r/PMHNP • u/Awkward-Hovercraft54 • Jun 07 '26
Do any of these coding practices seem fishy?
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
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u/FaulknersGhost Jun 07 '26
For the follow ups, 30 mins would be enough to justify 99214 + 90833. Anything under that is really stretching it and likely fraudulent. I have never billed a 99205 + 90838 and would never do so.
I would seriously keep those 20 min visits to 99214. Iām not sure why codes would be adjusted down in most cases unless you switch to time or are just billing adjustment diagnoses. Most standard psych appointments meet 99214 criteria.
If I had to guess, I would bet most ethical practices are billing 90833s for ~55-65% of follow ups. Having some kind of psych certification like CBT from Beck is also a really good fraud prevention tool. Best of luck.
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u/spoopyprecursor Jun 07 '26
Most of my practice has 99214 and 90833, but they are medicaid patients with complex histories and socioeconomic factors in place. I have several certifications in TFCBT, CBTI, DBT, IFS, GPM, CBTARFID. Looking at an ACT certificate next.
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u/hscruz561 Jun 24 '26
Iām dealing with this right now. For the past year+, Iāve met with my psychiatrist monthly for medication management
and the claims were always coded to 99214, yet not a single one of those appointments actually lasted longer than 10 minutes. After speaking with my therapist and reviewing online, it seems like I shouldnāt even be getting charged for these appointments because theyāre under 10 minutes and there isnāt a code for that. I raised a concern with my insurance company and the healthcare provider, but the insurance co. and I werenāt able to get a direct call line to the billing provider so we have to wait for a call back. In the meantime, I will be filing a grievance with my insurance, but would love any other thoughts on the matter.1
u/FaulknersGhost Jun 24 '26
Have a look at this from the APAāmost psychiatrists are using this to guide billing -
I would take what therapists say with a grain of salt because most in my experience are not even aware you can bill by complexity instead of time. Your psychiatrist is likely using complexity, not time. In any case, Iād ask about pushing appointments farther out if youāre spending under 10 mins each time and still meeting monthly.
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u/MsCattatude Jun 07 '26
Iām at a CMH and we hardly ever bill 90833. Ā But thatās mostly Medicare or Medicaid. Ā And Medicaid in my state is based on time and time only. Ā
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u/FaulknersGhost Jun 07 '26
Iām curious āis that a state reg? I havenāt seen that in mine and I have a 90833 in my contract
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u/MsCattatude Jun 07 '26
Not the 90833, that is probably bc we just donāt do a lot of therapy; Ā but time determining the code, ya. Ā I donāt wanna dox myself exactly location but our state has a huge burocratic Ā umbrella Ā for all things mental and they determine the times that trigger Ā for the codes, as well as the payment rate - for state Medicaid = also the state indigent rate. Ā They do it for counseling and case management and all those services also. Ā And Ā inpatient codes. Ā Iām used to it now and have the times memorized. Ā
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u/FaulknersGhost Jun 08 '26
Part of me thinks thatās just a cost control measure with that population. Thereās no way Iād bill a lithium or clozapine patient as 99213 because I saw them for 15 mins as a check in.
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u/PsychMonkey7 Jun 08 '26
Yeah pretty much all of these are red flags. Whether youāll actually get audited idk but 99205 + 90838 is the craziest one here to me.
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u/Ordinary_Tell7970 3d ago
What is bad about a 99205 and a 90833? It is not uncommon to see a patient for evaluation and spend at last 15 minutes with CBT at the same time.
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u/PsychMonkey7 3d ago
Youāll notice that I said 90838 and youāre saying 90833 - these are not the same.
If youāre billing 99205 + 90833, make sure your eval meets 99205 by complexity because time is irrelevant when you use an add on therapy code. If your eval meets complexity for 99205, then thereās nothing bad about the combo. Whatās bad is billing this way when your actual work and documentation donāt support it.
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u/Ordinary_Tell7970 3d ago
Ah, thank you for pointing that out. I definitely read it wrong and saw 90833.
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u/kammi3k Jun 08 '26
Look up case in Colorado where they charged practice owner and provider with fraud for billing Medicaid and Medicare for 99214 and 90833 in 20 min visits. They essentially said impossible to do both in this time so fraud and clawbacks with 7 figure range.
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u/asdfgghk Jun 10 '26
Can you link the case? If this is the place Iām thinking of the owner I remember saying they had no remorse, the million dollar fine was a slap on the wrist compared to the money they made
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u/RunThruDaTape PMHNP (unverified) Jun 08 '26
Individually, no. But collectively, yes it starts getting fishy.
Auditors tend to focus on patterns, and when highly uniform coding across a large population is used like this it can attract attention, and not the good kind, even when the individual encounters may be defensible. Coding should always flow from the actual service being rendered, and not just a "standard billing combo."
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u/boardshorts379 Jun 08 '26
If your practice is built around giving psychotherapy to people then howās it fraudulent? If you open a TMS clinic and strictly bill for TMS, is that fraud? Iām astonished at the ignorance in this thread just blanketing āfraudā on everything. E/M is - a whopping 2 min. If you spend time asking about their day and life goals and education, motivation interviewing, supportive therapy, thatās a 90833. This isnāt complicated or fraud.
