Billing 90792 vs 99205

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PistolPete

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Why would a psychiatrist bill a 90792 for a new patient evaluation, if they can bill a 99204 or 99205 and get reimbursed more?
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Many psychiatrists are not familiar with the new E/M codes.
 
Depends on the insurance company. I know that Medicare does not recognize the 90792 code for billing. There is a bit more in reimbursements when you bill for 90792.
 
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That's interesting. When the billing codes switched over in 2013, APA and others (including Los Angeles DMH) recommended using 90792 to replace the old 90801.
 
Shikima said:
Depends on the insurance company. I know that Medicare does not recognize the 90792 code for billing. There is a bit more in reimbursements when you bill for 90792.
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When I look it up on Medicare fee schedule, 90792 for my area pays 153.41. 99204 pays 183.53 and 99205 pays 227.93. Shouldn't be too hard to bill for a level 4 NEW patient visit, so you'd expect the 99203-99205 codes to be used more since both apply to new patients, no?
 
PistolPete said:
Why would a psychiatrist bill a 90792 for a new patient evaluation, if they can bill a 99204 or 99205 and get reimbursed more?
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For some reason, I've found that 99204 pays better than 90792, but 90792 has a higher rvu number. I'm not sure if this is still true, but a friend on faculty at an academic center had said that he bills 90792 because his bonus is based on rvu's, not income generated.
 
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Have any of you received any guidance as to billing for a 99205? I work with a primarily child population, so my intakes are 90 minutes long, and I frequently interview parents and children/adolescents separately and together. I have debated on how I should be billing for this. It's fairly easy for me to score the number of problem points and data points needed for high-level medical-decision making and a 99205 (e.g., 4 problem points for a new problem with further work-up AND 4 data points (2 for collateral from parents and 2 for reviewing a rating scale v. getting a rating scale and labwork).

I've heard some say medical necessity trumps all of the above, and that if my patient isn't dying (any idea whether SI without plan or intent counts?), billing 99205 isn't appropriate. The AACAP webinar suggests that 99205 can be billed for ADHD with ODD, to the contrary.

http://www.aacap.org/AACAP/Clinical...spx?hkey=e53bd2fa-d1f9-4db5-bbfa-17f48bec4e35

My other thought is with these longer work-ups if I just couldn't do 99204 + 99354 extra time (30-74 minutes of additional time), as I'm easily in this window (45 minutes for 99204 + an additional 45 minutes of face-to-face time), and I do find that I typically get a much more thorough history from the patient and family and get care off to a better start this way.
 
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Information Underload said:
Have any of you received any guidance as to billing for a 99205? I work with a primarily child population, so my intakes are 90 minutes long, and I frequently interview parents and children/adolescents separately and together. I have debated on how I should be billing for this. It's fairly easy for me to score the number of problem points and data points needed for high-level medical-decision making and a 99205 (e.g., 4 problem points for a new problem with further work-up AND 4 data points (2 for collateral from parents and 2 for reviewing a rating scale v. getting a rating scale and labwork).

I've heard some say medical necessity trumps all of the above, and that if my patient isn't dying (any idea whether SI without plan or intent counts?), billing 99205 isn't appropriate. The AACAP webinar suggests that 99205 can be billed for ADHD with ODD, to the contrary.

http://www.aacap.org/AACAP/Clinical...spx?hkey=e53bd2fa-d1f9-4db5-bbfa-17f48bec4e35

My other thought is with these longer work-ups if I just couldn't do 99204 + 99354 extra time (30-74 minutes of additional time), as I'm easily in this window (45 minutes for 99204 + an additional 45 minutes of face-to-face time), and I do find that I typically get a much more thorough history from the patient and family and get care off to a better start this way.
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You should only do the extended visit code in conjunction with the 99205. If you'll be on the time of the night 9204
Information Underload said:
Have any of you received any guidance as to billing for a 99205? I work with a primarily child population, so my intakes are 90 minutes long, and I frequently interview parents and children/adolescents separately and together. I have debated on how I should be billing for this. It's fairly easy for me to score the number of problem points and data points needed for high-level medical-decision making and a 99205 (e.g., 4 problem points for a new problem with further work-up AND 4 data points (2 for collateral from parents and 2 for reviewing a rating scale v. getting a rating scale and labwork).

