So How Is Everyone Interpreting 90833?

[hippopotamusoath]

I'm wondering how everyone here interprets the 90833 psychotherapy add-on code. If I am working on cognitive distortions or introducing the CBT model, it's simple--I document the therapy and move on.

But I am finding a lot of my therapeutic work is supportive. I'm failing to see why almost every 30 minute follow-up with a psychiatrist wouldn't have a 90833 attached to it? I have not been coding that way, but the more I think about it, I wonder if I should.

For the people who see 30 minute followups--what percentage are coded with +90833? How do you personally decide which ones qualify and which ones don't? The community standard for "therapy" from a LCSW or whomever is actually quite low. It seems like the average psychiatrist is probably delivering something that qualifies as supportive therapy nearly 100% of the time.

Obviously, I don't want to up-code, but I also don't want to under-code, and it seems like there's a strong case to be made for calling the average 30-minute interaction with a psychiatrist (of which maybe 5 minutes are about medications) as easily qualifying as supportive therapy. 100% of the time I am displaying unconditional positive regard, active listening, helping with re-framing etc. for the sake of the patient, and I think that has value.

Anyway, just curious to hear if anyone else has thought about this and how they've decided to code. Does anyone basically code every visit as 99213 or 99214 + 90833?

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[Bartelby]

I add 90833 about 70 percent of the time, maybe more. If someone just needs a quick check in mainly focused on medication I do not, or if most of the time is real data gathering without even supportive therapy I do not.

Most of the time I am doing supportive therapy, CBT including CBTi, or other brief interventions based in various schools of psychotherapy. I feel it adds value and improves treatment , which the 90833 captures. It would be easy to take part in care where I focus only on meds and gather just enough data to make a decision about the meds for that session, pushing off anything else as the domain of the therapist. That seems to me like pure 99213 or 99214, and frankly it would be easier and faster (though I think less helpful and less satisfying as a practice style).

 

[annoyedpsychiatrist]

probably 70-80% of my patients are 90833 adjunct because we do 30 minute follows and our patients are typically more moderate to high acuity with some in the lower acuity. ADHD 3mo refills i typically dont do the adjunct because it probably wouldnt make sense, but supportive therapy is still therapy theoretically. If its a very short visit and theyre compltely stable on something benign then im unlikely to try and bill for it

 

[clausewitz2]

I bill easily 90% of my 99214s as +90833 and from time to time a 99215+90833. I have exclusively 30 minute follow-ups and use that time. Most appointments that don't have +90833 are either someone showing up just before the 15 minute mark at which I make people reschedule, or are people I generally point back towards their PCP.

 

[Merovinge]

The field is in a better place when 30 min f/u are the norm for everyone (even adults!) where psychotherapy is expectation rather than the rule.

The docs who want to see 50 patients a day for 10 min 99214's can still make their crazy salaries but it leaves room for everyone else to practice good medicine and make a good salary seeing 2 f/u's per hour.

 

[hippopotamusoath]

I bill easily 90% of my 99214s as +90833 and from time to time a 99215+90833. I have exclusively 30 minute follow-ups and use that time. Most appointments that don't have +90833 are either someone showing up just before the 15 minute mark at which I make people reschedule, or are people I generally point back towards their PCP.

I like this a lot. When I think about times I debate on whether the 90833 is justified with what I've done, it's often people I should probably be sending back to their PCP. There are many patients who so clearly need it that I don't have a microsecond of internal debate. An excellent litmus test.

 

[yoloswagpoop42069]

Just graduating residency and coding is confusing at first.

So I can add on +90833 to any E/M evaluation, including initials and follow-ups, as long as I feel the therapy given has passed the 16 min mark?
Reading prior threads it looks like there's some confusion if this can be added to initial evaluations, or if its only allowable for follow-ups?

I tried to google add on therapy codes, and found this: Mental Health CPT Codes: The Definitive Guide [2022].
which was NOT helpful.

What do you even write in the note to document that supportive psychotherapy was provided? "Displayed unconditional positive regard, active listening, helped with re-framing," or delineating further specific CBT techniques?

Edit: Nevermind, on previous threads this was said about documentation: Separate from the evaluation and management portion of today's visit, a psychotherapy procedure was performed. Primarily used today was [supportive therapy, insight oriented, CBT, etc] for a total of [##]min. Brief therapy notes in addition to HPI, include: [stuff goes here]. Progress today is rated as [stuff goes here].

