Thank you all for coming. My name is Jeremy Musher and I'm going to be chairing this session and we'll get into introductions in a second. So for the APA, I am the chair of the APA's RBRBS Codes and Reimbursements Committee. I also have been the APA's advisor to both the CPT and the RUC for about 10 years, 12 years, something like that, and a member of the committee for a while before that. My day job is that I'm the chief behavioral medical officer for LifePoint Health. And I'll let David Yancora introduce himself. My name is David Yancora. For the APA, I'm a member of the RBRBS Codes and Reimbursement Committee. I'm also the alternate advisor to the RUC for the APA in my regular job. I'm the medical director for Coding and Compliance as well as the medical director for ED Telepsychiatry at UPMC. So welcome. There is a third person up there, Patrick Ying. Patrick wasn't able to join us, although he helped considerably with a part of this program which we'll go into a little later. We have some examples of documentation and we'll have an interactive session where you'll be able to vote on what you think the codes are and then we'll be able to discuss that. So Patrick was instrumental in helping us to be able to pull that together. We have no financial relationships or conflicts of interest to disclose. We always recommend that you review the manual, the CPT Manual, 2023 Manual, and check with your local carrier as well as commercial payers for any specific guidelines. We're going to be sharing with you, some of what we're going to be sharing with you is how we would view how to do some things so they represent our views, not necessarily the views of the APA. So the learning objectives, we're going to be reviewing code selection criteria for the E&Ms. We're going to be primarily focusing on inpatient and outpatient. And you'll see that other settings of care like nursing home, et cetera, really follow the same pattern. We're also going to be applying generally accepted documentation requirements for E&M and also talk about how you would do E&M plus psychotherapy if you're going to be doing that and how to document that. And then we're going to be talking some about tele-psychiatry. So let me start with some key changes that, and this slide is important. And by the way, this session is part of the APA On Demand, the audio. So if anybody has questions, please use the mics so that it will be captured. I've been to a couple of these sessions where that request was made and people still sat at their seats and asked questions for like a two and a half minute question that nobody else heard and then was summarized in a sentence. So if you have a question, please go to the mics. Otherwise I won't be able to recognize you or David won't. Also, the slides that we're going to be going through are available in the app, the APA app, so you can look at them, you can download them, et cetera. I will say that we did make a change so that we would be able to have this interactive session because in the app, the slide deck follows the codes numerically for the examples. We've shuffled it around so that it's not that easy. The last thing that I'll say going forward is that you'll see in our examples of documentation a particular format that we're using for them. And it's basically a simple narrative format. It's not checkbox, it's not one of a number of soap or anything like that. It's just a simple format that you'll see. There is no required format. So you can do the documentation any way you'd like. The reason that we're using that is it seems to flow more easily. I think it also makes sense. It's a sentence or two rather than a whole bunch of checkboxes that are hard to understand what you're saying sometimes. So let's look at the overview. First of all, the 2021 outpatient changes basically now apply across all sites of service, inpatient, nursing home, et cetera. So what that means is history and exam, no more bullet points. And we'll get into looking at that a little bit. The main focus then becomes medical decision-making. And so we'll be spending time talking about how to differentiate that. And the old examples that were in CPT on medical decision-making have been tweaked by CPT. So we'll show you how that has changed a little bit. In terms of observation codes, there aren't a lot of observation units in psychiatry, but there are some. And those codes for observation codes went away in 2023. So now you use the inpatient codes. For nursing facilities codes, if you're working in a psychiatric residential treatment facility, you're going to use nursing facility codes, as well as if you're working with a particular population in group homes, the patients who have intellectual disability. If on the other hand, you're working in a substance use residential treatment facility, for those patients you're going to use the home resident services codes. And the old domiciliary codes have gone away. All other group home visits other than for the IDD population would be served by the home resident services codes. Okay. So we're going to go through the documentation requirements and some definitions, because the definitions here are important. The history and exam, as I said, now are only what is medically appropriate. So what does that mean? Well, like beauty, it's in the eyes of the beholder. So you put down what you think is the medically appropriate history and the medically appropriate exam. Don't have to have bullets. But keep in mind, the purpose of documentation is not just to convey information to a colleague, et cetera, who may be covering, but also for payment purposes. And so it has to be enough information that somebody auditing will be able to determine that you've given reasonable information about both history and appropriate exam. So saying the same thing in everybody's exam when some patients are depressed and suicidal and some patients are psychotic is not medically appropriate. But we won't get into what is or isn't medically appropriate. The other thing that you no longer have to do is review of systems as part of your E&M under the history. I mean, you can certainly do it and it's appropriate. But it's not a requirement anymore for different levels. And then obviously you need to include a summary of your medical decision-making. And we'll get into more of that in a second. So the E&M selection is primarily then based on medical decision-making. Or the alternative way to approach it is time. And we have a section of the talk that will be specifically about how you would do that for time. And David will talk some more about that. The counseling and coordination of care idea of time has gone away. So it's real time doing things, not just the counseling and coordination of care. And then the psychotherapy billing with E&M, you have to, as you always have, you have to base the E&M portion of that note on medical decision-making, not on time. So I want to spend a couple of minutes talking about this first point here. The level of the medical decision-making is driven by the nature of the presenting problem. Or some people would refer to it as, how complicated is this visit? How complex is this visit? If you only use the data points that we'll be talking about, you're really not capturing what you're meant to be capturing and deciding in terms of the level of the visit. The level of the visit should not be determined by how much stuff you write down. The level of the visit is determined by how difficult was this visit? How sick was the patient this visit? Based on that, what's the level? And what do I need to document in order to be appropriately documenting that level? Does that make sense? You don't throw a bunch of stuff down and say, oh, this is a 99215, highest level outpatient. All right, I'll get paid more. When the patient is stable, recovering, doing fine, but you wrote a whole bunch of stuff. So you have to do it the other way around. Decide the complexity of the visit and then go ahead and document whatever it is. The medical decision-making is based on the best two out of three of problems, amount and or complexity of data, and risk. So you're going to just need two of those at or above the level that you bill in order to meet the requirements. Since all visits have problems and risks associated with them, in our mind it makes sense to forget about the amount and or complexity of data. Now I say that for most practices. There are practices, particularly for interventionalists, where there's a lot more data that you're reviewing. So TMS, ECT, et cetera. So for those individuals, this may not apply and you may want to use the amount and or complexity of data to determine