Income (in)Sanity

[DJspreadsheet]

A lot of talk of the money to be had. Looking at a job that gives me all the standard bennies and works on production. I get reimbursed on billing, not collections. I choose billing complexity. I've received the numbers on billing. According to my math, to make things extremely simple (and actually less than the reality of what I'd be seeing), seeing 10 patients a day at 99213 plus the 90833 addon gets me just over 300k. That's assuming a 25% no show. Add 5 99214s without any therapy addon, I'm pulling over 400k.

Am I missing something?

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[Shikima]

A lot of talk of the money to be had. Looking at a job that gives me all the standard bennies and works on production. I get reimbursed on billing, not collections. I choose billing complexity. I've received the numbers on billing. According to my math, to make things extremely simple (and actually less than the reality of what I'd be seeing), seeing 10 patients a day at 99213 plus the 90833 addon gets me just over 300k. That's assuming a 25% no show. Add 5 99214s without any therapy addon, I'm pulling over 400k.

Am I missing something?

What's your referral base? Depends on insurance company reimbursements also.

 

[DJspreadsheet]

What's your referral base? Depends on insurance company reimbursements also.

The organization recruits the patients from wherever, I don't know. Those reimbursement numbers are firm however, as dictated by the practice. Again, I get paid on billing, not collections. And it's a specified number. If I bill for a 99213, I get X no matter the insurance. Etc.

 

[nexus73]

I don't think you're missing anything. Psychiatry is in demand. What are they paying per RVU?

 

[st2205]

Sounds similar to what I'm doing. Love the idea of getting what you bill and not collect.

 

[DJspreadsheet]

I don't think you're missing anything. Psychiatry is in demand. What are they paying per RVU?

It's not RVU-based but code based. A 99213+90833 reimburses around 150.

 

[DJspreadsheet]

Sounds similar to what I'm doing. Love the idea of getting what you bill and not collect.

Indeed my friend. Are you coming up with similar hypotheticals? I keep hearing these low-ball numbers, so I feel like my math is all distorted. But it's not. Or is it? LOL.

 

[FlowRate]

I'm curious, who wants a psychiatrist enough to pay you on billing?

I guess maybe it's possible to be a hospital employee and have both the hospital and the psychiatrist make out better than if they didn't have each other? (See, as I mentioned elsewhere, the $500 facility fee at my hospital...)

 

[st2205]

I'm curious, who wants a psychiatrist enough to pay you on billing?

I guess maybe it's possible to be a hospital employee and have both the hospital and the psychiatrist make out better than if they didn't have each other? (See, as I mentioned elsewhere, the $500 facility fee at my hospital...)

I'm going to a hospital that will collect a facility. On top of that there are a lot of variables, such as them having their own health plan, wanting to be able to keep people within the system, etc. Believe you're worth less than your billing at your own peril.

Indeed my friend. Are you coming up with similar hypotheticals? I keep hearing these low-ball numbers, so I feel like my math is all distorted. But it's not. Or is it? LOL.

Yes. In fact, the 99213+90833 comes out to about the same as where I'm headed. Maybe it's the same place. Running some numbers based on what a normal heavy-ish job would require is an interesting exercise when compared with those jobs.

 

[DJspreadsheet]

I'm curious, who wants a psychiatrist enough to pay you on billing?

I guess maybe it's possible to be a hospital employee and have both the hospital and the psychiatrist make out better than if they didn't have each other? (See, as I mentioned elsewhere, the $500 facility fee at my hospital...)

I guess this organization does. My theory is their strategy is to be physician friendly, thus getting better physicians, thus providing a better product, and thus growing their brand. Mutually beneficial. I can tell you they aren't using recruiters or advertising jobs. Purely word of mouth and referral. I had a friend who got a job there that introduced and vouched for me. Same thing happened to him. Seems to support the adage that the best jobs aren't the ones on the backpage of Psychiatrist Today.

 

[DJspreadsheet]

I'm going to a hospital that will collect a facility. On top of that there are a lot of variables, such as them having their own health plan, wanting to be able to keep people within the system, etc. Believe you're worth less than your billing at your own peril.

Yes. In fact, the 99213+90833 comes out to about the same as where I'm headed. Maybe it's the same place. Running some numbers based on what a normal heavy-ish job would require is an interesting exercise when compared with those jobs.