For in-person appointments, are time-keeping records kept for 30 min follow-ups to see if you've actually had the patient in the room for a long enough time to pass the 16 min mark for that code to be billed appropriately on audits? Or is this basically honor code based, and make sure you don't do this for 100% of your follow-ups, especially if you aren't spending the 30 minutes with them, wink wink nudge nudge.

Out of curiosity, for 30 min follow-ups, are you guys really sitting in the room for the full 30 min doing just the eval, maybe typing a few short hand notes during the encounter? In my mind, during residency at least, I would try to do a good follow-up eval in like 20 min, leaving 10 minutes to finish cleaning up the note prior to the next patient coming in.

So if the actually eval is only like 20 min, with discussion of E/M and "16 min" of therapy, would that really count for 90833 or are we just being a little flexible here. I can't tolerate the thought of giving the entire 30 min to every follow-up patient, and then finishing up all 8-10 notes at the end of the day.

 

[claypigeon]

I’m about 50% 90833.

CBT, CBTI, relaxation techniques, brainstorming graded exposure homework, supportive therapy, etc. I could maybe code a few more but also find a lot of cases only need 10 minutes of therapy.

 

[ObsequiousAplomb]

Just graduating residency and coding is confusing at first.

So I can add on +90833 to any E/M evaluation, including initials and follow-ups, as long as I feel the therapy given has passed the 16 min mark?
Reading prior threads it looks like there's some confusion if this can be added to initial evaluations, or if its only allowable for follow-ups?

I tried to google add on therapy codes, and found this: Mental Health CPT Codes: The Definitive Guide [2022].
which was NOT helpful.

What do you even write in the note to document that supportive psychotherapy was provided? "Displayed unconditional positive regard, active listening, helped with re-framing," or delineating further specific CBT techniques?

Edit: Nevermind, on previous threads this was said about documentation: Separate from the evaluation and management portion of today's visit, a psychotherapy procedure was performed. Primarily used today was [supportive therapy, insight oriented, CBT, etc] for a total of [##]min. Brief therapy notes in addition to HPI, include: [stuff goes here]. Progress today is rated as [stuff goes here].

For in-person appointments, are time-keeping records kept for 30 min follow-ups to see if you've actually had the patient in the room for a long enough time to pass the 16 min mark for that code to be billed appropriately on audits? Or is this basically honor code based, and make sure you don't do this for 100% of your follow-ups, especially if you aren't spending the 30 minutes with them, wink wink nudge nudge.

Out of curiosity, for 30 min follow-ups, are you guys really sitting in the room for the full 30 min doing just the eval, maybe typing a few short hand notes during the encounter? In my mind, during residency at least, I would try to do a good follow-up eval in like 20 min, leaving 10 minutes to finish cleaning up the note prior to the next patient coming in.

So if the actually eval is only like 20 min, with discussion of E/M and "16 min" of therapy, would that really count for 90833 or are we just being a little flexible here. I can't tolerate the thought of giving the entire 30 min to every follow-up patient, and then finishing up all 8-10 notes at the end of the day.

I really hope it doesn't take 10 minutes to write outpatient follow up notes for you.

A course on typing could really help you add 20-30 wpm to your typing speed, and being briefer in your sentences helps too.

There's also writing parts of the note during the encounter. For nearly everyone I write the notes while I'm talking, I just make sure to have a silent keyboard and a silent mouse. This is especially helpful if you spend 1-2 minutes of your time copy-forwarding and pre-writing parts of your note. That way instead of writing an entire subjective you just update the subjective in the visit (changing number of hours slept, "nearly every day" to "most days" or "less than half" or "seldom." "Low" to "neutral." "Increased" to "back to baseline").

Patients tend to report liking that I am making sure to get it exactly right. Having the note in front of me from last session also prompts me to ask about things I might have forgotten in between sessions, like "trouble with brother" or "dreading Thanksgiving" can be brought up after Thanksgiving with their brother to see if social distress is improving.

I would be really upset if I didn't walk out the door with the last patient of the day, and I'm really glad that I always get to be home before my wife who, like you're saying, spends an hour or more after work writing notes.

 

[clausewitz2]

I really hope it doesn't take 10 minutes to write outpatient follow up notes for you.

A course on typing could really help you add 20-30 wpm to your typing speed, and being briefer in your sentences helps too.

