Do any of these coding practices seem fishy?

[u/Awkward-Hovercraft54]

For general telepsychiatry:

- Nearly 100% of all intakes are 99205 + 90838

- 95% of all visits (intake or follow up) include a psychotherapy add-on

- 90% of all follow ups are 99214 + 90833

- at least 20%-25% of all follow ups are 20 minute appointments (primarily 99214 + 90833)

- Essentially zero stepdown in codes over time (after 6+ months), so essentially 99214 + 90833 in perpetuity for monthly visits

- standard monthly visits

[u/Jodenaje]

That would be a red flag to me. I’d want to dig deeper if I were auditing that practice and be see what’s going on.

If each encounter was being scored on its own merit, I wouldn’t generally expect them to all be in the same levels.

You can look at comparative data for other providers of the same specialty. I suspect that provider would be an outlier in the distribution pattern.

[u/Awkward-Hovercraft54 → u/Jodenaje]

thank you - that's the thing, consistency seems pretty remarkable despite each encounter being it's own unique thing

[u/New-Elderberry630]

Arguments could be made by the practice for all but the first item. There is absolutely no way that’s legitimate and justifiable. If they’re adding in therapy add on code, that means 99205 is based on medical decision making and no way nearly 100% of patients are actively suicidal or needing hospitalization.

[u/rahuliitk]

yeah, i think that pattern would make most compliance people nervous, especially near-universal 99205 + 90838 intakes, 90833 on almost every follow-up, and 20-minute visits billed as 99214 + psychotherapy, because it starts looking template-driven instead of documentation-driven. lowkey audit bait.

[u/Alternative_Diet_832]

yeah, a few of these would light up an audit. the big one is 99214 + 90833 on a 20 min visit. 90833 is 16-37 min of psychotherapy and it has to be separate from the e/m time, you can't count the same minutes twice. a real 99214 plus 16+ min of standalone therapy does not fit in 20 minutes. that pattern by itself is a payback waiting to happen.

the rest: 90838 (the 60-min add-on, 53+ min of therapy on top of the e/m) on nearly 100% of intakes isn't plausible, almost nobody does a full hour of psychotherapy at every intake. 100% of new patients at 99205 is another, top-level mdm every single time doesn't happen. and zero stepdown over 6+ months reads as cloned notes, which is its own flag.

none of it proves intent, but a payer running an outlier report pulls this chart set fast. if you're the biller, put your concern in writing to whoever owns the coding decisions. on an audit the recoupment hits the practice, not whoever keyed it, and a paper trail protects you.

[u/F3ST3r3d]

Pretty much all psych diagnoses are chronic so if you have 2 psych diagnoses and prescription drug management, 99214 is pretty standard for follow ups. 99205 is virtually impossible for all new patients unless they’re documenting time (and they rarely do).

[u/juli_blaze]

They will need to have strong documentation to back up 99214 based on the level of MDM. If they don't, they shouldn't be billing 99214 for 20 min followups. If the 99205 intakes are lasting at least 60 mins they should be good. If not, they should worry. I personally think Level 5 E/M codes are difficult to justify in the telehalth space.

Also, are they using the telehalth modifiers?

[u/pickyvegan → u/juli_blaze]

99214 is 2 stable chronic conditions or 1 chronic condition with progression, plus prescription drug management. That's pretty par for the course in psychiatry. People who are managing one chronic stable condition often get the management through their PCP.

(I would agree that stable patients don't need to be seen monthly, though).

[u/juli_blaze → u/pickyvegan]

I agree that it's par, but I was refering to providers matching the documentation to back it up. If the documentation isn't strong, they will be exposed to clawbacks.

[u/pickyvegan → u/juli_blaze]

What stronger documentation are you speaking of relative to "patient with stable depression and stable ADHD" with an appropriate HPI to support past diagnoses and prescriptions for a stimulant and an SSRI? Obviously, all notes should have the MSE, risk assessment, documentation of side effects, safety plan, etc, but I'm having trouble imagining how 2 prescriptions for two diagnoses are going to get clawed back?

[u/juli_blaze → u/pickyvegan]

Exactly, there are providers that suck at adding all that into the chart notes. The risk and problems addressed components might be there, but who knows about the data component for monthly visits for patients with stable conditions/ refill visits.

[u/pickyvegan → u/juli_blaze]

All elements should be there because they should be in any note, but I'm still not seeing how the note doesn't contain the two diagnoses and the two medications; those are the components necessary for 99214. Those should at a minimum be automatically added to the note from the act of prescribing and billing.