Prolonged services code update 99417

[clozareal]

Now that we're 7 months into 2021, are people seeing reimbursements for 99417 prolonged service codes yet? How useful is this code?

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[Sushirolls]

I've been doing a lot of 99205 + 99417 + 99417.
1-2 insurance just don't pay for 99417, so I dropped one of those.
One insurance briefly requested records to review for 1 consult, no issue, they paid.
Really its pretty straightforward time = codes
If I get audited and push back from this, might just be my trigger to jump all in for cash only. How can you deny documented time of X for codes based on time?

I haven't done 90792 in who knows how long. Only if I have a very short, quick consult?

 

[calvnandhobbs68]

90792 would be terrible on a per hour basis. 99205 by itself pays better than 90792 almost universally.

You can’t do 99205 + 90838 if you’re billing based on time. I’ve seen/heard people do 99204 on complexity + 90833 or 90836.

 

[Sushirolls]

The one insurance company I dropped recently was oddly higher with 90792 than 99205. They seemed to be united in their efforts to stick it to 'providers.'

 

[hebel]

If strictly wRVU based, would 90792 be best? Seems simpler as far as documentation requirements go.

 

[clozareal]

I've been doing a lot of 99205 + 99417 + 99417.
1-2 insurance just don't pay for 99417, so I dropped one of those.
One insurance briefly requested records to review for 1 consult, no issue, they paid.
Really its pretty straightforward time = codes
If I get audited and push back from this, might just be my trigger to jump all in for cash only. How can you deny documented time of X for codes based on time?

I haven't done 90792 in who knows how long. Only if I have a very short, quick consult?

Really helpful. Did those insurance companies say why they didn't pay for 99417?

 

[Sushirolls]

Nope. They are united in their decision to not cover it. And they stand firm as a green tree to not cover it.

 

[Sushirolls]

If strictly wRVU based, would 90792 be best? Seems simpler as far as documentation requirements go.

Oddly, I do believe you are right, for those on the wRVU tread mill, this has more wRVUs than 99204, but I can't recall if more than 99205 or not.
But hands down 99205+99417+99417 has more wRVUs.

 

[nexus73]

Oddly, I do believe you are right, for those on the wRVU tread mill, this has more wRVUs than 99204, but I can't recall if more than 99205 or not.
But hands down 99205+99417+99417 has more wRVUs.

90792 is more RVUs IF your job is paying the higher RVU value. My job is still paying based on the previous value, which sounds like it's a pretty common practice with the changes just being implemented

 

[Stagg737]

Oddly, I do believe you are right, for those on the wRVU tread mill, this has more wRVUs than 99204, but I can't recall if more than 99205 or not.
But hands down 99205+99417+99417 has more wRVUs.

For 2021:
99204 is 2.60 wRVUs
99205 is 3.50 wRVUs
90792 is 4.16 wRVUs

So 99792 is 0.66 wRVUs higher than 99205 or $23.03 difference when converting at $34.89 per RVU.

 

[clozareal]

99417 is 0.61 wRVU

So a 70 minute (55+15 min) appointment at 99205+99417 = 4.11 wRVU vs 90792 at 4.16 wRVU.

If you have an 85 minute appointment, that would mean that doing 99205+99417x2 > 90792 in terms of wRVU compensation.

 

[robellis]

For 2021:
99204 is 2.60 wRVUs
99205 is 3.50 wRVUs
90792 is 4.16 wRVUs

So 99792 is 0.66 wRVUs higher than 99205 or $23.03 difference when converting at $34.89 per RVU.

Why would you be using 34.89 as the conversion number?

 

[Stagg737]

Why would you be using 34.89 as the conversion number?

Because that’s the standard CMS conversion per RVU for 2021. Down about $2 from 2020 after increasing wRVUs per code.

 

[calvnandhobbs68]

The one insurance company I dropped recently was oddly higher with 90792 than 99205. They seemed to be united in their efforts to stick it to 'providers.'

Interesting yeah all the rates people have showed me have all had 99205 > 90792 and 99204 about equal or maybe slightly less than 90792.

Also Sushi, have you reported the 99417 blanket coverage refusal thing to your state’s insurance commissioner? I feel like an insurance company’s blanket refusal of a valid generally used CPT code would be something to report.

 

[rjs2131]

Planning to use 99205 + 99417(2) for new evals - also important to note that the appointment itself doesn't have to be 90 minutes, just the total time you spent that day! In theory you could use 99205 + 99417(2) for a 60 min encounter if you're spending another 30 min on chart review, talking to therapist, etc in the same day.

 

[Sushirolls]

Different insurance companies have different requirements. Many have followed Medicare which requires you to spend 89 minutes before you can use 1 unit of 99417 (their equivalent code is G2212) for 99205 and 69 minutes before you can use 1 unit of 9941799215. So it doesn’t work out very well even if you get reimbursed. You should expect to your records to be reviewed and you won’t be able to get away with using it every evaluation unless you have good reason (I actually used 99205 +10x 99417 for typical evals but I have a very specialized clinic And for its very hit or miss in terms of reimbursement)

Spending the time and documenting it is the good reason. Nothing in all the AMA lectures hinted that they intended it as Time + Good reason. It's simply time. Historically 'good reason' was part of the 90354 code, but alas it is gone, and with it that reason too

 

[Stagg737]

Interesting yeah all the rates people have showed me have all had 99205 > 90792 and 99204 about equal or maybe slightly less than 90792.

I mean, insurances can do whatever they want as long as they don’t undercut CMS…

 

[rjs2131]

Anyone successfully used 99204 + 90833/90836 for an initial evaluation? Seems like a few insurance companies won't recognize 99417 yet, but for these panels the 99204+90833 combo would reimburse pretty similarly to 99205+99417(2).

I would think as far as the note goes, the main difference between a 99214 + 90833/90836 and 99204 + 90833/90836 is the fact that the 99204 is a new eval and will be a denser note as a result. Thoughts?

 

[clausewitz2]

Anyone successfully used 99204 + 90833/90836 for an initial evaluation? Seems like a few insurance companies won't recognize 99417 yet, but for these panels the 99204+90833 combo would reimburse pretty similarly to 99205+99417(2).

I would think as far as the note goes, the main difference between a 99214 + 90833/90836 and 99204 + 90833/90836 is the fact that the 99204 is a new eval and will be a denser note as a result. Thoughts?

99204+90833 is pretty common for me for initial evaluations, no pushback. Then again, the one insurance payor I have pays exactly the same for 99204 and 99214, so it's largely academic. I imagine that particular payor got wise to the potential of that combination some time ago.