There's also writing parts of the note during the encounter. For nearly everyone I write the notes while I'm talking, I just make sure to have a silent keyboard and a silent mouse. This is especially helpful if you spend 1-2 minutes of your time copy-forwarding and pre-writing parts of your note. That way instead of writing an entire subjective you just update the subjective in the visit (changing number of hours slept, "nearly every day" to "most days" or "less than half" or "seldom." "Low" to "neutral." "Increased" to "back to baseline").

Patients tend to report liking that I am making sure to get it exactly right. Having the note in front of me from last session also prompts me to ask about things I might have forgotten in between sessions, like "trouble with brother" or "dreading Thanksgiving" can be brought up after Thanksgiving with their brother to see if social distress is improving.

I would be really upset if I didn't walk out the door with the last patient of the day, and I'm really glad that I always get to be home before my wife who, like you're saying, spends an hour or more after work writing notes.

This is the way. Early on I tell people I am going to right stuff down because my memory is definitely not perfect and I want to make sure I don't miss things. Then a month later I get to ask 'so how long did it end up taking you to get power back at yours?' or 'so did you win the costume contest at the party?' or 'did the mac 'n cheese at Thanksgiving live up to your expectations?' It's a very small thing but putting down like two lines about specifics they mention to bring up next appointment seems to go a long way in making people cool with typing during the session.

EDIT: also touch typing is key.

 

[tr]

What do you even write in the note to document that supportive psychotherapy was provided? "Displayed unconditional positive regard, active listening, helped with re-framing," or delineating further specific CBT techniques?

Dot phrase: "I provided supportive listening and empathetic reflection."

Every note has a start and end time.
If I'm going to bill an add on-code I put "approximately 20 minutes (modality)" on the next line.

I actually find that the insurances I take seem to reimburse on time mostly, so I get the same amount for 25 minutes face to face regardless of whether I bill an add-on code. I therefore usually bill just straight 99214 unless I really did spend most of the session on psychotherapeutic interactions.

 

[clausewitz2]

Dot phrase: "I provided supportive listening and empathetic reflection."

Every note has a start and end time.
If I'm going to bill an add on-code I put "approximately 20 minutes (modality)" on the next line.

I actually find that the insurances I take seem to reimburse on time mostly, so I get the same amount for 25 minutes face to face regardless of whether I bill an add-on code. I therefore usually bill just straight 99214 unless I really did spend most of the session on psychotherapeutic interactions.

Important to know the details of your insurance contract, if they did not agree to a rate for add-on codes specifically then I agree there is not much point. Round here it probably increases compensation v the base 99214 by 30% so fairly significant.

 

[yoloswagpoop42069]

I really hope it doesn't take 10 minutes to write outpatient follow up notes for you.

A course on typing could really help you add 20-30 wpm to your typing speed, and being briefer in your sentences helps too.

There's also writing parts of the note during the encounter. For nearly everyone I write the notes while I'm talking, I just make sure to have a silent keyboard and a silent mouse. This is especially helpful if you spend 1-2 minutes of your time copy-forwarding and pre-writing parts of your note. That way instead of writing an entire subjective you just update the subjective in the visit (changing number of hours slept, "nearly every day" to "most days" or "less than half" or "seldom." "Low" to "neutral." "Increased" to "back to baseline").

Patients tend to report liking that I am making sure to get it exactly right. Having the note in front of me from last session also prompts me to ask about things I might have forgotten in between sessions, like "trouble with brother" or "dreading Thanksgiving" can be brought up after Thanksgiving with their brother to see if social distress is improving.

I would be really upset if I didn't walk out the door with the last patient of the day, and I'm really glad that I always get to be home before my wife who, like you're saying, spends an hour or more after work writing notes.

Yeah of course. I was being generous with my time.

And as a resident I should have clarified that that 10 min was for staffing with attending, waiting to staff, and signing the note.

In all I think a lot of people don’t do a true full 16 min of therapy with add on code 90833 and just add it on after saying whatever supportive things.

Or maybe you truly do. I’d say if an auditor were to actually monitor in real time many wouldn’t actually meet criteria. But whatever I’m not going to be rigid about this. People need to get paid.

Insurance sucks.

 

[clausewitz2]

Yeah of course. I was being generous with my time.

And as a resident I should have clarified that that 10 min was for staffing with attending, waiting to staff, and signing the note.

In all I think a lot of people don’t do a true full 16 min of therapy with add on code 90833 and just add it on after saying whatever supportive things.

Or maybe you truly do. I’d say if an auditor were to actually monitor in real time many wouldn’t actually meet criteria. But whatever I’m not going to be rigid about this. People need to get paid.

Insurance sucks.

