Transparent Discussion Income

[Marasmus1]

210 k straight out of fellowship as asisstant professor non-tenure. 20 days vacation, 12 federal holidays, 5 CME days (10 CME if presenting) and 12 sick days a year so In theory 49 days PTO practically somewhere around 40

Excellent retirement benefits. Fully paid pension plan by university and medical center sponsed IRA with %6 gross match.

8 hours of work from 9-5. Billing about 5 hours a day, 1 hour lunch and rest is administrative/teaching/research.

No mandatory call, Can cover weekend consults for 2500k a weekend additional stipend in the medical center. Weekends are staffed by one junior and one senior residents who do pretty much all the work (there is no inpatient psych in the hospital)

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[Plimpington2]

Unless you are committing fraud, you should bill for whatever you do. Ignore the audit risk. Even if there is a clawback, they are going to take back what you shouldn’t have received anyway. If you are found to be correct, they probably don’t bother you for quite some time. Every time you downcode to a 99214 instead of a 99215, you lose what $30? 100x and you lose $3000 right there.

This hits home to me. I am very new in my private practice (though was in with a hospital for years) and I dither back and forth about my billing. For a typical half hour visit, I am generally coding a 99214 + 90833. The 90833 seems straightforward, and I document it well. But I suspect I overthink the 99214. Typical situation - akathisia from Abilify. So if I address this (maybe reduce it, switch it, add a beta blocker or a benzo, whatever) and to my mind I have a legit 99214. But could it be a 99213? That's the rub. and how much to I throw away if I under code? ugh. It's hard.

 

[calvnandhobbs68]

This hits home to me. I am very new in my private practice (though was in with a hospital for years) and I dither back and forth about my billing. For a typical half hour visit, I am generally coding a 99214 + 90833. The 90833 seems straightforward, and I document it well. But I suspect I overthink the 99214. Typical situation - akathisia from Abilify. So if I address this (maybe reduce it, switch it, add a beta blocker or a benzo, whatever) and to my mind I have a legit 99214. But could it be a 99213? That's the rub. and how much to I throw away if I under code? ugh. It's hard.

Yes it’s a 99214.

 

[Abacab]

Great to see such an open discussion of compensation in this thread.

Outpatient telepsychiatry and a side gig of residential centers (also telepsych)

About 40 hrs a week total M-F. I take 4-6 weeks off per yr (unpaid). Rare weekend admits to residential (Tele visit only)

No mid-level supervision. No night call.

Between 650k-700k on 1099 (no bennies)
Loan repayment
Malpractice

 

[Cath Up]

Great to see such an open discussion of compensation in this thread.

Outpatient telepsychiatry and a side gig of residential centers (also telepsych)

About 40 hrs a week total M-F. I take 4-6 weeks off per yr (unpaid). Rare weekend admits to residential (Tele visit only)

No mid-level supervision. No night call.

Between 650k-700k on 1099 (no bennies)
Loan repayment
Malpractice

You hiring incoming interns by chance?

 

[jbomba]

Great to see such an open discussion of compensation in this thread.

Outpatient telepsychiatry and a side gig of residential centers (also telepsych)

About 40 hrs a week total M-F. I take 4-6 weeks off per yr (unpaid). Rare weekend admits to residential (Tele visit only)

No mid-level supervision. No night call.

Between 650k-700k on 1099 (no bennies)
Loan repayment
Malpractice

Soon to be pgy4 thinking of doing pp insurance. Was hoping I could get to your income level with about 40 patient hours a week. Do you have any thoughts?

Or any advice on finding a 1099 gig like you've got?

Thanks!

 

[painballer27]

Great to see such an open discussion of compensation in this thread.

Outpatient telepsychiatry and a side gig of residential centers (also telepsych)

About 40 hrs a week total M-F. I take 4-6 weeks off per yr (unpaid). Rare weekend admits to residential (Tele visit only)

No mid-level supervision. No night call.

Between 650k-700k on 1099 (no bennies)
Loan repayment
Malpractice

How far out of training are you? Is your outpatient practice cash only? How did you build such a successful practice?

 

[Abacab]

Soon to be pgy4 thinking of doing pp insurance. Was hoping I could get to your income level with about 40 patient hours a week. Do you have any thoughts?

Or any advice on finding a 1099 gig like you've got?

Thanks!

Hey there.
The approach I've taken is a steady hourly gig combined with niche side gigs which develop more sub-specialized skill sets and offer higher income for the smaller pool said skill set swims in. Best advice I can offer is to look for jobs via networking with colleagues, local groups, etc rather than recruiters that take a big piece of the piece. Then, negotiate effectively and know your value. At this time, there is absolutely no reason for a BC psychiatrist with a clean background to take less than $200/hr with a reasonable workload. Don't settle for gigs with these big box, PE backed organizations. There's no growth there and no value for your individuality. Grow with a practice/clinic/hospital/organization that values long term partnerships.

