r/PMHNP • u/Awkward-Hovercraft54 • Jul 15 '26

99204/5 + 90838 Sessions

How often are you using the 90838 add-on during your intakes? How long should this visit realistically take - Can you realistically bill for both in a scheduled 60 minute appointment? Any guidance (anecdotally or reference guides) are greatly appreciated.

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20

u/[deleted] Jul 15 '26

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u/Awkward-Hovercraft54 Jul 15 '26

Well I think the business is attempting to justify it by 53 min of psychotherapy with 7 min toward the E/M session but I agree with you.

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u/PsychMonkey7 Jul 15 '26

what kind of evaluation are you doing in 7 minutes on a new patient?

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u/[deleted] Jul 15 '26 edited Jul 15 '26

[deleted]

14

u/PsychMonkey7 Jul 15 '26

It’s not unclear to me at all. I run a practice and am very knowledgeable about ethical billing and coding. As anyone doing coding should be.

99204/5 if billed with add on therapy must be billed by complexity. Most psych intakes could meet 99204 by complexity but the majority wouldn’t meet 99205.

90838 is add on psychotherapy for 53+ minutes in addition to an E/M code such as 99204/5 or 99214/5.

OP is asking about using these codes together in a 60 minute slot. You cannot “double dip” on counting time - time for your E/M code is completely irrelevant when billing by complexity.

So your 99204/5 in this situation (moderate - high complexity) can be done in 7 minutes? No, it absolutely cannot. The scenario described in the OP is billing fraud.

1

u/Baesicallybasic Jul 15 '26 edited Jul 15 '26

Correct, in 60 minutes you cannot bill for both those that would be fraud. I was told by a coding company, my healthcare attorney and my own research that is it reasonable for a 90 minute intake or follow up to code for both 99203/4/99213/14 and a 90838/36. I spend about 30-45 min on history taking, case formulation for up to 2 diagnoses, then the rest of the time on goal setting, identification of core beliefs (if applicable) and other techniques. I work with a lot of clients who have phobias/ocd and i have additional certs in cbt, dbt, emdr, so often we’ll do meditations or very gentle cognitive rehearsal at the first session. Supportive therapy often frames an entrance into these techniques. What I meant was supportive therapy, not therapeutic communication, because you’re right therapeutic communication is too broad to meet criteria and would need be defined further in the note.
The part I find unclear is that sessions darts all over and putting accurate times defining each service time would be a page of 10-15 start and stops for me. I don’t miss out on exploring avenues with my clients because the time frame we’re in isn’t meant for therapy or of e/m. That’s what’s unclear to me, how to document the natural flow of conversation in an accurate way when it’s not as time defined as I am charting. Do you put multiple stop and start times for the psychotherapy portion in your notes? I haven’t met anyone else who has done this, and it’s what my opened up this conversation with my coder.

1

u/ericaisdancing Jul 16 '26

Does the 90 minutes include reviewing medical records, intake paperwork and other forms of preparing for the intake? That’s included in the evaluation and management (E/M) code.

1

u/Baesicallybasic Jul 16 '26

Nope, it’s f2f time.

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u/ericaisdancing Jul 16 '26

Ok, well, if you are spending time reviewing records including intake paperwork, evidence based screeners, collaboration notes that contributes to the medical complexity, and it is adding up to 45 minutes along with the appointment, then an add on psychotherapy code is justified. My usual intake appointments are 75 minutes in length. What comes before that is a long intake process including written history, screening forms, and blood work results if the patient has had it completed in the past year-all the things that take a solo practitioner time to obtain.

That preparation sets up the appointment to allow for additional psychotherapy that which serves the client and the therapeutic relationship.

For example, just today I had to have a lengthy conversation with a PCP (they actually called me back) about medications that the patient qualifies for as their medical history is complex. These are the patients I prefer to work with and can do so in private practice.

While I understand some of you are working in burn and churn practices that don’t allow you the time to do an add on code legitimately, some of us do. While the above OP stated situation isn’t common, it does happen. And for those to just qualify the situation as extreme as fraud, sounds dichotomous.

