The quest for CPT understanding, continued

A few weeks ago, I wrote about the early days of my quest to understand the new CPT codes for 2013.  It was facetious, but I did begin with the idea that I would figure them out so that I could write about them, and perhaps even make a teaching video.  

The weeks have gone by, and I have made an effort to learn the new coding and to figure out what changes I need to make in my own office to implement them. In my private practice, I don’t participate in any insurance networks, but I would like to comply with the new changes so that my patients receive fair reimbursement for the treatment they pay for upfront. Because I also work in a clinic, I am required to be in the Medicare network, and I do so as a non-participating psychiatrist, so these patients will be directly impacted by fees that change depending on the content of their sessions.  

The question has been raised as to whether out-of-network doctors must comply with the documentation requirements, whether solo psychiatrists who do psychotherapy and have small caseloads will be subject to chart audits, or whether Medicare will bother auditing, nitpicking, denying, or fining small-time docs who miss a few bullet points or simply don’t conform their notes to the Medicare requirements.  Questions have also been raised as to what insurance companies will allow – will they reimburse for a 60-minute (53 minutes, actually) psychotherapy session and a 99214 – medical management of a moderately complex problem – in the same visit? What would make more sense, to code a psychiatric evaluation as an E/M code with the many requirements for documentation of bullet points in the history and exam (the numbers of which depend on the code one uses), to code by time and make sure it’s documented that half of the session was spent on counseling and coordination of care, or to code a psychiatric diagnostic exam with medical services, 90792 – similar to the old code of 90801 – without the E/M documentation requirements, but with possibly a lower fee?  And oddly enough, the Medicare fees for 2013 pay higher rates if the psychiatric diagnostic exam is done without medical services, so social workers will be reimbursed more for their evaluation than psychiatrists will be, at least at this writing. I have no answers to these questions, nor do I know of anyone who does.

So let me tell you what I did to learn the old coding and what I’ve done to learn the new coding.  The old coding was self-explanatory. Mostly, I code 90807, a 50-minute psychotherapy session with medication management. I often run over and go closer to 60 minutes, but that’s fine,  and sometimes a patient is ready to go at 45 minutes, and that works, too. For education, I read the sentence. I use a different code if the session is only 30 minutes, or if a condition does not require medications, but reading the description was enough to get it.

For the new codes, I’ve done the following: I’ve gone through the National Council’s 99 slides. I’ve listened to an APA webinar. I’ve watched Dr. Ron Burd’s Vimeo. I’ve attended the Maryland Psychiatric Society’s seminar for 2.5 hours, talked briefly to Dr. Chet Schmidt, taken the APA’s online CPT course, followed another psychiatrist’s CPT blog (and even gone to meet her!). I’ve read more charts and algorithms than I can count, and I’ve read the sections of the E/M manual (several times over) pertaining to psychiatry that was made available on the APA’s free online course. With what I’ve learned, I have written 4 articles and produced a 4-part video tutorial on how to approach this coding for outpatient psychiatrists. In order to do that, I needed to use PowerPoint, iPhoto, Garageband, iMovie, and upload to YouTube and I am quite proud that I figured these out with minimal guidance from one of my techy co-bloggers. Finally, I finished the APA’s online CME course, and after all that, I failed the 9 question post-course quiz.

As the process has gone on, I have become more and more upset. Something as simple coding a psychotherapy session has become unnecessarily complex, and each session now needs 2, or even 3 different codes and the algorithms to figure out what the right codes are and involve pages of charts that layer in on one another. Figuring out an E/M code is like ordering from a Chinese menu, but you’d need an Excel spread sheet to get your lunch.  