the level. But I think for most psychiatrists, you're going to be better served by focusing your efforts on what were the problems and what was the level of risk and determine the level of the code based on that. So let's go through some definitions here. What is a problem? A problem by CPT standard is a disease, condition, illness, injury, symptom, sign, finding complaint. So it's not just a diagnosis. That's the point. When is a problem addressed or managed? When it's either evaluated or treated. And that can include consideration of further treatment and testing, even if you don't do it. But you document that that was considered and here's the reason why I didn't do it this time. And then when is a problem not addressed? Well, if you're getting history from a patient who's telling you about their diabetes and their other medical problems, but you're not treating them, you're documenting them because it may have something to do with how you're going to treat them pharmacologically, etc. But you're not treating it. That's not considered a problem for you in your documentation and coding. And if you refer without an evaluation or consideration of treatment. Okay, so we're going to go through the levels of problems. And the first level, the lowest level, are self-limited or minor problems. Honestly, you're not going to see a lot of those in your psychiatric practice. But a self-limited or minor problem is a problem that runs a definite and prescribed course, transient in nature, and not likely to permanently alter health status. Now I want to spend a few minutes talking about this table because the table is duplicated as we go forward with different levels so you get a sense of what's in the table. The table on the left column is for that level what the times are that you can use if you choose to code based on time and not medical decision-making. The next three columns are the problems, amount and or complexity of data, and risk. So again, we're going to be looking at the first and third columns. And I'll just say again, for those of you who may have entered a little late, these slides are all on the APA app. So they're available to you. So the other thing that I wanted to make note of is at the very bottom there, you'll see that the italicized red text signifies psychiatric-specific examples that the APA committee came up with. And the purple text signifies new text that's in the actual CPT manual. And you'll see that in a future slide. So for a self-limited or minor problem, the medical decision-making level of being straightforward and the risk would be minimal. And an example that we gave is a visit for an adjustment disorder following the death of a spouse, patient is stable, no medications indicated. That's pretty much the lowest level that we could come up with as an example. So now let's move on to what's a stable chronic illness. Stable has an interesting definition in CPT. It basically is any patient who has not yet met their treatment goal. They're not stable if they haven't met their treatment goals. Even if the condition hasn't changed between visits, if they haven't met their goal where you're trying to get them, then they're still not considered to be stable. And it's a problem with an expected duration of at least one year or until the death of the patient for chronic. And for the purposes of defining chronicity, conditions are treated as chronic whether or not stage or severity changes. So if you have uncontrolled diabetes or controlled diabetes, it's still chronic. And then the risk of morbidity without treatment is significant. Okay? And this is the table for what's considered low medical decision making. And you'll see now that we're starting to get some numbers of two or more of this or one of that. I would suggest that unlike the narrative sections of your history and exam, for your medical decision making, it probably makes sense for you to have in your note I'm talking about some kind of summary assessment statement. But then in order to make your notes clearly define why it is that you think they meet this level, I would come up with some potentially check boxes for things like one stable this and then say what it is. So it's just a line that says what it is. And that way you can check off what the problems are that you're identifying and what the risk level is so that you're justifying the level of your note. Okay. So for low, it's two or more self-limited or minor problems or one stable chronic illness, an example being recurrent depression in remission. One acute uncomplicated illness such as the adjustment disorder. One stable acute illness or one acute uncomplicated illness or injury. And this is low risk for low level medical decision making and we gave an example of that as the patient seen for follow-up visit for major depression, stable on medication, refill provided. Okay. Now we're moving a little higher levels of risk and medical decision making. Chronic illness with exacerbation, progression or side effects of treatment. Chronic illness acutely worsening, poorly controlled, progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects. Probably this is where most of your patients are going to fall in terms of risk, this and the next level. And an acute illness with systemic symptoms, so an illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, fever, body aches, et cetera, you may be treating them to alleviate symptoms. Systemic symptoms may be general or from a single system. So these are the examples for here. So number and complexity of problems have risen. So it's one or more chronic illnesses with exacerbation, progression, or side effects, like a recurrent major depression, moderate level. Two or more stable chronic illnesses, schizophrenia and alcohol use disorder, as an example. One undiagnosed new problem with uncertain prognosis, like a cognitive decline presentation. And one acute illness with systemic symptoms, anorexia with bradycardia and amenorrhea, as an example. And then for risk, moderate level risk, you can look at the table there. It includes social determinants of health, which is a new addition to that level of risk. But the thing to remember for moderate level risk, any time you take out your prescription pad and write a prescription, it's moderate level risk. Okay, any prescription is moderate level risk. Okay. And now we're moving to a higher level. Chronic illness with severe exacerbation. So the prior one was with an exacerbation. This is with severe exacerbation, progression, or side effects. And they have a significant risk of morbidity and may require escalation in level of care. And that's important in terms of meeting the threshold. An acute or chronic illness that poses a threat to life or bodily function. And it's in the near term if no treatment occurs. So this is high. This is the highest level. And you can see it's one or more chronic illnesses with severe exacerbation, progression, or side effects. And we gave the example of major depressive disorder recurrence severe with significant functional decline. Or one acute or chronic illness or injury that poses a threat to life or bodily function. Schizophrenic patient with command hallucinations to kill family members would be an example. And then for risk, the risk here is at the highest level. So some of the examples in CPT are drug therapy requiring intensive monitoring for toxicity. In psychiatry, certainly Clozarel would be an example that would meet that criteria. We think that starting someone on let's say lithium or Depakote is reasonable for that level. Maintaining them on it on the other hand is not. Because you're not really intensively monitoring them after that whereas you would be with Clozarel. And then the decision regarding hospitalization. So if you're seeing somebody in an outpatient setting and you're trying to decide whether to hospitalize them or not, that would be considered high risk. You don't have to decide to hospitalize them. But you have to document your consideration and why you chose not to or chose to do that. And then there are some examples there. I wanna go through some of these examples because once you've admitted a patient to the hospital, the baseline changes for risk, right? In order to get in the hospital, every patient has to be at a pretty high risk. But once they're in the hospital, you can't say that every patient is at high risk. Because you're comparing the risk level to other patients in the hospital. So now what differentiates patients by risk once they're in the hospital? Things like patient on one to one or line of sight for their behavior would be a higher level of risk. Let's say a patient that you're