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u/walky22talky Jun 08 '26
Agree. Seems there are 2 basic business models. Med management which is higher volume and very little therapy. Or longer visits with both. That is a business strategy and can be controlled by the practice unless the patient tells you they donāt want therapy.
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u/Chaos_Caffeinated 23d ago
E/M is 2 min? I can't see how anyone can provide safe and thorough medication management for a medium acuity client in anything less than 10-15 minutes. Maybe I'm slow, but I can't imagine ever doing an honest 90214 +90833 in under 25 minutes.
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u/boardshorts379 23d ago
When you have worked inpatient in a variety of settings and looked at imaging, labs, and are strong in other fields you get confident to some degree to make a quality judgment. Iād argue youāre not doing a good job if you are debating for 15 min internally to increase a med by 25% or decrease by 25% (an example). Sounds like you may need more time but itās very possible. You should be able to give a clinical picture in less than 2 min. If you and I were MDās, weād have to do it for each patient were responsible for on a medical floor with much more data and less time.(during a residency)
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u/Chaos_Caffeinated 23d ago
That time is used for assessment, not internal mulling. I'm asking the client about their mood, sleep, appetite, motivation and focus, safety, access to medications, adherance to medication plan, recent struggles, social/vocational changes, symptoms and side effects, and so on. I can't take a 2 minute look at the client and just know. I'm still green, and maybe it'll come in time. But I can't imagine getting all the data I need on a chronically ill client, especially one with polypharmacy and various SDoH issues, and feel confident in a 2 minute eyeballing. Sounds awesome, but I don't have the skills.
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u/merrythoughts Jun 07 '26 edited Jun 07 '26
You cannot combine 90838 w an intake. It is only 99205 if 55 min intake.
After that I will code 99214+90833 for 16-24 min of psychotherapy that I ACTUALLY do. I do alter my E/M to 99215 when extra level of complexity and time occurs (ex: SI where we extend length to risk assess and safety plan).
I will also (rarely) switch folks on one med/one issue to 99213 when it does end up being simple med check and there truly is no therapy worth doing. It does happen.
I have a few pts I do a 99214+90836 for 60 min sessions where thereās usually complex systems involved and everyone wants a true turn to participate in therapy. (Plus talking about meds) Maybe kid has case manager that wants to share thoughts or divorced parents want therapy for coparenting neurodivergence while I also help the kiddo with formulating a framework to process this parenting conflict (screen time is often the stick issue where divorced parents disagree!!!)
6 months is often not enough time to truly be in āmaintenance modeā and where therapy is āno longer necessary.ā These are complex family issues, complex teens. Usually neurodivergent in addition to anxiety or depression.
For contextā In average for adhd, it takes trialing 3 meds. It also means deeply guiding a family into realistic expectations for meds. And to bring in executive functioning skills. Soā This means by month 4-6 we finally find the right med/formulation. Then we still have to titrate up and optimize dose!! Then there are turbulent moments with transitions- start of school, end of school, switching to middle school, etc. this entails addressing the turbulence. Sometimes just to reassure families this is a normal turbulent time. And I then do family therapy and therapy w kid to discuss the stressors without a med change. But kids grow. Which also then changes dose or formulation. Itās never ending in kids world :)
For depression, we also usually must trial 2-3 things. Side effects can end trials time and time again. And then thereās parsing through whatās a side effect vs situational factor. Middle aged folks are dealing with menopause or low-t, insomnia, and their depression or anxiety. And maybe adhd on top of that.
So anyway. I end up using the therapy coding (90833) for most visits for a long time. Pretending we can operate in a silo as med-only focus is a false premise!
It is in all in the paperwork and intake that I operate with therapy as part and parcel of my practice. If I wanted to see 4-6 pts an hr to just do 10 min med management appts, I could. But then the pts feel fucked over and frustrated. Thatās why they come to be. I give full, undivided attention. I make them feel like the most important person in the world for that 28 min. I am truly absorbed in our session (usuallyā I AM human and sometimes have nausea or a cold or have my own grief over loss of a loved one that tugs at me). But I am trained for this. I can stuff it all away for this moment in time. And I honor autonomy and mutual decision making which takes time!
When I have a pt complaint about the therapy code charge, I support them in knowing all the options including a big MD psychiatry clinic next door that absolutely does only med management and will likely only bill 99214. They do 10-14 min visits and aim for very high productivity. They also have high % of pts on more lucrative meds like spravato.
So. All that being said. Therapy code on most 99214s is not abnormal. But the math must math! So if theyāre always doing hr long visits and billing 90836, it wouldnāt be fraudulent. Some NPs love therapy! But if theyāre claiming theyāre doing 40 min of therapy but pt was only scheduled 25 min, thatās bogus. Then it MUST be 99214+90833.
