Inpatient billing codes and reimbursement

[Psychresy]

As I mentioned in another thread, I feel like the outpatient side gets a lot of talk. However inpatient reimbursement feel like more of an unknown to me. Was hoping those in the know could share what their reimbursement is looking like on the inpatient side in they're specific locale.

Hopefully this will give those of us who are considering doing our own billings what to expect. Alternatively, for those taking employed jobs, this may help expose poor salary offers. Either way I think the community could benefit from an open discussion on the topic!

As a bonus, any tips to maximize billing/reimbursement, additional codes to use, or anything else helpful to know about inpatient billing?

---

Members don't see this ad.

 

[Psychresy]

Also, any tips for finding hospitals with better paying payor mix?

 

[BiscoDisco]

Another resident, would also like to hear about this from more experienced posters. Have literally no idea what to expect.

 

[comp1]

My advice is to get a salaried inpatient job and not have to worry about this.

 

[SpinDktr]

My advice is to get a salaried inpatient job and not have to worry about this.

Definitely this. I like to document well so I end up usually billing at an appropriate level anyway. A few extra dollars for the hospital. What I use:
99221 L1 admit 30 min
99222 L2 admit 50 min
99223 L3 admit 70 min
99231 L1 prog note 15 min
99232 L2 prog note 25 min
99233 L3 prog note 35 min
99238 D/C 30 min
99239 D/C 30+ min

For awhile I was using some other codes like 99356 if I had a long/complex admission with lots of people/guardians/involuntary/other issues, but then realized I am salaried. No real need to document or do that much. I think sometimes it was declined or staff had to fight to claim the $60 or whatever, so not worth it.

 

[BiscoDisco]

My advice is to get a salaried inpatient job and not have to worry about this.

Was told you could make pretty significant amount more doing it this way - a few posters on this board have mentioned this.

 

[BiscoDisco]

Definitely this. I like to document well so I end up usually billing at an appropriate level anyway. A few extra dollars for the hospital. What I use:
99221 L1 admit 30 min
99222 L2 admit 50 min
99223 L3 admit 70 min
99231 L1 prog note 15 min
99232 L2 prog note 25 min
99233 L3 prog note 35 min
99238 D/C 30 min
99239 D/C 30+ min

For awhile I was using some other codes like 99356 if I had a long/complex admission with lots of people/guardians/involuntary/other issues, but then realized I am salaried. No real need to document or do that much. I think sometimes it was declined or staff had to fight to claim the $60 or whatever, so not worth it.

Did you ever use 90833 or other therapy add on codes?

 

[SpinDktr]

I used to, but was told that they all get rejected. I think you can make more doing inpatient if doing your own billing and seeing 20-30+ patients per day, not my thing.

 

[Candidate2017]

My advice is to get a salaried inpatient job and not have to worry about this.

It's not that simple. The government has extracted settlements from psychiatrists for their employer's overbilling, despite the psychiatrist not being paid based on billing. Every doctor should know how to bill and put a CPT billing code in their inpatient note.

There are plenty of online resources to learn about billing codes and requirement. I used my free time in PGY-4 to read up and create my own templates that hit required billing codes.

 

[Candidate2017]

Did you ever use 90833 or other therapy add on codes?

90833 only makes sense outpatient. In the time that you do 90833 "therapy" on an inpatient, you could've seen almost two 99233s based on worsening criteria.

 

[SmallBird]

I'm a full time, busy inpatient doc and have been for six years, and I bill 90833 every single day. I have been audited twice, and the only thing that I've ever gotten feedback on is 99233.

 

[BiscoDisco]

90833 only makes sense outpatient. In the time that you do 90833 "therapy" on an inpatient, you could've seen almost two 99233s based on worsening criteria.

But if you have 15 patients, you have 15 patients. It's like you can just see more people that aren't on your list, right?

The reimbursement for a 90833 seems like it would more than make up for the 16 minute requirement.

 

[ObsequiousAplomb]

But if you have 15 patients, you have 15 patients. It's like you can just see more people that aren't on your list, right?

The reimbursement for a 90833 seems like it would more than make up for the 16 minute requirement.

Do you really think so?

15 x 90833 = minimum 4 additional hours for about $1200, and that's if and only if you actually get that much money. That's only if you do the bare minimum of 16 minutes, which is really hard to get down exactly each time. If you did more like 20 minutes average, that would be 5 hours.

You'd still have to do all your other work for those 15 patients that day. If you were planning on doing it all in the other 4 hours (or 3 hours if spending 20 additional minutes for the add-on), why not just leave after those first 4 hours (or 3 hours) and go to your outpatient clinic or other setting? If you went outpatient, you could be providing psychotherapy to people who would more likely benefit from it, in a setting you'd more likely be paid for it, and the outpatient med management codes generally pay more than the inpatient ones anyway.

Or you could go home earlier?

