How to bill complex cases that require a lot of extra coordination

[truthtopower]

I'm wondering if anybody knows the appropriate CPT code to utilize to bill for hours that are spent on complex cases that require a lot of extra coordination with family, team members, etc. where a lot of the extra coordination does not take place face-to-face – but actually takes place over email.

For example, suppose you have a very complex case that is high acuity and you're doing a lot of email back and forth with the family, as well as psychiatry, as well as family therapy in order to keep people abreast of clinical impresssions, come up with relative risk, etc. for somebody who is in and out of hospitalization. What is the appropriate CPT code for all of the email communication that goes back and forth – which seems to be an incredible expenditure of time? Is that just part of the job? Or is there a way to get compensated for this additional workload?

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[PsyDr]

1) The only email you should send to the patient or family is, "Please schedule an appointment to discuss.". We don't get paid to answer the phone or email. However, if you take the information, you are now liable for its results. The problem with that is:
a. the standard of care for treatment is not email
b. email based treatment evidence based.
c. you just lost the potential to make money
d. you reinforced the idea that you are the person to call

That would result in: "Dr. truthtopower, you were aware your patient was eating a pair of jeans? And you were aware that this could be life threatening? And isn't in person therapy the standard of care for treatment? And did you do that? " Boom. You just lost a malpractice case.

2) From a medicolegal perspective, risk is either present or not. If there is a risk, you send them to the ER or call 911. Playing the "maybe they are a risk, maybe they are not today" game, in timestamped writing, opens you up to liability.

3) To get paid for family conferences, the patient must be present. 90847 pays. 90846 does not. That may lead to some uncomfortable sessions, but we don't get paid to do something comfortable.

4) Fun fact: CMS says that coordination of care with other professionals is outside the scope of psychologists' practice. That means we cannot bill for 99487. You make your recommendations to the patient, document those recommendations, and move on. As a courtesy you should probably call medical providers back.

5) Remember, that you should never work harder than the patient.

6) Don't get sucked into roles that are not yours.

 

[Sanman]

The only codes that may apply:

98970-98972; Online assessment and management services
90785; Interactive complexity

Beyond that @PsyDr has good advice

 

[smalltownpsych]

I bill a monthly fee to cover the extra work and have interns and mentors do most of it for me. We don’t bill insurance. For insurance based practice, the crisis intervention codes can cover coordination of care, but that would be only for actual crises and not extra support you are providing ongoing.

 

[Doctor Eliza]

3) To get paid for family conferences, the patient must be present. 90847 pays. 90846 does not. That may lead to some uncomfortable sessions, but we don't get paid to do something comfortable.

Curious about your statement that 90846 does not pay. Do you mean doesn't pay well or not at all? I bill this with some regularity, as I work with children. Thanks!

 

[Therapist4Chnge]

100% agree w PsyDr.

Back when I took insurance I would require ALL paperwork and discussion be handled during a scheduled appointment, as that was the only sure way I could ensure payment w/o having to charge a separate fee, which would be problematic with Medicare billing. I never did email communication w my patients bc I didn’t want to open myself up to liability using that medium.

 

[PsyDr]

Curious about your statement that 90846 does not pay. Do you mean doesn't pay well or not at all? I bill this with some regularity, as I work with children. Thanks!

It looks like I'm wrong on this one. Thank you for the correction.

I'll have to ask my gal Friday about this. She may be misinformed.

 

[aim-agm]

2) From a medicolegal perspective, risk is either present or not. If there is a risk, you send them to the ER or call 911. Playing the "maybe they are a risk, maybe they are not today" game, in timestamped writing, opens you up to liability.

I would take issue with this binary approach, as risk is often indeterminate. In such cases, I think documenting your considerations and including the below (or a less verbose version of it) is the right approach from a clinical and liability standpoint.

"In order to make a recommendation for a clinical intervention, the standard of care requires that the expected benefits of the intervention outweigh the expected harms and risks. The expected harms and risks of involving emergency services or assessment in an emergency department are significant. The facts available to me at this time do not allow me to conclude whether patient's clinical status (including but not limited to their current risk profile) is such that the benefits of this intervention would or would not outweigh those significant expected harms and risks. As such I can neither make a recommendation for nor against emergency assessment at this time."

 

[WisNeuro]

I would take issue with this binary approach, as risk is often indeterminate. In such cases, I think documenting your considerations and including the below (or a less verbose version of it) is the right approach from a clinical and liability standpoint.

"In order to make a recommendation for a clinical intervention, the standard of care requires that the expected benefits of the intervention outweigh the expected harms and risks. The expected harms and risks of involving emergency services or assessment in an emergency department are significant. The facts available to me at this time do not allow me to conclude whether patient's clinical status (including but not limited to their current risk profile) is such that the benefits of this intervention would or would not outweigh those significant expected harms and risks. As such I can neither make a recommendation for nor against emergency assessment at this time."

Key words were "from a medicolegal perspective." You can do the "right" thing, of course, doesn't mean that you still can't have an attempted lawsuit or board complaint.

 

[PsyDr]

I would take issue with this binary approach, as risk is often indeterminate. In such cases, I think documenting your considerations and including the below (or a less verbose version of it) is the right approach from a clinical and liability standpoint.

"In order to make a recommendation for a clinical intervention, the standard of care requires that the expected benefits of the intervention outweigh the expected harms and risks. The expected harms and risks of involving emergency services or assessment in an emergency department are significant. The facts available to me at this time do not allow me to conclude whether patient's clinical status (including but not limited to their current risk profile) is such that the benefits of this intervention would or would not outweigh those significant expected harms and risks. As such I can neither make a recommendation for nor against emergency assessment at this time."

