Navigating Billing for Ketamine and Nasal Esketamine Treatments: A Guide to E/M Codes and Time-Based Billing

When it comes to billing for ketamine and nasal esketamine treatments, confusion often arises about which codes to use, when to bill, and how to accurately reflect the time spent on these services. Here's a clear breakdown to help you navigate the complexities of billing for these treatments.

Understanding the Billing Codes

In general, when billing for ketamine or nasal esketamine treatments, it's important to focus on time-based E/M codes rather than medical decision-making (MDM). This is because the administration and monitoring of these medications primarily involve time rather than complex decision-making.

Nasal Esketamine: Typically requires a minimum of a 120-minute visit, especially with brand-name medications. For these longer visits, the most appropriate codes are 99215 and one of the extended time codes—99415, 99417, or G2212—depending on your payer's requirements.

Ketamine: Usually involves a 60-minute visit, which aligns with code 99215.

Breaking Down the Codes

• Code 99215: This code is used for high-complexity E/M visits or visits lasting 40-54 minutes. For administering esketamine or ketamine, using time-based billing is advisable. Documenting the total time spent is crucial, including preparation, coordination of care, and patient monitoring. For the first hour of treatment, code 99215 is generally the starting point.

• Code 99417: This code is for reporting additional time beyond the base E/M service and is billed in 15-minute increments. Note that 99417 is not accepted by Medicare or Medicare plans but is often accepted by commercial and Medicaid plans. For example, if you’ve billed a 99215 and spent 55 minutes beyond that, you’d bill 1 unit of 99417. If you spent 70 minutes, you’d bill 2 units, and so forth.

• Code G2212: Similar to 99417, G2212 is billed in 15-minute increments but is accepted by Medicare. CMS requires that the full 15 minutes must elapse to bill one unit. For instance, if you have a total of 115 minutes, you would not bill G2212 until after this period has passed, ensuring you meet the minimum time requirement.

• Code 99415: This code is used for the first hour of additional time beyond the base E/M service and is billed in full 60-minute increments. To use 99415, you must wait until at least 115 minutes have passed. This code is appropriate when clinical staff spends additional time directly with the patient under the provider’s supervision.

Additional Considerations

When billing for treatments where the medication is supplied by the provider or for specific injection services, different codes may apply. These will be discussed in detail in future posts.

Key Takeaways:

1. Prioritize Time-Based Codes: For both ketamine and nasal esketamine treatments, document time spent carefully and use E/M codes based on time rather than MDM.
2. Know Your Payer: Understand your insurance contracts to choose the appropriate extended time code (99417, G2212, or 99415) based on their acceptance and billing guidelines.
3. Document Thoroughly: Always record the total time spent on treatment and any additional monitoring to support your billing.

By adhering to these guidelines, you can ensure accurate billing and appropriate reimbursement for ketamine and nasal esketamine treatments. Stay tuned for more insights into billing practices and code usage in our upcoming posts.

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The information provided in this blog post regarding medical coding for ketamine and nasal esketamine treatments is intended for general informational purposes only. While we strive to offer accurate and up-to-date guidance, coding practices can be complex and subject to change based on payer policies, government regulations, and specific clinical circumstances.

It is essential for healthcare providers and billing professionals to verify all coding and billing practices with the relevant payer guidelines and current government regulations before implementation. Payers may have specific requirements or restrictions that could impact the appropriate use of billing codes. Additionally, government regulations, including those from the Centers for Medicare & Medicaid Services (CMS), may have updates or nuances that affect coding practices.

Always consult with your payer and refer to the latest official guidelines to ensure compliance and accurate billing. The information provided here does not constitute professional advice or guarantee reimbursement and should not be relied upon as such.