PP insurance is very doable and can pay well. If I was in your shoes, I'd probably take a steady outpatient/inpatient part time 25-30 hr a week gig while building the PP on the side and then slowly trimming away those other hours as the PP builds. This gives you time and financial independence to build with the right payors and not settle for the cheapskates. And also allows you to learn the business side of things without being all in and making more costly mistakes.

 

[Abacab]

How far out of training are you? Is your outpatient practice cash only? How did you build such a successful practice?

Hi. I'm about 12 years out. My outpatient work is mostly insurance based with a sprinkling of cash. I've been working with this clinic for many years and have developed a very good relationship with them. There was a lot of turbulence during the pandemic where I helped them find their footing with the telehealth transition. I had some very lucrative offers around that time which I told them very frankly were too compelling to pass up and they gave me a large raise because they value our relationship beyond just the patient care aspect of my work.

For me, being successful has come down to a few things. I don't have an ivy league pedigree, no fellowship training. Went to a very middle of the road state md school.

Develop good relationships with the people you work with and treat your staff well. If people like you, they will treat you right and do what they can to keep you from leaving.

Learn to negotiate. Know your worth. Don't be afraid to ask for raises from time to time. Most people not in medicine expect their income to rise throughout their career. Many doctors allow their income to stagnate and this shouldn't be the way. I've never kept all my eggs in one basket, so I feel comfortable walking away if the numbers aren't staying in line with the market and/or my expectations. I typically ask for a raise every year or so - citing various reasons such as competing offers, inflation and cost of living changes. Right now, any BC psychiatrist with a clean record should not be taking anything less than $200/hr as a contractor. That's just the bottom floor to work up from. In this market we have now, most everything with a job is negotiable, even if they say it isn't.

Develop some particular interests and or skills that make you stand out. I've done a lot of different part time side gigs and cultivated some skills that have helped me pick up some interesting and lucrative side jobs. Get exposed to a variety of things because you never know when a particular skill set could open an exciting new door for you.

Don't sell out for a few bucks. Don't work for companies like teladoc, lifestance, amwell, cerebral, etc. There's no growth and it won't open any doors for you.

Network with colleagues and peers. Easy to stay in touch with things like linkedin, doximity and other professional social media. Recruiters should be seen as a backup option when looking for work, not a primary one. Being connected with psychiatrists, other mental health professionals, and non-psych physicians can be a great way to find some plum opportunities. The best jobs aren't the ones locums is cold calling you about.

Private practice cash pay is great, but remember there's more than one way to skin the golden goose. Don't discount the advantages of factors such as fat pension plans, being paid for no shows, and generous vacation packages. Seeing 4 patients an hour for $300 may sound good to some but the psychiatrist seeing two patients an hour for $200 is doing much better and working smarter, not harder.

 

[painballer27]

Hi. I'm about 12 years out. My outpatient work is mostly insurance based with a sprinkling of cash. I've been working with this clinic for many years and have developed a very good relationship with them. There was a lot of turbulence during the pandemic where I helped them find their footing with the telehealth transition. I had some very lucrative offers around that time which I told them very frankly were too compelling to pass up and they gave me a large raise because they value our relationship beyond just the patient care aspect of my work.

For me, being successful has come down to a few things. I don't have an ivy league pedigree, no fellowship training. Went to a very middle of the road state md school.

Develop good relationships with the people you work with and treat your staff well. If people like you, they will treat you right and do what they can to keep you from leaving.

Learn to negotiate. Know your worth. Don't be afraid to ask for raises from time to time. Most people not in medicine expect their income to rise throughout their career. Many doctors allow their income to stagnate and this shouldn't be the way. I've never kept all my eggs in one basket, so I feel comfortable walking away if the numbers aren't staying in line with the market and/or my expectations. I typically ask for a raise every year or so - citing various reasons such as competing offers, inflation and cost of living changes. Right now, any BC psychiatrist with a clean record should not be taking anything less than $200/hr as a contractor. That's just the bottom floor to work up from. In this market we have now, most everything with a job is negotiable, even if they say it isn't.

Develop some particular interests and or skills that make you stand out. I've done a lot of different part time side gigs and cultivated some skills that have helped me pick up some interesting and lucrative side jobs. Get exposed to a variety of things because you never know when a particular skill set could open an exciting new door for you.

Don't sell out for a few bucks. Don't work for companies like teladoc, lifestance, amwell, cerebral, etc. There's no growth and it won't open any doors for you.

Network with colleagues and peers. Easy to stay in touch with things like linkedin, doximity and other professional social media. Recruiters should be seen as a backup option when looking for work, not a primary one. Being connected with psychiatrists, other mental health professionals, and non-psych physicians can be a great way to find some plum opportunities. The best jobs aren't the ones locums is cold calling you about.

Private practice cash pay is great, but remember there's more than one way to skin the golden goose. Don't discount the advantages of factors such as fat pension plans, being paid for no shows, and generous vacation packages. Seeing 4 patients an hour for $300 may sound good to some but the psychiatrist seeing two patients an hour for $200 is doing much better and working smarter, not harder.