If you're dead-set on only doing inpatient work and you can knock out 15 in the first 3-4 hours you could easily see 15 more in the remaining 4-5 hours. Either you, a hospital administrator, or your partners would find a way to make you busy for those 4 additional hours that wouldn't be psychotherapy add-ons.

Then there's the issue as mentioned above where oftentimes the inpatient 90833 gets rejected anyway. So you did all that work and get nothing out of it.

 

[Psychresy]

Probably couldn't do 90833 on every patient. But if you did it on 8 that's an extra 600 dollars a day x 5 x 48 = 144k/year for 2 hours a day.

That doesn't seem terrible.

 

[ObsequiousAplomb]

Probably couldn't do 90833 on every patient. But if you did it on 8 that's an extra 600 dollars a day x 5 x 48 = 144k/year for 2 hours a day.

That doesn't seem terrible.

So the other 6 hours are for the in-hospital care? Wouldn't you rather see 5-10 additional patients in that extra 2 hours, where you'd be more likely to actually collect the money than the 90833? Even if you did it and billed it for 8 patients, you might get anywhere from 0-8 of those paid. Probably closer to the 0. I know I would rather see more people, knowing that would pay more and would be more appropriate care.

 

[Psychresy]

So the other 6 hours are for the in-hospital care? Wouldn't you rather see 5-10 additional patients in that extra 2 hours, where you'd be more likely to actually collect the money than the 90833? Even if you did it and billed it for 8 patients, you might get anywhere from 0-8 of those paid. Probably closer to the 0. I know I would rather see more people, knowing that would pay more and would be more appropriate care.

Maybe it's geographic dependent? It's regularly paid for around here.

And it wouldn't be 6 other hours. Could probably get through the remainder in another 2.5 hours which would free up afternoon for clinic.

I think inpatient work makes sense if you are efficient and able to round and leave.

 

[SmallBird]

Providing therapy to inpatients can greatly improve their experience. It more than doubles the RVU from each encounter and if you document well I have never had reimbursement issues.

 

[psychmd03]

So the other 6 hours are for the in-hospital care? Wouldn't you rather see 5-10 additional patients in that extra 2 hours, where you'd be more likely to actually collect the money than the 90833? Even if you did it and billed it for 8 patients, you might get anywhere from 0-8 of those paid. Probably closer to the 0. I know I would rather see more people, knowing that would pay more and would be more appropriate care.

No I wouldn’t because for most payors 90833 pays more than a 99232 and if you’re billing. Ally of 99233s have fun with audits. Even if your documentation backs it up it’s still massive time sink. 90833s won’t trigger audits and they generally make more than a follow up so yes I’d rather do a few extra 90833s than more only follow ups.

 

[Mad Jack]

No I wouldn’t because for most payors 90833 pays more than a 99232 and if you’re billing. Ally of 99233s have fun with audits. Even if your documentation backs it up it’s still massive time sink. 90833s won’t trigger audits and they generally make more than a follow up so yes I’d rather do a few extra 90833s than more only follow ups.

You still need a progress note daily for the per diem facility fee to be collected with insurance in my area, so you would have to do a second code and either two notes or a combined note, significantly increasing your risk of audit or rejection

 

[psych_0]

I'm a full time, busy inpatient doc and have been for six years, and I bill 90833 every single day. I have been audited twice, and the only thing that I've ever gotten feedback on is 99233.

What feedback have you gotten about your 99233 codes?

 

[surfguy84]

Providing therapy to inpatients can greatly improve their experience. It more than doubles the RVU from each encounter and if you document well I have never had reimbursement issues.

A biller I am considering using was arguing against me doing a 90833. He states since there are therapists doing groups and so on, how can you make the case for the psychiatrist to also be doing therapy daily with an inpatient. Thoughts on that?

 

[splik]

A biller I am considering using was arguing against me doing a 90833. He states since there are therapists doing groups and so on, how can you make the case for the psychiatrist to also be doing therapy daily with an inpatient. Thoughts on that?

They don’t know what they are talking about. Groups are group therapy. Now if someone is also doing individual therapy with the pts and billing you probably won’t collect on therapy add on codes but you should still bill them if you are indeed providing that level of service. As long as you aren’t billing this for demented or acutely manic pts etc

ETA do not use this biller

 

[psychmd03]

A biller I am considering using was arguing against me doing a 90833. He states since there are therapists doing groups and so on, how can you make the case for the psychiatrist to also be doing therapy daily with an inpatient. Thoughts on that?

Group and individual therapy are massively different and every patient is not going to every group. Many do not like groups and many do not participate. They are completely different and you wont get denial of payment from that.

 

[forchinet121]

It's not that simple. The government has extracted settlements from psychiatrists for their employer's overbilling, despite the psychiatrist not being paid based on billing. Every doctor should know how to bill and put a CPT billing code in their inpatient note.