Let me give you an example. Please feel free to skip this paragraph if you hate tedium. To start, Evaluation and Management coding has 3 components: the history, the exam, and the medical decision making. The history can be problem focused, expanded problem focused, detailed, or comprehensive.  The history consists of a chief complaint, and this is what it appears to be, with no layering or options.  The history of present illness is the second component, and there are 7 elements to consider: location, severity, timing, quality, duration, context, modifying factors, associated signs and symptoms. The HPI can be brief, meaning you’ve documented either 1-3 elements of those 7 elements, or you’ve skipped those 7 elements and documented 1 or 2 chronic conditions, or the HPI can be “extended” meaning you’ve documented 4 of the 7 elements, or skipped the HPI elements to document instead that there are 3 chronic conditions. May I mention that my patients haven’t generally “located” their psychiatric symptoms and often are unable to give precise details about duration, quality (quality?), modifying factors and associated signs and symptoms. The third part of the history is the past medical, family, and social history, and a “Pertinent” past medical, family, and social history requires one element, while a “Complete” past medical, family, and social history requires 2 elements for an established patient and 3 elements for a new patient. The third part of the history is the Review of Systems, and there are 14 bodily systems that can be reviewed.  For a problem-focused exam, you can skip this. For a problem-pertinent exam, you need to review one system and it should be related to the chief complaint.  An Extended ROS requires that 2-9 systems be reviewed, and a complete ROS requires review of 10-14 bodily systems. Okay, so now that we have the 4 parts of the history, there are 4 types of Exams: Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive. I’ll skip a little here and leave you with the concept that a Comprehensive history requires a chief complaint, an extended HPI (4 of 7 elements of the HPI or 3 chronic conditions), a complete past medical,  family, and social history (complete meaning 2-3 items), and a complete review of 10-14 bodily systems.  Are you still alive? Why do I think that no one wants me to go through these same types of layers for the Exam and Medical Decision Making? But for an existing patient, you only need 2 out of 3 of those components, and estimated times are given, so that if more then half of the estimated time is spent on counseling and coordination of care (yes, those, too, are specifically defined), then you skip the entire bullet point chaos I just put you through and code by time. Only, I haven’t been able to figure out if you can code a higher level (and higher reimbursing) code if you’ve done counseling and coordination of care, or have gotten all the bullet points, but the presenting problem was minor. We schedule our appointments by time, and sometimes patients come in feeling well, perhaps because we’ve done a good job treating them.

Is it strange that I’m annoyed? Is it odd that I wonder why this coding system, one which psychiatrists could always have coded by – and many did – is being forced on all of us? The theory is that it makes us real doctors, now able to define the varying complexity of what we do rather then lumping our visits together as 90862 “pharmacologic management” and hopefully will reimburse us better. Does anyone else think it’s funny that even the most complete of histories do not require a full history of past medical and surgical illnesses, a complete family psychiatric history, and a complete social history, including educational level and substance use? You only need a couple of bullet points; for all the graphs and charts and layers upon layers, you don’t even need to take a good psychiatric history, but by all means, ask the patient if he’s coughing up blood, but that’s not important if it’s a problem-focused exam. I’m going to assume that no one wants to read the same rituals for coding the Exam or deciding on how complex Medical Decision Making is.  

I haven’t touched on how psychotherapy is coded. There is one set of codes if there are no medical services, another set of codes if there are medical services, but those codes are used as “add-ons” to the E/M codes we just figured out above. The 50-minute psychotherapy session? Well, now it’s 30, 45, or 60 minutes, and actually, a 30-minute session can last for 16-37 minutes, a 45-minute session is 38-52 minutes, and a 60-minute session is more than 53 minutes. Finally, the psychotherapy and medical management must be distinct, a concept I can’t quite grasp. I might wonder if all these questions and reviews of systems, vital signs, exam points, documentation, and justification might distract from addressing the concerns of the patient. None of this coding makes sense for those of us who do therapy with med management, a segment of the psychiatrist population the APA seems to want to marginalize.

Dr. Burd was quoted in Psychiatry News as saying these codes shouldn't make much difference in payments to psychiatrists for 2013 but “might” in 2014.  And the APA has released a two-page template for the medical management segment of the appointment, and that does not include the therapy note. And the two-page template leaves no room to explain the clinically necessary rationale for why we’re doing what we’re doing – such as what symptoms a medicine is targeting, why it’s being discontinued, what other treatment options might be considered, why one medicine is being used instead of another, or what other factors might be affecting the current situation.

So what have we gotten? Our coding looks more like that of the other doctors, and their pay has reportedly increased while our CPT codes have not. Medicare reimburses me about $2 more for a 50-minute session than it did when I opened my practice in 1992. Still, more and more primary care doctors are opting out, so I’m not sure it’s working all that well for them, either.  

