Billing question

[yanks26dmb]

Regarding outpatient codes 99214, 99215.

For a 99214 lets say I have a patient with only GAD. Their anxiety is worse from previous visit. I am managing them with an SSRI. Would the fact their anxiety is worse since previous visit be considered 1 or more chronic illness with "exacerbation or progression"?

For a 99215 lets say I have a patient with Bipolar I. They are taking lithium. Their depression is worse than it was at last visit. Would this be considered a 99215 given "severe progression, exacerbation..." and given the fact lithium is a "drug therapy requiring intensive monitoring for toxicity"?

Thank you!

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[calvnandhobbs68]

Regarding outpatient codes 99214, 99215.

For a 99214 lets say I have a patient with only GAD. Their anxiety is worse from previous visit. I am managing them with an SSRI. Would the fact their anxiety is worse since previous visit be considered 1 or more chronic illness with "exacerbation or progression"?

For a 99215 lets say I have a patient with Bipolar I. They are taking lithium. Their depression is worse than it was at last visit. Would this be considered a 99215 given "severe progression, exacerbation..." and given the fact lithium is a "drug therapy requiring intensive monitoring for toxicity"?

Thank you!

1) Yes
2) No- Severe exacerbation is clarified as "The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospitalization." Would not meet 99215 criteria unless you're also meeting the data reviewed/analyzed component.
If you were considering hospitalizing them but decided against this and to increase lithium instead, you'd need to document this specifically and why you didn't think hospitalization was warranted.

 

[yanks26dmb]

1) Yes
2) No- Severe exacerbation is clarified as "The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospitalization." Would not meet 99215 criteria unless you're also meeting the data reviewed/analyzed component.
If you were considering hospitalizing them but decided against this and to increase lithium instead, you'd need to document this specifically and why you didn't think hospitalization was warranted.

Gotcha. Alternatively, if the visit lasted 40 minutes, I could bill 99215 based on time though?

Can I still use a therapy add on if billing E/M on time? Would it be 56 total then for a 99215 + 90833?

 

[splik]

Gotcha. Alternatively, if the visit lasted 40 minutes, I could bill 99215 based on time though?

Can I still use a therapy add on if billing E/M on time? Would it be 56 total then for a 99215 + 90833?

If you spent 40 minutes on activities on the day of visit you could use 99215 (including writing note, reviewing record, calling collateral etc), doesn't have to be 40 minutes F2F with patient anymore.
No you cannot use therapy add on codes if biling on time. Ever.

 

[ObsequiousAplomb]

Gotcha. Alternatively, if the visit lasted 40 minutes, I could bill 99215 based on time though?

Can I still use a therapy add on if billing E/M on time? Would it be 56 total then for a 99215 + 90833?

time-based is for E&M only. As Splik said, you can count any of the time for the encounter as long as half the time is face-to-face. You cannot use time-based billing for E&M if you are also using an add-on psychotherapy code. Ever.

In example 2 above, if you were providing between 16 and 37 minutes of psychotherapy during the 56 minutes then you could bill it as 99214+90833. More realistically though you would probably have been doing between 38 and 52 minutes of psychotherapy, so you would bill it as 99214+90836. 99214+90836 pays substantially less than 99215+90833 but more than 99214+90833

In DC/MD/VA:
- 99215: $209
- 99214: $148
- 90833: $78
- 90836: $99

- 99215+90833: $287
- 99214+90833: $226
- 99214+90836: $247

 

[splik]

time-based is for E&M only. As Splik said, you can count any of the time for the encounter as long as half the time is face-to-face.

No, half the time does NOT to be face to face. I frequently use time based codes where 75+% time is non-face-to-face. For example, if you spent 10 minutes with the patient but 30mins getting collateral from a therapist or reviewing past records and writing a note, you could still bill 99215 with the 2021 E&M changes.

 

[yanks26dmb]

time-based is for E&M only. As Splik said, you can count any of the time for the encounter as long as half the time is face-to-face. You cannot use time-based billing for E&M if you are also using an add-on psychotherapy code. Ever.

