Minimum time to code based on MDM?

[Coriolanus]

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So I am doing some quick back of envelope calculations, considering making the jump into telepsych-heavy private practice accepting commercial insurance and Medicare, and I have the following question. Is there a minimum time I a required to spend "face to face" (screen to screen) with a patient if I am coding, say, a 99214 based on MDM?

Of course I know the time limits apply if you are coding based on time, but let's say hypothetically I spend 7 minutes face to face with a patient for a follow-up of anxiety and depression (2 stable problems), who is being prescribed Lexapro and needs refills (i.e. "moderate" complexity, taking psych meds). Could I code this patient 99214?

 

[Stagg737]

You bill based on MDM OR time. If you take 5 minutes to see a 99214 that meets criteria and is properly documented, then you bill 99214. Time doesn’t matter. I rarely bill based on time, and pretty much only when a patient takes up a lot of time for whatever reason but MDM would be a lower code.

If you’re billing 99214 six+ times per hour, you’re setting yourself up for an audit, but it is possible to do.

 

[Coriolanus]

You bill based on MDM OR time. If you take 5 minutes to see a 99214 that meets criteria and is properly documented, then you bill 99214. Time doesn’t matter. I rarely bill based on time, and pretty much only when a patient takes up a lot of time for whatever reason but MDM would be a lower code.

If you’re billing 99214 six+ times per hour, you’re setting yourself up for an audit, but it is possible to do.

Thanks that is super helpful. And just to be sure, what you are saying applies both to commercial insurance AND Medicare? I have been doing some locums telepsych work with a group of community clinics, and during a recent meeting our medical director was under the impression that Medicare may have such a requirement, even if coding based on MDM.

 

[calvnandhobbs68]

Thanks that is super helpful. And just to be sure, what you are saying applies both to commercial insurance AND Medicare? I have been doing some locums telepsych work with a group of community clinics, and during a recent meeting our medical director was under the impression that Medicare may have such a requirement, even if coding based on MDM.

Not to my knowledge. Like stagg said you can code either/or if billing purely E+M codes. So you could see a patient for 5 minutes if you want but one would probably question exactly how complex your MDM truly is if you’re seeing 10 “moderate” complexity patients an hour (but there’s no rule against it technically).

Now where this matters is with psychotherapy add ons. Most commercial insurers want you to separate out psychotherapy time from E+M time and you can only do E+M based on complexity with psychotherapy add ons (even though we know this is all BS…). So for instance when I do this I put:
Total face to face time start: 9:30
Total face to face time stop: 10:00
Psychotherapy time start: 9:30
Psychotherapy time stop: 9:47

 

[webpharoh]

Not to my knowledge. Like stagg said you can code either/or if billing purely E+M codes. So you could see a patient for 5 minutes if you want but one would probably question exactly how complex your MDM truly is if you’re seeing 10 “moderate” complexity patients an hour (but there’s no rule against it technically).

Now where this matters is with psychotherapy add ons. Most commercial insurers want you to separate out psychotherapy time from E+M time and you can only do E+M based on complexity with psychotherapy add ons (even though we know this is all BS…). So for instance when I do this I put:
Total face to face time start: 9:30
Total face to face time stop: 10:00
Psychotherapy time start: 9:30
Psychotherapy time stop: 9:47

Hi,

I’m planning to see five patients in an hour for 99214 is that unreasonable.

Usually what happens is these are the follow up patients that are stable with two or three conditions and I see them every two or three months. Then I of the five patients one of them will be a little bit difficult. I’m just wondering if insurances will audit me or not. My notes would have a good discussion is it

 

[splik]

Hi,

I’m planning to see five patients in an hour for 99214 is that unreasonable.

Usually what happens is these are the follow up patients that are stable with two or three conditions and I see them every two or three months. Then I of the five patients one of them will be a little bit difficult. I’m just wondering if insurances will audit me or not. My notes would have a good discussion is it

This would be atypical for psych. It's not unheard of in primary care. Obviously if you are billing 99214 across the board with a high volume, you are more likely to be flagged for audit. Being audited in itself is not an issue (it is an occupational hazard if you accept insurance or have pts using OON benefits). Being able to survive and justifying your medical decision making is the issue. You would have to be scheduling pts for basically 10 min appts for this to work. The quality of are you are providing would rightly be questioned. Most commonly what I see is psychiatrists not documenting appropriately to justify 99214.

