Risk assessment billing code

[nexus73]

I think there should be a cpt code for psychiatric risk assessment. This is a separate task we have to perform beyond psychiatric medication management, beyond psychotherapy. And it’s not compensated.

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[WisNeuro]

There's the pittance that is the interactive complexity code.

 

[ObsequiousAplomb]

If you're making a major risk assessment like whether a patient genuinely needs to be admitted or not, then it's probably a level 5 visit. I think the risk assessment falls neatly within the level 4 / level 5 decision tree, and is a part of the medication management component. It would be nice to be paid more for it, but I'm not sure that adding another code for it is the answer.

 

[nexus73]

Our billers said level 5 can only be billed if the patient gets admitted to the hospital that day. It annoys me that a family doc sees someone in 10 minutes for HTN and hypothyroidism both stable and bills level 4. I see some with suicidal ideation and take 35 minutes to discuss medications, assess risk factors, and discuss a safety plan and bill level 4.

 

[calvnandhobbs68]

Our billers said level 5 can only be billed if the patient gets admitted to the hospital that day. It annoys me that a family doc sees someone in 10 minutes for HTN and hypothyroidism both stable and bills level 4. I see some with suicidal ideation and take 35 minutes to discuss medications, assess risk factors, and discuss a safety plan and bill level 4.

Whenever I’m doing a real risk assessment and developing a safety plan with someone, I’m definitely billing a 90833 for that encounter.

 

[NickNaylor]

Our billers said level 5 can only be billed if the patient gets admitted to the hospital that day. It annoys me that a family doc sees someone in 10 minutes for HTN and hypothyroidism both stable and bills level 4. I see some with suicidal ideation and take 35 minutes to discuss medications, assess risk factors, and discuss a safety plan and bill level 4.

Uh, it sounds like your billing people are pretty dumb.

 

[ObsequiousAplomb]

Uh, it sounds like your billing people are pretty dumb.

I agree. The billers are wrong. You shouldn't listen to a biller when they are wrong. Saying someone needs to be admitted would just mean that we would be pressured to admit people who don't warrant admission.

The criteria is not "I'm sending to the hospital" but instead "I'm making a serious decision about the indication of an admission."

If they have diagnoses that also meet level 5 criteria, then it's absolutely a level 5.

Saying "I think you would benefit from hospitalization but you do not meet involuntary criteria. I cannot force you to go" definitely meets the muster for risk.

It would also work if you evaluated someone with chronic suicidal ideation who is having a brief dip in their mood with self-injurious behavior and you need to assess whether they need medical or psychiatric hospitalization, regardless of whether or not they do in fact need it. Obviously, saying you made that level of an evaluation for a thin scratch instead of an actual cut of skin probably doesn't meet level 5.

Command auditory hallucinations to harm someone else that they can manage to ignore and they have an adequate support / supervision and safety plan and appropriate decisions are made regarding medications and other factors? Clozapine and/or ECT also discussed but ultimately not started after shared decision making? Also level 5 risk.


I also agree with adding a psychotherapy add-on, since I'm always doing some significant supportive psychotherapy while assessing someone who's that high risk, at least 16 minutes of that time.

If it takes 35 minutes face-to-face and you're not interested in doing the psychotherapy code, it isn't hard to do some medically indicated extra timed steps to ensure you meet time-based billing. Calling collateral could be helpful. Calling the PCP would count. Calling their pharmacist to discuss trends in prescription filling or complete a med rec to ensure they aren't stocking up on potentially toxic medications you aren't prescribing counts. Talking to a partner/colleague for advice counts. Reviewing your own records, sending prescriptions, and documenting your encounter counts. Calling the patient at the end of the day to ensure a new crisis hasn't come up counts. Any / all of those are warranted and the minimum time for 99215 is only 40 minutes.

