I posted the below information on a previous thread started by Vistaril recently. APA has been able to successfully lobby CMS into higher rates for psychotherapy provided by psychiatrists (MD's) when doing medication management starting this year. I believe an add-on psychotherapy code of 90833 (16-27 minutes) pays an additional ~1.8 RVUs or ~$60. Therefore, a 20-25 minute visit where you spend 5-10 minutes of med management with 16 minutes of time dedicated to therapy would now pay (99213+90833) $125-130 at Medicare rates. Before switching to E&M (prior to 12/31/2012) the same service would be billed as a 90805 and pay ~$70-75. This is a significant increase in reimbursement for the same service. Overall, this means you can schedule 2 follow-ups per hour and do OK.
race to the bottom job offer....
- Thread starter vistaril
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This is what I was getting at in one of my earlier posts about being able to bill an additional code so you get (at least partial) compensation for how you spend your time in a longer session.
I highly recommend anyone in private practice take the time to learn the Ins and Outs of billing or hire a company that can best account for your time spent providing clinical services. The best place to make up billable $'s is on the front-end and NOT on the back-end or through volume increase.
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Why use these codes when you can charge credit card, check, or cash?
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This is probably a joke but......Often, cash patients will want billing codes to get reimbursement themselves. A basic knowledge of codes is thus important.
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So how does this work without disillusioning the patient? You charge the patient, say, $200 for the hour session. You give the patient the billing code. The patient bills her own insurance only to find a reimbursement of, I don't know, $120. The patient feels something's amiss and wonders why the doctor is charging more than the reimbursement rate. Thievery! she cries. No?
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Transparency before the initial eval is even offered is key. I advise every to patient call their insurance company and ask for the amount they will get reimbursed for the various codes using their out-of-network benefits. After they do the research they are welcome to give me a call back for an appointment.
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Paperwork at the very beginning explains that billing codes are provided to seek partial reimbursement. Staff also helps clear up questions. Some patients are fine with this due to liking the doctor, often spending more time with a doctor, or the option of availability. Some patients say they will look for an in- network provider and not come back.
Our auditor/coder/whatever made a big point to tell us this year to be very careful about not having the code(s) reflect what we want to do in terms of designing a revenue model, as opposed to what the patient's needs are. Many of us asked the same question, and she basically said that scheduling followups like that and then billing 16 combined 99213(4)s/90833's every day is likely to raise some major red flags.
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If I avoided everything that involved a red flag, I wouldn't leave the house.
I get that, but I wouldn't want to have to explain to a medicare auditor(pick another auditor if you dont take medicare) that 32 straight patients had pathology that all required the exact same level of a psychotherapy add on(with mostly the exact same e/m code as well).
That makes us look like 'straight' chiropractors to be honest. Everyone who comes in gets their back cracked for a few minutes vs everyone that comes in getting the exact same level of psych care.
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Most pts know very little about how their insurance works (particularly in regard to MH coverage). It is unrealistic to expect them to know everything, but a bit of planning up front can save a lot of hassle on the back-end.
At the bare minimum:
-Provide your paperwork (and ideally have your admin follow-up and review docs…if you have one) PRIOR to the pt arriving for their initial eval
-Briefly discuss the paperwork during the first session
-Document in your note that you reviewed the paperwork
Your paperwork should include the standard HIPAA stuff, financial obligations/terms, release of information forms (if applicable), and an authorization to charge a CC for things like a no-show, outstanding balance, etc. Some people like to have a separate form outlining no-show appts, others will just have a line in their financial obligations form.
I don't really understand your argument here. In a general psychiatric practice you are going to have some patients who want just the quick medication managment visit after stable on their medication(s) and you will have some patients who want to spend more time with the psychiatrist. After an initial evaluation and a few visits you will have an idea what the patient wants and needs. If a patient wants more of your time per visit then you bill the add on psychotherapy code (if you spend at least 16 minutes in therapy). If not, just do a quick med management visit and bill only E&M. The bottom line is that whether you want to schedule two med/therapy patients per hour ($125 + $125 = $250), or 2 meds only and 1 med/therapy per hour (60 + 60 + $125), or 4 meds only per hour (60X4) you are no longer losing money by choosing to spend more time with patients (if it is necessary of course). The new changes allow the psychiatrist to practice comfortably and cater his or her time to the needs of the patient without having to worry about losing money per hour.