If you are aware of risks, there is a known risk. If you are unaware of any risk, then there is no known risk. You can call that indeterminate, but it’s the same thing. If you know of a risk and fail to use the standard of care to stop this risk, you are definitively negligent.

Case law would disagree with your position. And ultimately, the courts opinions are the only thing that matters.

Suicide After Wife Requests Divorce

Case #189

expertwitness.substack.com

 

[smalltownpsych]

If you are aware of risks, there is a known risk. If you are unaware of any risk, then there is no known risk. You can call that indeterminate, but it’s the same thing. If you know of a risk and fail to use the standard of care to stop this risk, you are definitively negligent.

Case law would disagree with your position. And ultimately, the courts opinions are the only thing that matters.

Suicide After Wife Requests Divorce

Case #189

expertwitness.substack.com

The court didn’t rule in this case. There was a settlement. In any case, the opinion of the reviewer at the end was that the problem was not having an assessment by a psychiatrist. I used to do ED assessments all the time from referrals from ED physicians and I think that was where the failure in standard of care was. Whether or not I send a patient from my office to the er is a bit of a different question.

 

[PsyDr]

The court didn’t rule in this case. There was a settlement. In any case, the opinion of the reviewer at the end was that the problem was not having an assessment by a psychiatrist. I used to do ED assessments all the time from referrals from ED physicians and I think that was where the failure in standard of care was. Whether or not I send a patient from my office to the er is a bit of a different question.

I understand. The plaintiff committed suicide 18 days after being in the ED. Despite this fact, the attorneys decided that settlement was the way to go.

aim-agm is saying that risk isn't binary. I'm saying that if you document issues of risk to self or others, your personal liability is extremely broad. In 11 states, the courts have ruled that we owe a duty of care to unknown 3rd party individuals. Since 1977, case law has literally stated that we owe a duty of care to some random guy walking down the street, when our patients are driving. That liability extends to actions committed by patients using drugs, even if we are not aware of this use.

 

[ClinicalABA]

I understand. The plaintiff committed suicide 18 days after being in the ED. Despite this fact, the attorneys decided that settlement was the way to go.

aim-agm is saying that risk isn't binary. I'm saying that if you document issues of risk to self or others, your personal liability is extremely broad. In 11 states, the courts have ruled that we owe a duty of care to unknown 3rd party individuals. Since 1977, case law has literally stated that we owe a duty of care to some random guy walking down the street, when our patients are driving. That liability extends to actions committed by patients using drugs, even if we are not aware of this use.

It's interesting how much of this is pure cya stuff. In my local ED, the physician would refer this to the psych evaluator, who is likely a minimally trained LMHC who had no other options than to take the overnight shift doing psych evals in the ED. Not quite the same as a highly trained psychiatrist (oxymoron?) quickly reporting to the ED to conduct an assessment in the best interest of the patient.

 

[clausewitz2]

Key words were "from a medicolegal perspective." You can do the "right" thing, of course, doesn't mean that you still can't have an attempted lawsuit or board complaint.

Welp, I don't pay my malpractice insurer because I don't expect to be sued at some time in my career. You either accept this comes with the territory as a physician (and we are so much luckier than almost every other specialty in that regard) or you are kidding yourself.

Also not super worried about board discipline, given what it appears to take to get my state's board to bestir itself based on publicly available decisions.

 

[WisNeuro]

Welp, I don't pay my malpractice insurer because I don't expect to be sued at some time in my career. You either accept this comes with the territory as a physician (and we are so much luckier than almost every other specialty in that regard) or you are kidding yourself.

Also not super worried about board discipline, given what it appears to take to get my state's board to bestir itself based on publicly available decisions.

Likewise. I will almost assuredly have multiple board complaints in my career, particularly given my forensic focus, but I imagine I will have zero board actions during my career. I agree, I check the public actions now and then, and the people who have actions against them, almost unanimously have majorly screwed up. No grey areas, they simply and very obviously screwed up.

 

[PsyDr]

Welp, I don't pay my malpractice insurer because I don't expect to be sued at some time in my career. You either accept this comes with the territory as a physician (and we are so much luckier than almost every other specialty in that regard) or you are kidding yourself.

Also not super worried about board discipline, given what it appears to take to get my state's board to bestir itself based on publicly available decisions.

There’s a bit of a difference in how psychology boards approach complaints relative to medical boards. Psychologist boards seem to be motivated to actually want to issue complaints. IMO, medical boards seem more balanced.

But our fines are hilariously low.

 

[WisNeuro]

There’s a bit of a difference in how psychology boards approach complaints relative to medical boards. Psychologist boards seem to be motivated to actually want to issue complaints. IMO, medical boards seem more balanced.

But our fines are hilariously low.

Maybe slightly. At least locally, I have never read a board action that I did not agree with the board on.

 

[Sanman]

It's interesting how much of this is pure cya stuff. In my local ED, the physician would refer this to the psych evaluator, who is likely a minimally trained LMHC who had no other options than to take the overnight shift doing psych evals in the ED. Not quite the same as a highly trained psychiatrist (oxymoron?) quickly reporting to the ED to conduct an assessment in the best interest of the patient.

True. However, that is the hospital's staffing choice and their liability.

 

[Sanman]

It's interesting how much of this is pure cya stuff. In my local ED, the physician would refer this to the psych evaluator, who is likely a minimally trained LMHC who had no other options than to take the overnight shift doing psych evals in the ED. Not quite the same as a highly trained psychiatrist (oxymoron?) quickly reporting to the ED to conduct an assessment in the best interest of the patient.

I was thinking about this comment in relation to my career and many others I know. It really is ironic how when one becomes more experienced, one tends to move toward the less acute portion of the spectrum where that experience is not necessarily needed. While I continue to carry some high acuity cases, a lot what I experienced a younger person will not be repeated (mostly because I have money and options).