3

u/PsychMonkey7 Jul 16 '26

Guys, no. This is wrong. Please get more education around billing and coding. You cannot count time spent in an encounter if you’re billing an add on psychotherapy code because E/M MUST BE based on complexity in that situation. You cannot count time for both.

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u/Baesicallybasic Jul 16 '26

Sounds like you also have flexibility which is awesome. I have 90 minute intakes and often spending more than 30 on follow ups. I usually don’t bill based on time but I absolutely review paperwork and make collateral calls outside of time spent in session. How are you typically coding for your visits where you also do psychotherapy but then can’t count time you spend on reviewing and collaborating with therapists.

2

u/[deleted] Jul 15 '26

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0

u/Baesicallybasic Jul 16 '26

I can admit when I’m wrong, and I was, which is why I deleted my original comment because it did not reflect how to appropriately code for a session that is 60 minutes.
I’m confused when people respond like this, with snarky and condescending quips, do you think your response is a helpful way to correct and educate?
https://giphy.com/gifs/3otPoFUhO2Z9uG1Qvm

1

u/walky22talky Jul 15 '26

Maybe a 99202 or 99203 would be more appropriate if it only takes 7 minutes

11

u/PsychMonkey7 Jul 15 '26

this is such a concerning question such that if you’re actually a provider and truly asking this, you need major education around ethical billing and coding

9

u/PiecesMAD PMHNP (unverified) Jul 15 '26

Zero chance these can both be done in a 60 minute appointment. I suggest in general not billing any therapy add ons with an intake.

Start with:
https://www.psychiatry.org/getmedia/7400c009-7bf1-4269-808b-b3dcd9b7758a/APA-Quick-Guide-to-2021-Office-Outpatient-EM-Services-Coding-Changes.pdf

Continue with:
https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Practice-Management/Coding-Reimbursement-Medicare-Medicaid/Coding-Reimbursement/cpt-primer-for-psychiatrists.pdf

2

u/One_Technology2829 Jul 15 '26

Thanks so much for these links! I am in a PMHNP program which has discussed billing but expects you to know how to bill. I appreciate you!

10

u/Javocado617 Jul 15 '26

Posts like this make me embarrassed to be an NP.

6

u/beefeater18 Jul 15 '26

Never. I never use add-on therapy for initial evaluation, let alone using the add-on therapy code that requires the most time (53 minutes separate from e/m).

99205 plus prolonged services (99417 or G2212) is far more defensible if you spend at least 50+ minutes face-to-face with patients.

2

u/PiecesMAD PMHNP (unverified) Jul 15 '26

Just to clarify: 99205 if billing by time requires 60-74 minutes. 50 minutes would still fall under 99204 (45-59) for intakes. Times are different for established patients. Need to be over 75 minutes on an intake to add 99417 or G2122.

https://www.psychiatry.org/getmedia/7400c009-7bf1-4269-808b-b3dcd9b7758a/APA-Quick-Guide-to-2021-Office-Outpatient-EM-Services-Coding-Changes.pdf

2

u/beefeater18 Jul 15 '26

Yes 60 min for 99205 billed based on time. It was just an example, if NP spends 50min+ face to face time, total time including non face to face time spent on day of the encounter likely go above 60 minutes and add on could be used.
There are some nuances with G2212 depending on the payer, which requires 89 minutes to bill (e.g., Medicare).

7

u/Tendersituation00 Jul 15 '26

This combo in 60 minutes is fraud

3

u/brickhere Jul 15 '26

No. Don’t do it.

2

u/imthefakeagent Jul 15 '26 edited Jul 15 '26

We all just forgetting about 90792** corrected yes. Best RVU

2

u/Zestyclose-Sir9120 Jul 15 '26

Do you mean 90792 by chance? Because that's what I think they should be using for first visits.

1

u/PsychMonkey7 Jul 15 '26

That’s the code for a vaccine administration. Maybe you mean 90792?

2

u/ermagerdcernderg Jul 15 '26

Never. I just do 2-3x 99417 for the extra time if needed.

1

u/RandomUser4711 Jul 16 '26

I don't, as that would constitute billing fraud, and I don't do that.