 

[ObsequiousAplomb]

This would be atypical for psych. It's not unheard of in primary care. Obviously if you are billing 99214 across the board with a high volume, you are more likely to be flagged for audit. Being audited in itself is not an issue (it is an occupational hazard if you accept insurance or have pts using OON benefits). Being able to survive and justifying your medical decision making is the issue. You would have to be scheduling pts for basically 10 min appts for this to work. The quality of are you are providing would rightly be questioned. Most commonly what I see is psychiatrists not documenting appropriately to justify 99214.

I mean, isn't it really easy to code for a 99214 with the current guidelines?
ex for GAD/MDD follow-up in a stable patient:

cc: follow up for depressed mood and anxiety

subjective:
Mr/Ms. X reports that overall mood has been {mood}. {comment on anhedonia/energy/sleep/appetite/concentration}.
Overall level of anxiety has been {adjective}. {comment on nervousness/tension/muscle aches/fatigue}.
{Comment on social event or recent holiday and patient response relevant to diagnosis}.
{No obsessions/compulsions/AH/VH/SI/HI}.

{PMH/FMH/PPH/FPH/SH, typically copy-forwarded from previous note, though not exactly necessary}
{Medications, though not entirely necessary to list all medications they are taking from various providers, but a good practice}

MSE: just hit a few categories, not hard to mention appearance, mood, affect, speech, thought content/process, perceptions, judgement

Assessment:
1. GAD: {stable/unstable; improving/unchanged/worsening}
2. MDD: {stable/unstable; improving/unchanged/worsening}

Plan:
Refill {Drug dose quantity}
{Safety plan template}
{RBA / informed consent template}

If you want to add in a 90833:
{Start Time, Stop Time, Total therapy time}
{Type of therapy}
{Specific Goals of therapy}
{Techniques used from that therapy}

 

[splik]

I mean, isn't it really easy to code for a 99214 with the current guidelines?
ex for GAD/MDD follow-up in a stable patient:

cc: follow up for depressed mood and anxiety

subjective:
Mr/Ms. X reports that overall mood has been {mood}. {comment on anhedonia/energy/sleep/appetite/concentration}.
Overall level of anxiety has been {adjective}. {comment on nervousness/tension/muscle aches/fatigue}.
{Comment on social event or recent holiday and patient response relevant to diagnosis}.
{No obsessions/compulsions/AH/VH/SI/HI}.

{PMH/FMH/PPH/FPH/SH, typically copy-forwarded from previous note, though not exactly necessary}
{Medications, though not entirely necessary to list all medications they are taking from various providers, but a good practice}

MSE: just hit a few categories, not hard to mention appearance, mood, affect, speech, thought content/process, perceptions, judgement

Assessment:
1. GAD: {stable/unstable; improving/unchanged/worsening}
2. MDD: {stable/unstable; improving/unchanged/worsening}

Plan:
Refill {Drug dose quantity}
{Safety plan template}
{RBA / informed consent template}

If you want to add in a 90833:
{Start Time, Stop Time, Total therapy time}
{Type of therapy}
{Specific Goals of therapy}
{Techniques used from that therapy}

This template is not sufficient for 99214

 

[ObsequiousAplomb]

Really? It covers two chronic conditions and moderate complexity medical decision making.

 

[clausewitz2]

Really? It covers two chronic conditions and moderate complexity medical decision making.

Where is the decision making part?

 

[Candidate2017]

Where is the decision making part?

The explicit intent of the new coding criteria is to "reduce documentation burden." But psychiatrists being psychiatrists, are loathe to abandon their schema of longer note = better care, doing something, and magical amulet against medmal lawyers.

MDM is Problems, Data, and Risk. 2 of those 3 must be met. That’s all. Two problems (not necessarily diagnoses) will meet criteria for Problems. Refilling/prescribing (or social issues that affect diagnosis/treatment) meets criteria for Risk.

Nothing else is required, including past history or review of systems. The note, for insurance purposes, could literally be: MDD, GAD, Prozac. Though not advisable.

I'm happy with the revised coding criteria because it actually gets to the core of our job: diagnose mental illness, consider social determinants that affect outcomes, prescribe meds +/- therapy.

aafp.org has good examples. Our FM friends can teach us a thing or two about level 3 vs level 4.

 

[Merovinge]

This template is not sufficient for 99214

Can you explain further. One of the docs at my last job saw thousands of patients for 10 min slots using exactly that style of documentation and never had any issues over several years from my understanding. It's actually uncanny how similar his notes were to that template listed above.

