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99214 will get you like 130 by most insurance companies, with overhead and no shows that’s not too great without the 90833 for a 30 minute visit unless I’m missing something
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Sure but if the majority of those visits aren’t involving therapy, it would make a lot more sense to revamp the schedule to not dedicate 30 minute slots to everyone. You could leave hours earlier or increase revenue. Stable patients can be referred back to their PCP.
Maybe I’m misinterpreting and we are actually arguing the same thing, but I feel like a typical day is 80% therapy involvement. Maybe 20% isn’t. Even erring on a large standard deviation, <50% therapy with 30 minute slots and the clinic would be terribly inefficient.
This is where personal style comes in I think - I have a handful of these (usually male teenagers), but they've learned to treat our visits as "30 minutes of time for me" and I'll just space visits out further if there isn't as much to talk about. I always ask about things like stressors, school, parents, relationships, summer activities, etc and set the standard early on that I'm not the "quick in-and-out" psychiatrist who is just here to refill meds. If patients/families aren't cool with that, no problem - there are plenty of folks out there who will do the 10-15 min visit. In my experience, most patients like having the time and have no issues with it. It usually ends up being a win-win and allows the 90833.
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Yeah I was thinking about 50% would be right. Appreciate it. I will tend to get 99214 and NP the easier 99213.
as long as you are providing some kind of psychotherapeutic intervention that you can justify as medically necessary and the pt is capable of benefitting from it, you can use a psychotherapy add on. I do a lot of psychotherapy. I also see pts who are not capable of benefitting from therapy at all such as pts who are catatonic, have dementia, acutely manic, have severe intellectual disability, or otherwise significantly cognitively impaired due to neurologic disorders. in those cases, I do not use a psychotherapy add on because even if I were trying to provide therapeutic interventions the pt would not be able to benefit and it would be abuse of the codes and not appropriate. Similarly, if I am spending much of the time discussing medication options or providing counseling about interventions then it would not be appropriate to use a psychotherapy add on code.
We are definitely seeing very different patient populations (I'm a CAP but also see younger adults, usually higher functioning) but for most of the categories you mentioned, the patient is pretty limited in what they can communicate so I would assume you need another person present (family member, guardian, etc). I could see this translating into some family-based type of psychotherapy where you are helping the caregiver/family communicate with the patient and make treatment decisions. How you define that is up to you (I think supportive/expressive psychotherapy can encompass a lot of different things).
To each their own but I think it's pretty easy to justify therapy add-on codes because the burden of defining therapy is on us. Insurance companies don't know the difference between psychodynamic, CBT, MI, DBT, etc. Sure, if you are trying to be as "by the book" as possible and only thinking of psychotherapy as formal, manualized/evidence-based therapy that will limit your options. If my patients are getting better and I'm spending quality time with them, that's worth something - to me, that justifies a therapy add-on code. We're working in a system designed to maximize our efforts and minimize our compensation, so I have no problem finding creative ways to offset that.
No, that is not allowed. The rules are quite clear on this. Pt has to be capable of benefiting from it. There are separate family therapy codes that are not add on codes that require minimum of 26 mins in family therapy.
You say "insurance companies" don't know the difference but that is not true because it would be a psychiatrist reviewing the records for medically necessity. Also MI doesn't count.
I do think you can use add on codes most of the time, but the pt has to be capable of benefiting from it, otherwise it is considered abuse, and not appropriate.
For me, these are "see-pee-see-pee" patients. They get a copy of their final A&P to show their PCP (i.e., ADHD, stable on Adderall 30 mg QAM since childhood, compliant with all controlled sub policies, no diversion concerns, recommend PCP maintain dosage, agrees to discharge back to PCP). This reassures PCPs, and I don't have to waste time with the occasional anxious PCP who calls me.
Also, psychiatry is a two way relationship. The relationship needs to benefit me as well. Doing 10 minute refills all day neither grows me financially nor my therapeutic skills.
Seeing 4 patients an hour doing 10 minute visits would certainly benefit you financially..
For argument's sake - when have you met a patient who needs to consistently see a specialist level of care (psychiatrist) who is not capable of benefit from supportive/expressive therapy? I don't think I've ever met a patient like this. If they are truly that stable, they should be following up with PCP for med refills.