A lot of people do add on codes without documenting anything close to adequate, just like I am sure there are people who fudge the minutes they actually spend with the patient. Still, it's really not hard to do documenting for add on therapy that insurance is going to have a hard time taking issue with. Document a specific modality, specific techniques, and roughly the topics covered, put down the start and end time, and you're golden. Make a dot phrase for common modalities/techniques and it adds almost nothing to your burden.

The great (and initially terrifying) thing about being an attending is you aren't staffing s***t, it's all on you. Makes the timing work out better.

 

[rjs2131]

Essentially every visit of mine is 99214+90833. I am CAP and have 30 min follow-ups for every patient.

The 90833 question is something I thought a lot about when I first started out, but after observing the average quality of therapy in the community and the fact that our level of training allows us to supplement/provide therapeutic interventions that are generally higher quality than average, I think our time is worth more than just a 9921x. I don't love playing the insurance game but our time is valuable and reimbursement should reflect that!

 

[tr]

Important to know the details of your insurance contract, if they did not agree to a rate for add-on codes specifically then I agree there is not much point. Round here it probably increases compensation v the base 99214 by 30% so fairly significant.

Who knows. I have no contact with whatever bureaucrat negotiated the contract and I certainly have never been offered the opportunity to look at it. I just get a billing summary that details payment for each encounter, so I figure it out post hoc. I see the same payment value from a given insurance for a 30 min f/u regardless of the billing codes.

 

[clausewitz2]

Who knows. I have no contact with whatever bureaucrat negotiated the contract and I certainly have never been offered the opportunity to look at it. I just get a billing summary that details payment for each encounter, so I figure it out post hoc. I see the same payment value from a given insurance for a 30 min f/u regardless of the billing codes.

Not uncommon in my admittedly limited experience for bigger outfits to negotiate away reimbursement for therapy add-ons for psychiatrists to get a higher base rate for the E&M. Similarly, while 99204+90833 is way superior to 90792 for me in private practice, using the later was mandatory at my old CMHC job because they had finagled a really high rate for it. The statements do suggest that is what happened.

 

[Wheatbread]

Thanks for this info. I’m out of residency three years and probably underutilizing add on codes. I have a pretty clear picture of using them when I use specific methods but am hesitant when it’s “supportive”. I would say 90% of my 30min visits last 20+ min and the majority is talking about stressors with validation/support. Does anyone have a good resource/book for a quick and useful methodology for supportive therapy?

 

[Bartelby]

I hope someone else chimes in with a specific resource. I think of it in the traditional psychodynamic sense of supporting the ego strengths. The goal in supportive therapy is to mobilize the (often considerable) resources and problem-solving skills the patient already possesses to help them deal with their current problem. Often patients are impacted by social problems and with severe illness may have fallen into helplessness. In those cases, the goal of my supportive therapy is to help kick them into gear to start addressing whatever I / we see as various contributors to their ongoing distress. Basically, it frequently involves helping the person think through how to make real-world changes that will further their recovery.

 

[yoloswagpoop42069]

So can someone definitely clarify if 90833 can only be used as add on to follow-ups, or if it can be added to intial evals with resulting additional compensation?

 

[rjs2131]

So can someone definitely clarify if 90833 can only be used as add on to follow-ups, or if it can be added to intial evals with resulting additional compensation?

You can use 9083x (90833, 90836, 90838) for any visit that is coded based on MDM (not time). So if you use a 99204 for an initial eval based on medical complexity (i.e. 2 stable problems or 1 unstable problem, prescribing a med), you can then use the therapy add-on code for the additional time. As an example, one of my insurers doesn't acknowledge 99417 so for my 90-min initial evals, I code them as 99204 + 90838 and document accordingly.

You cannot use therapy add-on codes when you are coding for time...so a 99205 based on time couldn't have a 9083x attached to it, but a 99205 based on complexity (needing to hospitalize the patient, for example) could have a 9083x added.

 

[rjs2131]

Thanks for this info. I’m out of residency three years and probably underutilizing add on codes. I have a pretty clear picture of using them when I use specific methods but am hesitant when it’s “supportive”. I would say 90% of my 30min visits last 20+ min and the majority is talking about stressors with validation/support. Does anyone have a good resource/book for a quick and useful methodology for supportive therapy?

