cpt coding

CPT Coding, Billing, and Pain

Policy & Career Help

I’ll admit, I can’t stand billing or anything related to bills. Billers do not understand my pain and suffering but we want to get paid so billing matters. What’s sad is the countless hours of charting that I don’t get compensated for or the mental space being used since everything is coming down to numbers. Yet, we providers have to keep it cute and classy. So let me ramble and then go over a progress note so we can all suffer together.     

It’s time for people to see your documentation and many people are still not prepared. But you will get there because it’s a requirement. I previously wrote about how good language should convey the gist of your appointments. Some providers are assuming if I chart a few sentences, I can bill 99214 or however I want but you can’t chart or bill this way, because CPT codes have standards. This time I have to point out the importance of having the necessary items for your notes to be billable.

For the sake of simplicity, I’ll just be focusing on general outpatient psych notes since that’s the majority of care services. To summarize, have a system. One that is reliable and reflects a good picture of the medical decision-making process. This is how a profession is taken seriously. So we NPs have to step it up because we don’t have a choice. 

I write my notes in a way that a therapist, NP, the patient, or a physician should be able to know what’s going on. I’ll admit my charting was rough and if I had a bad day, I just gave up for that day because I was too stressed out to type. But once you have a system constantly work it out until it works out best for YOU.  For example, some people say consumers but I put the person’s first name to keep track of who I’m writing about… I have whole families, step-parents, half-siblings, etc. as my patients and it’s less confusing for me to just use the patient’s first name. So keep working on a system until it’s efficient and reliable for you. 

The main reason for this post and why your documentation has to be more clear is because insurance companies will NOT pay out if services (or whatever you wrote) don’t appear billable. Don’t let our profession get put in a fraudulent activity bin by writing 5 sentences as a progress note. If insurance companies continue to give you a hard time then at least you have the proper documentation to prove your claims or file a lawsuit to get the compensation but make sure you are charting the requirements. 

The new CPT codes reflect what medical decisions were needed for a patient visit, any additional factors that were used, and the reasoning for the complexity code. With anything, they are tons of outliers so things can get complicated but overall, CPT/billing is not considering the time if there’s no significant reason…and it makes sense, if you spend extra time with a patient, it has to be productive, not a picnic gathering. 

If you are doing things UNCONVENTIONAL please have the documentation/evidence to back it up. Your professional activities need to show that you’re within the scope of practice and providing safe care for what’s going on in this picture. In reality, a lot of things occur off the record but if you have the documentation, your coding needs to capture it or you’re wasting time/money or you may be causing liabilities. 

I’m going to make a long story short, but I’m getting slammed because I work with an FNP and insurance companies are no longer covering his services so I have to pick up his patients. I tell people well how would you feel if you needed brain surgery and urology showed up?? But I digress. I would never just jump into another domain but don’t worry, insurance companies and lawsuits will continue to be people and providers’ wake-up calls…  


A Simple (Standard) Guide 

I wanted to cover the importance of documenting the requirements for progress notes. There’s much information out there and healthcare changes every day so this note may not apply next week or for many other situations. The point is having a format to make sure you have the necessary information to make your notes billable. Some EMRs have checkboxes but you know they only give so much information…Here’s a format that’s frequently used by the NPs and physicians at my clinic: 

CC: the purpose of the visit, f/u (med review): Kim is a 17y/o AA/F who’s seen via telehealth, f/u for ADHD, GAD, MDD… The chief complaint is the focus of the exam. I usually end the note with the plan or goals for the next meeting (but it’s not necessary). If the patient has several complaints, document them in order of highest to lowest medical risk (quick sidenote: billing requires a ranking system but you don’t have to put it in the charting, mainly because the ranking is used when you put your diagnoses in the EMR) :

  • Problem 1 ADHD, stable/unstable -(also not necessary to write but gives the risk/degree of the problem), the s/s, and a plan. Here are 2 examples; 
  • Problem 2 GAD (mildly unstable) patient c/o restlessness, poor sleep, and hyperventilates during classes. Plan: continue propranolol 10mg BID as needed. Adhere with therapy and treatment. 
  • Problem 3 MDD (less unstable) patient continues to have crying spells, difficult thoughts, but reports medication is helping. Plan: increase fluoxetine to 20mg and may increase the frequency of dosing if the patient continues to have irritability and poor moods throughout the day.  

