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it is not possible you have to account for time to get pt out pf the room and the next one in. so yes its fraudRight, so is 3 x (99213 + 90833) per hour fraud or not fraud?
it is not possible you have to account for time to get pt out pf the room and the next one in. so yes its fraudRight, so is 3 x (99213 + 90833) per hour fraud or not fraud?
it is not possible you have to account for time to get pt out pf the room and the next one in. so yes its fraud
wtf no one is doing 8-9mons of psychotherapy (which would not be billable anyway) and to suggest so is degrading to the field. this race to the bottom of defining talking to the f'ing patient as "psychotherspy" (somethings docs in other fields do btw we are supposed to talk to patients ) cheapens what is actually psychotherapy."med management" (dont get me started on this stipid term we are not pharmacists! no other medical specialty does med management) does not necessarily involve psychotherapy - the patient may be beyond therapy, have a condition that does not respond to psychotherapy (e.g. dementia) or be having actual psychotherapy with a therapistBut 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.
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.
If the patient is coming to see you for a follow up appointment there has to be a reason for it. If they are stable and medication doesn't need to be changed, then I would think that you document the reasons for that and how you arrived at that conclusion. Maybe you can talk to them about what the next steps are as far as their treatment goes. How is their psychotherapy progressing? How is their overall health? For a patient with mental health issues, you are sort of the real PCP in a lot of ways. If they are so stable that a regular PCP could handle the case at this point, then maybe they don't need specialized care anymore.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.
Right, so is 3 x (99213 + 90833) per hour fraud or not fraud?
Come to Canada. Single payor, universal coverage. It means billings are collections if you code properly. And because you are normally dealing with one province, you only need to know one set of billing rules.
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How's the pay in Canada?Come to Canada. Single payor, universal coverage. It means billings are collections if you code properly. And because you are normally dealing with one province, you only need to know one set of billing rules.
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Right, so is 3 x (99213 + 90833) per hour fraud or not fraud?
90833 requires a minimum of 16 minutes, not 17.If you can document appropriately based on components for a 99213 as well as document that at least 17 minutes of therapy was conducted, then yes, three 99213+90833 per hour would probably not be fraud. Probably not that realistic though.
90833 requires a minimum of 16 minutes, not 17.
wtf no one is doing 8-9mons of psychotherapy (which would not be billable anyway) and to suggest so is degrading to the field. this race to the bottom of defining talking to the f'ing patient as "psychotherspy" (somethings docs in other fields do btw we are supposed to talk to patients ) cheapens what is actually psychotherapy."med management" (dont get me started on this stipid term we are not pharmacists! no other medical specialty does med management) does not necessarily involve psychotherapy - the patient may be beyond therapy, have a condition that does not respond to psychotherapy (e.g. dementia) or be having actual psychotherapy with a therapist
All I wanted to know is how long a 99213 billing session should be clinically. I mean I'm surprised you're railing against "9 min psychotherapy" but appear ok with 16 minutes.
It seems to me that the RVU coding system is intended to grant approximately 3 RVUs per hour of time for most outpatient care, regardless of how that is divided between meds and therapy.
So a 99213 which is expected to take ~15-20 min is 0.97 RVU; 99214 expected to take ~25-30 min is 1.5 RVU; 99215 is expected to take ~40 min and is worth 2.11 RVU. Add-on 90833 is supposed to average 30 min (16-37 range) and is worth 1.5 RVU; add-0n 90836 is supposed to average 45 min (range 38-52) and is worth 1.9 RVU. So it adds up to approx 3 RVU if you do 30 of each (99214 + 90833), or 15 med + 45 therapy (99213+90836).
If all you do is therapy you get 1.5 RVU for half an hour (90832), 2 RVUs for 45 min (90834), and 3 RVUS for a full hour of therapy (53+ min, 90837).
It's possible to code more intensely than that by arguing that you dealt with lots of complexity in less time than average (hence squeezing 99213+90833 into 30 min or less), but doing that for every patient seems like it's not coding in the way that the system was intended to work.
