Credentialing & Enrollment
This identifier is required before you can bill insurance.
What is an NPI (National Provider Identifier)?
Providers must obtain an NPI through NPPES. Type 1 is for individuals; Type 2 is for organizations. Without an NPI, claims cannot be submitted.
A commonly used CPT code for moderate complexity outpatient psychiatric visits.
What is 99214?
E/M codes are determined by time or medical decision making. Many psychiatric visits meet moderate complexity
Legal process ensuring patients understand treatment risks and alternatives.
What is informed consent?
In psychiatry, informed consent should address medication risks, alternatives, and patient understanding.
Clause restricting where a provider may practice after leaving a job.
What is a non-compete clause?
Non-competes limit geographic area and time period after employment
Section of psychiatric note evaluating appearance, mood, and thought process
What is the Mental Status Exam (MSE)?
The MSE assesses psychological functioning during the encounter.
Patient messages requesting early refill of stimulant medication.
What is a potential controlled substance monitoring concern?
Early refill requests should prompt review of PDMP and adherence.
The federal system used to enroll providers to bill Medicare
What is PECOS?
PECOS enrollment allows providers to bill Medicare and must be completed before participation in many insurance networks.
The psychotherapy add-on code used when brief therapy accompanies medication management.
What is 90833?
90833 covers 16–37 minutes of psychotherapy with an E/M visit
Doctrine allowing providers to break confidentiality when a patient threatens someone
What is duty to warn or duty to protect?
Derived from the Tarasoff case; clinicians may notify victims or law enforcement if credible risk exists.
Compensation model based on revenue or productivity.
What is productivity-based compensation?
Often based on RVUs or collections.
Section describing clinical reasoning behind diagnoses and treatment.
What is clinical impression or medical decision making?
Explains how diagnoses and treatment plans were determined.
Providing therapy during a medication visit for 30 or less.
What is billing an E/M code with 90833?
Combination billing allows reimbursement for both medication management and psychotherapy
The process insurers use to verify your license,education, and training.
What is credentialing?
Credentialing verifies provider qualifications such as licensure, board certification, and malpractice history
The add-on code used when about 45 minutes of psychotherapy is provided
What is 90836?
90836 represents 38–52 minutes of psychotherapy delivered with medication management.
Malpractice claim based on failure to meet standard of care.
What is professional negligence?
Malpractice requires duty, breach of duty, causation, and harm.
Compensation model where clinicians receive fixed pay.
What is a salary model?
Provides stable income but less earning upside.
Key documentation element when prescribing controlled substances.
What is risk assessment and monitoring?
Includes substance history, PDMP checks, and safety monitoring.
Malpractice insurer requests documentation explaining decisions.
What is medical decision-making documentation?
Clinicians must show reasoning for diagnoses, medication changes, and safety planning.
The centralized credentialing database most insurers require.
What is CAQH?
CAQH houses credentialing information. Providers must re-attest every 120 days to maintain active profiles.
Documentation needed to support psychotherapy billing.
What is documented psychotherapy time and modality?
Notes should include time spent in therapy, modality used, and patient response.
Principle stating that undocumented care is legally considered not done.
What is defensible documentation?
Documentation should include reasoning, risk assessments, and patient education.
Work arrangement where clinicians are paid as independent contractors.
What is a 1099 contractor?
Contractors manage their own taxes and often have more flexibility.
Tool frequently used to evaluate suicide risk.
What is the Columbia Suicide Severity Rating Scale (C-SSRS)?
A standardized assessment tool used in many clinical settings.
Patient expresses suicidal ideation without plan or intent.
What is documenting suicide risk assessment and safety planning?
Documentation should include ideation level, protective factors, and follow-up plan.
The status indicating you have signed a contract with an insurance company.
What does it mean to be in-network?
Being in-network means accepting negotiated rates and being listed in insurer directories
Coding system used to determine reimbursement based on time or medical decision making.
What are Evaluation & Management (E/M) codes?
E/M codes represent complexity of care including diagnoses, medication decisions, and risk
Federal law governing patient health information privacy
What is HIPAA?
HIPAA regulates storage, sharing, and protection of patient health information.
Employment model with tax withholding and benefits.
What is W-2 employment?
Employers withhold taxes and may provide benefits such as health insurance.
Process insurers use to review documentation accuracy.
What is a chart audit?
Audits ensure coding matches documentation
Employer demands extremely high patient volume.
What is a productivity versus ethical practice dilemma?
Clinicians must balance productivity expectations with patient safety and quality care