Good feeling to be at the end of this slog and feel you're getting an honest deal, eh?

 

[nexus73]

It's not RVU-based but code based. A 99213+90833 reimburses around 150.

About $50 per RVU, which is on the lower end actually.

 

[DJspreadsheet]

About $50 per RVU, which is on the lower end actually.

Good to know! Then I guess my original question stands, if I only need to see 10 patients a day at 30 min a piece to crack 300k, what gives with everyone talking about psych being a 200ish job rather than a 300ish job?

 

[nexus73]

Good to know! Then I guess my original question stands, if I only need to see 10 patients a day at 30 min a piece to crack 300k, what gives with everyone talking about psych being a 200ish job rather than a 300ish job?

My only guess is it depends on where the job is. If it's a cush outpatient job in a large metro area they are not going to pay you like this because there are so many psychiatrists they don't have to. I'm guessing you're not in NYC, LA, Miami, etc? Places with less supply of doctors have to pay more. If this job is in a large metro area, don't say anything, but don't be surprised when pay eventually gets reduced.

 

[st2205]

About $50 per RVU, which is on the lower end actually.

$150 for 99213 + 90833 is closer to $61/RVU.

Good to know! Then I guess my original question stands, if I only need to see 10 patients a day at 30 min a piece to crack 300k, what gives with everyone talking about psych being a 200ish job rather than a 300ish job?

Probably more so that most jobs are still salary or at least have the largest component of it being a base. Some other jobs that are more production based may not be as good of a deal.

 

[DJspreadsheet]

My only guess is it depends on where the job is. If it's a cush outpatient job in a large metro area they are not going to pay you like this because there are so many psychiatrists they don't have to. I'm guessing you're not in NYC, LA, Miami, etc? Places with less supply of doctors have to pay more. If this job is in a large metro area, don't say anything, but don't be surprised when pay eventually gets reduced.

Based on the RVU to CPT code conversions I'm testing out, I'm ranging $60 for the 99213+90833, and up to $80 for some other codes I trialed. Certainly not in LA, Miami, NYC - but not in Fargo either.

 

[SmallBird]

Good to know! Then I guess my original question stands, if I only need to see 10 patients a day at 30 min a piece to crack 300k, what gives with everyone talking about psych being a 200ish job rather than a 300ish job?

There is a myth that exists on this forum that hospitals and clinics will only pay what a physician collects in direct billing minus an overhead (propogated by he who must not be named). There may be some settings where this applies, but it is not the case in academia, the VA, community mental health centers, and most larger hospitals (which is a lot of jobs). CMHCs for example are required to have psychiatrists for accreditation and regulatory purposes and in many parts of many states this is really difficult for them; as such we have value that may far exceed what we can bill directly. In truth, psychiatry salaries are more governed by standard economic principles than doing the math on billing codes. In desirable areas, we may be offered less than what we bill because their is less of a shortage. And the opposite applies in other settings. This is a great offer you received, hope it works out!

 

[DJspreadsheet]

There is a myth that exists on this forum that hospitals and clinics will only pay what a physician collects in direct billing minus an overhead (propogated by he who must not be named). There may be some settings where this applies, but it is not the case in academia, the VA, community mental health centers, and most larger hospitals (which is a lot of jobs). CMHCs for example are required to have psychiatrists for accreditation and regulatory purposes and in many parts of many states this is really difficult for them; as such we have value that may far exceed what we can bill directly. In truth, psychiatry salaries are more governed by standard economic principles than doing the math on billing codes. In desirable areas, we may be offered less than what we bill because their is less of a shortage. And the opposite applies in other settings. This is a great offer you received, hope it works out!

Thanks for the well wishes SmallBird!

 

[sweetlenovo88]

Nice read, could someone please chime in on these questions. Questions are for the private practice vs employed/contractor setting. could someone break down these codes to time? Is 99213+90833 a 30 or a 60 minute visit? What about a 99214+90833? Will most big private insurers compensate for these without a fuss if done once a month or every couple months? Will medicaid HMOs (which are abundant in this large metro), pay for the therapy add on or is it required to go more rural to get this reimbursement? Any issues combining these billing codes with telepsych?