Nice. I deeply respect your hustle and resourcefulness. Have you and your group ever thought of hiring any NPs? I bet if you took on a couple you could get up near 7 figures and even cut back your own clinical time.

 

[medhead1990]

Develop some particular interests and or skills that make you stand out. I've done a lot of different part time side gigs and cultivated some skills that have helped me pick up some interesting and lucrative side jobs. Get exposed to a variety of things because you never know when a particular skill set could open an exciting new door for you.

My interest is piqued and could you give examples of what skills or pt population are you treating? (Can be vague if preferred) My first thought was that forensic work is a great way to make some big money as a side gig but you mentioned that you are not fellowship trained. Are you trained in a special type of therapy? Ketamine treatments? Addiction for professionals? Eating disorders? Treating celebrities or CEOs?

Obviously you’re welcome to be somewhat vague for anonymity sake’s.

 

[Abacab]

My interest is piqued and could you give examples of what skills or pt population are you treating? (Can be vague if preferred) My first thought was that forensic work is a great way to make some big money as a side gig but you mentioned that you are not fellowship trained. Are you trained in a special type of therapy? Ketamine treatments? Addiction for professionals? Eating disorders? Treating celebrities or CEOs?

Obviously you’re welcome to be somewhat vague for anonymity sake’s.

Hey. Yeah, so I do quite a bit of addictions in residential treatment settings. Have been doing it in some capacity or another for a decade. No celebs or CEOs but I'd say the majority are upper middle class to well off, many professionals.

I did TMS in the past but stopped around the peak of the pandemic and haven't gone back to it but might again in the future. I do some esketamine in my practice, but it isn't a lot and is more out of wanting to provide more options for patients that are treatment resistant and to do something a bit different as it doesn't really pay all that well for the time staff and I end up spending on it.

 

[Abacab]

Nice. I deeply respect your hustle and resourcefulness. Have you and your group ever thought of hiring any NPs? I bet if you took on a couple you could get up near 7 figures and even cut back your own clinical time.

Thank you bdoc. My group had a bad experience with two NPs back to back a few years ago (one was copying and pasting the same note visit after visit with not a word changed like a robot) Since then, they have decided to stick with only physicians for psychiatric care.

 

[Blitz2006]

Great Thread, very informative.

So I'm shifting into Per Diem, Outpatient Private Practice in September.

Some questions, for newbie private practice:

1. Since for the first few months, I will be less busy, I have asked the practices for a per diem hourly rate, for the 1st 3-4 months. I am asking for around $220/hour, 8 hours/day, 3 days a week. Is this a reasonable hourly request? Do You think it is wise that I ask for an hourly rate for my first few months out, or should I just go straight to % collections?

2. What is a good % of collections? All the practices I have interviewed at are saying 70%?

3. For Outpatient billing, what is the most ethical/efficient/responsible way to bill per hour for follow-ups? 99213 + 90833 x 2 patients, and 1 99214 patient? Or do I just do 99213 x 4 patients per hour?

Thanks!

 

[Blitz2006]

This hits home to me. I am very new in my private practice (though was in with a hospital for years) and I dither back and forth about my billing. For a typical half hour visit, I am generally coding a 99214 + 90833. The 90833 seems straightforward, and I document it well. But I suspect I overthink the 99214. Typical situation - akathisia from Abilify. So if I address this (maybe reduce it, switch it, add a beta blocker or a benzo, whatever) and to my mind I have a legit 99214. But could it be a 99213? That's the rub. and how much to I throw away if I under code? ugh. It's hard.

Related to my question above, can anyone expand when it is appropriate to bill:

99213
99214
99213 + 90833
99214 + 90833

I presume 99213 + 908033 is when you spend 16 minutes with a patient, but why can't you bill just straight 99214 then? What is difference between 99213 + 90833 vs. 99214 alone?

Can you bill 99214 x 3 in 1 hour? Or is that not correct.

 

[deleted456421]

Great Thread, very informative.

So I'm shifting into Per Diem, Outpatient Private Practice in September.

Some questions, for newbie private practice:

1. Since for the first few months, I will be less busy, I have asked the practices for a per diem hourly rate, for the 1st 3-4 months. I am asking for around $220/hour, 8 hours/day, 3 days a week. Is this a reasonable hourly request? Do You think it is wise that I ask for an hourly rate for my first few months out, or should I just go straight to % collections?

2. What is a good % of collections? All the practices I have interviewed at are saying 70%?

3. For Outpatient billing, what is the most ethical/efficient/responsible way to bill per hour for follow-ups? 99213 + 90833 x 2 patients, and 1 99214 patient? Or do I just do 99213 x 4 patients per hour?

Thanks!

$220 is definitely fair, especially in the northeast. I bill 99214 alone 60% of the time, 99214 + 90833 30%, and 99213 or 99215 the rest.

The most ethical method is to bill fairly. You should look up the APA MDM guidelines.