following was in seclusion or restraint and after you left that day, you come back the next day and you're hearing a report about seclusion or restraint. That visit the next day, you can document about the patient having been in seclusion or restraint, et cetera, and count that as high risk. And then perhaps the patient after they receive emergency medications, a NOW order because of severe agitation, whatever, they got an IM injection or whatever they got. And then anyone on a forced medication protocol would, and again, these are not in CPT. These are the committee's recommendations about what might meet those thresholds. Okay, now I just wanna spend a few minutes talking about E&M plus psychotherapy and how you would document that. So E&M and psychotherapy is an integrated service. We've been hearing things from insurers. Actually, we hear from members about insurers related to this because some insurers have gotten the idea that because there are two codes there, there's the E&M code and the add-on psychotherapy code, and it's two services, it's E&M and it's psychotherapy, but it's hard for them sometimes to understand that it's an integrated service. So I guess some of them think that you sit down, you do the E&M, and then you say, stop, we're moving into psychotherapy now. And then, so if you did that, it would be interesting, because you'd be saying, stop, psychotherapy. Wait, now we're back to E&M. Now we're back to psychotherapy. Because it's integrated, right? You're talking with them over a period of time, and some of the information is related to the E&M portion, and some of it is psychotherapy. So the concept and what was approved by CPT some years ago when we pulled this together is that if over the course of that visit, you have done E&M work, and at least 16 minutes of psychotherapy, and psychotherapy is a procedure. Every time a psychiatrist talks to a patient is not psychotherapy, right? Just want to be clear. So it is a procedure, and you should be doing it thoughtfully as I'm deciding to do psychotherapy. Doesn't matter what kind, you know, insight-oriented, CBT, DBT, whatever you're doing is fine. If it's psychotherapy, ego-supportive psychotherapy, whatever. So what you would do then is you'd build the E&M portion based on the work that you did, the complexity of the work, not the time, but the complexity of the work, and then the psychotherapy portion based on time. And to determine the correct codes to use, the psychotherapy time is you determine the approximate amount of time spent on the E&M portion, subtract that from the total time of the service, and if the remaining time was spent providing psychotherapy, use the appropriate code based on that time. You want to document the time, you want to document the time of the psychotherapy, and you have to have separately identifiable notes. What that means is you have to have either two notes, which most people don't do, most people have a separate section of the note that's labeled psychotherapy, and where you talk about whatever the psychotherapy was. The other thing to keep in mind is that E&M work takes time, right? So one of the other things that insurance companies have problems with is when you use a E&M level 99214, for instance, and a 90836, 45-minute psychotherapy code add-on, which requires a minimum of 38 minutes of psychotherapy, so you have a moderate level E&M, I mean, there's gotta be some complexity there, you're doing some work, and a 38-minute minimum psychotherapy, and you're billing it weekly for weekly psychotherapy, you're billing the two together, and the whole visit is like 45 or 50 minutes. Well, that doesn't make sense. You're not accounting for enough time for the E&M, number one, and number two, it's unlikely, at least I did psychotherapy and E&M work together for many years, and it's unlikely that any patient requires 99214 level E&M work every week. Right? So you have to be reasonable about what it is you're billing. So you should be asking yourself two questions. If you're seeing patients on a weekly basis, is the E&M work medically necessary at the level I billed? And did I appropriately allot for a reasonable amount of time as part of the total time of the visit for the E&M level I billed? Now, there is some controversy over whether you should be billing any E&M if you're seeing a patient in psychotherapy weekly. Are you, in fact, always, every week, doing some kind of E&M work when you're seeing a patient for prescribed psychotherapy? Some people would say no, and in that case, if you believe that, you should be using the standalone psychotherapy codes. The committee, and I think most people, would say yes, because as a psychiatrist, you are, I mean, a lot of the patients are on medication, and you may be asking at different times about issues related to the medication, but you're always listening with an ear towards E&M-related work. So as an example, I saw a patient for a long period of time, elderly woman, who had an anxiety disorder, and I was treating her for anxiety, and she described her anxiety in a different way one time, and I said, you know, that sounds more cardiac-related. Why don't you go see your, and she was, you know, having atrial fibrillation. So you're always thinking about it, and so I think it's reasonable, at least at the 99212 level, to be adding an E&M, but it's up to you. You have to justify it, and you have to document to cover it. The other thing that we've heard from payers is some payers require that you document either total time of the visit, meaning the total time, both E&M and psychotherapy, or start and stop time sometimes of the total visit. Whatever you have to meet in terms of those requirements, and they can set those requirements for you. As a minimum, you always have to put the amount of time that you spent in psychotherapy if you're going to do the, build the psychotherapy codes. Another issue that you need to be aware of in terms of documentation in the inpatient setting is the coding requirements, billing requirements, are not the only requirements we have to meet when we document, right? So, for instance, in inpatient settings, we are still subject to the conditions of participation under Medicare, and that COP requires certain things, like in the psychiatric evaluation, there are a bunch of things that you have to include that you wouldn't have to include if it was just a straight E&M note. So you have to include past history, family, educational, vocational, et cetera, attitudes and behavior, and very specifics in the mental status exam related to things like appearance, behavior, thought content, an estimate of intellectual functioning and memory functioning, at least at two levels, and orientation. And in some of those cases, like memory, you have to show your work. You have to say how you determined it. And that's just all related to the conditions of participation, which, by the way, some years ago, Joint Commission adopted. So, whether it's a CMS surveyor, state surveyor wearing a CMS hat, or the Joint Commission coming, they're all gonna look for that. Okay, I'm gonna turn it over to David to talk about time. Thank you. So, health bill by time changed significantly for outpatient services in 2021. So, hopefully you're already aware of that. And then for other E&M services, including inpatient consult and nursing facility services in January 2023. So, what we're gonna talk about now is already in place, essentially for all of those services. So, in the past, the Department of Care needed to dominate the service in order to bill by time, but that's no longer the case as of 2021 for outpatient services in January for the other services. So, as an alternate to billing on medical decision-making, as Dr. Musher just discussed, you're also now able to bill on the total time spent caring for the patient that you spend on the calendar date of the patient encounter. So, you're now able to bill on the activities that would be included when you come up with that total time for how long you spent caring for that patient. And if you look at this list, it includes most everything you're going to be doing for that patient that day, seeing the patient, doing the exam, looking through the record beforehand, putting in orders, doing psychoeducation with the patient or family. But keep in mind that these activities need to occur if you have clinic on Monday morning and like to look at the patient charts on Sunday, that time can't be counted. If you instead wake up early on Monday and look at the chart, now the time can be counted for that calendar date. Similarly, if you want to talk with the patient's primary care physician, if you're