 

[PistolPete]

99213+90833 is 30 minutes, 99213+90836 is 60 minutes. Dunno about your other questions. Would like to know myself.

 

[Blitz2006]

Based on the RVU to CPT code conversions I'm testing out, I'm ranging $60 for the 99213+90833, and up to $80 for some other codes I trialed. Certainly not in LA, Miami, NYC - but not in Fargo either.

Where do you find RVU geographic rates?

I searched but couldn't find it anywhere

 

[st2205]

Where do you find RVU geographic rates?

I searched but couldn't find it anywhere

Not sure but I haven't ever seen RVUs vary too significantly from location to location. I'd say the vary about as much as resident salaries, and, oddly enough, I'd imagine if you took the resident salary of the location you're looking at, moved the decimal to the left 3 places and then multiplied by 0.95, you'll probably have the RVU dollar amount for that location.

 

[DJspreadsheet]

Where do you find RVU geographic rates?

I searched but couldn't find it anywhere

My quotes weren't geographic rates. They were simply converting what a certain CPT code (eg: 99213) equates to in RVUs, which I presume is a conversion that isn't affected by region.

Here's a site that converts: https://www.aapc.com/practice-management/rvu-calculator.aspx

So per this, a 99213 equates to 0.97 RVUs. If I make $100 (randomly chosen number) when billing a 99213, that's essentially making $103 per RVU. For some reason, the 90833 equates to 1.5 RVUs (which is tacked onto the 99213).

With the job I'm looking at, when converted to RVUs, I'd make between 60-80 per RVU. As I delve into the math, my average RVU reimbursement, upon conversion, is about $70 per RVU.

What WILL vary upon region, however, is how much each RVU is reimbursed (or similarly, how much the CPT code is reimbursed).

 

[DJspreadsheet]

Not sure but I haven't ever seen RVUs vary too significantly from location to location. I'd say the vary about as much as resident salaries, and, oddly enough, I'd imagine if you took the resident salary of the location you're looking at, moved the decimal to the left 3 places and then multiplied by 0.95, you'll probably have the RVU dollar amount for that location.

Interesting, but it's not true in my case, and it would also imply high cost cities would reimburse higher. A la NYC, paying residents in the 70k range (COL allowance presumably), when in reality those locations suck for reimbursement. I think?

 

[st2205]

Interesting, but it's not true in my case, and it would also imply high cost cities would reimburse higher. A la NYC, paying residents in the 70k range (COL allowance presumably), when in reality those locations suck for reimbursement. I think?

Yeah. In any case I've never really seen them vary more than a couple dollars +/- $50 for an RVU. Some systems may reimburse their own rates for RVUs but that's completely independent of what they're actually getting from insurance companies and is only what they're paying their physicians.

 

[hamstergang]

could someone break down these codes to time? Is 99213+90833 a 30 or a 60 minute visit? What about a 99214+90833? Will most big private insurers compensate for these without a fuss if done once a month or every couple months? Will medicaid HMOs (which are abundant in this large metro), pay for the therapy add on or is it required to go more rural to get this reimbursement?

90833 is an add-on psychotherapy code requiring that 16-37 minutes be spent in psychotherapeutic activities in addition to the E&M (evaluation and management). 90836 requires 38-52 minutes.

99213 and 99224 are E&M codes that don't require any specific amount of time (though you could bill for them based on time, but then you can't add on the 90833 or 90836).

Therefore, 99213 or 99214 plus 90833 requires at least 17 minutes in the visit, but more realistically 30, or maybe 20. I don't believe any insurance company has an issue with the proper use of these codes, which is at every visit with the psychiatrist.

 

[Blitz2006]

90833 is an add-on psychotherapy code requiring that 16-37 minutes be spent in psychotherapeutic activities in addition to the E&M (evaluation and management). 90836 requires 38-52 minutes.

99213 and 99224 are E&M codes that don't require any specific amount of time (though you could bill for them based on time, but then you can't add on the 90833 or 90836).

Therefore, 99213 or 99214 plus 90833 requires at least 17 minutes in the visit, but more realistically 30, or maybe 20. I don't believe any insurance company has an issue with the proper use of these codes, which is at every visit with the psychiatrist.

Hold Up.

