Inpatient docs, it's 2023 with new rules, can we bill 99233 on complexity?

[nexus73]

We have new cpt code criteria. Based on the criteria I reviewed for 99233, looks like the two components that would practically apply to psych are:
1. Number and Complexity of Problems addressed.
2. Risk of Complications and/or Morbidity or Mortality of Patient Management

*3. Amount of Data Reviewed and Analyzed will likely never apply as we don't order labs/imaging etc.

You must meet 2 of the 3 above to be 99233.

For #1 you need either
1. One or more chronic illness with severe exacerbation (seems like this would be common for psych) OR
2. One acute or chronic illness that poses a threat to life or bodily function (If suicidal or gravely disabled it would pose a threat to life, and depending on definition of bodily function this could apply to many if not all psych condition--cognition is a bodily function, sleep is, concentration is, eating (appetite) is)

For #2 there are several options, but the only one that might apply to psych is:
1. Decision regarding hospitalization or escalation of hospital level care

Any thoughts on this last point and how it would or would not apply to a patient on inpatient psychiatry?

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[splik]

I think it is hard to meet 99233 if not based on time. It's going to be 99232 most of the time, some 99231s for the rocks. You can use 99233 if you are say treating a patient with lithium or clozapine and they are acutely manic, psychotic or depressed. I don't understand what you mean by not ordering labs though. You would need to be ordering and reviewing labs for 99233 for the meds used. If you have to transfer a patient to a medical service or ICU that would also count, but you might also just use the discharge codes.

 

[SmallBird]

I think it is hard to meet 99233 if not based on time. It's going to be 99232 most of the time, some 99231s for the rocks. You can use 99233 if you are say treating a patient with lithium or clozapine and they are acutely manic, psychotic or depressed. I don't understand what you mean by not ordering labs though. You would need to be ordering and reviewing labs for 99233 for the meds used. If you have to transfer a patient to a medical service or ICU that would also count, but you might also just use the discharge codes.

So one thing that I've taken away from the guidelines is that you don't necessarily have to prescribe lithium, you just have to discuss it. So if you have an acutely manic patient and you discuss options and you go with an atypical but to get there you reviewed the pros and cons of lithium, you can bill it. This helps because I talk about lithium more than I actually prescribe it.

 

[michaelrack]

For #2 there are several options, but the only one that might apply to psych is:
1. Decision regarding hospitalization or escalation of hospital level care

Any thoughts on this last point and how it would or would not apply to a patient on inpatient psychiatry?

For this last point, for a suicidial patient it might include putting on a higher level of precautions- going from q 15 minute checks to line of sight, and putting on suicide precautions for example.

 

[ObsequiousAplomb]

A related question I have been wondering about is how to consider the risk if I'm instructing someone to have guns removed from the home or I'm pursuing legal action to have the guns removed. In my mind this sounds like it's as high a risk for complications (if not higher than) a decision to hospitalize someone. Would others consider this a factor for high level MDM?

 

[Wheatbread]

We had meetings about this last week and I have ongoing talks with our coders. Column 3 on the MDM tool is what’s going to determine the code how I see it. Vast majority of our patients have a severe exacerbation of a chronic illness which will take care of Number/Complexity (column 1) for high. In talking with the billing folks, we can have a high risk (column 3) if we order a lab for specific med (lithium, etc) and/or the patient has a risk of morbidity from not receiving treatment. Again, for the vast majority of patients they are high risk from suicidal/psychosis, so that would put them in high risk category. There’s also a blurb about “social determinants of health” in the coding changes that can be used to justify high risk.

 

[nexus73]

I think it is hard to meet 99233 if not based on time. It's going to be 99232 most of the time, some 99231s for the rocks. You can use 99233 if you are say treating a patient with lithium or clozapine and they are acutely manic, psychotic or depressed. I don't understand what you mean by not ordering labs though. You would need to be ordering and reviewing labs for 99233 for the meds used. If you have to transfer a patient to a medical service or ICU that would also count, but you might also just use the discharge codes.

i was being unclear, we don’t order enough labs or other tests, especially not tests we’re discussing with another doctor, typically to qualify for the complexity arm. It’s more trouble than it’s worth.