Now we have more codes, knowing quite well that the insurance companies might refuse to pay for our codes. It will take a considerable amount of work to figure out what needs to be done to justify those codes, both in terms of how we alter our interactions with patients and how we document them.  We’ll need to change our computer and billing programs. Our fees or reimbursements might differ for every patient, for every session. Patient care gets templated, and care ceases to be about the individual, it’s more about asking the questions that are needed for documentation and reimbursement. And the idea that using more than half the session for counseling and coordination of care will bypass some of this – well, isn’t is a funny statement in psychiatry that we should be spending more time talking than listening? Finally, there are the concerns that Medicare and private insurance companies might audit charts, then refuse to pay, request refunds, or levy accusations of fraud.

I realize that with time, this will just be what we do, that it won’t be such a burden because we’ll get used to asking the required questions, writing out our bullet points, and figuring out ways to make it about the patient. We’ll learn what codes and combinations of codes the insurance companies will reimburse us for and whether we’re better off using the 90792 diagnostic evaluation code or documenting an E/M code. We’ll counsel and coordinate so we can skip some of the steps, and we, like the patients, will fit neatly in our templates. I also realize that many psychiatrists, at least in the APA leadership, see this as a victory, and say it will all be quickly simplified and that we’ll all be valued and paid more. Even I have moments of wondering if they might be right.

Nevertheless, at this moment, it mostly feels like a tremendous and unnecessary burden that diverts us from issues of patient care. I feel strongly that APA should be protecting us from this type of burden, not advocating for it.  
I do hope you’ll find the CPT Coding Tutorial for Outpatient Psychiatrists helpful. I’ve divided into four short segments, and think it may help you to begin to organize how you might think about this.  To access the training videos, please click here. You’re also welcome to share them to your own blog or Facebook page. Happy Holidays.

—Dinah Miller, M.D.

A few weeks ago, I wrote about the early days of my quest to understand the new CPT codes for 2013.  It was facetious, but I did begin with the idea that I would figure them out so that I could write about them, and perhaps even make a teaching video.  

The weeks have gone by, and I have made an effort to learn the new coding and to figure out what changes I need to make in my own office to implement them. In my private practice, I don’t participate in any insurance networks, but I would like to comply with the new changes so that my patients receive fair reimbursement for the treatment they pay for upfront. Because I also work in a clinic, I am required to be in the Medicare network, and I do so as a non-participating psychiatrist, so these patients will be directly impacted by fees that change depending on the content of their sessions.  

The question has been raised as to whether out-of-network doctors must comply with the documentation requirements, whether solo psychiatrists who do psychotherapy and have small caseloads will be subject to chart audits, or whether Medicare will bother auditing, nitpicking, denying, or fining small-time docs who miss a few bullet points or simply don’t conform their notes to the Medicare requirements.  Questions have also been raised as to what insurance companies will allow – will they reimburse for a 60-minute (53 minutes, actually) psychotherapy session and a 99214 – medical management of a moderately complex problem – in the same visit? What would make more sense, to code a psychiatric evaluation as an E/M code with the many requirements for documentation of bullet points in the history and exam (the numbers of which depend on the code one uses), to code by time and make sure it’s documented that half of the session was spent on counseling and coordination of care, or to code a psychiatric diagnostic exam with medical services, 90792 – similar to the old code of 90801 – without the E/M documentation requirements, but with possibly a lower fee?  And oddly enough, the Medicare fees for 2013 pay higher rates if the psychiatric diagnostic exam is done without medical services, so social workers will be reimbursed more for their evaluation than psychiatrists will be, at least at this writing. I have no answers to these questions, nor do I know of anyone who does.

So let me tell you what I did to learn the old coding and what I’ve done to learn the new coding.  The old coding was self-explanatory. Mostly, I code 90807, a 50-minute psychotherapy session with medication management. I often run over and go closer to 60 minutes, but that’s fine,  and sometimes a patient is ready to go at 45 minutes, and that works, too. For education, I read the sentence. I use a different code if the session is only 30 minutes, or if a condition does not require medications, but reading the description was enough to get it.