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I'd also like to see an auditor demonstrate how a psychiatric patient requiring ongoing medication couldn't benefit from therapy.
I'm happy to bill 99213/4 as legally allowed.
if it's done for every patient, I'd bet they would have a pretty reasonable argument.
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Like what, for instance?
umm...that it's extremely unlikely that for such a percentage of patients therapy would be indicated.
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Unlikely based on what? Who's the doctor here? Me or you?
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Please guys stop egging on Vistaril's trolling, its blatantly obvious he is just looking to stir up trouble.
It appears that these billings codes allow for greater flexibility in the way psychiatrists can practice while still maintaining an expected level of income. Instead of acknowledging the positives or possible benefits of these changes to psychiatric practice, Vistaril immediately finds new a new way to antagonize, ("chiropractors").
You would think someone like Vistaril who is apparently super passionate about practicing in the manner he sees best would find any change allowing more flexibility to be a huge positive...
It appears that these billings codes allow for greater flexibility in the way psychiatrists can practice while still maintaining an expected level of income. Instead of acknowledging the positives or possible benefits of these changes to psychiatric practice, Vistaril immediately finds new a new way to antagonize, ("chiropractors").
You would think someone like Vistaril who is apparently super passionate about practicing in the manner he sees best would find any change allowing more flexibility to be a huge positive...
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If V would learn a little bit about persuasion and sales, he would learn that credibility is huge. Having a credible source tell you something makes it more believable, and you're more likely to believe or act on it.
Car companies also sell on value. There are $100,000 cars and $10,000 cars. One company says, "they're all the same - they just drive you from here to there." The other company says, "this is an exceptional ride. There is tremendous value in this fine automobile."
Guess what? The people who don't care about quality pick the crappy car. Those who understand the value of having an exceptional product will chose the more expensive car.
A person who has the belief they are equivalent will never be successful selling the $100,000 car. In the back of his mind he thinks he's cheating a person out of 90k.
I believe there is value in the extra training. Even if there wasn't, the credibility alone would be worth it. Show me a social worker who has written an authoritative text on therapy.
Anyway, agreed with the post above. The V man is trolling. Place him on ignore FTW!
Choose your ride:
The Vistrail
Or the luxury car of your choice!
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huh? it appears....based on what? There is nothing to suggest these billings codes 'allow for greater flexibility'. Not sure how you got that idea. You are supposed to do what's clinically indicated, and then bill for it. If the treatment is decided on ahead of time, that isn't greater flexibility. That is basically fraud.
Based on probabilities....no different than it being unlikely every single cardiology clinic patient will need to be cathed.
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If only there was some research that showed that therapy+ meds had a better outcome than medication alone.
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Are you really equating meds + therapy to meds + CARDIAC CATH?? For real?
obviously the scope, cost, risks are different....but the principle is exactly the same.
therapy + meds for EVERY PT in EVERY clinical scenario(which is the discussion here) would certainly not have a better outcome. Also I suggest you read all that research....that's a different type of therapy for the most part than what this discussion is about. We're talking about psychs who are essentially scheduling patients as if they are med mgt patients(ie every 6-12 weeks or whatever most likely...shorter f/us for intakes) in 30 minute(or 20 minute for the lesser add on) blocks and tacking on the psychotherapy add on....and then having them followup again in 8-12 weeks to wash, rinse, repeat. Comparing that to the therapy in the large amount of research we have on the matter is ridiculous.
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The principle is really not exactly the same. This isn't worth the headache...
sure it is- both involve the provider going with a business model convenient for revenue purposes, even if it doesn't align perfectly with pt needs.
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Agree with Vistaril. Medicare doesn't care what the patient wants or what allows a psychiatrist to practice comfortably. Using the same code for all patients would be a red flag.
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I don't think people were really suggesting that except for in jest, there are plenty of patients who just want a quick appointment to check in and get refills or don't like the concept of psychotherapy, etc.