Even if it is a psychiatrist that is working for the insurance company and determining whether or not therapy is a medical necessity - how do you actually prove that it's not? Your notes are the only basis they have for this, as they aren't seeing this patient regularly like you are. Unless you're seeing a stable patient every week and using therapy add-on codes (which some folks do and get reimbursed for without an issue), I'm not sure how you can argue that the q2-3 month patient that you see for 30 minutes isn't benefitting from some type of therapy. I'll take those odds.
Also, please do share where MI/family therapy is specifically excluded as an acceptable therapeutic modality for therapy add-on codes! I may have missed this but I haven't seen a document that outlines what specific therapeutic modalities are acceptable, would love to have that info.
Sure but I mean like I don't care. I still make plenty and I just use the time for other stuff. In the spirit of this thread, I would easily still make low 300s if I just left everyone as a 99214 based on time for 32 hours a week. I don't feel like trying to figure out who is or isn't going to be a 15min followup and then sometimes 15min turns into 20 minutes and then you're 5 minutes behind and then another 10 minutes behind...I know how that goes.
I send the people who are essentially 99213s back to their PCP but again, even I billed straight 99214s on time all day, I'd still be very comfortable. I usually offer people go back to their PCPs if they're pretty stable but a lot of them rather stay with me.
Indeed.com
Motivational interviewing is not an accepted type of therapy for add-on codes. Family therapy isn’t either, but as CAP, we generally aren’t doing family therapy in the true sense of it. We are doing individual therapy or play therapy or interpersonal therapy or PCIT with family present. Family may have involvement, but our aim is treating the child, not the family.
Do you know where I can find that explicitly stated (MI/family therapy not accepted)?
And yeah, agree with the points about family therapy. I also don’t think most are doing formal manual based therapy for 16 min to justify a 90833, so a lot of this is semantics anyway. Might as well have the semantics work in your favor.
This brings up an important point - I think a lot of the differences in opinion on therapy add-on codes probably relates to total compensation. I would barely break 200k with only using 99214s for 30 pt hours (30 min visits), so you’ve probably got a better insurance contract. Those 90833s are what get me closer to the 300k mark.
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It is news to me that MI does not count as well. Does that mean no one can ever be reimbursed by insurance for doing MI? Or is it specific to a 90833 add on?
Wow that’s actually nuts..you would barely break 200k while he makes 325k for the same exact work…that’s unfortunate
I haven’t seen anything with the 2021 E&M Update that would change it, but E&M claimed that motivational interviewing was not therapy. They said motivational interviewing was a type of interviewing or a part of collaborative care with patients. This is E&M powers that be, not a mental health group.
If you think that’s nuts, take a look at what hospitals make off facility fees and then what they pay people in academic/hospital clinics. Literally bill for 2-3x what someone can bill in a stand-alone clinic or private practice.
And it’s not necessarily the same work. If you look at what we said, I don’t care as much about putting in the effort to discharge relatively stable patients or try to get to a 30min visit because I’m just fine billing 50% without the therapy add on code. But that also means my patient panel might have more stable patients or might be more inefficient overall.
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Well the codes (90832-90839) are specifically for individual therapy. It is in the name. It can't get much clearer than that. Look it up in the AMA CPT book. There are separate codes for family therapy (90846 and 90847). They are not add on codes. You could use them with E&M with modifier -25 but you need to spend at least 26 mins in family therapy and write a separate note from the E&M note and both services must be separately identifiable.
Definitely defer to your expertise as to the letter of the law, but I've used this code successfully in child and adolescent inpatient work to capture family therapy in addition to the E/M code and our main payor was ok with this - I guess its possible that they were allowing something they didn't need to, but it was certainly a dialog as they even gave feedback as to asking that if we did this we identify the specific type of family therapy.
I feel like a lot of this is still open to interpretation. Guess everyone’s getting “supportive/expressive” therapy or “insight-oriented” therapy until further notice!
I don’t see it that way - it depends on the setup. The patient population I see + the autonomy I have in PP are invaluable. It’s not the exact same work!
That being said, I don’t think making >300k using purely 99214s for 30 min visits is common…I’ve only seen that happen when working for a big hospital system but that brings along other headaches.
120 avg per 99214 x 2 an hour x 32 hours x 48 weeks a year x .85 = 313k
That’s the simplest way that assumes a completely full schedule but also involves only having 32 patient contact hours a week. If one saw 35 patient hours a week, would likely actually average at least 32 a week.
Yeah math checks out but is this PP or employed? The numbers I’m using are PP after you take out overhead.
If we’re talking gross income before any overhead/expenses, that’s definitely >300k for purely 99214s.