For the new codes, I’ve done the following: I’ve gone through the National Council’s 99 slides. I’ve listened to an APA webinar. I’ve watched Dr. Ron Burd’s Vimeo. I’ve attended the Maryland Psychiatric Society’s seminar for 2.5 hours, talked briefly to Dr. Chet Schmidt, taken the APA’s online CPT course, followed another psychiatrist’s CPT blog (and even gone to meet her!). I’ve read more charts and algorithms than I can count, and I’ve read the sections of the E/M manual (several times over) pertaining to psychiatry that was made available on the APA’s free online course. With what I’ve learned, I have written 4 articles and produced a 4-part video tutorial on how to approach this coding for outpatient psychiatrists. In order to do that, I needed to use PowerPoint, iPhoto, Garageband, iMovie, and upload to YouTube and I am quite proud that I figured these out with minimal guidance from one of my techy co-bloggers. Finally, I finished the APA’s online CME course, and after all that, I failed the 9 question post-course quiz.

As the process has gone on, I have become more and more upset. Something as simple coding a psychotherapy session has become unnecessarily complex, and each session now needs 2, or even 3 different codes and the algorithms to figure out what the right codes are and involve pages of charts that layer in on one another. Figuring out an E/M code is like ordering from a Chinese menu, but you’d need an Excel spread sheet to get your lunch.  

Let me give you an example. Please feel free to skip this paragraph if you hate tedium. To start, Evaluation and Management coding has 3 components: the history, the exam, and the medical decision making. The history can be problem focused, expanded problem focused, detailed, or comprehensive.  The history consists of a chief complaint, and this is what it appears to be, with no layering or options.  The history of present illness is the second component, and there are 7 elements to consider: location, severity, timing, quality, duration, context, modifying factors, associated signs and symptoms. The HPI can be brief, meaning you’ve documented either 1-3 elements of those 7 elements, or you’ve skipped those 7 elements and documented 1 or 2 chronic conditions, or the HPI can be “extended” meaning you’ve documented 4 of the 7 elements, or skipped the HPI elements to document instead that there are 3 chronic conditions. May I mention that my patients haven’t generally “located” their psychiatric symptoms and often are unable to give precise details about duration, quality (quality?), modifying factors and associated signs and symptoms. The third part of the history is the past medical, family, and social history, and a “Pertinent” past medical, family, and social history requires one element, while a “Complete” past medical, family, and social history requires 2 elements for an established patient and 3 elements for a new patient. The third part of the history is the Review of Systems, and there are 14 bodily systems that can be reviewed.  For a problem-focused exam, you can skip this. For a problem-pertinent exam, you need to review one system and it should be related to the chief complaint.  An Extended ROS requires that 2-9 systems be reviewed, and a complete ROS requires review of 10-14 bodily systems. Okay, so now that we have the 4 parts of the history, there are 4 types of Exams: Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive. I’ll skip a little here and leave you with the concept that a Comprehensive history requires a chief complaint, an extended HPI (4 of 7 elements of the HPI or 3 chronic conditions), a complete past medical,  family, and social history (complete meaning 2-3 items), and a complete review of 10-14 bodily systems.  Are you still alive? Why do I think that no one wants me to go through these same types of layers for the Exam and Medical Decision Making? But for an existing patient, you only need 2 out of 3 of those components, and estimated times are given, so that if more then half of the estimated time is spent on counseling and coordination of care (yes, those, too, are specifically defined), then you skip the entire bullet point chaos I just put you through and code by time. Only, I haven’t been able to figure out if you can code a higher level (and higher reimbursing) code if you’ve done counseling and coordination of care, or have gotten all the bullet points, but the presenting problem was minor. We schedule our appointments by time, and sometimes patients come in feeling well, perhaps because we’ve done a good job treating them.

Is it strange that I’m annoyed? Is it odd that I wonder why this coding system, one which psychiatrists could always have coded by – and many did – is being forced on all of us? The theory is that it makes us real doctors, now able to define the varying complexity of what we do rather then lumping our visits together as 90862 “pharmacologic management” and hopefully will reimburse us better. Does anyone else think it’s funny that even the most complete of histories do not require a full history of past medical and surgical illnesses, a complete family psychiatric history, and a complete social history, including educational level and substance use? You only need a couple of bullet points; for all the graphs and charts and layers upon layers, you don’t even need to take a good psychiatric history, but by all means, ask the patient if he’s coughing up blood, but that’s not important if it’s a problem-focused exam. I’m going to assume that no one wants to read the same rituals for coding the Exam or deciding on how complex Medical Decision Making is.  