So according to DJspreadsheet,

99213 = 0.97 RVU
99224 = 1.5 RVU

According to you, 99213 + 90833 = 17 minutes.


At $50/RVU, thats $125/patient.

So that means if you see 3 pts/hour from 8am to 4pm (30 min lunch) that is 22 patients. 25% No Show rate = 16 patients/day.

Do notes and stuff from 4:00pm to 5:30pm.

Is that correct?

 

[st2205]

Hold Up.

So according to DJspreadsheet,

99213 = 0.97 RVU
99224 = 1.5 RVU

According to you, 99213 + 90833 = 17 minutes.

Now I looked up on Google and 1 RVU = $37

How are you guys getting $50 per RVU?

I know people have run into some trouble doing 3 90833s in one hour because it's technically a range with 30 mins being the median.

I see RVUs for psych being around $47-48. Facility I'm at (internally) is reimbursing psych for more than this. With bonus it's a reasonable amount more and they pay more per RVU for child psych. Again, this isn't really what they're (the facility) is necessarily getting, it's just how much they'll pay their psychiatrist per RVU.

 

[hamstergang]

According to you, 99213 + 90833 = 17 minutes.

That's not quite what I said. I said that 99213 (or 99214 or 99215) + 90833 requires a minimum of 17 minutes (16 for the 90833 and at least 1 for the E&M). I don't know how you'd do that, but at least it wouldn't be insurance fraud based on the time itself.

 

[DJspreadsheet]

Hold Up.

So according to DJspreadsheet,

99213 = 0.97 RVU
99224 = 1.5 RVU

According to you, 99213 + 90833 = 17 minutes.


At $50/RVU, thats $125/patient.

So that means if you see 3 pts/hour from 8am to 4pm (30 min lunch) that is 22 patients. 25% No Show rate = 16 patients/day.

Do notes and stuff from 4:00pm to 5:30pm.

Is that correct?

As mentioned, my RVU equivalent would be about $70. With 30 min f/u, one could get away with billing the therapy add-on as well. So as described in the intro, with 10 measly patients you'd exceed 300k.

 

[splik]

That's not quite what I said. I said that 99213 (or 99214 or 99215) + 90833 requires a minimum of 17 minutes (16 for the 90833 and at least 1 for the E&M). I don't know how you'd do that, but at least it wouldn't be insurance fraud based on the time itself.

I would say that is definitely insurance fraud!!! if you could do one minute E&M visits, then why not bill 40 99213s an hour (accounting for 30seconds to get each pt in/out of office)?!

 

[dl2dp2]

Your numbers are not wrong and it's not even a geographical issue. Bay area Kaiser is now starting at 300k + very heavy benefits. Non-manhattan NYC city hospitals are paying $160-180 per hour for 1099 regardless of whether patients show up--remember these are block Medicaid driven facilities. A friend of mine says that SoCal Kaiser, which is notorious for paying squat has increased their fellowship starting to 300k to compete with NorCal Kaiser.

Now, Kaiser jobs are heavy. Usually > 10 pt per day...but that said, it's a fixed thing and the benefits are pretty sweet.

5 days a week of 10 patients a day should get you somewhere close to 300k in most of the markets, give or take...not counting academia, which continues to pay very bad. $150-$200 raw billing for this set of code is not uncommon for medium/low end insurance. Overhead is in the 30% range.

Factors:
1. when therapy add-ons were introduced, there was a noticeable bump.
2. demand at facility based is very high
3. a lot of people don't take insurance, which means if you do, you get flooded

Why do you think psych had 3-5 years of consecutive 10% increase in AMG matches?

 

[smalltownpsych]

That's not quite what I said. I said that 99213 (or 99214 or 99215) + 90833 requires a minimum of 17 minutes (16 for the 90833 and at least 1 for the E&M). I don't know how you'd do that, but at least it wouldn't be insurance fraud based on the time itself.

Whether or not it would be insurance fraud, I have found it extremely difficult to do three 30 minute sessions an hour myself. I have done three 45 minutes in two hours though cause I get three extra minutes per. I find that this only works with kids though. Ending a session with adults is too variable to hit the 17, 37, or 53 minute spot well at all. At 52 minutes, I ask another question, next thing you know it's 58.