Also its not like suddenly all these new patients are being advised to get psychotherapy that weren't otherwise, the treatment was always indicated, its just that now the psychiatrist would be providing some portion of that treatment. Whether physicians decide to refer for certain treatment/procedures or do them on their own has always been somewhat tied to reimbursement so I don't think its fraudulent to consider billing when deciding which treatments/procedures you want to do yourself and what portion you refer out.
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Nobody is going to use the same code for every single patient. That would be absurd. But to suggest that doing so literally equates to doing a cath on every patient that walks in your cardiology clinic is insulting.
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I do wonder what would raise flags for Medicare though. I mean, as a competent outpatient psychiatrist, sure you'll see some pretty easy med refill cases, but you probably won't bill more than 5% of your visits as 99212. Even the guide says this is used for a 5 minute appointment. So the majority will be 99213 and 99214. A few 99215's maybe. So the bulk of your coding will be 99213, 99214, with a large portion (hopefully) for therapy, so you would use the add-on therapy code. After all, we are more than just pill pushers, so why would it be so absurd for most of my coding to be 99213's, 99214's, + therapy add on?
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that sounds reasonable
with this argument, you really need to ask yourself are you actually doing the treatment(in this case therapy) yourself. If the pt needs cbt, for example, and you want to do the cbt.....you actually need to *do* the cbt. And you're not going to get away(or you may...lots of people get away with things I guess) with billing a 99213 + add on for a little bit of cbt every 1 week to 2 weeks. They'll reject the e/m portion for that because of frequency....or the pt will run out of visits by march. And I seriously doubt the psychiatrist is going to be content billing 4 pure psychotherapy codes for every 1 e/m + add on.....
it's going to be hard to have it both ways. I think it's difficult to honestly bill e/m + therapy add ons for the vast majority of your patients. Because if the pt needs therapy, the pt actually.....needs therapy. Therapy in most cases require a frequency beyong e/m visits. We all know this. One alternative may be to see the pt at med mgt intervals and bill therapy + e/ codes for your visit and then the pt has a therapist who is actually providing therapy weekly or every two weeks or at whatever higher frequency interval. But then the obvious question issue is you're billing therapy codes and the pt has a psychologist/lcsw/lpc who is also billing therapy codes.
basically, if you actually think through these scenarios logically, there are a lot of reasons why it would be difficult(logistically and ethically) to have a majority of your outpt codes be e/m + therapy add ons. They either need the service or they don't. And if they do need it, then they actually need it and not something like 19 minutes of work every 8-12 weeks or however often you refill their meds.
but my point was if you're actually doing therapy with them, surely you are seeing most of these patients for therapy(or someone is) more frequently than you are refilling their adderall. I think a lot of the people in here are taking therapy in this case to mean:
spending 15-20 minutes catching up with your pt and asking about their life. No, that's not therapy. That's not what the code is for. What that may be useful for is better understanding their life so you can more properly provide the e/m service, but it's not therapy.
I don't think your reading comprehension is top notch today....once again, the principle is the same. Much like the taking a pack of cigarettes from Wal Mart is based on the same principle as stealing a 60 inch tv. They obviously are not the same thing though.
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Debates aside, for billing purposes is MI considered psychotherapy?
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Is the principle the same? Let's say we're doing some form of therapy (meeting at least the minimum time and content requirements of Medicare, whatever they may be) with every patient in our psychiatry clinic and billing a therapy add-on code for each of these patients. Let us compare this possibility with a cardiologist doing a cardiac catheterization on every single patient he/she sees in clinic. The principle of doing an intervention which could be indicated and of demonstrable benefit in every patient we see is not exactly the same as doing an invasive, risky procedure which can be demonstrated to have no indication or possible benefit (and even may have demonstrated harms) for most cardiology clinic patients.
Potentially yes. How it is likely done in most outpt clinics, no.
there is no way therapy could be indicated in every outpt you see.
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A better analogy would be a sleep doctor doing a polysomnogram on every patient he sees in clinic - essentially riskless (less risky than psychotherapy). And medicare is closely watching over this.
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Even if you billed everyone a 99214 for medicare you would get audited based purely on the statistical deviation from the average.. This is also anazlyed closer because the EM codes are a large expenditure so its been monitored specfically to those who use it the most (level 4 and 5). Not sure how much details they have on EM plus therapy for psychiatrist... likely the data is limited and at least for now would be hard to prove fraudulent provided you have the necessary documentation and time spent. if someone were to see say 24 pts a day in PP.. doing 8 (99213), 8( 99214) and 8( 99212/99213 + therapy) would probably be more reasonable on average.