 

[calvnandhobbs68]

If it takes 35 minutes face-to-face and you're not interested in doing the psychotherapy code, it isn't hard to do some medically indicated extra timed steps to ensure you meet time-based billing. Calling collateral could be helpful. Calling the PCP would count. Calling their pharmacist to discuss trends in prescription filling or complete a med rec to ensure they aren't stocking up on potentially toxic medications you aren't prescribing counts. Talking to a partner/colleague for advice counts. Reviewing your own records, sending prescriptions, and documenting your encounter counts. Calling the patient at the end of the day to ensure a new crisis hasn't come up counts. Any / all of those are warranted and the minimum time for 99215 is only 40 minutes.

Right, literally typing your note and sending prescriptions should take 5 minutes and gets you to a 99215. But you'll bill higher with a 99214+90833.

 

[Sushirolls]

I think there should be a cpt code for psychiatric risk assessment. This is a separate task we have to perform beyond psychiatric medication management, beyond psychotherapy. And it’s not compensated.

Before we would ever get specific pay for doing the routine Suicidal Risk Assessment, I think we'll have a better chance at getting dropped as part of standard of care. I believe some posters on here have referenced to the poor data that they don't make a difference and have no clinical merit.

We know there are actuarial risk factors but they don't correlate to clinical utility - If I recall the other posters correctly.

Correct me if I'm wrong. I've avoided digging into this to see if there is truth that our whole SI risk assessment process is a complete farce and waste of time. The amount of time in my life I have spent reviewing/documenting/thinking/adjusting etc on SI risk assessments in EVERY note... I don't even want to process the feelings of what that would elicit knowing that once again I'm doing another bureaucratic dance of virtue signaling. To know that our esteemed societies have perpetuated a practice as standard of care with no evidence to support. So for now I keep on doing the standard with my head in the sand.

 

[calvnandhobbs68]

Correct me if I'm wrong. I've avoided digging into this to see if there is truth that our whole SI risk assessment process is a complete farce and waste of time. The amount of time in my life I have spent reviewing/documenting/thinking/adjusting etc on SI risk assessments in EVERY note... I don't even want to process the feelings of what that would elicit knowing that once again I'm doing another bureaucratic dance of virtue signaling. To know that our esteemed societies have perpetuated a practice as standard of care with no evidence to support. So for now I keep on doing the standard with my head in the sand.

lol this is a totally different subject but yes, it's pretty much a waste of time. Also yes, we have to do it to cover our asses. But even the vaunted CSSRS has basically no evidence for prediction of actual suicide, the best they get is "suicidal ideation" and "suicide attempts" both of which we know have much much higher incidence rates than actual suicide (which should be the outcome we ultimately care about).

Individual risk assessment is basically hand waving and we do not much better than chance at predicting who will actually commit suicide.

Meta-Analysis of Longitudinal Cohort Studies of Suicide Risk Assessment among Psychiatric Patients: Heterogeneity in Results and Lack of Improvement over Time

Objective It is widely assumed that the clinical care of psychiatric patients can be guided by estimates of suicide risk and by using patient characteristics to define a group of high-risk patients. However, the statistical strength and reliability of suicide risk categorization is unknown. Our...

journals.plos.org

"Over an average follow up period of 63 months the proportion of suicides among the high-risk patients was 5.5% and was 0.9% among lower-risk patients. The meta-analytically derived sensitivity and specificity of a high-risk categorization were 56% and 79% respectively."

 

[PikminOC]

Uh, it sounds like your billing people are pretty dumb.

Sounds like they don't want to be audited

 

[Stagg737]

Uh, it sounds like your billing people are pretty dumb.

It's especially dumb since you may not even get reimbursed for that 99215 that's admitted if insurance only feels like billing the admission H&P.

Correct me if I'm wrong. I've avoided digging into this to see if there is truth that our whole SI risk assessment process is a complete farce and waste of time. The amount of time in my life I have spent reviewing/documenting/thinking/adjusting etc on SI risk assessments in EVERY note... I don't even want to process the feelings of what that would elicit knowing that once again I'm doing another bureaucratic dance of virtue signaling. To know that our esteemed societies have perpetuated a practice as standard of care with no evidence to support. So for now I keep on doing the standard with my head in the sand.