85% is my cut from the overall group so it’s after their take (thus the .85 at the end). I do realize this is a solid split.
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Yeah 85% is incredible...I've never seen anything >70%. Your practice must be extremely efficient with overhead/expenses for that to work. Are you doing a lot of your own admin work (PA's, scheduling, etc)?
If you took your numbers and applied a more common split of 70%, it'd be more like 250k with only 99214's.
They also contacted me by LinkedIn
Seems low. As a moonlighter I'm getting like 75 more per hour than this works out to. Would also have potential to go full time with benefits at 9x12s.
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Eh it’s salaried with bennies (even matches 4% of gross) and the best part…no one’s breathing down my throat, whether I end up seeing 4/day or 12. I refuse to take on an underlying productivity requirement worked into any base salary compensation formula.
But yes, academic, east coast, and low. I only do it in exchange for a PSLF loan payoff (hopefully) while getting 19-20 days per month off. I primarily dislike the city I live in, which makes it work out. The winters are so god awful though that one can get trapped.
You’re making like 35 dollars per hour..unless I’m missing something…
That’s a sobering calculation. However I factor in 500+K in loans which will (again hopefully) get discharged in 2.5 years.
How do you get that? 10 shifts a month, 12 hours, I get to $152 an hour.
I wondered the same thing…I’m not selling my soul for that cheap. And I do get a month of vacation/year on top of 20 days a month off.
I knew something was off, sorry I made a mistake it is in fact 152 per hour I accidentally had you working 10 shifts a week instead of per month. Lol
I agree 85 is great, but I negotiated my way up to 80 after a year from 70% split by saying, "I want 80%", to which the practice owner replied, "okay." Worth pushing a bit for it. I do my own PAs, (maybe 1-2 hours a week tops, many weeks none) and I schedule people for their next appointment at the end of every appointment. I vastly prefer scheduling follow-ups myself because I have a sense of who would be a bad idea to put at the end of the day, who is never going to make it at 8 AM, and who to always schedule right before lunch because they inevitably run a bit long. Some people are also exhausting enough that I do not want them to be back to back for my sake. Admin schedules intakes and handles all billing.
That's great! We've got our own folks that do PAs and really any admin stuff other than occasional scheduling (I'll do my own for virtual visits because it's easier). I think our setup is different as well where the split is the same for every partner but there are bonuses that are based on productivity. I do think the percentages could be better, but tough to argue this when it's the same for everyone else...maybe the practice just needs to be more efficient.
So an interventional cardiologist and a trauma surgeon walk into a psychiatry forum...
…And neither of them entertained 152 an hour! <sipping my poolside daiquiri>
…and immediately leave to answer a page.
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I enjoyed reading through this thread. Sounds like many are making great money in psychiatry. I'm currently active duty military planning to separate in 1 year. Very likely going to work for VA in OK or TX. I have a pretty good idea of what VA entails and the income possible working with them. I will also be buying back my active duty time towards the pension. I am looking to moonlight some while working if possible. Does VA have any sort of non compete clause for contracts with them preventing you from moonlighting? If no, how difficult is it to find moonlighting jobs? Do you just cold call places and see if they're looking for someone to pickup extra shifts? Just trying to start preparing for when I'm out on the civilian side.
There are no contracts with VA. If you go tenure-track on the faculty at a VA with an associated medical education program, however, this can come with strings attached even if they aren't really paying you. Finding moonlighting is largely market dependent and also depends on a variety of factors, what kind of work you want to do and when, etc.
A couple of ways I've seen people find moonlighting is posted PRN/coverage jobs and most commonly by networking/word of mouth. Depending what sort of place you land, I'd reach out to local psych units or any academic psych departments directly.
Huh? Our VA definitely has contracts. There are some limitations on what you can say/receive as a representative of the VA, but generally speaking outside of your "active tour" hours you can pretty much moonlight wherever you want here. However, one cannot do any kind of outside work whatsoever during VA work hours.
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I figured this process was universal for VA systems but I guess that is not the case. I have never signed a contract. I'm sure we have any number of policies on what we can/can't do as employees (outside jobs during your tour are obviously out), but it did not involve a contract. The only thing I signed was an agreement to pay back the signing bonus on a prorated basis if I left within 2 years. There is a reddit on this and most agreed they did not have a contract:
Interesting, maybe the offer letter at our VA is just really detailed. I know there are contracted docs, but I'm pretty positive the federally employed docs where we're at have contracts as well.
You are doing telepsych to USA Im assuming?
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