I haven’t touched on how psychotherapy is coded. There is one set of codes if there are no medical services, another set of codes if there are medical services, but those codes are used as “add-ons” to the E/M codes we just figured out above. The 50-minute psychotherapy session? Well, now it’s 30, 45, or 60 minutes, and actually, a 30-minute session can last for 16-37 minutes, a 45-minute session is 38-52 minutes, and a 60-minute session is more than 53 minutes. Finally, the psychotherapy and medical management must be distinct, a concept I can’t quite grasp. I might wonder if all these questions and reviews of systems, vital signs, exam points, documentation, and justification might distract from addressing the concerns of the patient. None of this coding makes sense for those of us who do therapy with med management, a segment of the psychiatrist population the APA seems to want to marginalize.

Dr. Burd was quoted in Psychiatry News as saying these codes shouldn't make much difference in payments to psychiatrists for 2013 but “might” in 2014.  And the APA has released a two-page template for the medical management segment of the appointment, and that does not include the therapy note. And the two-page template leaves no room to explain the clinically necessary rationale for why we’re doing what we’re doing – such as what symptoms a medicine is targeting, why it’s being discontinued, what other treatment options might be considered, why one medicine is being used instead of another, or what other factors might be affecting the current situation.

So what have we gotten? Our coding looks more like that of the other doctors, and their pay has reportedly increased while our CPT codes have not. Medicare reimburses me about $2 more for a 50-minute session than it did when I opened my practice in 1992. Still, more and more primary care doctors are opting out, so I’m not sure it’s working all that well for them, either.  

Now we have more codes, knowing quite well that the insurance companies might refuse to pay for our codes. It will take a considerable amount of work to figure out what needs to be done to justify those codes, both in terms of how we alter our interactions with patients and how we document them.  We’ll need to change our computer and billing programs. Our fees or reimbursements might differ for every patient, for every session. Patient care gets templated, and care ceases to be about the individual, it’s more about asking the questions that are needed for documentation and reimbursement. And the idea that using more than half the session for counseling and coordination of care will bypass some of this – well, isn’t is a funny statement in psychiatry that we should be spending more time talking than listening? Finally, there are the concerns that Medicare and private insurance companies might audit charts, then refuse to pay, request refunds, or levy accusations of fraud.

I realize that with time, this will just be what we do, that it won’t be such a burden because we’ll get used to asking the required questions, writing out our bullet points, and figuring out ways to make it about the patient. We’ll learn what codes and combinations of codes the insurance companies will reimburse us for and whether we’re better off using the 90792 diagnostic evaluation code or documenting an E/M code. We’ll counsel and coordinate so we can skip some of the steps, and we, like the patients, will fit neatly in our templates. I also realize that many psychiatrists, at least in the APA leadership, see this as a victory, and say it will all be quickly simplified and that we’ll all be valued and paid more. Even I have moments of wondering if they might be right.

Nevertheless, at this moment, it mostly feels like a tremendous and unnecessary burden that diverts us from issues of patient care. I feel strongly that APA should be protecting us from this type of burden, not advocating for it.  
I do hope you’ll find the CPT Coding Tutorial for Outpatient Psychiatrists helpful. I’ve divided into four short segments, and think it may help you to begin to organize how you might think about this.  To access the training videos, please click here. You’re also welcome to share them to your own blog or Facebook page. Happy Holidays.

—Dinah Miller, M.D.

A few weeks ago, I wrote about the early days of my quest to understand the new CPT codes for 2013.  It was facetious, but I did begin with the idea that I would figure them out so that I could write about them, and perhaps even make a teaching video.  

The weeks have gone by, and I have made an effort to learn the new coding and to figure out what changes I need to make in my own office to implement them. In my private practice, I don’t participate in any insurance networks, but I would like to comply with the new changes so that my patients receive fair reimbursement for the treatment they pay for upfront. Because I also work in a clinic, I am required to be in the Medicare network, and I do so as a non-participating psychiatrist, so these patients will be directly impacted by fees that change depending on the content of their sessions.  