 

[nexus73]

Whether or not it would be insurance fraud, I have found it extremely difficult to do three 30 minute sessions an hour myself. I have done three 45 minutes in two hours though cause I get three extra minutes per. I find that this only works with kids though. Ending a session with adults is too variable to hit the 17, 37, or 53 minute spot well at all. At 52 minutes, I ask another question, next thing you know it's 58.

You're too nice. /s

 

[michaelrack]

I would say that is definitely insurance fraud!!! if you could do one minute E&M visits, then why not bill 40 99213s an hour (accounting for 30seconds to get each pt in/out of office)?!

because that would be be malpractice. if you are able to obtain and documement the proper info in 60 sec, it would not be insurance fraud.

 

[PistolPete]

Realistically, and for good care, one needs to spend 30 minutes with a patient if you want to bill 99213 or 99214 with the 90833 therapy add-on code. This would come out to about 20 minutes of therapy (17 minutes minimum) and 10 minutes of medication management. I would argue if one wants to bill a 99213 or 99214 with the 90836 therapy add-on code, you would need to spend 50 minutes with the patient, 10 minutes of med management and 40 minutes of therapy (38 minutes minimum).

The question is, would insurance companies pay for these visits, if the patient comes monthly? Quarterly? I wonder what would trigger an audit.

 

[Blitz2006]

Realistically, and for good care, one needs to spend 30 minutes with a patient if you want to bill 99213 or 99214 with the 90833 therapy add-on code. This would come out to about 20 minutes of therapy (17 minutes minimum) and 10 minutes of medication management. I would argue if one wants to bill a 99213 or 99214 with the 90836 therapy add-on code, you would need to spend 50 minutes with the patient, 10 minutes of med management and 40 minutes of therapy (38 minutes minimum).

The question is, would insurance companies pay for these visits, if the patient comes monthly? Quarterly? I wonder what would trigger an audit.

I think the problem is no one has yet defined how much time you need to spend on 99213.

Is it 1 Min?, 5 min? 10 min?

90833 and 90836 have been defined clearly, not 99213.

I mean if you can do med check in 2 min then surely you can do 3 x 99213 + 90833 in 1 hour.

Question is, is this legal?

 

[PistolPete]

I don't see how anyone can do a proper med management check in under 10 minutes. Legally you could do a med management visit in 1 minute, sure, but it would probably be unethical and malpractice.

 

[Information Underload]

I don't know how anyone could legitimately bill 3x90833's per hour. Almost all psych patients require a 99213 for complexity (level 2s are typically for self-limiting problems and hence not psychiatric), and the suggested time for such a visit is at least 15-minutes. Yes, I know that time is not required, but if the suggested time is 15-minutes and you are on a consistent basis doing med-evals in 1-5 minutes for psychiatric problems, that stinks up to high heaven. I just don't see the reason to get greedy over it, and I don't think it's good patient care. I guess for rock solid patients who walk in and tell you everything is great, they aren't anxious, but there is this thing at work or school they aren't sure about, it could happen. But not for the majority of patients.

I personally do 40-minute med/therapy appointments and 20-minute med appointments. That gives me time with my patients and further puts me safely in the expected time frame for appointments, as most of my patients are 99214+90833 (suggested time is 25-minutes+therapy). The med appointments sometimes run over, and hence I keep most of my appointments at 40-minutes.

I see RVUs for psych being around $47-48.

As an aside, Becker puts the median pay for psychiatrists at $254k and median wRVUs as 4079. When you do the math, that translates to a median of $62/wRVU.

 

[st2205]

I think the problem is no one has yet defined how much time you need to spend on 99213.

Is it 1 Min?, 5 min? 10 min?

90833 and 90836 have been defined clearly, not 99213.

I mean if you can do med check in 2 min then surely you can do 3 x 99213 + 90833 in 1 hour.

Question is, is this legal?

99213 as far as subjective, objects objective and level of complexity. Alternately, you can skip requires documentation and bill based solely on time. I forget exactly how much time because I never do that. If you bill based on time and. It documentation then you cannot add on therapy codes.