 

[splik]

Really? It covers two chronic conditions and moderate complexity medical decision making.

It does neither

 

[clausewitz2]

The explicit intent of the new coding criteria is to "reduce documentation burden." But psychiatrists being psychiatrists, are loathe to abandon their schema of longer note = better care, doing something, and magical amulet against medmal lawyers.

I am under no illusions that word count correlates with better or more legally secure treatment.

MDM is Problems, Data, and Risk. 2 of those 3 must be met. That’s all. Two problems (not necessarily diagnoses) will meet criteria for Problems. Refilling/prescribing (or social issues that affect diagnosis/treatment) meets criteria for Risk.

Agree with you about the problems in this template. Based on the guidelines document from the AMA it seems like Risk is met by showing some indication that you are making a decision or somehow taking into account the morbidity from treatment. The template above doesn't show any evidence of that, just a note that the existing treatment is continuing without a gesture at explanation.

similarly, where in the template above is there any indication of diagnosis or treatment being "significantly limited" (the actual language) by social determinants of health ?

Nothing else is required, including past history or review of systems.

Yes, I am aware.

The note, for insurance purposes, could literally be: MDD, GAD, Prozac. Though not advisable.

Listing diagnoses is not demonstrating that you addressed those problems in any way in the visit. You can't just note that someone has OSA and have it count if you don't document anything about their sleep and aren't providing CPAP or anything else in particular (or provide some statement as to why you are not doing it).

I'm happy with the revised coding criteria because it actually gets to the core of our job: diagnose mental illness, consider social determinants that affect outcomes, prescribe meds +/- therapy.

aafp.org has good examples. Our FM friends can teach us a thing or two about level 3 vs level 4.

Splik of course will have his own opinions about this but I do think it is going to be hard to justify meeting the current criteria without providing a touch more detail. I don't think you'd have to add very much, but you do need to make it clear in what way your treatment plan was responsive to the factors above. Not a novel, but a couple sentences for sure.

 

[ObsequiousAplomb]

So even though the assessment does clearly say whether the response is adequate, the patient is or isn't improving, you think I should say explicitly "the medication being prescribed is to maintain the stability of the two chronic stable conditions" or something to that effect, to make it clear that I'm making a decision?

The HPI clearly is addressing the symptoms of the two problems and social aspects of the problem. If social issues arise in the HPI, it makes sense to make a statement a the end (e.g. provided coupon or sample or recommended goodRx or sent new Rx to pharmacy with lower price if the patient says they missed doses due to cost following a reduction in work hours).

The plan, to me at least, is clear enough already. Prescribing a medication implies that a decision was made to prescribe. Documenting a discussion of the risks, benefits, and alternatives also makes this clear, at least to me. I could see how someone disagrees with this.

I've yet to see notes from another psychiatrist who was billing level 4s with the current guidelines who even approach the level of detail in that template (which, admittedly, is less detail than my notes typically include). They almost never explicitly cover the symptoms of the disorder. They usually don't comment on stability or instability. They usually use less specific icd-10 codes like "depressive disorder" to describe any mood disorder, including ones they're treating with two antipsychotics, two anticonvulsants, an SSRI, and a PRN med. Based on my reading of the guidelines you can even say insomnia and depressive disorder as two separate problems (especially when treated by a sedating antidepressant or an add-on low dose sedating antidepressant) and it's kosher.

The fact that everyone else seems to be doing just fine documenting much less than the above template tells me that the actual requirements must be lower than the template. I also get that impression from having read the CMS guidelines, APA guidelines, AMA guidelines, AFP guidelines, and the various articles written by coding companies.

 

[Stagg737]

Really? It covers two chronic conditions and moderate complexity medical decision making.

MDD is not necessarily chronic if it's MDD, single episode, mild and the episode was 2 years ago. You either need to be explicit that the conditions are chronic, or that one is chronic with an exacerbation. You probably wouldn't get dinged for it, but technically just saying MDD isn't adequate even if you're saying stable/unstable or improving/unchanged.

The plan, to me at least, is clear enough already. Prescribing a medication implies that a decision was made to prescribe.