an outpatient psychiatrist because of the medication you're prescribing, if you can get the primary care doctor on the phone on the calendar date you saw the patient, that conversation, the time spent there would be counted. If the PSCP doesn't call you back till next Tuesday, now you can't count it anymore. So just be cautious that we're looking at the calendar date of the service. The changes to billing on time also had removed the restrictions about where the time is spent in caring for the patient. So you can now include the time you spend caring for the patient, regardless of your physical location. In the past, the rules had been, at least for inpatient services, on the floor or unit, and now that has gone away. There are a few activities that are not included in the total time that you would count for that patient for the day. Such things as travel, teaching. Looks like this is not advancing. Use the computer instead. This was the list of activities that would be included, so I'll leave that up for a moment so you can see it. And then this is the next slide that we were just talking about. Thank you. And so the other part that would not be counted is time that's spent on a procedure that's separately billable. We're not gonna see that a lot in psychiatry, but certainly primary care doctors, and that may come up if you're doing some sort of knee injection. That's not gonna be included in the time spent on the office E&M visit for that date. So this slide looks at the times, and these were on one of Dr. Musher's slides earlier, that we would need to spend if we're going to decide to bill by time. On the left side is the current times for outpatient E&M services. And just as a comparison, we have the old times on the right side. So now since 2021, we would be using the times on the left-hand side there. And as Dr. Musher had mentioned, please keep in mind that if you're doing a psychotherapy add-on service, you cannot bill the E&M component based on time. You would have to bill the E&M component based on medical decision-making, and then the time would be used to select the appropriate psychotherapy add-on code. And this slide has the times for inpatient services. Again, the current times as of January 2023 are on the left-hand side. And just as a comparison, the prior times are listed there. So we're going to switch now to documentation examples. If you already have your phones out, now's the time to close Instagram or TikTok. If you don't have your phones out, now's the time to get those out. And I'm going to try to switch over to a different set. I would also ask if you have the slides open on the APA meeting app, if you could close those. And because those do have some of the codes listed on there, so this is for your benefit. Cheating is not going to help you. Nobody's having to pay money back, and we're not giving anybody extra money, depending on what you picked. So as it says at the top of the slide, if you go to menti, M-E-N-T-I dot com, it's going to ask for that code, which is eight digits long, and that should get you synced up with the slides that we're showing on here. So just to make sure things are working, if everybody can vote on that first one to see where we're at. So it looks like most of you have figured out how this works. So this is our first outpatient example, so I'll give you a moment, I'm not going to read through the slides, I trust that everybody can read, to decide what code you would use to bill this patient. It's like a horse race. Well the good news is nobody picked 212 and 215. So I'll close it there and we'll move. So I would recommend billing this as a 99214. Again if we sort of ignore the data component, there wasn't anything in the note about data anyways. We have two stable diagnoses, a bipolar I disorder, an alcohol use disorder. So that would put the problems component at the moderate level for medical decision making which would correspond to 214. And you're managing the patient's lamictal so you're writing a prescription for that which is also at the moderate level as far as risk of complications. So we have two levels of medical decision making at the moderate level which would then put us at 214 for the final code. So another outpatient example, we'll give you a couple minutes to vote on that and then Dr. Musher will be discussing this one. Okay, while some of you are finishing up, I wanted to point out a couple of things about the format, et cetera, and then we'll get into the discussion about it. But before I do, I was remiss in not introducing another member of our committee, which is Junji Takashita, who is also on our committee and joining us, and then Becky Yao, who stepped out of the room. Some of you may have seen her sneak out. She's our staff from the APA and has been with the committee since before I've been with the committee. And she may be the one who you talk to if you call the APA about questions, her or Ellen Jaffe. In terms of the format, I just wanted to point out that you'll see, as I was saying before, that it's a narrative format for documentation that we've used. Chief Complaint, History, Exam and Medical Decision Making along with Diagnosis are the parts of the Medical Decision Making note. And the reason that we've included Chief Complaint there is that you always have to have some way of making the note be clear about the medical necessity of the visit. Was this visit medically necessary? One way to do that pretty succinctly is to have a reason for the visit that spells out why the patient's there. And that counts as your Chief Complaint, but it also is a nice way to describe the medical necessity of why that patient needed to come and see you. Okay. So you can see that we didn't agree with the majority of you. And let me walk through why. Because technically the majority of you are correct. It should have been a 99213 and a 90836 based on time. So the code selection rationale, even though this patient has a stable chronic illness and moderate risk, the prescription, and would typically meet criteria for a 99213, the level of E&M work done on this date of service is straightforward, associated with checking on side effects or other complaints, which meets medical necessity for 99212. So if the patient, for instance, had had side effects that warranted further exploration, but determined not to require a med change, for example, mild headache or nausea, that may have been a 99213. If the patient was experiencing more significant side effects, it may have been a 214. And in order to be a 215, it would be much more complex. So we're not right. You're not right. You have to decide. But the reasoning there is, again, you have to be thinking about what makes sense in terms of this visit, how much work did I actually do, not how much did it meet the criteria specifically for stable chronic, et cetera. So again, no right answer. But you're going to have to justify it if you get audited. So just keep that in mind. And then the code selection for the psychotherapy code was based, obviously, on the time and taking the total time of the visit, eliminating the time spent for E&M and seeing if the rest was associated with psychotherapy. You need a minimum of 38 minutes for that level code. Again, you need to be clear that E&M work takes time. So don't shortchange the total time by giving a high level E&M. Okay. This is our third outpatient example. So I'll give you a minute or two to vote on that. So it looks like most people have converged on 99213, which is where I would recommend billing this. So for this we have one stable chronic illness, which is major depressive disorder in remission, which would be at the low level as far as number of problems. You're also managing the patient's Prozac, which would put the risk of complications of patient management one level higher at the moderate level, but because we need two levels or components of medical decision-making at or above a level to bill it, we would bill at the low level overall for medical decision-making because we have one component at low and one component at moderate. Our fourth outpatient example. Is that a diagnosis in ICD or something, or DSM? Yes. Both, or do you know which one it is? What the diagnosis number is? Oh, no. Is it present in DSM as well, uncomplicated breathing, or just ICD? As far as I know, it's in DSM, yeah. Five. I just hadn't heard of it. Okay. Most of you are at the 99212 level and that's what we would agree, that this is straightforward medical decision making with a self-limited problem, that being bereavement and minimal risk. Any questions? Okay. Next one. This is our fifth and final outpatient example. Thank you very