If you can document appropriately based on components for a 99213 as well as document that at least 17 minutes of therapy was conducted, then yes, three 99213+90833 per hour would probably not be fraud. Probably not that realistic though.
im not okay with 16 mins, but CMS apparently is. mine is not to question that. you seem to be confused about what an E&M code is. it is for evaluation and management and does not include psychotherapy at all (by that "8-9 minutes" or 50 minutes). There are add on codes for separately identifiable visits. everyone knows the 90833 is mostly BS but it has been enormously favorable to psychiatry and allowing psychiatrists to capture more revenue for spending appropriate time with patients, so who is going to knock that? The add on codes themselves however do not make any sense since they require psychotherapy be separately identifiable from the E&M component. no medical psychotherapist in reality compartmentalized the medical and psychotherapeutic but that's how the system is set up...All I wanted to know is how long a 99213 billing session should be clinically. I mean I'm surprised you're railing against "9 min psychotherapy" but appear ok with 16 minutes.
I mean 16 minutes for psychotherapy in my opinion is a joke. If I told my supervisors I was doing 16 minutes of psychotherapy with my therapy patients I would get kicked out of residency immediately. We have a rule that all our therapy patients should be seen for a minimum of 40 minutes. But thats besides the point. The point is you can bill for 16 minutes of psychotherapy, 90833. And thats what I wanted to know, what is the reasonable length of time for 99213. I'm not interested in how people spend their time in 99213, whether its talking about side effects or medications or "9 minutes of psychotherapy" (and yes, I do know psychiatrists who do this, I'm not condoning it)
im not okay with 16 mins, but CMS apparently is. mine is not to question that. you seem to be confused about what an E&M code is. it is for evaluation and management and does not include psychotherapy at all (by that "8-9 minutes" or 50 minutes). There are add on codes for separately identifiable visits. everyone knows the 90833 is mostly BS but it has been enormously favorable to psychiatry and allowing psychiatrists to capture more revenue for spending appropriate time with patients, so who is going to knock that? The add on codes themselves however do not make any sense since they require psychotherapy be separately identifiable from the E&M component. no medical psychotherapist in reality compartmentalized the medical and psychotherapeutic but that's how the system is set up...
E&M codes can be billed based on time (in which case a 99213 would be 15 minutes of which >50% is on counseling and coordination). If based on elements, then it doesnt matter whether you spent 30 seconds or 30 mins with the patient from the perspective of billing as time is no longer considered, only that the level of service was medically necessary and you documented the elements necessary for the level.
BTW in a 30 minute visit I will routinely document and bill for 5 or 10 minutes E&M + 25 or 20 minutes of supportive psychotherapy/CBT what have you for the remainder
It seems to me that the RVU coding system is intended to grant approximately 3 RVUs per hour of time for most outpatient care, regardless of how that is divided between meds and therapy.
So a 99213 which is expected to take ~15-20 min is 0.97 RVU; 99214 expected to take ~25-30 min is 1.5 RVU; 99215 is expected to take ~40 min and is worth 2.11 RVU. Add-on 90833 is supposed to average 30 min (16-37 range) and is worth 1.5 RVU; add-0n 90836 is supposed to average 45 min (range 38-52) and is worth 1.9 RVU. So it adds up to approx 3 RVU if you do 30 of each (99214 + 90833), or 15 med + 45 therapy (99213+90836).
If all you do is therapy you get 1.5 RVU for half an hour (90832), 2 RVUs for 45 min (90834), and 3 RVUS for a full hour of therapy (53+ min, 90837).
It's possible to code more intensely than that by arguing that you dealt with lots of complexity in less time than average (hence squeezing 99213+90833 into 30 min or less), but doing that for every patient seems like it's not coding in the way that the system was intended to work.
90832, 90834 and 90837 are psychotherapy codes NOT E&M codes (these codes are used by psychologists, LCSWs and other non-medical psychotherapists, though we can use them too and often they reimburse more for MDs than PhDs etc but not always depending on the insurance)But quoting TR:
"If all you do is therapy you get 1.5 RVU for half an hour (90832), 2 RVUs for 45 min (90834), and 3 RVUS for a full hour of therapy (53+ min, 90837)."
Aren't 90832, 90834 and 90837 psychotherapy E&M codes? Or no?