Something to keep in mind, population studies should not be extrapolated as gospel to individual patients. A lot of what we do with risk assessment is very likely overkill, and I agree with the lesson that if someone really wants to kill themselves then they'll find a way to do it.

However, I do think there is utility on an individual level for screening and basic assessment in primary care and ER settings where a patient may otherwise not be asked about it or it is just brushed over. I can recall a small number of patients who I think may have legitimately killed themselves, but ended up doing okay because we got them plugged into a MH clinic where they previously had no MH treatment. Conversely, I also think that if a patient has gotten to the point of being seen by psychiatry, doing an excessive CYA risk assessment is unlikely to realistically add much to whether they complete suicide or not.

 

[calvnandhobbs68]

However, I do think there is utility on an individual level for screening and basic assessment in primary care and ER settings where a patient may otherwise not be asked about it or it is just brushed over. I can recall a small number of patients who I think may have legitimately killed themselves, but ended up doing okay because we got them plugged into a MH clinic where they previously had no MH treatment. Conversely, I also think that if a patient has gotten to the point of being seen by psychiatry, doing an excessive CYA risk assessment is unlikely to realistically add much to whether they complete suicide or not.

Again, not the main point of this post, but the big issue this comes up in is:
1) Liability- Although psychiatrists are not expected to predict suicide by courts, they are expected to do a "risk assessment" which is essentially a misnomer since there are NO EVIDENCE BASED RISK FACTORS FOR SHORT TERM SUICIDE RISK. So then you have to ask, risk of what? Suicide in the next 5 years? (look at the timeframe of the above meta-analysis, 1/18 of "high risk" patients died by suicide over 5 years)

2) Involuntary admission- If we have no evidence that these risk factors predict short term suicide risk (there are basically no studies looking at risk over a time period <6 months because suicide is such a statistically rare event), then how can we possibly justify involuntary admitting someone as being "high risk" for suicide against their wishes?

Is there utility in linking patients long term with treatment? Yes, but with the acknowledgement that these are long term suicide risk factors (ex. history of a suicide attempt) and a long term outcome we are trying to reduce probability of occuring and not at all predictive of if someone is going to kill themselves today or next week.

 

[Stagg737]

Again, not the main point of this post, but the big issue this comes up in is:
1) Liability- Although psychiatrists are not expected to predict suicide by courts, they are expected to do a "risk assessment" which is essentially a misnomer since there are NO EVIDENCE BASED RISK FACTORS FOR SHORT TERM SUICIDE RISK. So then you have to ask, risk of what? Suicide in the next 5 years? (look at the timeframe of the above meta-analysis, 1/18 of "high risk" patients died by suicide over 5 years)

2) Involuntary admission- If we have no evidence that these risk factors predict short term suicide risk (there are basically no studies looking at risk over a time period <6 months because suicide is such a statistically rare event), then how can we possibly justify involuntary admitting someone as being "high risk" for suicide against their wishes?

Is there utility in linking patients long term with treatment? Yes, but with the acknowledgement that these are long term suicide risk factors (ex. history of a suicide attempt) and a long term outcome we are trying to reduce probability of occuring and not at all predictive of if someone is going to kill themselves today or next week.

Agree, I was pointing out that there is likely some utility for risk assessment in terms of screening and actually establishing people with care they'd otherwise not receive. But in terms of our assessments as psychiatrists, the actual realistic benefits of the evaluation to the patient are probably minimal if present at all and are primarily present for legal purposes to cover everyone else.

 

[splik]

I think there should be a cpt code for psychiatric risk assessment. This is a separate task we have to perform beyond psychiatric medication management, beyond psychotherapy. And it’s not compensated.

Risk assessment is part of medical decision making. It comes under E&M and is compensated. you could argue that you're not getting compensated enough, but that is a separate issue altogether.
There is no code for "medication management" for physicians anymore, only psychologists.