much. It looks like most of you are converging on 99215, which I would agree with. So here we have one problem, major depressive disorder with a severe exacerbation. So far as number of problems for that component of decision making, that would put us at the high level. You've also decided with the patient to pursue hospitalization. So from the risk of patient management options, you'd also be at the high level. So you have two components of medical decision making at the high level, which puts you at 99215. We have two more examples. Both of these are inpatient services. So the code numbers have changed. I'll just point out that the chief complaint here includes a quote from the patient. That's something that joint commission in particular likes to see. Okay. Again, it looks like people have converged on 99233, the highest level inpatient code, and we would agree this is a high-level inpatient visit. Patient has an acute illness that poses a threat to life, as well as being on line-of-sight observation and in seclusion, either one of which would have put them at higher level of risk, so 99233 would be appropriate. As would describing all of the reasons in your note, right? This is our final example, also an inpatient service. While you're filling that out, I just wanted to point out one other thing on the format and documentation. You notice the sentence, we'll consider raising to 40 milligrams tomorrow. I have always found it helpful in an outpatient setting. It's one thing if it's inpatient, you're going to see them the next day. You're going to remember what you're doing and what your plan is. In outpatient, sometimes you're not seeing a patient for a month, two months, three months. I've always found it helpful, rather than having to spend the time to reinvent what I was thinking three months ago, at the end when I'm saying, here's the plan of what I'm doing right now, adding, and if this doesn't work, the next step would be mainly to help my memory. »» For this one the majority chose 99232, which I would agree with as well for this example. So as far as the problem component of medical decision-making, we have an illness that poses a threat to life. So that particular component is at the high level which goes for 233 for inpatient services. But as far as the risk component goes, we're managing prescription drug in the hospital with the thought of increasing Prozac. The patient has not been on one-to-one. The patient's not been in seclusion. So that would put the risk at the moderate level which is 232. And again, we need two components of medical decision-making at or above the billed level. So one is moderate, one is high, would bill at the moderate level or 99232. So switching back to briefly review some information on telehealth, the CPT panel has created 17 codes to report telehealth office visits. The codes that have been created include separate codes for audio-video and audio-only services with codes for both new and established patients. These codes are currently going through the RUC process for valuation recommendations which are then sent to CMS. And then the codes are slated to be published in the 2025 CPT Manual once CMS makes a decision on the final valuation for those codes. So stay tuned for further information. These could be coming down the road in about two years. As I said, these codes will be surveyed as part of the RUC process. So as part of that process, APA members may be randomly selected to do a survey on these codes. So if you get that, please fill it out as that information is then used by the RUC as part of the valuation process to make recommendations to CMS. APA is going to be advocating that payments are equal to those received as if the care was in person. I just want to emphasize the process. CPT creates and revises codes. The RUC, the RVS Update Committee, puts a valuation on those codes. The valuation is predominantly based on these surveys. So it's important that the members fill out the surveys so that we have data to present at the RUC to support the valuation that we're asking for. And then whatever the RUC passes then goes to CMS and they can accept or not accept that. I think 90-some percent of the time they accept it. Related to Medicare and the telehealth provisions there, Medicare has permanently allowed audio-only services for patients with mental health and or substance use diagnoses. As part of that, clinicians must have the capability to provide audio-video services. But audio-only services can be used if the patient doesn't have access to, doesn't consent to, or can't use video. Because that's how they've done the rules, I would encourage you in your notes if you're doing audio-only services to document that you have the capability to do audio-video services and the reason why the patient wouldn't or couldn't do the audio-video component and just did the audio-only part. Starting in a few months, clinicians are going to be required to go back to using a HIPAA-compliant platform that had been put on hold during the pandemic. But now in August we're going to be going back to that. We know that some of you have closed your physical offices. So we do want to emphasize that while it's theoretically possible now to maintain an all-virtual practice, you need to start thinking through how you're going to handle patients that need to be seen in person, either because of clinical reasons or because of changes in regulations. So that's something to start thinking about now so you're not scrambling at the last minute depending on sort of where the rules land in a couple months. The in-person requirements for Medicare have been delayed through the end of 2024. But other payers and regulatory bodies may be reinstituting some in-person requirements. So pay attention to those changes because they may very well affect you depending on sort of state regulations and other regulations. And the DEA had also put forward some proposed rules with changes. They received a huge number of comments to these proposed rules. So to allow them time to review and respond to the comments, for now they have just implemented an extension of the flexibilities that were allowed during the pandemic. But stay tuned for further information so that you are aware of whatever rule is ultimately finalized by the DEA in regards to prescription for controlled substances via telehealth. For audio, video and audio care, for psychiatric evaluations and the various other psychotherapy codes for Medicare, you would continue to build the standard codes. For outpatient E&M services, you'd build a standard office E&M code unless the service is provided audio only. And for those services to Medicare, you would build a telephone E&M code with modifier 93 and FQ through December 31st, 2024. Through December of this year, all telehealth services should continue to be billed with the place of service that would have been reported had the service occurred in person. But starting in 2024, there's going to be changes to which place of service you use. So that will change to either place of service 10 if the patient's at home, or place of service 2 if the patient's somewhere else. The other change to note for 2024 is that CMS plans to pay the facility rate payment for audio, video and audio only services, which is going to constitute a reduction relative to in-person, in-office visits. As far as private payers, the top carriers of private insurance all offer some form of telehealth coverage, but the coverage varies widely depending on the specific plan selection. So I'm not going to go through that here because we couldn't possibly ever cover that. I would encourage you to verify each payer's policy and also ask the patients to verify coverage prior to having an appointment because the rules are so vastly different. A quick note for prolonged services. It's important to note that there are different codes and rules for CPT and for CMS. The slides that are in the APA Meetings app, we've gone through a slightly different version here and have chosen not to go through some of these slides in the interest of time. But the slides that are on the Meetings app do have additional information on the prolonged services codes as well as the differences between CPT and CMS. As far as other private payers, I would encourage you again to go to the private payers to see which version of the rules they're using, if they're following Medicare's version or if they're following what's in CPT because that makes a difference on how and when you can report these prolonged services. A couple other resources that are here. This slide has a number of helpful resources. The links will work if you go to the