And 90833 and 90836 are add on codes, not E&M codes?
90832, 90834 and 90837 are psychotherapy codes NOT E&M codes (these codes are used by psychologists, LCSWs and other non-medical psychotherapists, though we can use them too and often they reimburse more for MDs than PhDs etc but not always depending on the insurance)
90833 and 90836 and 90838 are add on codes (i.e. add on to E&M)
How's the pay in Canada?
I'm somewhat confused as I'm not getting the impression that anyone thinks two 99213s (with 90833 add ons) or even two 99214s when indicated (with 90833 add ons) per hour is abusing the system or being perceived as abuse. Yet those would amount to 4.94 and 6 wRVUs per hour, respectively.
Yes I never code 99214+90833 for 30 minutes, but have for 45 minute visits. We have to be careful about not abusing these codes as the insurance companies will catch on. For example when they created the new 90837 code all of sudden therapists were switching to doing 53 minute therapy sessions when before they were doing 45 min sessions. One the major insurers in the area I was in decided to stop paying for 90837 in response.I can't really say what the gods of coding think about 99214+90833 in 30 min but the guideline for 99214 when used on its own is moderate complexity, or about 25 minutes of time. I understand that when you use the E&M + therapy codes together the E&M is coded on complexity not time. But how does it make sense that you could suddenly handle a level of complexity that should ordinarily require 25 minutes in just 14 minutes (leaving you 16 to meet the bare minimum time to bill 90833)? Over and over again for every patient? Doesn't that seem implausible?
All over the place for psychiatry. For other specialties I think it is fairly comparable.
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everyone knows the 90833 is mostly BS
Why do you say overhead is 30% or 100k? Could someone break that down? Also, if you want to venture out into a new location, can you contact insurers beforehand and see their rates?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?
Why do you say overhead is 30% or 100k? Could someone break that down? Also, if you want to venture out into a new location, can you contact insurers beforehand and see their rates?
Why do you say overhead is 30% or 100k? Could someone break that down? Also, if you want to venture out into a new location, can you contact insurers beforehand and see their rates?
30% is a TYPICAL facility based overhead number. They use it to pay for medmal, administrators, billing fees, real estate, hospital CEO. etc.
In solo, especially cash, that number is quite a bit lower, typically ~10%, sometimes lower.
You can always try to call insurance companies to get rates, but often that info isn't released until you start a formal credentialing process. Thankfully, you can always start the process but then decide to not sign.
Are you sure you don't want to at least try cash? About 50% of psychiatrists in the US are cash. You should also look into joining a group as "partnership tracks" still exist in small markets. I don't think solo insurance based (i.e. "call insurance company") is very efficient, to be honest. These numbers aren't very useful to you if you are a facility based provider, unless you have administrative aspirations. And if you are actually running a fairly large behavioral health provider organization, your ability to negotiate with insurance companies change quite dramatically. I.e. I know of organizations that are getting preferential rates that are often comparable to cash rates for some individuals (employees, etc.), so the numbers insurance companies give you as a solo provider are often inaccurate. Things to think about. My friends and colleagues who end up doing cash have a high degree of variance in terms of their business savviness, but my observation offhand has been even people who are AWFUL at business are filling cash patients, and people who are fairly good are filling within 6 months. So...keep that in consideration. Once you take on a bunch of insurance patients, it might be hard to transition back to cash.
This is all extremely annoying IMHO because to the small guys (either individual patient/insurance enrollee or provider), nothing is transparent in our system. As Fonzie said in a different thread, insurance companies and facilities (through chargemaster rates, facility fees, technical fees, etc.) basically plot, sometimes together sometimes independently, by giving consumers and providers random numbers that are inaccurate, hire a bunch of cheap administrators to flood people with paperwork and negotiation procedures, and try to take advantage whenever they can. On the other hand, it really rewards people who are good at taking advantage of this lack of transparency and make a HUGE amount of money. Whatever floats your boat I guess... /soapbox
Cash practice can fill in 6 months? I wonder what area of the country you're talking about, because I've heard from cash-pay psychiatrists that it'll take a good 1-2 years to fill 40 hours per week of cash-paying patients. Now that the medicare (and I'm assuming private insurance) rates are pretty good if you include therpy add-on codes, I've thought about taking insurance, but I just keep hearing how much of a headache it is, waiting for the reimbursements, or audits for "medical necessity," and the like, so I may just stick to cash.