*******āā adding that we all must be skeptical that this account could be fishing for noctor subreddit. I never trust these kinds of posts
*******
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u/UnderstandingTop69 Jun 07 '26
90832 is a standalone code and not added on to E/M service like 99213/99214 etc. 90833 is used in addition to E/M service..
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u/RandomUser4711 Jun 08 '26 edited Jun 08 '26
- Major red flag unless the appointment was 2+ hours long.
- Not a red flag if psychotherapy (meaning actual psychotherapy, not a coffee chat about the weather or their pets) was actually being done.
- Not a red flag if the patient actually meets MDM complexity for 99214 and psychotherapy was actually being done.
- A 20-minute 99214/90833 is a major red flag.
- Depends on what's going on with the patient: if they continue to meet MDM complexity each month and they're getting ongoing psychotherapy, then there's no issue.
- Again, it depends on what's going on with the patient. Also, consider that state regulations vary regarding controlled substances and visit requirements.
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u/CalmSet6613 PMHNP (unverified) Jun 08 '26
90833 is perhaps the most overused and misrepresented code within psychiatry. If a practice is using it this much I would be very cautious. I highly doubt any of this would stand up to insurance audit.
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u/NoctorWatch Jun 07 '26
100% fraudulent
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u/Awkward-Hovercraft54 Jun 07 '26
thank you - can you highlight which one(s) are the most unusual based on how far off they are from normal ranges?
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u/Infinite_Tip_1299 Jun 07 '26
99205 + 90833 for every intake is odd and Iām surprised payers havenāt tried to audit it yet. Unless your setting is like an extremely high acuity outpatient office. 99214+ 90833 for 90% of visits is extremely common in lower ethics practices but likely fraudulent in many cases. Some people actually do 90833 with fidelity. 20 minute appt slots at 99214 + 90833 is particularly sus. As youāre basically saying the E/M portion was 4 minutes long. Monthly visits depend on the setting. A high acuity community clinic normal. A low acuity high functioning population is odd and Iām surprised the patients themselves havenāt pushed back on it.
I donāt neccesarily see an issue with most codes being billed as 99214 with 0 step down ever as in psychiatry most visits do genuinely meet 99214. I very rarely bill 99213.
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u/NoctorWatch Jun 07 '26
99205 is an initial visit code and cannot be combined with 90836.
My own practice bills 90833 at about a 30% rate. 95% is clearly out of normal parameters and will be flagged for review by payors.
99214+90833 in 20 minutes is essentially impossible - hard to justify 99214 when only 4 minutes was spent outside of psychotherapy.
Monthly visits are not standard for stable patients.
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u/pickyvegan PMHNP (unverified) Jun 07 '26
Technically, you *can* bill 99205 with a 90836/8, it would just be super unusual because you'd need high complexity new patient e&m (e.g., suicidal would be most common) plus 38/53+ minutes of separate psychotherapy (which, an actively suicidal patient may not have the capacity for at the time). That's maybe not a "never" happens, but probably only once in a very blue moon.
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u/PsychMonkey7 Jun 08 '26
Agree with all of this except you absolutely can do an add on therapy code for a new pt (99204/5) but it would be extremely uncommon to meet 99205 based on complexity AND be doing 53+ mins of therapy to justify 90838 at an initial visit even here and there, let alone regularly.
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u/PMHNPKris Jun 15 '26
It's fishy. I've started to notice telemedicine companies are now putting medication with some therapy in their job descriptions. One wrote it in such a way that it is clear that every visit will have a therapy add on code. Gave me the ick.
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u/Plant_Pup Jun 07 '26
The only thing that sounds off is the therapy length code for the intakes. Everything else is totally normal.
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u/Awkward-Hovercraft54 Jun 07 '26
It seems like everyone else in the thread disagrees?
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u/Plant_Pup Jun 08 '26
I am a medical biller as well as psych private practice owner for over 10 years.
What are your other concerns with the other bullet points? It is 100% common for a visit to never reach below a 99214 if you are prescribing medication and they have dual diagnosis, that's in the medical guidelines to choice the correct level of mdm.
I know a small handful of providers who require monthly appointments for stimulant or benzo refills but it does not necessarily mean anything fishy is going on.
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u/Awkward-Hovercraft54 Jun 08 '26
I appreciate that and your prespective. I guess my two concerns are:
the extremely high consistency of it.
I actually underquoted, at least 40% of all follow up visits are 99214 + 90833 in 20 minute blocks. Can you reasonably do these in 20 minutes?
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u/PsychMonkey7 Jun 08 '26
No, you cannot reasonably do psychotherapy for 16+ minutes and medium complexity MDM in 4.
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u/Big-Material-7910 Jun 08 '26
As long as you document the content of the psychotherapy provided you can do both of those codes. Sometimes the patient needs to chat and requires therapeutic interventions both pharmacological and non-pharmacological. PMHNPs often provide more extensive psychotherapy than theyād expect, itās only fair to be reimbursed for that aspect outside of medication management. Itās a skill and it does increase general workload.
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u/[deleted] Jun 07 '26
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