The question has been raised as to whether out-of-network doctors must comply with the documentation requirements, whether solo psychiatrists who do psychotherapy and have small caseloads will be subject to chart audits, or whether Medicare will bother auditing, nitpicking, denying, or fining small-time docs who miss a few bullet points or simply don’t conform their notes to the Medicare requirements.  Questions have also been raised as to what insurance companies will allow – will they reimburse for a 60-minute (53 minutes, actually) psychotherapy session and a 99214 – medical management of a moderately complex problem – in the same visit? What would make more sense, to code a psychiatric evaluation as an E/M code with the many requirements for documentation of bullet points in the history and exam (the numbers of which depend on the code one uses), to code by time and make sure it’s documented that half of the session was spent on counseling and coordination of care, or to code a psychiatric diagnostic exam with medical services, 90792 – similar to the old code of 90801 – without the E/M documentation requirements, but with possibly a lower fee?  And oddly enough, the Medicare fees for 2013 pay higher rates if the psychiatric diagnostic exam is done without medical services, so social workers will be reimbursed more for their evaluation than psychiatrists will be, at least at this writing. I have no answers to these questions, nor do I know of anyone who does.

So let me tell you what I did to learn the old coding and what I’ve done to learn the new coding.  The old coding was self-explanatory. Mostly, I code 90807, a 50-minute psychotherapy session with medication management. I often run over and go closer to 60 minutes, but that’s fine,  and sometimes a patient is ready to go at 45 minutes, and that works, too. For education, I read the sentence. I use a different code if the session is only 30 minutes, or if a condition does not require medications, but reading the description was enough to get it.

For the new codes, I’ve done the following: I’ve gone through the National Council’s 99 slides. I’ve listened to an APA webinar. I’ve watched Dr. Ron Burd’s Vimeo. I’ve attended the Maryland Psychiatric Society’s seminar for 2.5 hours, talked briefly to Dr. Chet Schmidt, taken the APA’s online CPT course, followed another psychiatrist’s CPT blog (and even gone to meet her!). I’ve read more charts and algorithms than I can count, and I’ve read the sections of the E/M manual (several times over) pertaining to psychiatry that was made available on the APA’s free online course. With what I’ve learned, I have written 4 articles and produced a 4-part video tutorial on how to approach this coding for outpatient psychiatrists. In order to do that, I needed to use PowerPoint, iPhoto, Garageband, iMovie, and upload to YouTube and I am quite proud that I figured these out with minimal guidance from one of my techy co-bloggers. Finally, I finished the APA’s online CME course, and after all that, I failed the 9 question post-course quiz.

As the process has gone on, I have become more and more upset. Something as simple coding a psychotherapy session has become unnecessarily complex, and each session now needs 2, or even 3 different codes and the algorithms to figure out what the right codes are and involve pages of charts that layer in on one another. Figuring out an E/M code is like ordering from a Chinese menu, but you’d need an Excel spread sheet to get your lunch.  

Let me give you an example. Please feel free to skip this paragraph if you hate tedium. To start, Evaluation and Management coding has 3 components: the history, the exam, and the medical decision making. The history can be problem focused, expanded problem focused, detailed, or comprehensive.  The history consists of a chief complaint, and this is what it appears to be, with no layering or options.  The history of present illness is the second component, and there are 7 elements to consider: location, severity, timing, quality, duration, context, modifying factors, associated signs and symptoms. The HPI can be brief, meaning you’ve documented either 1-3 elements of those 7 elements, or you’ve skipped those 7 elements and documented 1 or 2 chronic conditions, or the HPI can be “extended” meaning you’ve documented 4 of the 7 elements, or skipped the HPI elements to document instead that there are 3 chronic conditions. May I mention that my patients haven’t generally “located” their psychiatric symptoms and often are unable to give precise details about duration, quality (quality?), modifying factors and associated signs and symptoms. The third part of the history is the past medical, family, and social history, and a “Pertinent” past medical, family, and social history requires one element, while a “Complete” past medical, family, and social history requires 2 elements for an established patient and 3 elements for a new patient. The third part of the history is the Review of Systems, and there are 14 bodily systems that can be reviewed.  For a problem-focused exam, you can skip this. For a problem-pertinent exam, you need to review one system and it should be related to the chief complaint.  An Extended ROS requires that 2-9 systems be reviewed, and a complete ROS requires review of 10-14 bodily systems. Okay, so now that we have the 4 parts of the history, there are 4 types of Exams: Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive. I’ll skip a little here and leave you with the concept that a Comprehensive history requires a chief complaint, an extended HPI (4 of 7 elements of the HPI or 3 chronic conditions), a complete past medical,  family, and social history (complete meaning 2-3 items), and a complete review of 10-14 bodily systems.  Are you still alive? Why do I think that no one wants me to go through these same types of layers for the Exam and Medical Decision Making? But for an existing patient, you only need 2 out of 3 of those components, and estimated times are given, so that if more then half of the estimated time is spent on counseling and coordination of care (yes, those, too, are specifically defined), then you skip the entire bullet point chaos I just put you through and code by time. Only, I haven’t been able to figure out if you can code a higher level (and higher reimbursing) code if you’ve done counseling and coordination of care, or have gotten all the bullet points, but the presenting problem was minor. We schedule our appointments by time, and sometimes patients come in feeling well, perhaps because we’ve done a good job treating them.