HPI: the last encounter with patient/client/name/family was on 3/24/21. Per my billing department, the history should only be listed if something has changed (but again, figure out the best system that works for you). I normally put the entire history here and what did/didn’t change from the last visit to the current one but here’s a formal example of an HPI: Patient and daughter report increasing distress related to finding that he has repeatedly lost small objects (e.g., keys, bills, items of clothing) over the past 2-3 months [duration]. Patient notices intermittent [timing], mild [severity], forgetfulness [quality] of people’s names and what he is about to say in a conversation. There are no particular stressors [modifying factors] and little sadness [associated signs and symptoms]. –AAPC

ROS: the ROS is any issues TODAY? At least note neuro, alrtx3, mental, and any SI, HI, AH, VH… or you can say increase headache off/on, skin rash noted r/arm r/t infection…etc.. basically what you have assessed or changes related to the person’s exam.

PFSH: family hx of mental illness/substance abuse, who the person is living with, etc. 

MSE: Patient answers and communicates appropriately, proper temperament, and is cooperative. Has moderate insight into actions and consequences. Capable of communicating appropriately and following instructions. Behavior and mood are consistent. The client is able-bodied and without learning disabilities. No obvious/major concerns or distress.

PLAN: What was discussed or patient education, medication changes or the plan/goals for the next meeting, how soon to f/u, etc. ex: Adhere with treatment and therapy, possibly increase propranolol for breakthrough anxiety, RTC <4 weeks or sooner for emergencies

**Extra**

(this also isn’t necessary) Medical/Surgical Hx: NKDA. I just put med/surg information in my note since I have so many patients that I would get confused plus it’s my way of assessing other conditions, ruling out adverse events/complications, and f/u with other issues i.e. expressed following up with endocrine for diabetic management and medication adherence. Also consider vitals, height/weight, AIMS, social/drug hx, or usage


What determines 99215 is the complexity. Our billing department said 99215 can be billed if someone is on Clozaril, lithium, and sometimes with the substance abuse population. Telehealth doesn’t have a billable 99215. Overall, you can’t bill higher just because you talk to a patient for 3 hours, for example, the time alone doesn’t make it a complexity. Technically speaking, if you’re not the designated therapist, it’s probably not appropriate to bill “talk therapy”. What makes your decision complex are the following reasons:

  • Medical/Psych Conditions and their severity
  • Additional people, services, care, and other specialties involved i.e. pregnancy  
  • Complications  or worsening Outcomes/Hospitalization/Crises event  
  • The number of medications, monitoring, s/e, or going over test/lab results
  • If there is talk therapy/counseling, it should be formal, goal-oriented, with start/stop times, and is coded differently/separately

If there’s stability, the coding should reflect that. I doubt the patient is a 99215 every single time or the insurance/billing may get more involved to ding you. In other words, 99215’s are rare for outpatients or it should include an extremely high level of documentation. My collaborative physician and I just recently stopped doing 99215s because things were complex but billing wanted it documented/coded separately and it’s like we don’t have time for all that. An example of a 99215 is a hospitalization. 

Mainly 99213 and 99214s are the most common codes I use. I think all kids or specialties need higher coding. For example, a 4y/o doesn’t have much history but it’s more complex than a healthy 17 y/o and it’s more complicated if a person of any age is using drugs or hearing voices…so it gets frustrating.

99212’s or less are for simple reviews but then I got accused of down coding so I just stick to the middle and try to document as accurately as possible. Some people want to do their own billing but I think if you’re a new grad or dealing with a special population, really try to learn and work with a billing department before branching out on your own. It is not easy to keep up with all the healthcare changes and how to bill/capture services especially with the pandemic and telehealth so it’s okay if things aren’t 100% clear. I also made this post because school usually does a poor job covering this topic. 

However, all providers need to be aware of the bare minimum for billing and documentation. Get into the habit of learning and correcting your mistakes so it’ll get easier with time and avoid bigger problems like losing wages and the IRS.  

Additional Help 

 

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