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  • Private Practice (February)
  • E&M Codes for Fun and Profit: A Story of 4 Psychiatrists

E&M Codes for Fun and Profit: A Story of 4 Psychiatrists

The Carlat Psychiatry Report, Volume 14, Number 2, February 2016
https://www.thecarlatreport.com/newsletter-issue/tcprv14n2/

From The Carlat Psychiatry Report, February 2016, Private Practice

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Practice Tools and Tips

Print Friendly, PDF & Email

Daniel Carlat, MD

Editor-in-Chief, Publisher, The Carlat Psychiatry Report

Dr. Carlat has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Since 2013, all psychiatrists have had to use new CPT (Current Procedural Terminology) codes. We published a primer on the system in our May 2013 issue, but the codes are still complicated. The good news is that the new system values psychiatric services at a higher level, and reimbursements per visit have increased substantially, by 20% or more. Hopefully, this will encourage psychiatrists who have fled insurance networks to return to them—you can now be assured of a robust income with an insurance-based practice, even if you choose to see many of your patients for therapy.

I don’t intend to rehash all the guidelines—I’ve added some links at the end of this article for those wanting to immerse themselves in the details. Instead, in this article I’ll give you a quick overview of evaluation and management (E/M) coding, and I’ll share the experiences of 4 psychiatrists who have been using these codes over the last 3 years. Each clinician has a somewhat different approach, but they have all found ways to integrate E/M coding into their busy practices, and they will offer some shortcuts and other tips.

The new CPT codes have essentially split up our old procedure codes into two: The E/M codes reflect what you do when you evaluate a patient for medication management, and the revamped psychotherapy codes are for the therapy component of visits. Since many of us do both med management and therapy, we now use 2 codes for most of our patients—an E/M and a psychotherapy code.

The psychotherapy codes are pretty easy. For short visits (around 20 minutes), you can code 90833 (requires at least 16 minutes of face-to-face time), and for longer visits (around 40 minutes), code 90836 (at least 38 minutes of face-to-face time). To document therapy, write something like, “provided supportive therapy for family stressors;” in other words, lots of detail is neither required nor advised, since these are notes that can be shared with other practitioners under HIPAA guidelines. Take-home point: Don’t neglect these therapy codes, since they may pay as much if not more than E/M codes, and it is perfectly kosher for you to add a therapy code to your E/M visit.

The potential documentation nightmares arise with E/M codes, which require that you document 3 main elements of your psychiatric visit: the history, the exam, and “medical decision-making.” Note that these elements correspond to what we’ve been doing all along, though we may use different terms. For instance, I tend to think about my follow-up visits as encompassing history, mental status exam, and an assessment/plan. Some think in terms of a SOAP note, in which case S, subjective, is “history,” O, objective, is “exam,” and A/P, “assessment/plan,” is “medical decision-making.”

In this article, my focus is on follow-up visits (and not the initial evaluation), and on psychiatrists who are not using complex electronic health record (EHR) systems. If you are using an EHR, you are likely engaging in a click-fest that may be tedious, but on the other hand, it generally guarantees that your documentation will survive an insurance company audit. There are advantages and disadvantages of EHRs, and if you are employed by a large practice or health system, you may be required to use the software which they have purchased. Research on EHRs has paradoxically found that they lower physician productivity in smaller practices (Adler-Milstein J and Huckman RS, Am J Manag Care 2013 Nov;19(10 Spec No):SP345−352.)—which is why many psychiatrists have avoided these systems thus far.

If you don’t use an EHR, you’re likely using paper, or perhaps you’ve created your own progress note template in Microsoft Word. Either of these lower-tech systems can play just fine with E/M codes. I interviewed several practicing psychiatrists so that you can learn from their real-world experience with E/M coding. All of my respondents requested anonymity, allowing me creativity in naming them. Spoiler alert: The best solution may be to ignore the guidelines and to simply write a good, thorough SOAP note for all your patients.

Dr. Old School: Pen and paper, baby
Dr. Old School is a senior psychiatrist in private practice who accepts insurance. She schedules most of her patients for 45-minute visits combining therapy and medication. Before 2013, she billed 90807 (individual therapy with medication management) for almost all of her sessions, writing out notes on paper during visits.

With the new CPT, Dr. Old School has changed only one thing in her practice: Instead of billing 90807, she codes all her visits as 99213 with the add-on therapy code 90836. Her notes, still generated via pen and paper, follow a loose format that usually includes a few lines about the interval history, the diagnosis, and some comments on meds. A typical note, for example, would be, “The patient discussed his guilt about not being able to support his parents. Appears to have some OCD symptoms of checking, in addition to depression. Currently taking Wellbutrin, which is helping, will add fluoxetine for OCD.”

When the new codes were released, she spent minimal time reviewing the information—“They were so complicated they gave me a headache,” she said. She decided to use 99213 for all patients primarily because it seemed to represent an average visit. “I didn’t want to bill too high, because it seemed that they required a lot of documentation. I’m not very good at documenting.” One insurance company asked to review some of her records, but it didn’t give her any feedback (positive or negative), and the company continued to reimburse her charges.