Never tried % of collections. Been too afraid of underperforming an hourly rate.

 

[Blitz2006]

$220 is definitely fair, especially in the northeast. I bill 99214 alone 60% of the time, 99214 + 90833 30%, and 99213 or 99215 the rest.

The most ethical method is to bill fairly. You should look up the APA MDM guidelines.

Never tried % of collections. Been too afraid of underperforming an hourly rate.

Thanks for the helpful, informative response.

Few follow-up questions:

1. How many follow-up patients do you usually see in 1 hour, 2 or 3 or 4?

2. How does one bill, 99214 + 90833? That seems like a lot of time/complexity for a follow-up? I was under impression you can normally only do 99213 + 90833 or just 99214?

3. How does cash based practice work? You can only charge cash on insurance panels you don't take?

 

[deleted456421]

1. Never more than one patient per 30 minutes

2. I have lots of patients with 2-3 chronic issues on medications whom I provide psychotherapy. It's honestly hard to hit MDM criteria for a 99213.

3. Never tried a cash practice. I've been living the employed-life while building a nest egg.

 

[painballer27]

Is it common for outpatient psychiatrists to see 4 or more patients in an hour?

 

[deleted456421]

Is it common for outpatient psychiatrists to see 4 or more patients in an hour?

Many of the previous psychiatrists at my institution had 10-15 minute slots.

However, they all quit within the last few years after hitting 80. They also prescribed copious quantities of benzos. They also seemed to flee when a competent medical director started her job. They also diagnosed everyone with borderline personality disorder as bipolar.

Overall, don't recommend nor does it seem to be the norm these days, despite numerous patients telling me "I'm here to check in and tell you I'm doing okay with my 4 mg of Klonopin daily, don't ask me any questions please."

 

[hallowmann]

Is it common for outpatient psychiatrists to see 4 or more patients in an hour?

No. 2-3/hr is pretty much the most you should be seeing to give adequate care unless you are literally doing a very regimented action.

An example in one set of clinics that I saw where people struggled to start clozapine in patients, there was one doc that basically saw everyone on clozapine once a month for their lab and to screen for adverse effects in order to streamline the process for other psychiatrists so more patients that were appropriate could get on it. He'd only make management decisions if urgently needed, he'd screen for adverse effects of clozapine, draw levels or prescribe meds if needed to manage clozapine adverse effects, and they'd see their regular psychiatrist at more reasonable intervals. He'd see 4 in an hour and typically bill 99213 or 99214 depending on if he actually changed something or not.

 

[deleted456421]

No. 2-3/hr is pretty much the most you should be seeing to give adequate care unless you are literally doing a very regimented action.

An example in one set of clinics that I saw where people struggled to start clozapine in patients, there was one doc that basically saw everyone on clozapine once a month for their lab and to screen for adverse effects in order to streamline the process for other psychiatrists so more patients that were appropriate could get on it. He'd only make management decisions if urgently needed, he'd screen for adverse effects of clozapine, draw levels or prescribe meds if needed to manage clozapine adverse effects, and they'd see their regular psychiatrist at more reasonable intervals. He'd see 4 in an hour and typically bill 99213 or 99214 depending on if he actually changed something or not.

Also saw a few docs run clozapine groups and bill 99214 for their patients at a CMHC. I have no idea if that's appropriate.

 

[TexasPhysician]

Related to my question above, can anyone expand when it is appropriate to bill:

99213
99214
99213 + 90833
99214 + 90833

I presume 99213 + 908033 is when you spend 16 minutes with a patient, but why can't you bill just straight 99214 then? What is difference between 99213 + 90833 vs. 99214 alone?

Can you bill 99214 x 3 in 1 hour? Or is that not correct.

You need to research this heavily. There is MDM and time based coding +/- psychotherapy codes +/- interactive complexity. There are also other billable codes. Learn them and memorize them. It was all updated in 2021. Find the updates through Google. Understanding it all is not brief enough to learn via a forum.

 

[Blitz2006]

You need to research this heavily. There is MDM and time based coding +/- psychotherapy codes +/- interactive complexity. There are also other billable codes. Learn them and memorize them. It was all updated in 2021. Find the updates through Google. Understanding it all is not brief enough to learn via a forum.

Ok awesome, will do.

 

[deleted456421]

Ok awesome, will do.

Also, learn if your organization even supports this kind of billing. I've worked at places that didn't allow time-based billing (sometimes superior to MDM) or that had coders whom discouraged interactive complexity.

 

[hallowmann]

Also saw a few docs run clozapine groups and bill 99214 for their patients at a CMHC. I have no idea if that's appropriate.

Might be appropriate. It all depends on the patients and what is addressed in the visit.

 

[randomdoc1]

Many of the previous psychiatrists at my institution had 10-15 minute slots.

However, they all quit within the last few years after hitting 80. They also prescribed copious quantities of benzos. They also seemed to flee when a competent medical director started her job. They also diagnosed everyone with borderline personality disorder as bipolar.

