Inpatient docs, it's 2023 with new rules, can we bill 99233 on complexity?

[nexus73]

We have new cpt code criteria. Based on the criteria I reviewed for 99233, looks like the two components that would practically apply to psych are:
1. Number and Complexity of Problems addressed.
2. Risk of Complications and/or Morbidity or Mortality of Patient Management

*3. Amount of Data Reviewed and Analyzed will likely never apply as we don't order labs/imaging etc.

You must meet 2 of the 3 above to be 99233.

For #1 you need either
1. One or more chronic illness with severe exacerbation (seems like this would be common for psych) OR
2. One acute or chronic illness that poses a threat to life or bodily function (If suicidal or gravely disabled it would pose a threat to life, and depending on definition of bodily function this could apply to many if not all psych condition--cognition is a bodily function, sleep is, concentration is, eating (appetite) is)

For #2 there are several options, but the only one that might apply to psych is:
1. Decision regarding hospitalization or escalation of hospital level care

Any thoughts on this last point and how it would or would not apply to a patient on inpatient psychiatry?

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[splik]

I think it is hard to meet 99233 if not based on time. It's going to be 99232 most of the time, some 99231s for the rocks. You can use 99233 if you are say treating a patient with lithium or clozapine and they are acutely manic, psychotic or depressed. I don't understand what you mean by not ordering labs though. You would need to be ordering and reviewing labs for 99233 for the meds used. If you have to transfer a patient to a medical service or ICU that would also count, but you might also just use the discharge codes.

 

[SmallBird]

I think it is hard to meet 99233 if not based on time. It's going to be 99232 most of the time, some 99231s for the rocks. You can use 99233 if you are say treating a patient with lithium or clozapine and they are acutely manic, psychotic or depressed. I don't understand what you mean by not ordering labs though. You would need to be ordering and reviewing labs for 99233 for the meds used. If you have to transfer a patient to a medical service or ICU that would also count, but you might also just use the discharge codes.

So one thing that I've taken away from the guidelines is that you don't necessarily have to prescribe lithium, you just have to discuss it. So if you have an acutely manic patient and you discuss options and you go with an atypical but to get there you reviewed the pros and cons of lithium, you can bill it. This helps because I talk about lithium more than I actually prescribe it.

 

[michaelrack]

For #2 there are several options, but the only one that might apply to psych is:
1. Decision regarding hospitalization or escalation of hospital level care

Any thoughts on this last point and how it would or would not apply to a patient on inpatient psychiatry?

For this last point, for a suicidial patient it might include putting on a higher level of precautions- going from q 15 minute checks to line of sight, and putting on suicide precautions for example.

 

[ObsequiousAplomb]

A related question I have been wondering about is how to consider the risk if I'm instructing someone to have guns removed from the home or I'm pursuing legal action to have the guns removed. In my mind this sounds like it's as high a risk for complications (if not higher than) a decision to hospitalize someone. Would others consider this a factor for high level MDM?

 

[Wheatbread]

We had meetings about this last week and I have ongoing talks with our coders. Column 3 on the MDM tool is what’s going to determine the code how I see it. Vast majority of our patients have a severe exacerbation of a chronic illness which will take care of Number/Complexity (column 1) for high. In talking with the billing folks, we can have a high risk (column 3) if we order a lab for specific med (lithium, etc) and/or the patient has a risk of morbidity from not receiving treatment. Again, for the vast majority of patients they are high risk from suicidal/psychosis, so that would put them in high risk category. There’s also a blurb about “social determinants of health” in the coding changes that can be used to justify high risk.

 

[nexus73]

I think it is hard to meet 99233 if not based on time. It's going to be 99232 most of the time, some 99231s for the rocks. You can use 99233 if you are say treating a patient with lithium or clozapine and they are acutely manic, psychotic or depressed. I don't understand what you mean by not ordering labs though. You would need to be ordering and reviewing labs for 99233 for the meds used. If you have to transfer a patient to a medical service or ICU that would also count, but you might also just use the discharge codes.

i was being unclear, we don’t order enough labs or other tests, especially not tests we’re discussing with another doctor, typically to qualify for the complexity arm. It’s more trouble than it’s worth.