Inpatient RVUs?

[samac]

Does anyone have a guide for inpatient billing?
Wasn’t included in my residency, just outpatient and I’m starting an attending job next year and want to make sure I bill appropriately to get that $$$.

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[comp1]

See attachment. 99238 for discharge day if you spent 30 minutes or less on discharge and 99239 if you spent more than 30 minutes. These are all inclusive codes. It's all boring compared to the weirdness of outpatient.

 

[samac]

See attachment. 99238 for discharge day if you spent 30 minutes or less on discharge and 99239 if you spent more than 30 minutes. These are all inclusive codes. It's all boring compared to the weirdness of outpatient.

As far as what qualifies for moderate is it similar to outpatient as far a chronic condition with exacerbation

 

[comp1]

I would really recommend basing it more on time. Remember that ALL medical specialties use these same exact codes inpatient. But if you want to get into the finer grained details, you can review it here: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

 

[mistafab]

Does anyone get pushback adding on a 90832 for multiple days in a row of supportive psychotherapy? I.e. borderline gets admitted with self harm behaviors. 99232 + 90832 working on reducing polypharm and reducing maladaptive behaviors for like 4 days. Does Medicaid or others actually pay for this?

 

[splik]

Do you mean 90833? 90832 is not an add on code it’s a standalone therapy code. You can use add on codes if you are actually providing some kind of therapeutic interventions and actually spending time with pts, documenting appropriately and they can benefit (ie don’t use for acutely manic or demented pts). Whether Medicaid pays for it is state dependent. Where I am Medicaid never pays for therapy add on codes in any setting but I think that is unusual.

 

[comp1]

I don't think it's unusual. When I said all inclusive, I'm pretty sure it's right not to pay inpatient. I haven't seen add ons to inpatient codes.

 

[Sushirolls]

A Big Box shop I used to work at, the Med Dir would drop therapy add on with IP all the time, and even on C/L patients.

However, after I had submitted my resignation I observed this code put on a patient we'd been seeing for delirium. First non-moonlighting, "real job" post residency. Had I stuck around and observed that on more occasions I would have considered addressing directly with Med Dir or reporting to some one. Didn't fully sink until career progressed and learned more with more jobs. But with only that one stand out to my memory, may have simply been an honest mistake, would need to see the clear pattern of bad.

But to answer the question, you can drop therapy add on with any setting, just make sure what's in your note is justifiable.

 

[Stagg737]

I would really recommend basing it more on time. Remember that ALL medical specialties use these same exact codes inpatient. But if you want to get into the finer grained details, you can review it here: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

Disagree with the bolded. Many inpatient psych patient easily hit 99233 criteria but can be done in 20 minutes (manic without insight, severe/acute psychosis, severe depression, catatonia, etc). Going mostly based on time is going to undercode a lot of 99233's which is a 0.8 wRVU difference (from 99232) every time it's done. Can make a difference of hundreds or even thousands of wRVUs annually.

 

[nexus73]

I've had severely depressed patients who weren't progressing inpatient, then started doing some basic therapy with them and they turned the corner fairly quickly.

 

[samac]

Disagree with the bolded. Many inpatient psych patient easily hit 99233 criteria but can be done in 20 minutes (manic without insight, severe/acute psychosis, severe depression, catatonia, etc). Going mostly based on time is going to undercode a lot of 99233's which is a 0.8 wRVU difference (from 99232) every time it's done. Can make a difference of hundreds or even thousands of wRVUs annually.

This is what I was thinking and why I asked the question, severely ill patients that don’t get actual benefits from spending more than 10-15 minutes with them it definitely seems like billing based on MDM side would be the way to go, but as it falls to psych on inpatient feels less clearly defined to me?

 

[psych_0]

See attachment. 99238 for discharge day if you spent 30 minutes or less on discharge and 99239 if you spent more than 30 minutes. These are all inclusive codes. It's all boring compared to the weirdness of outpatient.

Idk where this image comes from but I have never billed a 99223 for an intake on inpatient. I use 90792 and I see no reason why you would not. It's the highest wRVU code available to us (4.16) and can be used multiple days a month/week on frequent fliers.

 

[SmallBird]

I would really recommend basing it more on time. Remember that ALL medical specialties use these same exact codes inpatient. But if you want to get into the finer grained details, you can review it here: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

That would be a terrible strategy for me. Sometimes patients with very complex med regimens need brief check-ins, particularly if they are highly agitated or psychotic. And for less acute patients, my strategy was to spend around 25 minutes with them, but most of that was therapy, after which I have most of the clinical data I need for the E and M and could bill and add-on.