Dr. Out of Network: Notes for the patient’s benefit
Like Dr. Old School, Dr. Out of Network sees patients in 45-minute increments, combines meds and therapy, and he bills all of his patients 99213 plus 90836. Unlike Dr. Old School, Dr. Out of Network does not contract with insurance companies and charges $300 per session, with a sliding scale for those who can’t afford his fee. However, he does provide his patients with a bill they can forward to their insurance companies, many of which provide out-of-network benefits after a deductible is met. For this reason, he uses a Microsoft Word template that encompasses the major elements of the HPI, the MSE, diagnosis, and meds. He does this primarily to support the billing code in case an insurance company asks for documentation before reimbursing a patient.

Dr. By the Book: Pathways to success
Dr. By the Book works in a group practice and schedules 3 patients per hour, accepting most insurances. She bills either 99214 or 99213, and for some patients also bills an add-on 90833 for therapy. She has made a careful study of the billing rules, and has developed shortcuts to ensure that she documents exactly what needs to be in the chart to support a given code—no more and no less.

Over the last 3 years, she has developed a limited number of documentation “pathways” for each code. Below are the main pathways for 99213 and 99214. 

Important note: E/M coding criteria refer to “problems” rather than “diagnoses.” Sometimes these are identical, (such as “depression”—usually both a problem and a diagnosis), but often patients present with more general problems that are not DSM diagnoses, such as weight gain, anxiety, forgetfulness, anger, etc. Keep this in mind as you read the next 2 approaches, since patients frequently will have only 1 or 2 diagnoses, but may have many more problems, each of which “counts” when you are deciding which code to use.

99213: 

  • Patients with 1 problem: Document the problem, one medical review of system (ROS) item, which can be psychiatric (eg, “denies anxiety”), and at least 6 items from the mental status exam. (No documentation of medication is required in this pathway, though she usually does so.)
  • Patients with 2 problems: Document the problems, one ROS item, and the prescription of a medication.

99214: 

  • Patients with 2 problems: Document the problems, at least 4 symptom “elements” in the HPI (such as severity, duration, timing, and quality), at least 9 items on the mental status exam, 2 ROS categories (not necessarily psychiatric), and social history (such as “spending more time with friends”).
  • Patients with 3 problems: Document the problems, the social history, 2 ROS categories, and the prescription of a medication.

Dr. Volume: A systematic approach
Dr. Volume typically sees 5 patients per hour (a high “volume” practice), billing about 60% of visits 99214 and 40% 99213. He very rarely bills an add-on therapy code, and most of his patients see other clinicians for psychotherapy.

Like Dr. By the Book, Dr. Volume has studied the rules carefully, but he does not use distinct documentation pathways. He has created his own comprehensive progress note template, which includes all the elements of history, exam, and medical decision-making required for any E/M code. He fills out the template for all patient visits, ensuring that his documentation always meets criteria for the highest level of visit. However, he doesn’t bill 99214 for all patients, realizing that there is meaningful variation in the complexity of visits.

His shortcut for deciding which code to use is a sort of streamlined version of Dr. By the Book’s:

  • One problem: 99213.
  • Two problems that are stable: also 99213.
  • Two problems, one of which is worsening: 99214.
  • Three problems: 99214.

One insurance company audited his records and told him that he bills more 99214s than other psychiatrists. “I told them that I researched the regulations extensively, and I’m following all the rules, and they said, okay, that’s fine, and I never heard from them again. I think a lot of psychiatrists are giving up a lot of money if they are billing only 99213s.”

Conclusion
I’ve described 4 approaches to coding for follow-up visits, and they all work for the psychiatrists who use them. Everyone’s practice style is different. The safest policy is to document all your visits thoroughly, but not so comprehensively that you are taking too much time away from your clinical work. If you document the interval history, the MSE, your assessment, and your plan, you will be able to successfully bill a combination of 99214s and 99213s—and probably more 99214s, which will significantly increase your income. The amount of time you spend with patients is not closely related to how high you can bill, within reason, of course. Dr. Volume will never bill a 99214 for a five-minute in-and-out medication refill patient. But there are plenty of fairly complicated patients with 3 or more problems that we can evaluate and treat in 15–20 minutes and who should be billed as a 99214.

For those who want to really get into the rules, I recommend going to the APA website for coding and reimbursement and downloading at least the following 2 documents:

  • E/M Services Guide: Coding by Key Components (summary chart)
  • Patient Examples Outpatient E/M Visits

There are additional longer documents on the site as well, one of which is a chapter from one of the definitive resources, Procedure Coding Handbook for Psychiatrists, 4th Edition.

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  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Chris Aiken, MD

Dr. Aiken is the director of the Mood Treatment Center in North Carolina, where he maintains a private practice combining medication and therapy along with evidence-based complementary and alternative treatments. He has worked as a research assistant at the NIMH and a sub-investigator on clinical trials, and conducts research on a shoestring budget out of his private practice.

Full Editorial Information

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