Overall, don't recommend nor does it seem to be the norm these days, despite numerous patients telling me "I'm here to check in and tell you I'm doing okay with my 4 mg of Klonopin daily, don't ask me any questions please."

The interesting thing is that insurance is about cost containment (which I understand, or else it can easily go bankrupt). I suspect if a well conducted study was done on outcomes of the "15 min med check" versus a 25-30 min visit, you'd see better outcomes and lower longterm healthcare costs. If only insurance could start incentivizing these forms of care that are actually in everyone's best interests. Although, that's the problem with healthcare in general, little financial incentive to be preventative but big bucks for tertiary care. Part of it probably has to do with how difficult it is to implement even good change in large systems. My mother has Medicare through United. I found it interesting that they offered these free home visits and they did POC labs and checked her ABIs. Which makes sense, they know those are very well established risk factors for long term cardiovascular cost. It's about saving on health care costs for them which I'm in support of that move. Although United has plenty of other issues too that I won't bore people with.

No. 2-3/hr is pretty much the most you should be seeing to give adequate care unless you are literally doing a very regimented action.

An example in one set of clinics that I saw where people struggled to start clozapine in patients, there was one doc that basically saw everyone on clozapine once a month for their lab and to screen for adverse effects in order to streamline the process for other psychiatrists so more patients that were appropriate could get on it. He'd only make management decisions if urgently needed, he'd screen for adverse effects of clozapine, draw levels or prescribe meds if needed to manage clozapine adverse effects, and they'd see their regular psychiatrist at more reasonable intervals. He'd see 4 in an hour and typically bill 99213 or 99214 depending on if he actually changed something or not.

I may be wrong, but management of medications like lithium or clozapine for bipolar I or schizophrenia respectively--I thought that could easily meet 99215 criteria via MDM? They are chronic conditions that can be life threatening with intensive monitoring for potential toxicity/severe SE and you'd be reviewing prior notes, test results and ordering tests.

 

[hallowmann]

The interesting thing is that insurance is about cost containment (which I understand, or else it can easily go bankrupt). I suspect if a well conducted study was done on outcomes of the "15 min med check" versus a 25-30 min visit, you'd see better outcomes and lower longterm healthcare costs. If only insurance could start incentivizing these forms of care that are actually in everyone's best interests. Although, that's the problem with healthcare in general, little financial incentive to be preventative but big bucks for tertiary care. Part of it probably has to do with how difficult it is to implement even good change in large systems. My mother has Medicare through United. I found it interesting that they offered these free home visits and they did POC labs and checked her ABIs. Which makes sense, they know those are very well established risk factors for long term cardiovascular cost. It's about saving on health care costs for them which I'm in support of that move. Although United has plenty of other issues too that I won't bore people with.



I may be wrong, but management of medications like lithium or clozapine for bipolar I or schizophrenia respectively--I thought that could easily meet 99215 criteria via MDM? They are chronic conditions that can be life threatening with intensive monitoring for potential toxicity/severe SE and you'd be reviewing prior notes, test results and ordering tests.

A lot of the point of the United in home "annuals" is generally less about promoting "prevention" as much as increasing HCC and diagnoses to increase their cut from Medicare because your mom is now "more complex" than she was immediately before the visit. Actual management doesn't happen at these visits ("talk to your PCP about this") and they do not do a good job of getting the diagnostic or note information to the actual PCPs. I say this as someone who has many patients that have these at home annual wellness visits.

Regarding the MDM, the vast majority of management in the clinic that I'm talking about was done by the primary psychiatrist, and this individual was doing only med monitoring of clozapine or in only urgent/emergent situations managing the primary illness (in which case a 99215 certainly could be appropriate). This person was basically seeing 2 psychiatrists, one that made sure they were adherent with clozapine, did their labs, didn't have toxic levels, didn't have terrible adverse effects, and the other psychiatrist that actually managed the condition for which clozapine was needed (as well as any other chronic conditions).

 

[splik]

I may be wrong, but management of medications like lithium or clozapine for bipolar I or schizophrenia respectively--I thought that could easily meet 99215 criteria via MDM? They are chronic conditions that can be life threatening with intensive monitoring for potential toxicity/severe SE and you'd be reviewing prior notes, test results and ordering tests.

It's pretty hard to meet 99215 based on MDM. lithium or clozapine is one point but basically the pt has to be acutely decompensated as well or you have to be reviewing enough data (which is hard to meet for follow ups). your typical f/u visit isn't going to meet criteria for it. It was easier in the old system to meet 99215. That is by design. The 2021 changes meant that most cases will be 99214 and fewer are 99213 or 99215.

 

[wannabie]

I work in the midwest doing telepsych from home. I work thirty five clinical hours and have five admin hours. I have sixty minute new patient visits and thirty minute follow-ups. I make 331k base. I had a 20k signing bonus the first year and a 15k bonus if I resign. They offer benefits but I don't take health insurance. I get thirty days of vacation and five days of CME.