 

[samac]

Idk where this image comes from but I have never billed a 99223 for an intake on inpatient. I use 90792 and I see no reason why you would not. It's the highest wRVU code available to us (4.16) and can be used multiple days a month/week on frequent fliers.

Oh I didn’t know that could be used for an H&P inpatient!

 

[Stagg737]

Oh I didn’t know that could be used for an H&P inpatient!

It can be used in any setting for a new eval. New eval can include ER visits on back to back days.

 

[psych_0]

It can be used in any setting for a new eval. New eval can include ER visits on back to back days.

I didn't think it could be used in the ER if they end up being admitted. That would mean a 90792 in the ER day 1 and the 90792 the next morning on inpatient. I don't believe that works.

 

[nexus73]

I didn't think it could be used in the ER if they end up being admitted. That would mean a 90792 in the ER day 1 and the 90792 the next morning on inpatient. I don't believe that works.

At our hospital the ED 90792 is the admit billing code and first day on unit is a follow up. Not everyone gets seen by psych in the ED though so where end when the admit code is billed varies.

 

[samac]

I didn't think it could be used in the ER if they end up being admitted. That would mean a 90792 in the ER day 1 and the 90792 the next morning on inpatient. I don't believe that works.

At our hospital the ED 90792 is the admit billing code and first day on unit is a follow up. Not everyone gets seen by psych in the ED though so where end when the admit code is billed varies.

So our hospital writes a consult note and then an H&P the next day because we can’t bill for resident notes, so the H&P is the first one billed.
Is this typical?
If an NP sees them and writes a consult at 2pm one day and then on the actual unit is an H&P is that problematic?
Just trying to learn the things that weren’t taught in residency lol

 

[psych_0]

At our hospital the ED 90792 is the admit billing code and first day on unit is a follow up. Not everyone gets seen by psych in the ED though so where end when the admit code is billed varies.

We use 99223 in the ED, then 90792 the next day on the inpatient unit.

 

[Stagg737]

We use 99223 in the ED, then 90792 the next day on the inpatient unit.

We do it the opposite if I see them in the ER. I do the 90792 in the ER and I believe the inpatient docs then does a 99223 the next day (not 100% sure what codes they use though). Not everyone I see in the ER and recommend inpatient admission gets accepted to our inpatient unit (depending on bed availability, behavior on previous admissions, current acuity, or invol status) and sometimes sit in the ER for days before getting admitted somewhere. I can't bill a 99223 for day 1 ER if they're not admitted right away since my ER "follow-up" notes are outpatient codes since the ER is technically an outpatient setting.

 

[psych_0]

We do it the opposite if I see them in the ER. I do the 90792 in the ER and I believe the inpatient docs then does a 99223 the next day (not 100% sure what codes they use though). Not everyone I see in the ER and recommend inpatient admission gets accepted to our inpatient unit (depending on bed availability, behavior on previous admissions, current acuity, or invol status) and sometimes sit in the ER for days before getting admitted somewhere. I can't bill a 99223 for day 1 ER if they're not admitted right away since my ER "follow-up" notes are outpatient codes since the ER is technically an outpatient setting.

Yea this would be a huge fight at our hospital. Us inpatient folks would not be OK giving up 90792's to the ER psych team lol.

 

[Stagg737]

Yea this would be a huge fight at our hospital. Us inpatient folks would not be OK giving up 90792's to the ER psych team lol.

Do you accept pretty much everyone that the ER psych docs say needs admission though? (Or just eval the ER patients yourselves?)

Where I'm at inpatient docs turn a significant number of recommended admissions away. So it would kind of hypocritical for them to demand we not use 90792s and then decline half the people we say need admission (since they do not accept any involuntary patients and turn down many voluntary admits).

 

[psych_0]

Do you accept pretty much everyone that the ER psych docs say needs admission though? (Or just eval the ER patients yourselves?)

Where I'm at inpatient docs turn a significant number of recommended admissions away. So it would kind of hypocritical for them to demand we not use 90792s and then decline half the people we say need admission (since they do not accept any involuntary patients and turn down many voluntary admits).

We only turn down dementia admits and autism/ID admits.

ER psych will see every patient and usually only admit ~30-35% of them to inpatient. Probably 75% of the admissions that actually arrive to our inpatient unit are involuntary.

I'm not sure what code they use for ER patients that they send home.