy (90833, 90836, 90838) are reported.
5. A separate diagnosis for a psychiatric or medical condition is not required for the reporting of E/M and psychotherapy on the same date of service.
Documentation must include the required key components of the selected E/M code and
the additional time for the psychotherapy service. Total time for the encounter is not needed. Psychotherapy must be at least 16 minutes to be reported."

Thus, once I obtain the required information for e/m, the bare minimum, I am allowed to do things like set an agenda for my CBT session that includes the patient saying, well, since I haven't been sleeping, I'd like to start with that. At any time, I can add in an e/m clarification question, have you been snoring loudly? That will only minimally interrupt the therapy as is perfectly allowed. The remainder of the time is spent doing therapy, not shooting the ****.

This works extremely well when you know your patients well, see them often enough, and prescribe evidence based regiments less frequently then you see them. You can always deviate into e/m when things get complicated, i.e. a new significant problem arises or you're rethinking your formulation.

Finally, can you refer me to the specific text that says that motivational interviewing doesn't count as psychotherapy?

my understanding is: "
CPT defines counseling as discussion with a patient or related party concerning one or more of the following areas:
Diagnostic results, impressions, and/or recommended diagnostic studies
Prognosis
Risks and benefits of management (treatment) options
Instructions for management (treatment) and/or follow-up
Importance of compliance with chosen management (treatment) options
Risk factor reduction"

To me, the above just doesn't sound like MI, it sounds like provider driven classic medicine: you might gain weight or get TD from your zyprexa and you need to come see me if you're thinking of suicide. It does not sound like, "so what's in favor of using cocaine again tonight?" While of course the patient can ask your opinion in an MI session, the focus is on resolving their ambivalence and edging their motivation towards positive changes (which is more or less the goal of any therapy), and I believe that would be clearly distinct from e/m.

 

[TexasPhysician]

It is true that E/M doesn’t consider Motivational Interviewing as therapy. They specifically differentiate it as a type of counseling which could assist you in time based coding. Therapy and counseling while often used interchangeably in mental health settings are different things to E/M coding.

 

[nexus73]

It’s interesting that we have our sense of what counseling and therapy mean (typically the same thing). But every other area of medicine considers counseling to be non psychotherapy, and therapy doesn’t mean psychotherapy until you’ve asked if they mean physical therapy or occupational etc etc.