 

[J ROD]

Is it common for outpatient psychiatrists to see 4 or more patients in an hour?

pill md psychiatry. Stimulants and benzos.

 

[TexasPhysician]

Is it common for outpatient psychiatrists to see 4 or more patients in an hour?

Psych doesn’t have a “common”. Some see 1/hr with therapy. Some see 8+/hour.

If I had a scribe, very stable patients, no therapy, etc., 4+ isn’t hard. I had faculty with stable patients that has a quota. Instead of spreading out 15 follow-ups, they saw them all in 2 hours. Minimal controlled scripts and patients were happy with short wait times. No one complained.

Psych seeing 4+ are generally older and don’t utilize therapy codes. I would earn more with:
99214 + 90833 x 2 +
99214 x 1

Than 99214 x 4

 

[Blitz2006]

It's pretty hard to meet 99215 based on MDM. lithium or clozapine is one point but basically the pt has to be acutely decompensated as well or you have to be reviewing enough data (which is hard to meet for follow ups). your typical f/u visit isn't going to meet criteria for it. It was easier in the old system to meet 99215. That is by design. The 2021 changes meant that most cases will be 99214 and fewer are 99213 or 99215.

Really?

Aren't straight medical refill visits 99213, which makes up a large portion of follow ups?

 

[Psychferlyfe3000]

Around 600K per year. Mix of inpatient work, clinical trials, and outpatient consulting work.

What is the work relating to clinical trials? / What % of your income do those make up?

 

[splik]

Really?

Aren't straight medical refill visits 99213, which makes up a large portion of follow ups?

If they have 2 or more stable problems (and I would say for many psychiatrists their pts often have more than one problem) and you are doing rx management, its 99214 now (since 2021). It used to be you had to have 3 stable problems.

 

[Blitz2006]

If they have 2 or more stable problems (and I would say for many psychiatrists their pts often have more than one problem) and you are doing rx management, its 99214 now (since 2021). It used to be you had to have 3 stable problems.

Thanks

So 2 stable problems would be like

-depression and insomnia?
Or
- depression and pain?

 

[rjs2131]

Thanks

So 2 stable problems would be like

-depression and insomnia?
Or
- depression and pain?

Yes - also, don't forget about things like "unspecified anxiety", "unspecified depression", "unspecified xxx" which make it incredibly rare for you to have a patient with only one problem. Also, 99214 applies to one unstable problem as well, so if they aren't in remission/you're still making adjustments to meds that's also a 99214.

 

[calvnandhobbs68]

Thanks

So 2 stable problems would be like

-depression and insomnia?
Or
- depression and pain?

Yes - also, don't forget about things like "unspecified anxiety", "unspecified depression", "unspecified xxx" which make it incredibly rare for you to have a patient with only one problem. Also, 99214 applies to one unstable problem as well, so if they aren't in remission/you're still making adjustments to meds that's also a 99214.

We're getting a bit off topic here but I'm going to correct you all a little, moderate complexity is: 2 stable "chronic illnesses" (NOT just problems) OR 1 chronic illness with exacerbation/progression/treatment side effects OR 1 undiagnosed problem with uncertain prognosis OR 1 acute illness with systemic symptoms OR 1 acute complicated injury.

Chronic illness is "a problem with an expected duration of at least 1 year or until the death of the patient". So it might be difficult at times to justify things like "unspecified anxiety" as a chronic problem if it came to an audit, unless you can clearly delineate the chronicity of this.

 

[TexasPhysician]

We're getting a bit off topic here but I'm going to correct you all a little, moderate complexity is: 2 stable "chronic illnesses" (NOT just problems) OR 1 chronic illness with exacerbation/progression/treatment side effects OR 1 undiagnosed problem with uncertain prognosis OR 1 acute illness with systemic symptoms OR 1 acute complicated injury.

Chronic illness is "a problem with an expected duration of at least 1 year or until the death of the patient". So it might be difficult at times to justify things like "unspecified anxiety" as a chronic problem if it came to an audit, unless you can clearly delineate the chronicity of this.

Using your example, is unspecified anxiety not an undiagnosed problem with uncertain prognosis then? Or even an acute illness with systemic symptoms.

Unspecified anxiety if still being treated is either a chronic illness or a yet undiagnosed/unspecified type of anxiety or an acute issue. In what ways is it none of these if still treating it?

 

[rjs2131]

We're getting a bit off topic here but I'm going to correct you all a little, moderate complexity is: 2 stable "chronic illnesses" (NOT just problems) OR 1 chronic illness with exacerbation/progression/treatment side effects OR 1 undiagnosed problem with uncertain prognosis OR 1 acute illness with systemic symptoms OR 1 acute complicated injury.

Chronic illness is "a problem with an expected duration of at least 1 year or until the death of the patient". So it might be difficult at times to justify things like "unspecified anxiety" as a chronic problem if it came to an audit, unless you can clearly delineate the chronicity of this.