Not 40 hours. If you work 40 hours at cash rates you will make close to a million a year. Filling a cash practice means working 3 days a week...
Interesting. I've always seen/heard cash rates as $300/hr or so, which comes out to about 400k per year working 30hrs/week, minus overhead and no-shows.
Ginormous N=1 but the folks around me I have spoken to take no less than $400/hour (that is $200 for a 30 min apt). This is because billing 99213 +30 min psy therapy add on is paying over $200 from the big PPO in town, so no reason to go lower on your cash patients.
Ginormous N=1 but the folks around me I have spoken to take no less than $400/hour (that is $200 for a 30 min apt). This is because billing 99213 +30 min psy therapy add on is paying over $200 from the big PPO in town, so no reason to go lower on your cash patients.
Cash practice can fill in 6 months? I wonder what area of the country you're talking about, because I've heard from cash-pay psychiatrists that it'll take a good 1-2 years to fill 40 hours per week of cash-paying patients. Now that the medicare (and I'm assuming private insurance) rates are pretty good if you include therpy add-on codes, I've thought about taking insurance, but I just keep hearing how much of a headache it is, waiting for the reimbursements, or audits for "medical necessity," and the like, so I may just stick to cash.
I dunno, I was all about cash as well, until last few weeks.
Here in NYC area the going rate is $300/hr. If you're a superstar $450/hr. This is just based on my interactions.
But some attendings have told me that with cash you have higher no-show rate, and obviously, its almost impossible to fill a 40 hour work week with cash (even in NYC). Whereas you can easily fill a 40 hour work week with insurance.
Thats why I'm so interested in knowing how much you can legally bill in 1 hour. I mean if you can do 3 x (99213 + 90836) in 1 hour, then insurance might be the way to go....
Thanks. How long do you realistically think you could do three 99213+90833 per hour? You don't think you'd burn out in like a year?
Definitely.
But expectations are (relatively) lower in insurance patients. Again I've generalizing, but a lot of cash patients expect 24/7 service, your cell phone number, calls on weekend about whether or not the 25 mg trazodone is giving me loose stools even though I ate taco bell 3x today.....
But yeah, I also see your point. I don't know how long I could sustain 3 x (99213 = 90833)...
As long as they pay you handsomely for the calls, I'd almost prefer it. Bill per 5 min/round up is how the 3 cash psychiatrists I know all do it and their number of calls is WAY less than I get as a fellow.
That's ethical? Isn't standard of care to be available 24/7 by phone for emergencies? Wasn't aware I could bill someone in 5 min increments if they call me due to an adverse medication side effect, for example.
I think its absolute insanity to say SoC is 24/7 availability for emergencies. I sure as hell cannot get hold of my PCP or any other medical specialist 24/7, why would that be SoC for psychiatry? If there is an imminent emergency every pt has gone over basic safety planning that involves calling 911 or going to the nearest emergency room. Many people would like to have after hours access which is fine, but then you pay for it.
Some of the people on this very forum have advocated the idea that 24/7 immediate availability (or at least to a covering psychiatrist if you're in group practice) is SoC. There are ample medicolegal blog posts that say the same thing.
As for whether it's really possible to get in touch with most psychiatrists at 4AM, I don't know.
Some of the people on this very forum have advocated the idea that 24/7 immediate availability (or at least to a covering psychiatrist if you're in group practice) is SoC. There are ample medicolegal blog posts that say the same thing.
As for whether it's really possible to get in touch with most psychiatrists at 4AM, I don't know.
It's hard enough getting people within our own field to recognize and accept this, never mind a judge or jury.There is little one can do other than seeing them the next day or sending to the ER for admission. No medication will correct the psychosocial crisis they're in.
It's hard enough getting people within our own field to recognize and accept this, never mind a judge or jury.
Define "all over the place," I'm curious. I hear the lengths of stay for inpatient average around 20 days which is unheard of here in the US (3-4 days usually).