There are plenty of online resources to learn about billing codes and requirement. I used my free time in PGY-4 to read up and create my own templates that hit required billing codes.

Can you provide any evidence of this? You getting into trouble for over billing when you’re not the one doing the billing? That is interesting

 

[splik]

Can you provide any evidence of this? You getting into trouble for over billing when you’re not the one doing the billing? That is interesting

The government's perspective is that you are responsible for any billing done under your name.

 

[Psychresy]

Group and individual therapy are massively different and every patient is not going to every group. Many do not like groups and many do not participate. They are completely different and you wont get denial of payment from that.

So if I'm taking a job that is like 70/30 medicare vs private, would it be safe to assume I could generate $74 (99232) + $75 (90833) on all of my non-completely psychotic, manic, demented patients? I would imagine the private might pay a bit more.

With a patient load of 15 I have assumed there would be like 11 follow ups. 7 are amenable to therapy. 2 discharges, 2 admissions. Would these numbers make sense to you (assuming all medicare for simplicity)?

7 * 149 + 4 * 74 + 2 * 100 + 2 * 220 = $1,979 per day.

 

[psychmd03]

So if I'm taking a job that is like 70/30 medicare vs private, would it be safe to assume I could generate $74 (99232) + $75 (90833) on all of my non-completely psychotic, manic, demented patients? I would imagine the private might pay a bit more.

With a patient load of 15 I have assumed there would be like 11 follow ups. 7 are amenable to therapy. 2 discharges, 2 admissions. Would these numbers make sense to you (assuming all medicare for simplicity)?

7 * 149 + 4 * 74 + 2 * 100 + 2 * 220 = $1,979 per day.

That would be a solid estimate. Could shave maybe 15% just be extra conservative and account for any breakage. But your numbers are a solid guess.

 

[surfguy84]

How does an inpatient psych hospital make money? My understanding is that (may be wrong) for medicaid patients as an example, medicaid will pay a per diem rate each day the patient is hospitalized. Then, whatever billing is done by the doc, there is a facility fee on top of this. I'm imagining a private insurer to be something similar to this.

Is this understanding accurate?

 

[SpinDktr]

Inpatient treatment does have a per diem, but it will vary. I don't know all the details, but at least with Medicare the per diem is usually pretty good at first, but gradually goes down the longer a person is hospitalized. I think I looked at it a few years ago, from my memory it started at around $1500/day for a semi-private and $1800/day for private rooms; but again declines over time (Not sure where you can find updated numbers on this, and it might also vary depending on location).

Also, people are limited to I think around 180 days of inpatient treatment over their lifetimes which "incentivizes" hospitals to discharge them to a more stable long term situation, so sometimes chronically mentally ill patients aren't covered. Also, with Medicare and advantage plans, they will often times cut people's stay at a hospital if they feel a patient no longer requires inpatient level of services.

Still, this can end up being a profit maker for hospitals, but not the big bucks that surgical procedures brings in.

 

[surfguy84]

Inpatient treatment does have a per diem, but it will vary. I don't know all the details, but at least with Medicare the per diem is usually pretty good at first, but gradually goes down the longer a person is hospitalized. I think I looked at it a few years ago, from my memory it started at around $1500/day for a semi-private and $1800/day for private rooms; but again declines over time (Not sure where you can find updated numbers on this, and it might also vary depending on location).

Also, people are limited to I think around 180 days of inpatient treatment over their lifetimes which "incentivizes" hospitals to discharge them to a more stable long term situation, so sometimes chronically mentally ill patients aren't covered. Also, with Medicare and advantage plans, they will often times cut people's stay at a hospital if they feel a patient no longer requires inpatient level of services.

Still, this can end up being a profit maker for hospitals, but not the big bucks that surgical procedures brings in.

Thanks for the input. So I did some digging and it appears different hospitals have different rates if I interpreted the document I found correctly. As an example one hospital I may work at appears to get ~$850 per diem from Medicaid. Then they get the facility fee. So when I'm carrying 16 patients they are making at a minimum $13,600 per day before facility fees. In reality its higher than this since the medicaid population is roughly 40% of their payor mix. I'm trying to take these numbers into negotiations with them. So when I ask them for an extra $200 bucks per night of phone call or a bigger signing bonus I can be like, see I know you afford it!

 

[Sushirolls]

Private for profit hospitals are making their money on IP psych by barely staffing with RNs and almost entirely with MA like techs.
And expecting their physicians to see more than 10-12 people, but 15-20...

Large "non-profit" hospitals make their money showing their losses on the unit, to get grants or other tax breaks that can amount to millions. BUT the hospital will still complain we losing money, we can't afford XYZ, etc, despite the grants/or tax benefits derived from the losses actually surpass had they had better payer mix AND better collections. I've seen this in play at one former Big Box shop I worked at. If the psych unit didn't exist, and these benefits did exist, things would be actually be bad at the hospital.