What is considered "prescription drug management" for 99214?

[hebel]

I have an appendix section from AACAP that says when considering risk level within the MDM, that "the risk of complications...includes the possible management options selected and considered, but not selected, after shared medical decision making with the patient and/or family."

Does this mean if I discuss potential medication options, but end up not prescribing a medication because the patient declines medication that this would still fall under "prescription drug management?"

Then, let's say the above patient is still seen by me weekly for therapy, but at each visit I am still technically monitoring whether or not a medication would be warranted based on symptom progression at each visit. Can those visits still meet criteria for moderate risk based on "prescription drug management" even if the extent of medication involvement is me internally assessing whether or not therapy-only treatment remains appropriate?

I would say scenario 1 meets moderate risk criteria, but 2 probably doesn't. Does that sound correct? Can 2 meet that criteria if I simply checked in with the patient about if they still wanted to remain off the medications I suggested?

---

Members don't see this ad.

 

[FlowRate]

While we're asking questions about vaguely worded E+M levels:

"1 (or more) chronic illness with exacerbation, progression, or side effects of treatment."

My question with this one is really when are you definitely NOT coding PA as lv4? Yearly check-in on someone with completely remitted MDD who's taking an SSRI from which they've never had side effects? If their PHQ-9 changes by even one point does that count as progression/exacerbation?

(This is more an academic point for me, most pts have at least 2 diagnoses or have obvious changes in sx)

 

[calvnandhobbs68]

I have an appendix section from AACAP that says when considering risk level within the MDM, that "the risk of complications...includes the possible management options selected and considered, but not selected, after shared medical decision making with the patient and/or family."

Does this mean if I discuss potential medication options, but end up not prescribing a medication because the patient declines medication that this would still fall under "prescription drug management?"

Then, let's say the above patient is still seen by me weekly for therapy, but at each visit I am still technically monitoring whether or not a medication would be warranted based on symptom progression at each visit. Can those visits still meet criteria for moderate risk based on "prescription drug management" even if the extent of medication involvement is me internally assessing whether or not therapy-only treatment remains appropriate?

I would say scenario 1 meets moderate risk criteria, but 2 probably doesn't. Does that sound correct? Can 2 meet that criteria if I simply checked in with the patient about if they still wanted to remain off the medications I suggested?

So yes, for Scenario 1 I would call that a 99204/99214 based on MDM for sure. AACAP slides about E+M for 2021 also support that as well (as you noted).

https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/business_of_practice/cpt/EM_2021_office_visit_codes_intro_scripted.pdf

Also remember for 99214 if someone is on a medication, as long as you're "monitoring" the medication and stating that you are (so stating what side effects the patient does/does not have, any lab/vital/EKG/etc monitoring you're anticipating and what schedule this would be, discussing the efficacy of the medication in your assessment and plan), if they have a chronic condition (depression) and they're on a medication (fluoxetine) but you don't adjust the dose even if there is a change in their symptoms (say they come in, say they've been feeling more down and lower appetite for the past couple weeks, but you decide not to change the med dose at that time, tell them to have more regular followup visits with their therapist and schedule them to come back in 3-4 weeks to re-eval), then it still counts as a 99214 as long as you throw in a few sentences about it. Another bonus for child is that "diagnosis or treatment is significantly limited by social determinants of health", so for instance if mom and dad disagree about meds or they're a foster child and you can't get med consent readily that day and you decide not to prescribe anything that visit because of this, you can document that in a sentence or two and still hit criteria for a 99214 (could also bill interactive complexity 90785 if you were billing 90833 add on for that too).

For Scenario 2, I think if the insurance company ever takes a good look at those notes, if you're billing 99214 + 90833 for instance for those visits but seeing them weekly, they're probably gonna try to claw that back into a 99213 + 90833 (or even ask why you're not just using therapy only codes). They're probably going to say you'd be hard pressed to justify evaluating them WEEKLY for medications, given that a typical CBT course will last a few months. Now if you were coding like one of those visits a month 99214 + 90833 and stating in that note you've been working with them in therapy for x sessions, response has been x, again discussed meds with parents due to unsatisfactory progress, etc....you can probably justify that.

Take this with a grain of salt as I only code for outpatient at my moonlighting (which pays hourly) and one of my community clinics and so don't have a great great idea of how my codes have been accepted/kicked back, although I think if lots of them had been kicked back I would have heard about it. I am joining a private practice next year though so I've been trying to be as accurate as possible about this so it doesn't bite me in the ass next year.

 

[calvnandhobbs68]

While we're asking questions about vaguely worded E+M levels:

"1 (or more) chronic illness with exacerbation, progression, or side effects of treatment."

My question with this one is really when are you definitely NOT coding PA as lv4? Yearly check-in on someone with completely remitted MDD who's taking an SSRI from which they've never had side effects? If their PHQ-9 changes by even one point does that count as progression/exacerbation?

(This is more an academic point for me, most pts have at least 2 diagnoses or have obvious changes in sx)

Really I think 99213 is only appropriate in psychiatry for patients with ONE problem who are completely stable in terms of problem treatment and medication management. So like a 13yo with just ADHD who comes in to refill 60mg Vyvanse and is doing totally fine, no problems with medication to discuss, no problems with school or home to discuss, vitals are completely normal, growth is completely normal. I could also see that patient in 15-20 minutes as well though and bill 3-4 99213s an hour.

You're right that by the time they get referred to us, it's usually people with multiple problems (ADHD and MDD, MDD and social anxiety, MDD and substance abuse, etc). I common thing I see a lot of people forgetting to assess and bill for as well is nicotine use disorder...everyone who smokes basically has NUD and if you say you continue to address this using MI techniques, offer med management for it, etc, you're addressing the problem.

Basically if they could probably be seen by their PCP probably qualifies as a 99213.

 

[robellis]

I don’t think in a typical outpatient practice you should ever be billing less than 99214

 

[clausewitz2]

While we're asking questions about vaguely worded E+M levels:

"1 (or more) chronic illness with exacerbation, progression, or side effects of treatment."

My question with this one is really when are you definitely NOT coding PA as lv4? Yearly check-in on someone with completely remitted MDD who's taking an SSRI from which they've never had side effects? If their PHQ-9 changes by even one point does that count as progression/exacerbation?

(This is more an academic point for me, most pts have at least 2 diagnoses or have obvious changes in sx)

APA put out a document that suggested that chronic illnesses should not be considered "stable" if the person in question has not reached their treatment goals, even if progress in that direction has stalled. so if the PHQ-9 is still outside of the normative range, it doesn't need to have changed to get you to level 4.

Your completely remitted example with no side effects and who is generally satisfied with their lives is probably a level 3 without another problem.