How to Code for Complex Yet Stable Patients

Q: An insurance company has recently been denying the evaluation and management (E/M) care for which I bill when I see one of my patients with bipolar disorder. To maintain his stability, I see this 45-year-old man weekly for 50 minutes of psychotherapy and E/M services and bill 99214 for the E/M and 90836 for the psychotherapy. At each visit I check on the patient’s physical status and any adverse drug reactions, and if all is well, I spend 45 minutes providing supportive psychotherapy. The patient is on medication for diabetes and a heart condition, and these must be taken into account in the treatment I provide—it includes three psychotropic medications that were found to be effective over time after a very rocky initial response to other medications and combinations of medications. Despite having reviewed my documentation, which shows the extreme complexity of this patient’s treatment, the insurer is insisting that there is no justification for using the level 99214 for the E/M. Is the insurer correct?

A: In all likelihood the insurer is correct in suggesting that 99214 is too high a level for a patient who is stable, even though the patient has complex physical and psychiatric symptoms that are being kept in abeyance by the ongoing care you (and his other physicians) are providing. The level of E/M is selected on the basis of the patient’s presentation on the day of the treatment you are documenting. During the early stages of treatment, before the patient was stabilized, it might have been appropriate to be coding at the 99213 or 99214 level. However, now that the patient is stable and you are doing no more than establishing that the stability is continuing, there is probably no reason to use an E/M code higher than 99212 for a patient seen with such frequency. Nonethelesss, if the patient comes in one week with changes in his condition that must be must be taken into account to maintain stability, then you should choose a higher level of E/M based on the complexity of the issues that must be resolved. ■

APA members who have questions about reimbursement, coding, documentation, and other related practice issues may contact the Practice Management HelpLine at [email protected] or (800) 343-4671.