Yes, and again you probably wouldn't get dinged, but you're not really providing any info regarding that decision-making other than you prescribed. I always put the reason and what the med is specifically treating. For example: Prozac 40mg daily for MDD and GAD. It's not much, but it specifically identifies what I'm prescribing the med for. That also may not technically be enough, but given the rest of my note and that I do include a couple of sentences of assessment I doubt I'll have issues in terms of meeting criteria.

 

[FlowRate]

This is how our organization wants us to document chronic medical conditions and seems to be what some people ITT are getting at w/r/t showing you're actually addressing things in your visit:

•T.O.F.U. is a mnemonic that identifies what is considered quality documentation in your Assessment/Plan.
•T.O.F.U. stands for:
Treatment – Hyperlipidemia: continue statin
•OR
Observation – A.Fib: rate controlled with pacemaker
•OR
Follow-Up – DM2: recheck HgA1c in 3 months

•Note: To meet the T.O.F.U. standard of quality documentation and depending on the diagnosis, you do not need to document the treatment AND Observation AND follow-up.

Seems like a good way of thinking about it is to use verbs to describe what you did regarding the diagnosis (recommended, verified, ensured, discussed, planned).

My usual style has diagnoses listed separate from narrative assessment and summary/bulleted plan which I guess doesn't as directly show individual problem-based decision making.

 

[ObsequiousAplomb]

MDD is not necessarily chronic if it's MDD, single episode, mild and the episode was 2 years ago. You either need to be explicit that the conditions are chronic, or that one is chronic with an exacerbation. You probably wouldn't get dinged for it, but technically just saying MDD isn't adequate even if you're saying stable/unstable or improving/unchanged.


Yes, and again you probably wouldn't get dinged, but you're not really providing any info regarding that decision-making other than you prescribed. I always put the reason and what the med is specifically treating. For example: Prozac 40mg daily for MDD and GAD. It's not much, but it specifically identifies what I'm prescribing the med for. That also may not technically be enough, but given the rest of my note and that I do include a couple of sentences of assessment I doubt I'll have issues in terms of meeting criteria.

You're right, those are valid points. Admittedly, in the template I actually use it forces me to put start/refill/continue/stop before the med, and the plan does line up to each problem in the way you're saying.

For each problem it does require a comment of stable/unstable/improving/worsening/needs improvement. Since the EHR does encourage me to put the full specifiers for MDD when selecting the icd-10, I do that and hadn't really thought about single episode mild depression. Usually that is something I would code as a level 3, but I so rarely see something that simple.

 

[justordinary]

You bill based on MDM OR time. If you take 5 minutes to see a 99214 that meets criteria and is properly documented, then you bill 99214. Time doesn’t matter. I rarely bill based on time, and pretty much only when a patient takes up a lot of time for whatever reason but MDM would be a lower code.

If you’re billing 99214 six+ times per hour, you’re setting yourself up for an audit, but it is possible to do.

If time doesn't matter to bill 99214, then why is it that some say you can't bill 99214 + 90833 for a 20min follow-up visit? I've been told that you have to justify making a mdm of 99214 in 4 minutes (since 20min visit minus 16min psychotherapy leaves you with 4min to do mdm... which I find doesn't make sense if they do not take "time" into account) or even a 99204 + 90838 for a 60min new evaluation...?? it's very confusing.....

 

[calvnandhobbs68]

If time doesn't matter to bill 99214, then why is it that some say you can't bill 99214 + 90833 for a 20min follow-up visit? I've been told that you have to justify making a mdm of 99214 in 4 minutes (since 20min visit minus 16min psychotherapy leaves you with 4min to do mdm... which I find doesn't make sense if they do not take "time" into account) or even a 99204 + 90838 for a 60min new evaluation...?? it's very confusing.....

You keep asking these questions, you probably just need to do something like this.

The Psychiatry E/M Coding Curriculum

You're just very confused on what this all means and you're having trouble differentiating E+M from psychotherapy. Technically you are stating that you provided TWO SEPARATE services but time is only the controlling factor for the PSYCHOTHERAPY service while complexity is the controlling factor for the E+M service. So, for instance, you couldn't have a 46 minute long visit and call it 30min E+M for a 99214 and 16min psychotherapy for a 90833. But you also would need to justify in an audit that you completed all your E+M medical decision making in whatever time you had leftover in an appointment time after you subtract out the time for psychotherapy.

So, for instance, if you had a 30min appointment and stated 18 minutes of this was spent doing psychotherapy, even if you do not state it that means that the remaining 12 minutes were spent in E+M medical decision making. Is it realistic that you could go over GAD and ADHD sx in 12 minutes and refill prozac and concerta (2 chronic conditions with medication management= 99214)? Sure. Is it realistic that you could do this 4 minutes? You decide.