I've heard some say medical necessity trumps all of the above, and that if my patient isn't dying (any idea whether SI without plan or intent counts?), billing 99205 isn't appropriate. The AACAP webinar suggests that 99205 can be billed for ADHD with ODD, to the contrary.

http://www.aacap.org/AACAP/Clinical...spx?hkey=e53bd2fa-d1f9-4db5-bbfa-17f48bec4e35

My other thought is with these longer work-ups if I just couldn't do 99204 + 99354 extra time (30-74 minutes of additional time), as I'm easily in this window (45 minutes for 99204 + an additional 45 minutes of face-to-face time), and I do find that I typically get a much more thorough history from the patient and family and get care off to a better start this way.
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You should only add the extended visit code to a 99205.
 
99205 can usually be met in psychiatry. Generally the PCPs can handle the simple stuff (at least around here).

1) You should be able to meet the history and exam portions.
2) On the MDM, you are generally going to have 2 diagnoses, for example the ADHD/ODD in child as mentioned above or depression/anxiety/insomnia/substance abuse etc in adults.

If you only have one diagnosis: This is from the AACAP site:
One or more chronic illnesses with severe exacerbation, progression, or side effects;
Acute or chronic illnesses that pose a threat to life or bodily function
 
if you are billing on the basis of counseling and coordination of care, then time alone matters. so if you are doing a 60 minute visit w/ >50% time in counseling and coordination of care (which seems unlikely for an initial visit but whatevs) then that would be a level 5.
 
Information Underload said:
Any particular reason?
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Yes. If billing based on time, the 99204 is used for 45-59 minutes. 99205 is used for 60+ minutes. To use the extended visit add on (99354) you would have to go 90+ minutes (60 + at least 30 more minutes to use 99354).

However my initial answer was not fully complete. If billing based on complexity (level of service), you can bill a 99204 + 99354 extended service. For example, if the documentation justifies a 99204 and the total visit was 1 hour 15 minutes, you could subtract the usual 99204 time (45 minutes), leaving the 30 minutes required to use the add on 99354.
 
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Information Underload said:
Have any of you received any guidance as to billing for a 99205? I work with a primarily child population, so my intakes are 90 minutes long, and I frequently interview parents and children/adolescents separately and together. I have debated on how I should be billing for this. It's fairly easy for me to score the number of problem points and data points needed for high-level medical-decision making and a 99205 (e.g., 4 problem points for a new problem with further work-up AND 4 data points (2 for collateral from parents and 2 for reviewing a rating scale v. getting a rating scale and labwork).

I've heard some say medical necessity trumps all of the above, and that if my patient isn't dying (any idea whether SI without plan or intent counts?), billing 99205 isn't appropriate. The AACAP webinar suggests that 99205 can be billed for ADHD with ODD, to the contrary.

http://www.aacap.org/AACAP/Clinical...spx?hkey=e53bd2fa-d1f9-4db5-bbfa-17f48bec4e35

My other thought is with these longer work-ups if I just couldn't do 99204 + 99354 extra time (30-74 minutes of additional time), as I'm easily in this window (45 minutes for 99204 + an additional 45 minutes of face-to-face time), and I do find that I typically get a much more thorough history from the patient and family and get care off to a better start this way.
Click to expand...

My understanding is that yes, medical necessity trumps all. You only get paid for the work you do. Doesn't make sense to get paid 99215 money for a 10 minute visit. So I think most insurances will look at MDM first, regardless of the other criteria.

I think based on how you schedule your visits you should have no problem coding for 99204 or 99205 + 99205 as you list above (which was new to me).
 
Information Underload said:
Have any of you received any guidance as to billing for a 99205? I work with a primarily child population, so my intakes are 90 minutes long, and I frequently interview parents and children/adolescents separately and together. I have debated on how I should be billing for this. It's fairly easy for me to score the number of problem points and data points needed for high-level medical-decision making and a 99205 (e.g., 4 problem points for a new problem with further work-up AND 4 data points (2 for collateral from parents and 2 for reviewing a rating scale v. getting a rating scale and labwork).