I don't think I've found a good answer for this and it seems what people define as supportive psychotherapy can vary. Supportive/expressive psychotherapy or insight-oriented psychotherapy are much less clear cut than manualized CBT. I like to think that as a psychiatrist, you have a better understanding of what constitutes therapy vs what doesn't - if you find that you're spending a lot of time on the nuances of this, you're probably overthinking it! I would consider discussion of stressors and validating/supporting a patient through this as "supportive/expressive psychotherapy". When in doubt, if you've spent 30 min with a patient you have likely justified a 90833.

 

[clausewitz2]

Thanks for this info. I’m out of residency three years and probably underutilizing add on codes. I have a pretty clear picture of using them when I use specific methods but am hesitant when it’s “supportive”. I would say 90% of my 30min visits last 20+ min and the majority is talking about stressors with validation/support. Does anyone have a good resource/book for a quick and useful methodology for supportive therapy?

Might want to check out one of many books on Problem-Solving Therapy. This is a good candidate for what a lot of our supportive psychotherapy approximates and it is not difficult to wrap your head around.

 

[Stagg737]

Thanks for this info. I’m out of residency three years and probably underutilizing add on codes. I have a pretty clear picture of using them when I use specific methods but am hesitant when it’s “supportive”. I would say 90% of my 30min visits last 20+ min and the majority is talking about stressors with validation/support. Does anyone have a good resource/book for a quick and useful methodology for supportive therapy?

Gabbert's "Introduction to Supportive Psychotherapy" is a fairly quick and easy read. It's part of the APA's "Core Competencies in Psychotherapy" series.
Markowitz also has a new book out called "Brief Supportive Psychotherapy" that's only 160 pages. I have not read it, but skimming the first couple chapters on Amazon it seems decent and has chapters called "The Structure of Brief Supportive Psychotherapy" and "Adjusting Brief Supportive Psychotherapy to Different Disorders", so may be helpful for what you're looking for.

Might want to check out one of many books on Problem-Solving Therapy. This is a good candidate for what a lot of our supportive psychotherapy approximates and it is not difficult to wrap your head around.

Any specific recommendations? I've never read anything specific to this as it always just seemed like common sense to me.

 

[clausewitz2]

Gabbert's "Introduction to Supportive Psychotherapy" is a fairly quick and easy read. It's part of the APA's "Core Competencies in Psychotherapy" series.
Markowitz also has a new book out called "Brief Supportive Psychotherapy" that's only 160 pages. I have not read it, but skimming the first couple chapters on Amazon it seems decent and has chapters called "The Structure of Brief Supportive Psychotherapy" and "Adjusting Brief Supportive Psychotherapy to Different Disorders", so may be helpful for what you're looking for.

Markowitz book goes in the Amazon cart.

Any specific recommendations? I've never read anything specific to this as it always just seemed like common sense to me.

"Problem Solving Therapy: A Treatment Manual" from 2012 is meant to be good, written by some of the people who developed PST formally.

 

[Stagg737]

Also, thanks everyone for insights here. I've been hesitant to use 90833 because we couldn't use those codes in residency and our instruction on what qualified was pretty limited but strict. I've had some people be very strict about what qualifies and someone who literally added "supportive psychotherapy provided" and added 90833 to every f/up, so hearing different perspectives of how people use those codes.

Markowitz book goes in the Amazon cart.



"Problem Solving Therapy: A Treatment Manual" from 2012 is meant to be good, written by some of the people who developed PST formally.

Went straight to my "professional stuff" list after I skimmed the intro, lol.

 

[splik]

Any specific recommendations? I've never read anything specific to this as it always just seemed like common sense to me.

For free: Materials | National Network of PST Clinicians, Trainers, & Researchers

 

[yoloswagpoop42069]

You can use 9083x (90833, 90836, 90838) for any visit that is coded based on MDM (not time). So if you use a 99204 for an initial eval based on medical complexity (i.e. 2 stable problems or 1 unstable problem, prescribing a med), you can then use the therapy add-on code for the additional time. As an example, one of my insurers doesn't acknowledge 99417 so for my 90-min initial evals, I code them as 99204 + 90838 and document accordingly.

You cannot use therapy add-on codes when you are coding for time...so a 99205 based on time couldn't have a 9083x attached to it, but a 99205 based on complexity (needing to hospitalize the patient, for example) could have a 9083x added.

Awesome perfect response thank you

 

[calvnandhobbs68]

Yeah I also interpret 90833 quite expansively and view it as a way to capture value/actually pay for the fact that I do real 30 minute followups and the patient is spending a decent amount of time with a specialist. You can call quite a lot of things "supportive psychotherapy" or incorporating elements of CBT or insight oriented therapy (despite not being some kind of real deal CBT program, which we wouldn't be doing anyway unless I was seeing the patient weekly for 12-16 weeks straight).