Fair points, but...isn't it the psychiatrist who ultimately determines these things (i.e. has to document in a way that reflects what you've mentioned)?

I also think that in our field, adjustment disorder is probably one of the few diagnoses that one could argue is time-limited...nearly every other "problem" in psychiatry is going to be chronic to some degree.

I see Unspecified Anxiety Disorder as a diagnosis that reflects some ongoing components of anxiety but not enough to meet GAD/Panic d/o - I guess if you don't document when the "unspecified anxiety disorder" started, it could be harder to justify as a chronic problem. GAD is technically >6 months so in theory you may need to document that as well to meet the "chronic" category, but the wording also says expected duration which I would think most would argue tends to be longer.

Lots of nuance here but I agree that if you're trying to be as safe as possible, over documenting these things could be helpful. That said, I doubt most physicians are specifying the length of time specifically for every problem/illness they're using to justify the 99214.

 

[splik]

Fair points, but...isn't it the psychiatrist who ultimately determines these things (i.e. has to document in a way that reflects what you've mentioned)?

I also think that in our field, adjustment disorder is probably one of the few diagnoses that one could argue is time-limited...nearly every other "problem" in psychiatry is going to be chronic to some degree.

I see Unspecified Anxiety Disorder as a diagnosis that reflects some ongoing components of anxiety but not enough to meet GAD/Panic d/o - I guess if you don't document when the "unspecified anxiety disorder" started, it could be harder to justify as a chronic problem. GAD is technically >6 months so in theory you may need to document that as well to meet the "chronic" category, but the wording also says expected duration which I would think most would argue tends to be longer.

Lots of nuance here but I agree that if you're trying to be as safe as possible, over documenting these things could be helpful. That said, I doubt most physicians are specifying the length of time specifically for every problem/illness they're using to justify the 99214.

50% of pts with MDD never have another episode. panic disorder is curable. So is PTSD, which isn't chronic if treated promptly. there is also acute stress disorder. brief psychotic disorder. most problems are chronic though.

I haven't had a full audit but I recently had an insurance company (anthem bc) stop paying for a pt I was seeing twice weekly for psychodynamic therapy billing 99214+90838 for a yr. Dx including persistent depressive disorder and unspecified anxiety. I had to send all the records. Having some expertise in documentation I was interested to see how this would play out. they quickly paid out the 3 months of claims that they had held up (over 20 sessions).

 

[calvnandhobbs68]

Using your example, is unspecified anxiety not an undiagnosed problem with uncertain prognosis then? Or even an acute illness with systemic symptoms.

Unspecified anxiety if still being treated is either a chronic illness or a yet undiagnosed/unspecified type of anxiety or an acute issue. In what ways is it none of these if still treating it?

Sure and also the points @rjs2131 makes are correct, these are the examples AAPC gives for these definitions.

Undiagnosed new problem with uncertain prognosis- A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without medical intervention. An example may be a lump in the breast.

Acute illness with systemic symptoms- An illness that causes systemic symptoms (symptoms affecting one or more organ systems) and has a high risk of morbidity without medical intervention.
For systemic general symptoms such as fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or to prevent complications, see the definitions for ‘self-limited or minor’ or ‘acute, uncomplicated.’ Systemic symptoms may not be general, but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.

If you don't specify, these things will likely be up to interpretation by reviewers in an audit. So I would likely specify exactly WHAT kind of problem I think "unspecified anxiety disorder" is (do I think this is chronic, do I think this is an undiagnosed new problem, is this an acute issue and there are there other systemic symptoms from this, etc). Because what I see happen is people pull something like "unspecified anxiety disorder" forward for 6 months, which probably isn't really gonna pass the "undiagnosed new problem" test. In fact, they may not go for it at all considering DSM definition of unspecified anxiety disorder is:

"This category applies to presentations in which symptoms characteristic of an anxiety dis order that cause clinically significant distress or impairment in social, occupational, or oth er important areas of functioning predominate but do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class. The unspecified anxiety disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific anxiety disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings)."

Other specified anxiety disorder, on the other hand, IS a specified anxiety disorder not meeting other anxiety disorder criteria

 

[SpinDktr]

Trying to get back on topic;

$320k/yr doing inpatient geriatric psych work. It's tough and I am 4 years into a 5 year contract. I like aspects of it; working more with families, and the great staff members and nurses. I don't like the headaches of insurance reviews, court hearings, and bad staff members and nurses. Also, I had to physically restrain a patient last week twice. I have never been hurt or injured. I consider myself adept at reading patients and knowing when and where it is appropriate to restrain patients, but also not something I like or want to keep doing. I think I've been involved in about 4 or 5 restraints since starting? Something like that...

I am looking at possibly breaking out of my contract sooner than 5 years, and take a part time gig while moving to private practice myself. Whether cash or insurance, I'd like to have a more collaborative experience with my patients. I don't really even care about money that much anymore. Would take half my current salary for much less stress....and feel that is very doable.