I've heard some say medical necessity trumps all of the above, and that if my patient isn't dying (any idea whether SI without plan or intent counts?), billing 99205 isn't appropriate. The AACAP webinar suggests that 99205 can be billed for ADHD with ODD, to the contrary.

http://www.aacap.org/AACAP/Clinical...spx?hkey=e53bd2fa-d1f9-4db5-bbfa-17f48bec4e35

My other thought is with these longer work-ups if I just couldn't do 99204 + 99354 extra time (30-74 minutes of additional time), as I'm easily in this window (45 minutes for 99204 + an additional 45 minutes of face-to-face time), and I do find that I typically get a much more thorough history from the patient and family and get care off to a better start this way.
Click to expand...


I don't think ratings scales are considered "data points". I wish they were, but I looked around online and I can't find any evidence supporting it. However, you can code 96110 for each rating scale. I think it's 0.36 RVUs or something like that.

In my experience, it's really hard to hit the 3-4 data points, even in child psych. The collateral 2 points is automatic with parents, but we rarely get labs, imaging, or EKGs, and talking to the patient's therapist or PCP is also uncommon. My billing usually comes down to problem points and risk.
 
Shikima said:
The caveat is that CMS doesn't allow for this code any longer. Straight E&M coding from here on out.
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thx, that's good to know. I haven't had any problem with billing 90791 for inpatients in MS, but I have never tried billing this code for an outpatient. I will be sure and check with my billing dept regarding if 90791 on inpatients.
 
michaelrack said:
many psychiatrist will bill the 90791 for a new patient eval. This code does not require a ROS or physical exam.
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the APA recommends that psychiatrists use 90792 and don't use 90791 which is really for non-psychiatrists. They argue by definition "medical services" are provided by psychiatrists all the time. Technically 90791 does require ROS and examination (the "physical exam" in psychiatry is obviously just the mental status examination).There is no difference between the codes except "medical services" which isn't defined.

and you don't have to use the E/M code, you can still use 90792 for iniital evaluation.
 
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Not sure if this is the right thread for my question, but I figure I post here instead of start a new thread:

1. In actual private practice, what is the turn around time from when you bill the insurance, to when you receive payment?
2. In your guys' experience, how often does insurance balk and say they won't pay for a 99214, but will only pay for a 99213, for example, despite adequate documentation?
 
PistolPete said:
Not sure if this is the right thread for my question, but I figure I post here instead of start a new thread:

1. In actual private practice, what is the turn around time from when you bill the insurance, to when you receive payment?
2. In your guys' experience, how often does insurance balk and say they won't pay for a 99214, but will only pay for a 99213, for example, despite adequate documentation?
Click to expand...

For me? 6ish weeks with a 97% return rate. I've got good office people... the girls are on top of it. The only time you'd see an ins company balk at a 213 v 214 will be through random or scheduled reviews of charts which they have legal access to.
 
Jester25 said:
I don't think ratings scales are considered "data points". I wish they were, but I looked around online and I can't find any evidence supporting it. However, you can code 96110 for each rating scale. I think it's 0.36 RVUs or something like that.

In my experience, it's really hard to hit the 3-4 data points, even in child psych. The collateral 2 points is automatic with parents, but we rarely get labs, imaging, or EKGs, and talking to the patient's therapist or PCP is also uncommon. My billing usually comes down to problem points and risk.
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See at 25:00 minutes into this video from AACAP.



A rating scale nets you 2 data points. I posted the youtube link because it's easier to navigate, but here is the link to the AAAP site:

http://www.aacap.org/AACAP/Clinical...spx?hkey=e53bd2fa-d1f9-4db5-bbfa-17f48bec4e35
 
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Shikima said:
For me? 6ish weeks with a 97% return rate. I've got good office people... the girls are on top of it. The only time you'd see an ins company balk at a 213 v 214 will be through random or scheduled reviews of charts which they have legal access to.
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Awesome, thanks. Nice to see that you actually get paid for the work that you do. Looks like taking insurance is now a good gig since the new E&M codes.

If you don't mind my asking, do you use EPIC, or some other EMR? What was the insurance credentialing process like?
 
