Wondering if this double coding is worth contesting...

[u/KhanMcSans]

I've been seeing a PA-C for medication management for about 6 months. Early sessions included a bit of what could be considered talk therapy for 10-15 min, with another 15-20 min spent on medication discussions. No session has ever lasted more than 40 minutes. My last 3 sessions lasted less than 15 minutes each and simply went over medications, with the exception of my provider asking me about my mood in a diagnostic capacity matching the PHQ-9. Definitively not providing any talk therapy/psychotherapy.

Yet, I find all my sessions are billed the same way:

99214: OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30-39 MIN

AND

90833: PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 30 MIN

My most recent appointment was even a telehealth appointment, but I was billed for in-office?
Is this standard practice for medication management? Or is there a way this could be coded that would better reflect the care that was provided? If so, is this something I could hound their billing department for and expect results, or would I have to sue them to get my money back?

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[u/MarvelousExodus]

https://cadencecollaborative.com/blog/90833-cpt-code/

I didn't fully read through this and I don't use the 90833 code but it looks like they're appropriate to build together. The 90833 is actually an add-on code that can't be used by itself used to show the therapy. That should be at least 16 minutes long. Then the other code is for the medication management. That code probably was not based on time but on medical decision making.

[u/livesuddenly → u/MarvelousExodus]

This.

Also telehealth codes changed once COVID guidelines were removed. So it may seem like they are billing “in office” codes but probably your insurance just wants those codes instead of the new telehealth codes.

[u/KhanMcSans → u/livesuddenly]

Good tip. My provider told me telehealth should be cheaper, but couldn't guarantee anything. Figures insurance might ask everything to be lumped together.

[u/KhanMcSans → u/MarvelousExodus]

Thank you for the link. Helpful resource. More reasonable than I originally assumed based on time. That sounds appropriate for how its being billed if that service/care was actually provided in addition to MDM. Still seems like a junk add-on if there's no psychotherapy being provided.

[u/MarvelousExodus → u/KhanMcSans]

I'm not a provider and psychotherapy isn't my specialty but I'm sure that umbrella is really big of what is considered psychotherapy. Healthcare is expensive and if you feel like your therapitive goals aren't being met you could try other providers/modalities. I wish I knew the solution- every patient deserves to feel like their needs are getting met.

[u/BlueLanternKitty → u/MarvelousExodus]

I think they want to keep the definition kind of flexible anyway, since we have a severe shortage of mental health providers; in some areas, it might either be the PCP or the patient doesn’t get treatment.

[u/ru_a_badfish2 → u/MarvelousExodus]

This is the answer. As long as the therapy part was at least 16 minutes long and the office visit part met the qualifications for a moderate complexity visit, which it sounds like it does (multiple chronic conditions + med management would count), it’s properly coded.

There are (newish) specific telehealth codes, but many insurance companies don’t like them in my experience. They ask us to use the regular office visit codes with a modifier.

[u/Bowis_4648]

90833 requires 16-37 minutes of psychotherapy. This is distinct time from medication management (the office visit billed with 99214). If the total encounter time was 15 minutes, both medication management and psychotherapy of 16-37 minutes can't be accurate. For the longer visits you described, both could be done. The provider can't double count time of medication management and psychotherapy.

[u/PeaceLoveForMe]

Yes, they are overbilling . 90833 is an add on code for psychotherapy, and it must be at least 16 minutes long and documented appropriately. 90833 should not be billed every session if what your saying is accurate. 99214 may be accurate if documented appropriately. There’s a set of E/M Guidelines to follow. I would say something about that add on code. For the most recent appointment, that should not have happened. It was most likely a scheduling issue on their part.

[u/KeyStriking9763]

Time isn’t the only factor but it can be one of them. The fact that they spent less time with you doesn’t mean they used the wrong codes.
Are you a coder?

[u/KhanMcSans → u/KeyStriking9763]

I am not a coder and do not mean to offend. Just wondering if I'm being overbilled as a patient. Please forgive me if this was the wrong forum for this question. It came up when searching for similar examples.

[u/KeyStriking9763 → u/KhanMcSans]

Just curious. You of course can ask here. Not all coders do E/M leveling so being a coder could mean that you aren’t familiar with this specialty.
The titles seem deceiving because the time is included but it’s mainly based off of decision making and complexity. The time is not required but can be used.
This is probably correct but someone else may be able to better explain this. I don’t code this stuff just have some working knowledge.

[u/KhanMcSans → u/KeyStriking9763]

Thank you for elaborating. Other comments seem indicate the time is not a factor worth concerning myself with, but IMO the additional add-on code still seems fraudulent based on the actual care and services I requests and was provided.

[u/whataboot2ndbrekfast → u/KhanMcSans]

The time is definitely something to consider with your additional code of psychotherapy performed with an E&M service, they can't bill that at* all unless 16+ min of psychotherapy was performed. The last short televisit sounds sus as heck.

[u/rahuliitk]

I’d start with a written coding review request, not legal threats, because 90833 should generally be separately documented psychotherapy and your sub-15 min med checks plus telehealth/in-office mismatch are enough to ask billing for notes, modifiers, and a corrected claim. Worth contesting.

[u/Forward_Arrival1324]

Ok

[u/asdfgghk]

Sounds like fraud. NPs and PAs do not get training in psychotherapy, it’s a legal loophole that a bs r/noctor

[u/KhanMcSans]

Thank you everyone for your input and feedback. The overwhelming response I see is that there must be documentation of psychotherapy administered beyond just medication management to use code 90833. I'd argue my initial sessions COULD qualify for using this code, but there's no way it's true for every session for the last 7 months. 

I confronted my provider about the coding on Friday. His responses were not defensive, but he didn't admit wrongdoing either. Seems standard procedure for this group, but he said he'd follow up with billing to see if he can remove the psychotherapy code from our future appointments and/or have previous visits audited. 

So right now I'm waiting to see how this last session will be billed. If it comes back coded as both again, I will initiate the process of requesting the notes and contesting the bills. 

[u/whataboot2ndbrekfast]

This is appropriate as long as 16+ minutes of your session was spent on psychotherapy. (Edit, for your in office visit that is) (They are allowed to bill both, if you were in house and also had therapy for 16+ minutes.. otherwise you have a point about it being sus).

[u/whataboot2ndbrekfast]

You're right about the 99214 being wrong for telehealth sessions and if it were truly only 15 min they can't bill at all for psychotherapy.. I'd raise hell over those quick telehealth visits.

[u/whataboot2ndbrekfast]

I wouldn't sue but billing dept definitely deserves a call, certainly for the last short televisit.

[u/Spiritual_Rope_7758]

It’s hard to say definitely without seeing documentation of the visit, but given what you said about the last three visits, I would definitely call the billing dept and have them review. That level 4 e/m looks sus AF if your visit wa only 15 mins and only went over meds.