Not sure but are private insurances paying anything close to medicare for the add on codes?
Not sure but are private insurances paying anything close to medicare for the add on codes?
While I think you make a good point (which is that we inadvertently minimize psychotherapy), I'm pretty sure you're wrong. The code isn't for manual-based CBT or DBT. Its for "insight oriented, behavior modifying and/or supportive" psychotherapy. So no, probably not talking about the Super Bowl, but yes, probably sitting down seeing what hang-ups the patient had, how they resolved it, reenforcing positive behavior, etc. And while you can disagree with the mechanism this is coming to bear, it conceptually makes sense. Evidence is showing the type of psychotherapy is probably not as important as just having an empathetic, thoughtful individual listening to you. And the medical system as a whole is seeing value in having doctors who actively engage with their patient in a meaningful way, both as a means of improving compliance and to reduce larger costs down the road (inpatient admissions, medical comorbidity, disability, etc.)
You might run into issues if an LCSW is billing the same day you are for psychotherapy, but I'm not sure how Medicare or insurance companies audit this type of stuff. Given the type of fraud that goes on with Medicare with fake medical equipment and false billing, I'd be disappointed if they were spending a considerable amount of time or money on cracking down on psychiatrists giving psychotherapy.
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Reading from a recent CPT booklet with regards to Psychotherapy -
In reporting, choose the code closest to the actual time; 16-37 minutes code for 90832 and 90833, 38-52 minutes for 90834 and 90836, and 53+ minutes for 90837 and 90838. Do no report psychotherapy for less than 16 minutes.
I believe these to be rider codes in addition with the 99213/4/5 coding when using the first number. The 2nd number is for combined E&M+Psychotherapy.
Please correct me if I'm misreading this.
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Just fulfilling the time requirement and actually performing psychotherapy is not enough; it has to be medically necessary.
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I talk frequently with reps of durable medical equipment company- medicare is doing plenty of audits in this area
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What then is the standard for determining the medical necessity for psychotherapy?
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Good question.
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MDD. Dysthymic Disorder. Adjustment Disorders. Bereavement. Even Bipolar Disorder can benefit from therapy.
Pretty much all the anxiety disorders. Phobias. PTSD. Eating Disorders. Conversion Disorder
Personality disorders.
Substance use disorders, including tobacco.
"Relational Problems" (i.e. parent-child, etc).
Sexual disorders
In other words...most of our patients. People don't do it often, but you can even make a case for treating schizophrenia with therapy (after they're on meds, of course).
Pretty much all the anxiety disorders. Phobias. PTSD. Eating Disorders. Conversion Disorder
Personality disorders.
Substance use disorders, including tobacco.
"Relational Problems" (i.e. parent-child, etc).
Sexual disorders
In other words...most of our patients. People don't do it often, but you can even make a case for treating schizophrenia with therapy (after they're on meds, of course).
You have to go further though and ask- is the therapy *I'm* offering in this setting(which would likely be 15-20 minutes of supportive therapy every 8 weeks or whatever) the right treatment? Some patients aren't going to benefit from therapy at all. Many will, but need much more intensive or focused therapy. Many will need much more frequent therapy than e/m coding would allow. Those are three of the biggest issues with scheduling 16 pts a day in 30 minute slots and expecting to E/M + add on every on. There is no way that most of those patients are going to require a care plan that jives with that model. It's purely for the sake of the business model of the psychiatrist.
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You don't need to make the case. There are evidence based protocols for CBT-Psychosis that are extremely effective. I've had good results, especially for the negative symptoms that meds don't hit as well.
The concern I have with the idea of folks billing for psychotherapy on ALL patient visits is that you will not be providing psychotherapy on each patient visit. I understand the argument for supportive psychotherapy and motivational interviewing, but my ethical yardstick is that if you aren't doing anything more specialized than what any compassionate physician would provide instinctively, it doesn't meet billable criteria for psychotherapy. And many med visits (including many of my own) would honestly not meet that criteria.