 

[nexus73]

Revisiting this old thread to hear about any updates on what clinical situations inpatient docs are able to bill 99233 follow-ups based on complexity. The risks of patient management language for reference:

High risk of morbidity from additional diagnostic testing or treatment

Examples only:

• Drug therapy requiring intensive monitoring for toxicity•
• Decision regarding elective major surgery with identified patient or procedure risk factors•
• Decision regarding emergency major surgery•
• Decision regarding hospitalization or escalation of hospital-level care•
• Decision not to resuscitate or to de-escalate care because of poor prognosis•
• Parenteral controlled substances

At our hospital we satisfy criteria for 99232 on pretty much all patients every day. For 99233, our hospital coders seem okay with 99233 if we are ordering and/or reviewing labs for clozapine/lithium/depakote/tegretrol, but not for days in between labs. Also on day of court ordered commitment if we comment on need for escalation of hospital care (i.e., needing transfer to state hospital), but only one day not subsequent hospital days. I haven't used parenteral controlled substances as of yet, but assume a patient needing IM benzo would qualify. Also, curious what people's thoughts are for patients receiving ECT. It is a more invasive treatment, but known to be extremely safe, so not sure if this would qualify. Other scenarios for 99233 on complexity?

 

[michaelrack]

Decision regarding hospitalization or escalation of hospital-level care•

What about de-escalation. For me, changing someone from q15 to q 5 minute checks because they have become suicidal is an easy decision. Changing back to q15 checks is a more complex decision.

 

[psych_0]

We met with our billers and have been using almost 99233 exclusively, except in rare cases. I have not seen an official explanation of "Decision regarding hospitalization or escalation of hospital-level care." In my opinion, I make that decision every day regarding whether or not the hospital is the least restrictive environment for someone. All 5 other inpatient docs in my group bill the same way.

 

[Stagg737]

At our hospital we satisfy criteria for 99232 on pretty much all patients every day. For 99233, our hospital coders seem okay with 99233 if we are ordering and/or reviewing labs for clozapine/lithium/depakote/tegretrol, but not for days in between labs. Also on day of court ordered commitment if we comment on need for escalation of hospital care (i.e., needing transfer to state hospital), but only one day not subsequent hospital days. I haven't used parenteral controlled substances as of yet, but assume a patient needing IM benzo would qualify. Also, curious what people's thoughts are for patients receiving ECT. It is a more invasive treatment, but known to be extremely safe, so not sure if this would qualify. Other scenarios for 99233 on complexity?

This is incorrect. If they're taking a med requiring intensive monitoring, that counts regardless of if you're ordering labs that day. I've heard both irl and on SDN that "high intensity monitoring" means labs every 3 months or less. Clozapine always does in the US. Lithium usually will while inpatient too unless they're at a long-term unit and admitted for at least several months.

Depakote and Tegretol may count inpatient since you're monitoring while titrating up, thus needing labs more frequently than 3 months, but once outpatient I've been told it doesn't count since you're probably not getting labs that frequently. Same for lithium. I'll bill 99215 outpt if we increase lithium and require a lab in 5 days, but for patients stable on lithium only needing labs every 6 months or more it doesn't meet criteria anymore.

Like psych-0 said, while inpatient you're deciding every day if they require hospitalization. If you're documenting that decision, then you can bill for high complexity.

In my state ECT is considered a major procedure/psychosurgery so we bill as if it does hit 99233 criteria for that category.

 

[comp1]

Decision regarding hospitalization seems like something you should be doing every day of an admission. I suppose if you have an absolute rock in which no decision making is happening, maybe you would code less? It seems though that the large majority of cases should be 99233 if that's a criteria...

 

[calvnandhobbs68]

Like psych-0 said, while inpatient you're deciding every day if they require hospitalization. If you're documenting that decision, then you can bill for high complexity.

Decision regarding hospitalization seems like something you should be doing every day of an admission. I suppose if you have an absolute rock in which no decision making is happening, maybe you would code less? It seems though that the large majority of cases should be 99233 if that's a criteria...

I'd probably just see what your hospital coders/billing department says about this though. Remember these codes apply to every speciality, not just psychiatry. Sure, if your hospitalist group is billing 90%+ 99233s because they're saying they're making "decisions regarding hospitalization" every day besides the social admits/placements they're waiting to discharge, won't look like much of an anomaly. However, if all other specialities are billing significantly lower codes percentages and the psych inpatient unit is billing 99233s all day, there's probably going to be a problem there.