 

[PistolPete]

I don't know how anyone could legitimately bill 3x90833's per hour. Almost all psych patients require a 99213 for complexity (level 2s are typically for self-limiting problems and hence not psychiatric), and the suggested time for such a visit is at least 15-minutes. Yes, I know that time is not required, but if the suggested time is 15-minutes and you are on a consistent basis doing med-evals in 1-5 minutes for psychiatric problems, that stinks up to high heaven. I just don't see the reason to get greedy over it, and I don't think it's good patient care. I guess for rock solid patients who walk in and tell you everything is great, they aren't anxious, but there is this thing at work or school they aren't sure about, it could happen. But not for the majority of patients.

I personally do 40-minute med/therapy appointments and 20-minute med appointments. That gives me time with my patients and further puts me safely in the expected time frame for appointments, as most of my patients are 99214+90833 (suggested time is 25-minutes+therapy). The med appointments sometimes run over, and hence I keep most of my appointments at 40-minutes.



As an aside, Becker puts the median pay for psychiatrists at $254k and median wRVUs as 4079. When you do the math, that translates to a median of $62/wRVU.

Do you bill a 90833 for pretty much every patient visit? Do the insurance companies ever cause problems? Are most of these patients seen monthly or bi-monthly?

 

[Blitz2006]

Do you bill a 90833 for pretty much every patient visit? Do the insurance companies ever cause problems? Are most of these patients seen monthly or bi-monthly?

Good question.

Or can you do 4 x 99213 per hour instead?

 

[Shikima]

You can do both. If you're lucky, see 4x99214 in an hour.

 

[Blitz2006]

I don't see how anyone can do a proper med management check in under 10 minutes. Legally you could do a med management visit in 1 minute, sure, but it would probably be unethical and malpractice.

But in Psychiatry, med management involves psychotherapy, correct?

I mean, once a patient is stable on SSRI or Lithium after 5-6 sessions, you can't spend 10 minutes asking about side effects, 1-2 min maybe, the other 8-9 minutes is doing psychotherapy right?

So thats why I'm curious as to why can't you combine 99213 + 90833 for a 20 min visit, x 3 visits per hour? I'm talking strictly clinical time, obviously notes is later on/end of day.

 

[PistolPete]

Good question.

Or can you do 4 x 99213 per hour instead?

This would be the definition of "churn and burn" for me and not good psychiatric care. People out there do it, but it's not for me. This is the high-volume type of insurance practice where I hear patients complain that "the psychiatrist just looked at the screen and did a few clicks, gave me a prescription and I was out in 5 minutes."

 

[Blitz2006]

This would be the definition of "churn and burn" for me and not good psychiatric care. People out there do it, but it's not for me. This is the high-volume type of insurance practice where I hear patients complain that "the psychiatrist just looked at the screen and did a few clicks, gave me a prescription and I was out in 5 minutes."

I agree, but this thread is specifically about what is and isn't insurance fraud.

I'm not debating on whether or not this is good practice/good psychiatric care. That is a subjective argument. I'm sure there are psychiatrists who think you should spend 60 minutes with every patient, and that 30 minutes is churning and burning as well.

 

[Information Underload]

Do you bill a 90833 for pretty much every patient visit? Do the insurance companies ever cause problems? Are most of these patients seen monthly or bi-monthly?

Nope. I'm probably 40-50% for 90833s. I see patients based upon need, so I have some who I see every month, some every other month, and some every 3-months. Occasionally every-other-week for very short periods of time or weekly, but only in crisis. I'm in child, so there is plenty of room for application for CBT, supportive therapy and family therapy in most of my sessions.

 

[PistolPete]

Nope. I'm probably 40-50% for 90833s. I see patients based upon need, so I have some who I see every month, some every other month, and some every 3-months. Occasionally every-other-week for very short periods of time or weekly, but only in crisis. I'm in child, so there is plenty of room for application for CBT, supportive therapy and family therapy in most of my sessions.

Cool, good to know. Thanks.

 

[PistolPete]

I agree, but this thread is specifically about what is and isn't insurance fraud.

I'm not debating on whether or not this is good practice/good psychiatric care. That is a subjective argument. I'm sure there are psychiatrists who think you should spend 60 minutes with every patient, and that 30 minutes is churning and burning as well.

Fair enough. Then yes, four 99213's per hour would probably not be fraud.

 

[Blitz2006]

Fair enough. Then yes, four 99213's per hour would probably not be fraud.

Right, so is 3 x (99213 + 90833) per hour fraud or not fraud?