I bill at least 50% 99213/99214 +90833s , don't know the exact numbers though.

I take several different insurers and 99214+90833 puts me in the 170-190s range for a 30 minute followup which is very reasonable in my opinion, while 99214s only put me in the low 100s to 120s which is pretty crappy for 30 minutes (considering 99213s pay in the 70s-80s range, so if I just did 4x92213/hr 15min assembly line "med check" followups consistently I'd average quite a bit more than 2x99214s/hr). I also actually schedule all my patients for 30 minute followups and in child ultimately you may only have kids with 1 stablish problem (so 99213) who parents don't feel comfortable going back to pediatrics or pediatricians don't feel comfortable unless they're very stable but want to sit around and talk to you about all the complaints about their kid for the full 30 minutes. I do tend to try to send people back to their PCP if I'm finding myself calling them 99213 more than once in a row.

It's also opened my eyes to the billing practices of other people when I've gotten records from other practices over the past couple years. For instance, saw records from a local NP who did things like bill 20 minute visits as 99214+90833 having 20 minutes of "psychotherapy", then another routine followup visit billed a 99215 despite the actual appointment length being documented as again 20 minutes (so saying she did another 20 minutes of unspecified work outside the appointment for this routine followup). Also know another NP who literally bills everyone a 99214+90833 no matter what happens in the appointment. So yeah, there's actual fradulent stuff going on out there pretty commonly.

 

[Stagg737]

So how are people “timing” their therapy for documentation? Just saying something like “21 minutes spent performing xyz?”

 

[surfguy84]

So how are people “timing” their therapy for documentation? Just saying something like “21 minutes spent performing xyz?”

Ill typically discuss the modality of therapy performed then in regards to time will say, "...for 16+, 38+, 53+ minutes".

 

[calvnandhobbs68]

So how are people “timing” their therapy for documentation? Just saying something like “21 minutes spent performing xyz?”

Different insurers want different things...I make my note so it should meet criteria for all the insurers.
That includes setting specific stop and end times. So I'll write (because I'm child this is why it's phrased this way):
Time: 17 minutes of face to face time with patient and guardian, majority of time spent with patient.
Start time: 3:05PM
Stop time: 3:22PM

Ill typically discuss the modality of therapy performed then in regards to time will say, "...for 16+, 38+, 53+ minutes".

There have been reports that if this gets audited, depending on the insurer, they''ll deem this not enough documentation. They typically want a note as if you were documenting an actual psychotherapy progress note, which would typically include exact start and end times for the therapy appointment.

 

[Merovinge]

It's also opened my eyes to the billing practices of other people when I've gotten records from other practices over the past couple years. For instance, saw records from a local NP who did things like bill 20 minute visits as 99214+90833 having 20 minutes of "psychotherapy", then another routine followup visit billed a 99215 despite the actual appointment length being documented as again 20 minutes (so saying she did another 30 minutes of unspecified work outside the appointment for this routine followup). Also know another NP who literally bills everyone a 99214+90833 no matter what happens in the appointment. So yeah, there's actual fradulent stuff going on out there pretty commonly.

I generally really appreciate them adding all time spent during the day into time codes but have serious concerns about how this is going to play out with unscrupulous folks over billing now. It seems very hard to audit a whole day to prove this person wasn't looking at their chart at 10:00pm that day. I also hate that our system is designed like this so that folks willing to do this make massively more money (and are almost certainly worse clinicians), one of so many examples in the modern era where rent-seeking behavior is actively encouraged.

 

[clausewitz2]

So how are people “timing” their therapy for documentation? Just saying something like “21 minutes spent performing xyz?”

Separate from evaluation and management portion of encounter, psychotherapy was performed for XX minutes encompassing brief individual [MODALITY] focusing on [PROBLEM AREA] using [TECHNIQUE].

Start time: XX:XX
End time: XX:XX

 

[clausewitz2]

I generally really appreciate them adding all time spent during the day into time codes but have serious concerns about how this is going to play out with unscrupulous folks over billing now. It seems very hard to audit a whole day to prove this person wasn't looking at their chart at 10:00pm that day. I also hate that our system is designed like this so that folks willing to do this make massively more money (and are almost certainly worse clinicians), one of so many examples in the modern era where rent-seeking behavior is actively encouraged.