PistolPete said:
Awesome, thanks. Nice to see that you actually get paid for the work that you do. Looks like taking insurance is now a good gig since the new E&M codes.

If you don't mind my asking, do you use EPIC, or some other EMR? What was the insurance credentialing process like?
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I'm using Athenanet. It sucks. I wish I had EPIC, at least it was user friendly and configurable. The current system is meant for primary care only. Any PP venture, keep your OH costs to 20% or less. May need to join someone who is in PP and share costs that way. If you want to increase billing, do C&L but in reality, the medicine service docs then just consult you for everything under the sun -- Pt won't listen to medical advice, call psychiatry. Pt is angry at being in the hospital over Christmas, call psychiatry. But there can be some good benefits with billing for those services if you're easy going and don't mind rushing between the hospital and clinic and the OH associated with that is just the billing and electricity costs. I never did the credentialing, I let the PHO do that with the hospital I'm associated with - I feel that's their job.
 
Hey all,

Sorry to dig up such an old thread, but I am curious specifically about billing 99205 for intakes. I took EM University course which talks about the 4 problem points (additional workup required) as ordering blood tests, urine drug screen, etc. I was told by some that med changes qualify, but I am not sure if that's right. I watched the AACAP video and he says that using a rating scale after the initial visit qualifies as additional workup. Is that what you guys do? Just wondering how you all get the 4 problem points to meet criteria for 99205. I know I can do time based coding but then I cannot do add on, and I always spend 15 minutes minimum doing therapy on intakes. I never go off data points btw since it's too hard to get those in psychiatry.

Say I have a pt that definitely meets criteria for high risk (severe exacerbation of chronic illness or SI), how do I get 4 problem points? Is ordering labs or using a rating scale in the future the only way for "additional workup"? Or is simply seeing them in 2-3 weeks to reassess enough and noting "will evaluate further in the future to confirm diagnosis"? I'm also wondering if it is best to keep the diagnosis for initial appt vague, like unspecified mood disorder, and then in the follow up changing diagnosis to say MDD since it seems the "additional workup" is for figuring out a definitive diagnosis.
 
Last edited:
At the post above, this link explains it really well.
https://www.aacap.org/App_Themes/AA...f_practice/cpt/EM_Coding_SUmmary_Guide_v2.pdf

Specifically in regards to the problem points, my understanding is that any diagnosis you make since that patient is new to you anyways gives you three points. So if you diagnose more than one diagnosis which is more the norm than exception, that should get you well into those 4 points. To get 99205 you need a COMP history, COMP exam, and high MDM (if in your case the risk is already high, all you need is two diagnoses assuming you meet the history and exam requirements).
 
I appreciate the reply, but the link does not explain what I am referring to, namely what specifically meets criteria for the "additional workup" required for 4 problem points.
 
Don't know if using a scale really counts and I wouldn't risk it. I usually just list the primary diagnosis and often times patients have some anxiety or history of substance use and I use that as my second diagnosis which I find is an easier way to get a 99205.

e.g. unspecified anxiety disorder, ____ use disorder (in remission), etc.
 
randomdoc1 said:
Don't know if using a scale really counts and I wouldn't risk it. I usually just list the primary diagnosis and often times patients have some anxiety or history of substance use and I use that as my second diagnosis which I find is an easier way to get a 99205.

e.g. unspecified anxiety disorder, ____ use disorder (in remission), etc.
Click to expand...

If you're refering to "new problem" which is 3 problem points, you apparently can only use that once, so having multiple diagnoses doesn't make a difference unfortunately... I definitely thought the same thing though.
 
mixolyd said:
If you're refering to "new problem" which is 3 problem points, you apparently can only use that once, so having multiple diagnoses doesn't make a difference unfortunately... I definitely thought the same thing though.
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True, but you can still use the secondary diagnosis as an additional problem point.

For example, if the primary diagnosis is MDD, I think that would be 3 points. And if there is a substance use history or unspecified anxiety disorder, that can be an additional point. That racks you up to 4 problem points. Someone correct me if I am wrong though.

Even though those diagnoses are made when you are seeing that person for the first time, I have to think each problem has to count for something...
 
randomdoc1 said:
True, but you can still use the secondary diagnosis as an additional problem point.