In example 2 above, if you were providing between 16 and 37 minutes of psychotherapy during the 56 minutes then you could bill it as 99214+90833. More realistically though you would probably have been doing between 38 and 52 minutes of psychotherapy, so you would bill it as 99214+90836. 99214+90836 pays substantially less than 99215+90833 but more than 99214+90833

In DC/MD/VA:
- 99215: $209
- 99214: $148
- 90833: $78
- 90836: $99

- 99215+90833: $287
- 99214+90833: $226
- 99214+90836: $247

Helpful, thank you. Those are medicare rates I'm assuming?

 

[Stagg737]

If you were considering hospitalizing them but decided against this and to increase lithium instead, you'd need to document this specifically and why you didn't think hospitalization was warranted.

We also don't think about hospitalizing everyone with worsening depression, so I would also want to document why I considered hospitalization in the first place.

 

[jbomba]

1) Yes
2) No- Severe exacerbation is clarified as "The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospitalization." Would not meet 99215 criteria unless you're also meeting the data reviewed/analyzed component.
If you were considering hospitalizing them but decided against this and to increase lithium instead, you'd need to document this specifically and why you didn't think hospitalization was warranted.

What if GAD sx (as in OP example) are not necessarily worse, or perhaps somewhat improved from last appt, but not at 100% remission. Is that considered progression and able to bill 99214?

 

[Bartelby]

No, half the time does NOT to be face to face. I frequently use time based codes where 75+% time is non-face-to-face. For example, if you spent 10 minutes with the patient but 30mins getting collateral from a therapist or reviewing past records and writing a note, you could still bill 99215 with the 2021 E&M changes.

Is it the case that you can only bill for activities like calling collateral that are done on the day you have the patient visit? If so, do you have any way you capture billing for speaking with a therapist etc on days other than the day of the visit?

 

[calvnandhobbs68]

What if GAD sx (as in OP example) are not necessarily worse, or perhaps somewhat improved from last appt, but not at 100% remission. Is that considered progression and able to bill 99214?

Technically yes but if you're not making a change or recommending a change in management and the patient has no other conditions, I could see insurance companies giving you a hard time about it.

Is it the case that you can only bill for activities like calling collateral that are done on the day you have the patient visit? If so, do you have any way you capture billing for speaking with a therapist etc on days other than the day of the visit?

Yes, time based billing is only for things done the day of the visit, including documentation technically. You can capture "discussion of management or test interpretation" as part of the medical decision making as a point to get you towards higher complexity, as this isn't required to be done on the date of service:
"Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)"

https://static.aapc.com/aapc/images/b2b-ebrief-em-audit-tool.pdf

 

[splik]

Is it the case that you can only bill for activities like calling collateral that are done on the day you have the patient visit? If so, do you have any way you capture billing for speaking with a therapist etc on days other than the day of the visit?

Everything has to be on the same DOS unfortunately for E&M to count as time spent including discussion with other healthcare providers (contrary to other post above). That is because codes are based on the date of service. If you spend more than 30 mins calling collateral or reviewing records etc on a different DOS you could use the non-F2F prolonged services 99358 BUT only if you didn't use a therapy add on code for the actual visit (i.e. E&M only).
If you spend more than 26 mins talking to family members and it is mostly for their benefit (e.g. supportive care) than data gathering, you can use the 90846 code for family therapy w/o pt present, but only if they request it, and know it will be billed (will have a copay at least).

 

[calvnandhobbs68]

Everything has to be on the same DOS unfortunately for E&M to count as time spent including discussion with other healthcare providers (contrary to other post above). That is because codes are based on the date of service. If you spend more than 30 mins calling collateral or reviewing records etc on a different DOS you could use the non-F2F prolonged services 99358 BUT only if you didn't use a therapy add on code for the actual visit (i.e. E&M only).
If you spend more than 26 mins talking to family members and it is mostly for their benefit (e.g. supportive care) than data gathering, you can use the 90846 code for family therapy w/o pt present, but only if they request it, and know it will be billed (will have a copay at least).

That's for time based billing. Discussion with other healthcare providers does not have to occur on the date of service in order to count for complexity as far as I'm aware which is what I was talking about. That is a way you can "capture billing" for speaking with another provider outside the day of service.

For instance, if you discussed stability of the patient's cardiac condition with the patient's cardiologist on 12/5, saw the patient on 12/6 and documented that you had discussed management with the cardiologist since their last visit, that would count towards "Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)" which is a point towards MDM complexity in terms of data.