A Strategic Approach to Billing Codes

In the final part of this video series recorded at the 2024 Psych Congress NP Institute, Julie Carbray, PhD, PMHNP-BC, APRN, Co-Chair, Psych Congress NP Institute, and Desiree Matthews, PMHNP-BC, Steering Committee, Psych Congress NP Institute, talk about some of the considerations surrounding billing and E&M codes. Desiree explains why billing based on time may not be the best approach, while Julie delves into which types of clinical data points may be best used to support certain billing codes.

For more documentation insights from Desiree and Julie, check out these videos:

>>Overcoming Documentation Challenges

>>A Closer Look at Documentation Practices

Read the Transcript

Julie Carbray, PhD, PMHNP-BC, APRN: Hi, I am Julie Carbray. I'm a clinical professor of psychiatry and nursing at the University of Illinois Chicago, department of Psychiatry and College of Nursing. Desiree?

Desiree Matthews, PMHNP-BC: Thank you, Julie. My name is Desiree Matthews. I'm a board certified psychiatric nurse practitioner. I'm owner and clinical director at Different MHP in Charlotte, North Carolina.

Julie: So Desiree, medical decision-making and these E&M codes: can you talk a little bit about those critical elements that should be there to meet the criteria for those E&M codes?

Desiree: Certainly Julie. So when I think about billing in outpatient practice, you can do one of two things. You can either bill based on time, which is something I generally don't do, and we'll talk about why, because there's some different codes and different times and you get different reimbursement rates. So you can bill by time, but often we bill by our medical decision making and the complexity of that visit. When the payers are looking at your notes, they're looking for a few things. So first they're looking for the number of diagnoses that you have addressed in your treatment plan. So they may have what, 6 different diagnoses, but maybe you're addressing 3 of them.

Julie: Got it

Desiree: Right? You're addressing maybe major depressive disorder, generalized anxiety disorder, and maybe a post-traumatic stress disorder, right? Maybe they're all chronic and stable conditions. So when we look at this medical decision making, and this is guided by the AMA and this kind of standardized way that we are billing and payers will pay out money, we're really looking at, again, the number of diagnoses. We're looking at data points that we've reviewed in our visit. So this could be maybe I reviewed neuropsych testing, maybe I reviewed a clozapine level that was ordered, or maybe I'm reviewing records for like a CBC and A1C that maybe primary care did. And I'm reviewing that because I need to keep them safe with their antipsychotic use. So again, number of diagnoses that I am addressing and treating data points including ordering labs. Then lastly, the last column we would consider is the risk of that visit. So for most of us, if we are prescribing medication, that's automatically a moderate level of risk.

Now, there are some cases where that risk column will go too high. So clozapine management or management of drugs that have a narrow therapeutic index for safety, exactly like lithium. So for a lot of cases I see patients that probably have 2 or more chronic illness. I'm prescribing medication management that middle, if you look at the table for the medical decision making for E&M coding, If you look at the data sets to get a high degree in terms of your billing, like a level 5 for that data, you really have to be careful. You have to meet a high level amount of data that you're reviewing. So oftentimes might not get to a level 5—

Julie: Very often.

Desiree: But honestly for most of my patients it's a level 4. And for me, I could do possibly a level 4 in say 15 minutes or 20 minutes possibly. So if I bill by time, I would actually be down coding.

Julie: So it's better, then, to use your medical decision making.

Desiree: In many cases, I would say the exception for billing by time, if you do have to review a lot of records, because that billing based on time is not just the face-to-face time, it's any time you are doing something for that patient within that date of service. So I might review records from the hospital.

Julie: For our circumstances, often we're interviewing parents and children around that medication management session. So sometimes we might be using time codes just because of all of those data points, but again, assuring that you're including that family perspective and family rating skills along with your patient's rating skills. So yeah, it's that combination together.

Desiree: Because certainly if you are going to bill by time, it is really important to put somewhere in a little summary a bullet point of how you use that time. Because if you do get audited by the insurance company, which happens, they can clearly see how you used your time, you spent this much time with the family, you spent this much time with the child, you spent this much time reviewing hospitalization records or pharmacy records.

Julie: Exactly. Excellent points. Then, I think it's also important to have resources to be able to guide you along this decision making. I know that there are many that are accessible online. Some of our professional organizations have given great resources around videos with patient examples. I think as you're getting started in practice, this is one of those areas that can be very overwhelming. But as you continue to roll it out and have a guide, I liked how you were talking about the table and really being very clear around complexity and around those data points because I think that will really help with that decision making, especially for newer clinicians.

Desiree: Certainly. I encourage people if they don't have a good resource within their organization, get the CPT book. They publish a new one every year. It's from the AMA. I do recommend that. Flag the codes that you normally use, get to know the expectation so that way when you're documenting, you're making sure to set your note template up in a way that's easy to support your billing code,

Julie: And it really offers that confidence to be able to say, I can stand behind a level 4 for today.

Desiree: Exactly. So I hope this was helpful for your practice in terms of learning how to make sure that we document in a way that helps provide excellent patient care communication to other healthcare professionals, as well as to help support your billing and coding to ensure that you are getting reimbursed for the work that you're doing with your patients.

Julie: Yeah. Thank you so much for joining us. Look forward to hearing more tips and tricks from our experts in this area. Really trying to help us to be able to not only provide that excellent care, but attend to billing coding that really makes it necessary for us to continue to be there for our patients in meaningful ways.

Julie Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, holds her PhD (93) and Master of Science (88) degrees from Rush University, Chicago and her Bachelor of Science (87) degree from Purdue University in West Lafayette, Indiana. A clinical professor of psychiatry and nursing at the University of Illinois Chicago and the director of the Pediatric Mood Disorder Clinic, she has been practicing as a Psychiatric Nurse Practitioner for over 35 years.

Desiree Matthews, PMHNP-BC, is a board certified psychiatric nurse practitioner with expertise in treating patients living with severe mental illness. Beyond clinical practice, Desiree has provided leadership in advocating for optimal outcomes of patients and elevating health care provider education. Desiree is the founder and owner of Different MHP, a telepsychiatry practice founded with the mission of providing affordable, accessible precision focused, integrative psychiatry to patients through a rich and comprehensive mentorship of the health care providers within the company.

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