slides in the APA Meeting app. Two of the important ones are highlighted on here, both the Practice Management Helpline. So if you're an APA member you can use that email address to get some answers to questions that come up. And then there's also a telepsychiatry blog which is keeping track of some of the changes as they kind of happen and evolve with the end of the public health emergency for COVID. Later on during this meeting, the APA is also hosting a member forum to review the key policies related to telepsychiatry after the end of the public health emergency. This is going to take place on Monday, May 22nd from 3 to 4 p.m. So I'd encourage you all to attend that to get a little bit more information and discussion on telehealth with the end of the emergency. »» That is a members-only forum. »» References are here and on the slides on the Meeting app as well. I think we probably have time for a couple of questions. »» Please go to the mic if you have a question and we'll be happy to try and answer them. »» Thank you so much for this great session. So I'm Shubh Barman. I'm a psychiatrist, addiction psychiatrist working in Wisconsin. One of the things which has always intrigued me is that part of my work, I work in a partial hospital program for co-occurring substance use and mental health disorders. So why are the CPT codes for partial hospital the inpatient codes? That's something which has always intrigued me. I was curious about that. And I had another follow-up to that that was a little more specific. So you mentioned in one of the slides that monitoring, therapeutic monitoring generally makes it a higher level of coding. So I had a question about specifically, we do a lot of urine and oral fluid drug testing sometimes multiple times a week based on the complexity of the patient. So would that make it more complex as far as my coding? Because I'm like hearing you guys talk, I'm like, I've got to build a hell of a lot more 215s and equivalent for partial. So I just wanted to know. I hope that wasn't the takeaway from this meeting. For my patients, yes. The first part of your question, why they did partial for inpatient. Partial hospitalization, Medicare's definition is basically the patient meets criteria for inpatient except that they're safe to be at home during the day. So they consider it to be a pretty high-level service. However, some insurers will request that you bill outpatient codes for partial. So be aware that the payer can sometimes ask you to use a different set of codes than you're supposed to use according to CPT. In terms of the urinalysis issue, keep in mind that it's the best two out of three problems amount and or complexity of data and risk. So if you're choosing to use amount and or complexity of data, urinalysis is not going to give you much. You'd be better off with one of the other two probably. Okay. All right. Thank you. Sure. Hello. Thank you so much for the great talk. My name is Jacob. I'm a psychiatrist working in nursing homes in Illinois. So I started doing cognitive testing and billing the 96132 for that. And from my understanding, that's a time-based code. And so I understand that you can't do ENM time-based with add-on psychotherapy, but could you bill the 96132 30 minutes of neurocognitive testing in addition to psychotherapy add-on codes? I don't know the answer to that. If you do, it's typically with a modifier showing that you're providing two services on the same date. Some of those are accepted, some of those are not. And I don't know the answer for that specific code. I don't have anything else. I don't know that specific code either. I would agree if it's two separate services to use the modifier to denote that. And if I can, when do you guys use an initial visit versus a 90792? Well, first of all, you can use 90792 for any initial visit at any site of service, okay, inpatient, outpatient, et cetera. The determinant, since they both would apply, so you could use an inpatient. For inpatient, you could use the 992212 or 3, or the 90792, outpatient, the 99202, et cetera, or. So since either can be used, decisions are frequently made based on the higher level E&Ms, if you're at the highest level, will pay you a little more than the 90792. On the other hand, it used to be that the documentation requirements were much more for the E&M. Now it's not so much that. So you can do either. »» Yeah. Medicare poo-pooed me for my E&Ms always being at the highest level, even though there were like eight of them a year, but because I always did a 90792 if they were easy. »» Yeah. »» Thank you. »» Sure. »» I'll also add to that, the 90792 doesn't have the restrictions for new versus established patients as the E&M codes would, 99205, 204 versus 215 or 214. »» Right. So what he means by that is, for those of you in groups, particularly large groups, the initial E&M codes, if you or a member of your group saw the patient in the last three years, you or a member of your group in your same specialty or subspecialty, then you can't bill the initial E&M. So it's probably better to bill the 90792 under those circumstances. Or as some of you are in huge groups, you may not even know and your system may not trigger that on your EMR. So for those systems, sometimes they automatically bill them as 90792. Good point. »» Thanks for a great panel. I was wondering how often physicians pick 99212. It seems to me fairly infrequently as opposed to 213. And also are you aware of any trends in audit activity either on the part of CMS or private insurers these days? Thank you. »» Sure. 212 is, I don't have the exact numbers. The only numbers that we have are Medicare because the others are proprietary, the commercial payers. I don't remember what they are. But they're fairly low for the 212. In terms of audit activity, weekly psychotherapy with E&M, there's been a lot of audit activity on that. There also is always a lot of audit activity. you will trigger audits if you build the same code for services repeatedly. If you don't have any range and all your patients are 99215s or all your patients are 99214s, you may trigger an audit. »» Very quick questions. For the 02 versus the 10 for the place of service, the patient works from home, high functioning patient, I never understand why they care where the patient is. But if you have to put down home or not at home, patient works from home, is that a home visit, 10? »» If they're in their home, I would use the »» Yeah, if that's where they work. I mean, wasn't the purpose of this that less functioning patient was at home? But now most people work at home. So we're supposed to put the home code rather than the office code? »» I would still use the home code because they're technically still at their home even though they work there. »» I never understand why they ask that. The other thing is, have you guys ever made an argument for the audio versus video? I mean, I do almost all video. But when I do audio for the people that won't use it or can't, it's actually more work for me. I have to think more. I have to focus more. Why are we, you ever make an argument, why should we be paid less for more risk and more mental work? »» So I don't disagree. And this is what is going through the process now for RUC to try to value these codes. So if you would get a survey about this, I would encourage you to reflect your experience on the survey. »» Would you guys make that argument or believe in it? »» Yeah, I mean, I think that's a reasonable argument. You actually have to pay attention. »» Right. The last thing is on the example that everyone coded in 99215, the woman who was very suicidal. If that was a weekly or let's say a biweekly patient, would you have a problem building the 99215 still with a 90833 or a 90836? It was an hour session, you got all that data, she's suicidal, and the problem, is there any reason that you couldn't put the E&M and psychotherapy code with that? »» I don't remember. Was that an outpatient? »» Yeah, an outpatient. We all said it was like three examples ago. »» Yeah, absolutely. I mean, yeah, I just wouldn't do it every week. »» Right. No, exactly. »» Because that would have met the criteria if you also were able to document that you did at least 16 minutes of psychotherapy and put the code in. That does remind me that the things that were, first of all, keep in mind, separately identifiable, there has to be a psychotherapy section, and you'll notice that in that psychotherapy section what we put there was, I think, the time, but then also what the content was, something about goals, something about, there were like four sections there. The reason we use those is that many of the LCDs, local carrier