 

[Nines]

I work at a hospital affilated clinic in the midwest. All OP four 10 hour days per week. 30 min followups and 90 min intakes. One hour admin and one hour lunch daily. Weekend call covering the small unit and consults every 5 weekends and a couple of weekday calls per month over the phone. I do 2 days in office and 2 days tele from home. Salary 270k. Straight salary. Benefits pretty standard for a hospital system. The four day week and two days at home really make the job for me. I can never go back to full time in office or a 5 day week!

 

[forchinet121]

I work at a hospital affilated clinic in the midwest. All OP four 10 hour days per week. 30 min followups and 90 min intakes. One hour admin and one hour lunch daily. Weekend call covering the small unit and consults every 5 weekends and a couple of weekday calls per month over the phone. I do 2 days in office and 2 days tele from home. Salary 270k. Straight salary. Benefits pretty standard for a hospital system. The four day week and two days at home really make the job for me. I can never go back to full time in office or a 5 day week!

I like to put things in hourly compensation because it makes it easier to compare jobs. You’re essentially being paid 175 per hour with benefits which is reasonable.

 

[SubzDoc]

I like to put things in hourly compensation because it makes it easier to compare jobs. You’re essentially being paid 175 per hour with benefits which is reasonable.

OK, good point. I assume you calculated this by assuming 4 weeks of vacation and not being paid for admin or lunch.

So $270k / (1,920 hours per year * 80% face-to-face time) = $175.78 per hour.

But admin time in a salaried position should really be paid for. I do a lot of billable things during admin time. (phone calls, secure messages, etc.). And it doesn't account for other aspects of the job, like call.

There are advantages and disadvantage to reducing things to the hourly rate. It was elsewhere suggested that these descriptions should include some additional details to give a better sense of what the job really entails and what we're doing, and I agree.

As far as I can tell this is still decent for a salaried position in the midwest.

 

[Nines]

I like to put things in hourly compensation because it makes it easier to compare jobs. You’re essentially being paid 175 per hour with benefits which is reasonable.

Yeah that somehow makes the pay seem higher when you put it in terms of the hourly rate haha. I do think I'm paid fairly given they don't care about my RVUs and we have a 1 to 1 doc to nurse/MA ratio in the clinic which is really good and our staff is great which is def worth its weight in gold. Also no expectation to supervise NPs. Four weeks vacation and 5 k and 5 days CME time. Not bad at all.

 

[Nines]

OK, good point. I assume you calculated this by assuming 4 weeks of vacation and not being paid for admin or lunch.

So $270k / (1,920 hours per year * 80% face-to-face time) = $175.78 per hour.

But admin time in a salaried position should really be paid for. I do a lot of billable things during admin time. (phone calls, secure messages, etc.). And it doesn't account for other aspects of the job, like call.

There are advantages and disadvantage to reducing things to the hourly rate. It was elsewhere suggested that these descriptions should include some additional details to give a better sense of what the job really entails and what we're doing, and I agree.

As far as I can tell this is still decent for a salaried position in the midwest.

Yes it is actually on the higher end in my metro area. It's higher than the local academic center and the community mental health centers in the area and about par with the other community hospitals but with less work in my case as I know that the other major system demands 20 min followups and NP supervision though it does not require call. So many factors that go into what makes a job good or bad. It's all a tradeoff. I would rather make a bit less or take call if other aspects of the job are great.

 

[rjs2131]

50% of pts with MDD never have another episode. panic disorder is curable. So is PTSD, which isn't chronic if treated promptly. there is also acute stress disorder. brief psychotic disorder. most problems are chronic though.

I haven't had a full audit but I recently had an insurance company (anthem bc) stop paying for a pt I was seeing twice weekly for psychodynamic therapy billing 99214+90838 for a yr. Dx including persistent depressive disorder and unspecified anxiety. I had to send all the records. Having some expertise in documentation I was interested to see how this would play out. they quickly paid out the 3 months of claims that they had held up (over 20 sessions).

These things may be true in theory but...I'm not sure I've seen them much in practice. Seems most patients are just not that resilient even with great treatment. Agree with acute stress/brief psychotic, but those are things I have diagnosed maybe a handful of times. All that to say, I would still code a 99214 (or just use different diagnoses and play the game ) for visits with 2+ problems. Good to know you were able to get your worth with biweekly 99214+90838!

 

[clausewitz2]

These things may be true in theory but...I'm not sure I've seen them much in practice. Seems most patients are just not that resilient even with great treatment. Agree with acute stress/brief psychotic, but those are things I have diagnosed maybe a handful of times. All that to say, I would still code a 99214 (or just use different diagnoses and play the game ) for visits with 2+ problems. Good to know you were able to get your worth with biweekly 99214+90838!

The true anxiety disorders (so ironically not generalized anxiety disorder) are very curable most of the time with the actual appropriate treatment. OCD can be well-managed to the point that it has very little impact on someone's life without a single medication in some cases. About 30% of people who have a first psychotic episode never have another one.