For example, if the primary diagnosis is MDD, I think that would be 3 points. And if there is a substance use history or unspecified anxiety disorder, that can be an additional point. That racks you up to 4 problem points. Someone correct me if I am wrong though.
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I don't think you can since they're all new problems to you, and it seems you can only use that new problem without additional workup once. I hope I am wrong though because if you can then it would make qualifying for 99205 much easier for me.
 
Maybe someone can shed more light on this :).
 
mixolyd said:
Hey all,

Sorry to dig up such an old thread, but I am curious specifically about billing 99205 for intakes. I took EM University course which talks about the 4 problem points (additional workup required) as ordering blood tests, urine drug screen, etc. I was told by some that med changes qualify, but I am not sure if that's right. I watched the AACAP video and he says that using a rating scale after the initial visit qualifies as additional workup. Is that what you guys do? Just wondering how you all get the 4 problem points to meet criteria for 99205. I know I can do time based coding but then I cannot do add on, and I always spend 15 minutes minimum doing therapy on intakes. I never go off data points btw since it's too hard to get those in psychiatry.

Say I have a pt that definitely meets criteria for high risk (severe exacerbation of chronic illness or SI), how do I get 4 problem points? Is ordering labs or using a rating scale in the future the only way for "additional workup"? Or is simply seeing them in 2-3 weeks to reassess enough and noting "will evaluate further in the future to confirm diagnosis"? I'm also wondering if it is best to keep the diagnosis for initial appt vague, like unspecified mood disorder, and then in the follow up changing diagnosis to say MDD since it seems the "additional workup" is for figuring out a definitive diagnosis.
Click to expand...

Anyone know? Bueller?
 
Shikima said:
I'm still trying to figure this out in the context for psychiatry. It's easy enough with the other specialties...
Click to expand...

Here's what I have been doing. Any comments appreciated. From the AACAP video posted, they say that ordering use of a psychiatric rating scale after the initial visit qualifies as additional workup link (22:45). If you order labs, like urine drug screen, TSH, etc. then that qualifies as additional workup also. So here is what I do. I put in the Assessment section of the intake "patient has severe exacerbation of chronic *** (depression, anxiety, etc) - Will reassess in follow up visits and utilize diagnostic scales to determine specific diagnosis. Will monitor closely for recurrence of SI (if there is past hx) and run labs to rule out physiological causes." Then if I do not order labs, on their first followup I'll have them fill out MDQ scale. And in the followup note will write something like "Mood Disorder Questionnaire administered and reviewed. Section 1 has 1 positive responses and the rest negative. Bipolar unlikely." this way I believe I meet the requirements for 99205.

Now of course if someone just has a minor problem like test anxiety or something then that would not meet criteria, so it's best to either do 99205 time based or do 99204+90833 or whatever. I rarely have minor problems in my practice though. Everyone either has SI or hx of SI or just very sever exacerbation, so they all qualify for high risk, but CMS makes it more difficult as you say to meet full criteria in psychiatry since we do not always use labs or tests.
 
TexasPhysician said:
For some reason, I've found that 99204 pays better than 90792, but 90792 has a higher rvu number. I'm not sure if this is still true, but a friend on faculty at an academic center had said that he bills 90792 because his bonus is based on rvu's, not income generated.
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Yes, this does appear correct. Where I work I have an wRVU target to hit in order to get the remaining 20% of salary.
So 90792 is 3.25wRVUs, 99205 is 3.17wRVUs, 99204 is 2.43wRVUs.
you can search RVU data for all codes here: Physician Fee Schedule Search

so 90792 for me.
 
The whole RVU thing is overly complicated. 90792 is 3.25 work RVU but the non-facility total is 4.13 (which is what I get paid based on if the payer uses RVU). 99205 has work RVU of 3.17 but non-facility total is 5.83, so I get paid way more for 99205. Payers do not pay based on work RVU. They pay based on total RVU (facility or non facility). Not sure why you have a wRVU target instead of total RVU target. Doesn't seem very efficient since they're definitely getting reimbursed higher for a 99205 than 90792
 
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