decisions, that Medicare puts out, which are essentially what Medicare says are the guidelines for how you document, include those for psychotherapy. So go back and look at those to make sure you include those. »» Thank you. Chris Haken, North Carolina. I think on your slide it said that a chronic condition is not just chronic but also has to take a significant toll on, was it morbidity and mortality or what was it? »» That had to do, I believe, can you put that back up? This was the slide on, I think it was chronic disorder in remission, something like that. »» We'll rewind. »» By the way, that was a great point, whoever on the 99215, you could start your note by saying purpose of the visit is to keep them out of the hospital. You often have to see them more often in that kind of situation. Is that the slide? »» The risk, yeah. The risk of morbidity. Okay. I see that. And is this part of the definition of a chronic disorder? In other words, it's not just based on chronicity. »» Right. Yes. »» And how then should we document that or which psychiatric disorders happen to be chronic but don't have a significant risk of morbidity? »» Usually if you just put what the condition is, it's obvious that it's a chronic condition. »» Right. But I'm talking about the morbidity factor. Like is generalized anxiety disorder have significant morbidity? »» Again, most of the major psychiatric conditions that you would be treating, by putting the diagnosis, you don't have to say, and therefore, the risk of morbidity is significant. »» Gotcha. Because even ADHD, without treatment, there's a four-year reduction in lifespan. So that's great. Thank you. »» Nobody's going to split hairs over that. »» I have two questions. One is how does CMS decide how much time is supposed to be spent on each encounter based on the different CPT codes? How do they know, like, oh, you should only spend, like, based on the amount of work you have shown us, you should have only spent like 16 to 30 minutes. But I technically spent, I don't know, for some reason I'm slow, I spent, you know, 40 minutes. That's the first question. The second question is, if I am charging, if I'm out-of-network provider, do I still go through the same motions in order to have the insurance company reimburse the patient the highest amount of money possible, therefore reduce the burden on the patient? »» Yes. The answer to your second question is yes. If you're out-of-network or even if the patient's paying you directly and then submitting the bill to their insurance company, you have to do it the same way as if you were submitting the bill. In terms of the times, how did they determine the times? Surveys. »» Huh? »» The survey process. That's how they determine the times. »» Okay. So you can't be too slow. »» You can't what? »» You kind of have to, like, based on how fast other people do their work. So you can't, if it takes X amount of time for someone else to complete a 99213 amount, you kind of have to sort of be on the same efficiency. »» I mean, there are two ways to look at that. You're getting paid, you don't want to pay somebody more to be slow, right? So you want to pay somebody based on what's reasonable for that amount of time. What's reasonable is determined by the surveys. »» Okay. All right. Thank you. »» Sure. »» Hi. Aisha. Texas Tech El Paso. Thank you. Very informative talk. I wanted to ask you, what's the utility of adding in the initial appointments the family history, social history, developmental, all that stuff, and it's not even billable? I understand you communicate with your peers, but can it be, like, how do you document all that? »» Well, I think what most people would say is, because it's important as part of your evaluation, and therefore you are getting paid for it, you're just not the, I forgot what they called it, the something reduction act, the government decided that they agreed with physicians that they were spending too much time trying to figure out what to include for each bullet under history exam, et cetera, and that they should leave it up to the physician to do what was medically appropriate rather than to require certain numbers of bullets. The understanding there is that the physician will do what is medically appropriate, and for initial psychiatric evaluation, that would typically include all of those things. »» Awesome. The other question I wanted to ask, we use a lot of scales in our practice. So is that just billable as part of the time, or is it a separate billing entity? »» If the scales are separately billable, you're doing some instrument that's separately billable. »» Like Wanderbills we send home and they are not done the same day. It's like another day that it's done. So it's not counted, I understand, if it's not the same day. »» If it's not the same day, it would not be counted. If it's any sort of scale or test that is separately billable, it absolutely would not be included. You could probably, depending on how much data you got back from that, that may be a time to consider looking at data as far as basing medical decision-making instead of, as we sort of talked about, largely for psychiatry going to be ignored, but if you have a lot of that to review. »» I'm a child psychiatrist. ADHD is, I mean, we use a lot of Wanderbills, that's a teacher report. I cannot diagnose without that report. So do I bill it at subsequent appointment, that this scale was reviewed, and how do I do that? »» You should look at amount and or complexity of data as one of the two out of three for the visits where you're reviewing a lot of data, including reports from schools, et cetera. Keep in mind that most testing like that, there are all kinds of different tests, you know, PHQ-9 up to Rorschach's, right? And they require different levels of interpretation by and review by the psychiatrist. So the ones that require almost no interpretation don't really count for much of anything other than they are helpful for you. In order for you to get credit, you actually have to be doing some of the interpretation. So for instance, getting a X-ray report back for a primary care provider that they're interpreting by looking at it and writing it down gives them more credit than if they get a X-ray report back that some radiologist has interpreted. »» All right. Thank you so much. »» Sure. »» I would just add for your first question as well, you asked about like family history, social history, those kind of things. I would also be careful depending on what code you're usually billing for initial evaluations. We did not talk about billing requirements for 90792, the psychiatric evaluation. The requirements are quite vague, but a lot of those elements are actually required. »» Yeah. Yeah. That's a good point. There are required elements for 90792. »» Hi. How are you doing? I treat all ages. So if I see an adolescent for initial evaluation, medication management, I see the parents separately and then the child and the adolescent together, is a 90792, 99214, 90846 and a 90847 allowable? »» At the same visit? »» Yes. »» No. »» So what should I do? »» What you should do is, particularly for child and adolescent evaluation, sometimes they require two visits, one for the family, one for the kid, and it's all still part of the evaluation. You can actually, as long as they're on separate days, you can actually bill two 90792s. »» Despite it being on the same day? »» If it's on the same day, you're probably not going to be able to bill more than one visit, 90792, or an outpatient E&M level visit. »» Secondly, regarding memory, is simply documenting memory intact by observation adequate? »» For inpatient, no. »» Outpatient? »» For outpatient, yeah, because there's no real requirement for memory outpatient. »» I think that's it. Thank you. »» Alex Smirnoff, California. »» You mentioned in the beginning of the presentation that a review of symptoms is no longer necessary. Could you expand on that, and also what would be the meaningful substitution for that part of the psychiatric evaluation? »» I think the first part was, we said that review of systems is not necessary. Is that right? The reason that it's not necessary, let me change that. It's not that it's not necessary. Medically it may be necessary, and you may want to do it. It's no longer a requirement under the history part, because history is now medically appropriate. Whereas before, at higher levels, you were required to have a psychiatric review of system, and depending on the level, psychiatric and one other. And what was the second part? »» Yeah, and what would be the meaningful replacement if not doing the review of systems in the psychosocial? »» Well, you can