 

[Stagg737]

I'd probably just see what your hospital coders/billing department says about this though. Remember these codes apply to every speciality, not just psychiatry. Sure, if your hospitalist group is billing 90%+ 99233s because they're saying they're making "decisions regarding hospitalization" every day besides the social admits/placements they're waiting to discharge, won't look like much of an anomaly. However, if all other specialities are billing significantly lower codes percentages and the psych inpatient unit is billing 99233s all day, there's probably going to be a problem there.

Not really. I'm inpatient consults, so I write notes alongside the primary hospitalists and other specialties. Documenting if patient requires transfer to psych once medically stable or if it's recommended vs recommending discharge should count. It all really depends on how you document and justify your decision making. Inpatient psych in general is so different from inpatient medicine that Idk that it matters if you're doing something significantly different from hospitalists. That being said, I wouldn't bill 99233 just because we're not discharging someone. I document why I'm making that decision or why it's relevant (ex "patient requires ongoing hospitalization d/t continuing psychosis with SI and has ongoing increased risk of harming/killing self if discharged at this time").

Biggest issue I run into is medicine getting annoyed that patients have to continue medical admission d/t ongoing psych concerns when we aren't able to transfer them to psych right away.

 

[calvnandhobbs68]

Not really. I'm inpatient consults, so I write notes alongside the primary hospitalists and other specialties. Documenting if patient requires transfer to psych once medically stable or if it's recommended vs recommending discharge should count. It all really depends on how you document and justify your decision making. Inpatient psych in general is so different from inpatient medicine that Idk that it matters if you're doing something significantly different from hospitalists. That being said, I wouldn't bill 99233 just because we're not discharging someone. I document why I'm making that decision or why it's relevant (ex "patient requires ongoing hospitalization d/t continuing psychosis with SI and has ongoing increased risk of harming/killing self if discharged at this time").

Biggest issue I run into is medicine getting annoyed that patients have to continue medical admission d/t ongoing psych concerns when we aren't able to transfer them to psych right away.

Got it I wasn't really thinking of consults, it's probably easier to argue you're actually "deciding" whether to hospitalize someone or not on consults if you're documenting decision making and recommending admission vs not even if you've been seeing them for multiple days in a row.

I was thinking along the lines of people trying to make every psych inpatient a 99233. I honestly don't think that would fly or else again the vast majority of patients in the hospital overall are going to qualify as 99233 given many of them are going to have "one acute or chronic illness that poses a threat to life or bodily function". So if for instance the coders are going to say you can't bill a 99233 every day for an inpatient with cellulitis in for IV antibiotics it's going to be hard to say you can bill a 99233 every day for a psych inpatient with SI you're starting on Zoloft.

 

[psych_0]

Got it I wasn't really thinking of consults, it's probably easier to argue you're actually "deciding" whether to hospitalize someone or not on consults if you're documenting decision making and recommending admission vs not even if you've been seeing them for multiple days in a row.

I was thinking along the lines of people trying to make every psych inpatient a 99233. I honestly don't think that would fly or else again the vast majority of patients in the hospital overall are going to qualify as 99233 given many of them are going to have "one acute or chronic illness that poses a threat to life or bodily function". So if for instance the coders are going to say you can't bill a 99233 every day for an inpatient with cellulitis in for IV antibiotics it's going to be hard to say you can bill a 99233 every day for a psych inpatient with SI you're starting on Zoloft.

I have run into zero issues with billing 99233 for 98% of follow-ups over the last 2-3 years at this point. All of my colleagues bill the same way. Granted, my average length of stay is ~48 hours so I am genuinely deciding stay vs discharge every day and documenting reasons why.

My contract also stipulates that I get paid an wRVU bonus on what is billed, not collected. So even if I lose a peer-to-peer case for a placement type case, the hospital still pays out the wRVUs I have billed. Granted, I do try to argue as hard as I can to get days covered, but there are rare occasions when I get denied because that patient is truly just there for placement.

 

[michaelrack]

it's going to be hard to say you can bill a 99233 every day for a psych inpatient with SI you're starting on Zoloft.

Not if it's a teenager and you document you called the guardian to discuss the Blackbox si warning