I happen to be socially acquainted with one of my state's prosecutors who is part of the unit focusing on Medicare fraud. All of their time and resources are devoted to truly, utterly egregious cases (home health agency making up patients and just lying about which days they showed up at clients' homes to the tune of millions of dollars). It is honestly more surprising that there is not far more fraudulent billing given how easy it would be to get away with provided you didn't get carried away with it.

But then, they always get carried away with it...

 

[sloh]

I happen to be socially acquainted with one of my state's prosecutors who is part of the unit focusing on Medicare fraud. All of their time and resources are devoted to truly, utterly egregious cases (home health agency making up patients and just lying about which days they showed up at clients' homes to the tune of millions of dollars). It is honestly more surprising that there is not far more fraudulent billing given how easy it would be to get away with provided you didn't get carried away with it.

But then, they always get carried away with it...

How do they go about making up patients? Sounds absurd.

 

[calvnandhobbs68]

I generally really appreciate them adding all time spent during the day into time codes but have serious concerns about how this is going to play out with unscrupulous folks over billing now. It seems very hard to audit a whole day to prove this person wasn't looking at their chart at 10:00pm that day. I also hate that our system is designed like this so that folks willing to do this make massively more money (and are almost certainly worse clinicians), one of so many examples in the modern era where rent-seeking behavior is actively encouraged.

I agree that stuff is a double edged sword, probably overall beneficial but I bet we see audits trying to crack down on this over the next few years. The more relaxed rules do let me capture work more easily though, like today had a visit run 5 minutes over 35 minutes total with a kid and parents asking about side effects and stuff, probably not really a 90833 but I can capture that work pretty easily with a 99215 (cause I guarantee I spent 5 minutes outside the appointment reviewing notes, writing prescriptions and writing the note).

 

[splik]

Ill typically discuss the modality of therapy performed then in regards to time will say, "...for 16+, 38+, 53+ minutes".

You need to put the exact number of minutes, not acceptable to put 16+ etc.

I agree that stuff is a double edged sword, probably overall beneficial but I bet we see audits trying to crack down on this over the next few years. The more relaxed rules do let me capture work more easily though, like today had a visit run 5 minutes over 35 minutes total with a kid and parents asking about side effects and stuff, probably not really a 90833 but I can capture that work pretty easily with a 99215 (cause I guarantee I spent 5 minutes outside the appointment reviewing notes, writing prescriptions and writing the note).

So far, most insurances totally disinterested in 90833. 90838 has been more of an issue (some pay the same for 90838 as 90836 or even less!) however I recently had an insurance company pre-approve me to bill 99214+90838 up to 38 times in 6 months for 1 patient at my full fee.

 

[clausewitz2]

How do they go about making up patients? Sounds absurd.

Step 1: Find relevant identifying and insurance information of random old people who are not already receiving services.

Step 2: Fake some paperwork

Step 3: Start billing for services rendered to your "patient"

Step 4: ....go to jail, apparently.

 

[surfguy84]

You need to put the exact number of minutes, not acceptable to put 16+ etc.


So far, most insurances totally disinterested in 90833. 90838 has been more of an issue (some pay the same for 90838 as 90836 or even less!) however I recently had an insurance company pre-approve me to bill 99214+90838 up to 38 times in 6 months for 1 patient at my full fee.

Out of curiosity how do you know it's not acceptable? My medical director (who seems very knowledgeable) created a template for us which I have been using.

 

[Stagg737]

Different insurers want different things...I make my note so it should meet criteria for all the insurers.
That includes setting specific stop and end times. So I'll write (because I'm child this is why it's phrased this way):
Time: 17 minutes of face to face time with patient and guardian, majority of time spent with patient.
Start time: 3:05PM
Stop time: 3:22PM



There have been reports that if this gets audited, depending on the insurer, they''ll deem this not enough documentation. They typically want a note as if you were documenting an actual psychotherapy progress note, which would typically include exact start and end times for the therapy appointment.

Separate from evaluation and management portion of encounter, psychotherapy was performed for XX minutes encompassing brief individual [MODALITY] focusing on [PROBLEM AREA] using [TECHNIQUE].

Start time: XX:XX
End time: XX:XX

Might be a dumb question, but are you putting start and end time for the whole appointment or just the psychotherapy time? I already have a template where I state specific number of minutes and I saved my template from residency for telehealth notes in general where we were required to do the start and stop times for the full appointment. Trying to make sure I’m doing the documentation correct.