do a review of system. If that's medically appropriate, then do it. »» Okay. Thank you. »» Yes. »» So we'll keep answering questions if you have them, and if you don't and want to leave, by all means. Thank you all. But go ahead. »» So on the initial evaluation, you were saying something about if you're in a group practice, I'm an inpatient psychiatrist, if someone saw a patient two years ago and did the initial psych eval and build a 99223 maybe, then I wouldn't be able to do that? »» This is outpatient. »» Just outpatient. »» Just outpatient. »» So inpatient, two years later you could do a new psych eval. »» Correct. »» Okay. Thank you. »» Hey there. Okay. So I'm doing inpatient. I have a nurse practitioner that works with me. So I do all the initial evals and it's a dual diagnosis unit, so I do a lot of suboxone and then sometimes people come to me in acute detox, so I do transine or whatever. But I see them for the first four days, make a lot of medication changes, get them stabilized, and then we've got more people coming in and more people discharging, so the nurse practitioner sees them. Well, then I see them before they're discharged, I do all the discharge orders. If she's billing like a low code because she's just seeing them and she's just like, oh, if you want medication changes, see Dr. Skelton or whatever. And then I see them, you know, two to three days before discharge and they haven't had their effects are increased or, you know, suboxone or Worbiturin or whatever, right? I'm making medication changes and I look at their blood pressure, their heart rate and it's skyrocket and I'm like, okay, propranolol or whatever, I'm making all these changes and I'm trying to stabilize them and then I'm working on discharge and I'm doing the discharge meds. Well, I feel like that's more time. And I know you said you don't bill for time, but it's also complicated as well because I'm making med changes and I'm documenting all of that, right? So if the nurse practitioner bills low code, but then I built like a higher code right before discharge, is that a red flag? Is that wrong? Like... Let me describe something related to working with allied health professionals, NPs, PAs in inpatient. The inpatient, first of all, all patients in an inpatient setting must be under the care of a psychiatrist or of a physician, right? They cannot be under the care of a nurse practitioner or PA, regardless of what the state says, okay? And the reason for that is CMS as part of the Conditions of Participation requires that. So what that means is that your patient the whole time, whether you see them that day or the nurse practitioner sees them, you are responsible and you are setting the treatment plan and you should be discussing in treatment team meeting with the nurse practitioner what's going on and driving the care. It's not the NP does some stuff and then you come in and clean up. You're doing it together. They can see them on different days independently, but they are your patient and you are supervising the NP. So the NP may have high-level codes too on days that they see them and there's no reason they can't change medication, et cetera, because you and the NP are discussing it in treatment team. Again, if the patient is under your name, you are responsible for the care of the patient regardless of what economic arrangements you in the hospital, et cetera, make. Yes. »» So one of your slides on the table on medical decision-making had a point about parenteral control medications. I was wondering what I was referring to. From what I understand, is this referring to buprenorphine extended release? Yes, sublocate is what I'm thinking. »» Do you remember what that was in real? I mean, what it may have been is inpatient for risk level if you're giving an emergency medication, whether it's IM or oral is fine. »» But you're talking about controlled substance. So you're talking about lorazepam, IM? »» Anything you're giving for an emergent situation doesn't matter whether it's controlled or not. I mean, I don't know what would not be controlled that you would give for that. But yes, Ativan is perfectly appropriate on its own. »» I'm thinking controlled in the sense of DEA thinks controlled. So I was trying to clarify what you meant by that. »» I don't know what you would use that was not controlled. But the idea is it's not a medicine. »» Like olanzapine or haloperidol is not a controlled substance. »» It's not the medicine you give. It's that it's an emergency that you're giving the med for puts it at higher risk. »» Okay. Thanks for clarifying. »» I think the other clarification for this, if you look what they came out with was CPT when they made this extend to inpatient services, parenteral controlled substances on there. This is used across the House of Medicine. So if you're in a medical hospital, that's what that probably was designed for. The things on that slide that are in red below are the committee's interpretations of how those guidelines would apply to psychiatric treatment. So that's what we discussed here. »» When you're documenting a justification for the total time, do you have to list out all of those activities, like record review, you have to put that in the note, I reviewed the record? »» You need to document the total time that you spent in the note when you mean to bill by time. And that statement would be the billable part then of the note. A lot of folks are using some sort of macro or auto text to say I spent X number of minutes in the care for this patient on activities and potentially including seeing the patient, writing the record, doing the documentation, talking, coordinating care, et cetera. »» So that auto text, you recommend that? »» No, he does not. »» So you don't have to write that you did? »» You do have to document in general the stuff that you did. Whether you do it, what he's saying is that many people do use the auto text and we can't tell you whether that's allowable or not. It depends on the auditor. But the idea is that you do have to document what you did, but the detail of what you document is not spelled out. So it can be in general. I spent time doing the following in general. And then you write down some, you know, I documented in the record, I dictated, I met with the family, and I completed discharge paperwork. Whatever it is that you did. You don't have to say I spent 12 minutes doing this, 10 minutes doing that. »» I see. »» In other words, it's not implicit that you reviewed the record. You should actually probably say that you reviewed the record in the note. You should write that out. Even if it's not detailed, just say I reviewed the record. If you spent whatever, 15 minutes, 30 minutes. »» Again, auditors will vary. So that's why you're doing it, right? To justify that for time. So I can't tell you what one auditor will say is okay and another won't. »» All right. Thank you. »» Sure. »» Good afternoon. If you provided medical services for a patient and also provided psychotherapy, billed for it, and they saw a counselor or a formal therapist in your clinic or outside the same day, would both services be paid for? Just for the psychotherapy part? »» So you're doing an E&M plus psychotherapy on the same day a therapist in your office is doing a psychotherapy visit. »» Or patient goes to a private psychotherapist. »» Okay. That's different. So if the person is in your office under your tax ID, then probably not. If they're their own somewhere else and they happen to be there on the same day, then yes, that may be okay. »» What if you're doing the mental health part of the counseling and the therapist is doing more say addiction and it's documented that way? In the same tax ID? »» The answer is no. »» Just one other question on this high level of medical decision making. On an earlier presentation that I was reading, you had like alcohol withdrawal under the higher level of care, you know, risk of complications and stuff, and I didn't see it on this particular one. Could you comment on that? »» If somebody is needing medical detox, then that's a high level of medical, you know, potential complication. If on the other hand you're treating them for an ongoing substance use condition, then that would not necessarily be high level. It's the medical complications of withdrawal that was being looked at there. Any other questions? Thank you all. Have a great meeting.

psychiatric services

Evaluation and Management

E&M codes

medical decision-making

narrative documentation

APA committee

complexity levels

psychotherapy billing

Medicare guidelines

telehealth services

telepsychiatry

payer policies

billing scenarios

nurse practitioners