 

[FN9]

I think people are overthinking these time guidelines, when you do so called 16-30 min of therapy, its not psychoanalysis, you are probably doing therapy while gathering info for E&M portion of your appointment unintentionally, pt is talking about their symptoms, stressors, also you may have a 20 min follow up scheduled, finish the pt with 99214+90833 but then do the next one 99214 or 99213 in 10-15 minutes, so it evens out.

if you schedule 24 patients for an 8 hour schedule thinking they will all take 20 min each, in reality you will put in 10-12 hours to cover all the 99214+90833 notes and details. What happens in reality for 20 minute slots ( 3 per hour) is 2 patients will qualify for 99213/99214+90833 and the third would be a straight 99213 or 99214 that takes a few minutes. There is also how efficient a person is with their EHR.

 

[calvnandhobbs68]

I think people are overthinking these time guidelines, when you do so called 16-30 min of therapy, its not psychoanalysis, you are probably doing therapy while gathering info for E&M portion of your appointment unintentionally, pt is talking about their symptoms, stressors, also you may have a 20 min follow up scheduled, finish the pt with 99214+90833 but then do the next one 99214 or 99213 in 10-15 minutes, so it evens out.

if you schedule 24 patients for an 8 hour schedule thinking they will all take 20 min each, in reality you will put in 10-12 hours to cover all the 99214+90833 notes and details. What happens in reality for 20 minute slots ( 3 per hour) is 2 patients will qualify for 99213/99214+90833 and the third would be a straight 99213 or 99214 that takes a few minutes. There is also how efficient a person is with their EHR.

Yeah but that’s not how you document it. It needs to be documented the way I outlined it for private insurers generally. You’re correct in that the APA has made it clear that the spirit of these codes was to incentivize psychiatrists spending time with patients and utilizing psychotherapeutic techniques within the context of the larger visit but insurers want this separated into two separate blocks since they consider this as providing two “separate” services in the same encounter.

I’ve seen people get burned for not documenting start and end times for psychotherapy, if you look in the billing handbook for your contracted insurance companies they probably require this (mine do).

 

[justordinary]

I think people are overthinking these time guidelines, when you do so called 16-30 min of therapy, its not psychoanalysis, you are probably doing therapy while gathering info for E&M portion of your appointment unintentionally, pt is talking about their symptoms, stressors, also you may have a 20 min follow up scheduled, finish the pt with 99214+90833 but then do the next one 99214 or 99213 in 10-15 minutes, so it evens out.

if you schedule 24 patients for an 8 hour schedule thinking they will all take 20 min each, in reality you will put in 10-12 hours to cover all the 99214+90833 notes and details. What happens in reality for 20 minute slots ( 3 per hour) is 2 patients will qualify for 99213/99214+90833 and the third would be a straight 99213 or 99214 that takes a few minutes. There is also how efficient a person is with their EHR.

This is what I thought too at first.. how can you neatly separate the time providing therapy from mdm? I thought that was a ridiculous requirement... But from what ppl are saying on this forum, it seems like that's not how insurance companies think......? they just care about documentation... Explains why so many clinics do 15mid med checks instead of 20 or 30min visits..

 

[FN9]

This is what I thought too at first.. how can you neatly separate the time providing therapy from mdm? I thought that was a ridiculous requirement... But from what ppl are saying on this forum, it seems like that's not how insurance companies think......? they just care about documentation... Explains why so many clinics do 15mid med checks instead of 20 or 30min visits..

Yeah but that’s not how you document it. It needs to be documented the way I outlined it for private insurers generally. You’re correct in that the APA has made it clear that the spirit of these codes was to incentivize psychiatrists spending time with patients and utilizing psychotherapeutic techniques within the context of the larger visit but insurers want this separated into two separate blocks since they consider this as providing two “separate” services in the same encounter.

I’ve seen people get burned for not documenting start and end times for psychotherapy, if you look in the billing handbook for your contracted insurance companies they probably require this (mine do).

Hence the part about being efficient with EHR, if you have a template ready to go or copy and paste then if psychotherapy happens, its already there in your template and you modify based on what you did and bill, if not then its a straight E&M.

if the private insurer wants to ding you, they will find a reason. Make sure you have a solid template.