 

[FlowRate]

Might be a dumb question, but are you putting start and end time for the whole appointment or just the psychotherapy time? I already have a template where I state specific number of minutes and I saved my template from residency for telehealth notes in general where we were required to do the start and stop times for the full appointment. Trying to make sure I’m doing the documentation correct.

Psychotherapy time, as that's what's being billed on time and is technically supposed to be a wholly separate service from the medical E/M, so you're saying those timestamps were the period of time spent providing the psychotherapy service.

Incidentally, that's how my dynamic supervisors recommended running integrated sessions (meds+scheduling at the beginning of the appointment), although not for billing reasons.

 

[hamstergang]

Out of curiosity how do you know it's not acceptable? My medical director (who seems very knowledgeable) created a template for us which I have been using.

Multiple people have claimed both here and on other groups/forums that when audited, some insurance companies have wanted actual start and stop times for the therapy (even though that's ridiculous). I believe others have stated they wanted just the total time. I don't recall anyone ever saying that an audit has been ok with a vague description of the time.

 

[Stagg737]

Psychotherapy time, as that's what's being billed on time and is technically supposed to be a wholly separate service from the medical E/M, so you're saying those timestamps were the period of time spent providing the psychotherapy service.

Incidentally, that's how my dynamic supervisors recommended running integrated sessions (meds+scheduling at the beginning of the appointment), although not for billing reasons.

Is this necessary if I'm also stating the specific number of minutes I'm doing therapy? I have a therapy template similar to what Clause posted and explicitly state "21 minutes of psychotherapy performed...". How are people documenting if you do 10 minutes of therapy, then check on other aspects for 5 minutes, then doing another 10 minutes of therapy?

 

[calvnandhobbs68]

Is this necessary if I'm also stating the specific number of minutes I'm doing therapy? I have a therapy template similar to what Clause posted and explicitly state "21 minutes of psychotherapy performed...". How are people documenting if you do 10 minutes of therapy, then check on other aspects for 5 minutes, then doing another 10 minutes of therapy?

You just make it up. There's been communication (I'd have to find it again) from the APA that the insurance companies have basically bastardized the concept of integrated psychotherapy in the appointment and the actual spirit of these codes was to pay psychiatrists for spending more time with patients so you don't incentivize the 10-15min "med checks" (which would clearly be the financial incentive if therapy add on codes didn't exist...like I mentioned before I can easily make more doing even 4x99213 15min appts never mind throwing a 99214 or two in there than 2x99214 30min appointments). So yes, in spirit you should be able to just put "17 minutes" but in practice many insurances require you to put down start and end times.

Pre 2013 the old codes (90811, 90813, etc) were actually for a range of time (20-30min, 45-50min) which is probably why some people still think its acceptable to put some kind of time range in there (16+ minutes, 38+ minutes) but if you look at the documentation requirements for insurers, that's not the case now.

 

[psychmd03]

Multiple people have claimed both here and on other groups/forums that when audited, some insurance companies have wanted actual start and stop times for the therapy (even though that's ridiculous). I believe others have stated they wanted just the total time. I don't recall anyone ever saying that an audit has been ok with a vague description of the time.

I have gone through note reviews with at least 5 different insurers at this point a few medicaids and a few medicare advantages and United and all of have paid 90833 with a generic +16 min documentation. I document a treatment modality (brief cbt, supportive therapy) a target sx, (mood anxiety, etc) that the patient was cognitively appropriate and gained benefit from therapy. But I wouldn't doubt some will be more specific about it.

 

[J ROD]

Related point. Can a psychiatrist add the 90833 code to a 99213/4 if later in the same day in your practice a therapist bills for psychotherapy?

 

[TexasPhysician]

Related point. Can a psychiatrist add the 90833 code to a 99213/4 if later in the same day in your practice a therapist bills for psychotherapy?

No. One therapy code per practice per day.

 

[J ROD]

Yep. Definitely need to consider that into the equation when thinking about possible revenue potential. Because I find most patients rightfully so try and schedule both appointments on the same day. I often could bill for 90833 but cannot for that reason.

 

[calvnandhobbs68]

Yep. Definitely need to consider that into the equation when thinking about possible revenue potential. Because I find most patients rightfully so try and schedule both appointments on the same day. I often could bill for 90833 but cannot for that reason.

I just tell them not to and that their insurance company is going to reject a code if they see us both on the same day. Most of them get it and it’s rarely a problem once you actually tell them about it, the patients often just aren’t aware of this.

I’m not undercoding or getting my time undervalued for their stupid insurance company rule.