Is it strange that I’m annoyed? Is it odd that I wonder why this coding system, one which psychiatrists could always have coded by – and many did – is being forced on all of us? The theory is that it makes us real doctors, now able to define the varying complexity of what we do rather then lumping our visits together as 90862 “pharmacologic management” and hopefully will reimburse us better. Does anyone else think it’s funny that even the most complete of histories do not require a full history of past medical and surgical illnesses, a complete family psychiatric history, and a complete social history, including educational level and substance use? You only need a couple of bullet points; for all the graphs and charts and layers upon layers, you don’t even need to take a good psychiatric history, but by all means, ask the patient if he’s coughing up blood, but that’s not important if it’s a problem-focused exam. I’m going to assume that no one wants to read the same rituals for coding the Exam or deciding on how complex Medical Decision Making is.  

I haven’t touched on how psychotherapy is coded. There is one set of codes if there are no medical services, another set of codes if there are medical services, but those codes are used as “add-ons” to the E/M codes we just figured out above. The 50-minute psychotherapy session? Well, now it’s 30, 45, or 60 minutes, and actually, a 30-minute session can last for 16-37 minutes, a 45-minute session is 38-52 minutes, and a 60-minute session is more than 53 minutes. Finally, the psychotherapy and medical management must be distinct, a concept I can’t quite grasp. I might wonder if all these questions and reviews of systems, vital signs, exam points, documentation, and justification might distract from addressing the concerns of the patient. None of this coding makes sense for those of us who do therapy with med management, a segment of the psychiatrist population the APA seems to want to marginalize.

Dr. Burd was quoted in Psychiatry News as saying these codes shouldn't make much difference in payments to psychiatrists for 2013 but “might” in 2014.  And the APA has released a two-page template for the medical management segment of the appointment, and that does not include the therapy note. And the two-page template leaves no room to explain the clinically necessary rationale for why we’re doing what we’re doing – such as what symptoms a medicine is targeting, why it’s being discontinued, what other treatment options might be considered, why one medicine is being used instead of another, or what other factors might be affecting the current situation.

So what have we gotten? Our coding looks more like that of the other doctors, and their pay has reportedly increased while our CPT codes have not. Medicare reimburses me about $2 more for a 50-minute session than it did when I opened my practice in 1992. Still, more and more primary care doctors are opting out, so I’m not sure it’s working all that well for them, either.  

Now we have more codes, knowing quite well that the insurance companies might refuse to pay for our codes. It will take a considerable amount of work to figure out what needs to be done to justify those codes, both in terms of how we alter our interactions with patients and how we document them.  We’ll need to change our computer and billing programs. Our fees or reimbursements might differ for every patient, for every session. Patient care gets templated, and care ceases to be about the individual, it’s more about asking the questions that are needed for documentation and reimbursement. And the idea that using more than half the session for counseling and coordination of care will bypass some of this – well, isn’t is a funny statement in psychiatry that we should be spending more time talking than listening? Finally, there are the concerns that Medicare and private insurance companies might audit charts, then refuse to pay, request refunds, or levy accusations of fraud.

I realize that with time, this will just be what we do, that it won’t be such a burden because we’ll get used to asking the required questions, writing out our bullet points, and figuring out ways to make it about the patient. We’ll learn what codes and combinations of codes the insurance companies will reimburse us for and whether we’re better off using the 90792 diagnostic evaluation code or documenting an E/M code. We’ll counsel and coordinate so we can skip some of the steps, and we, like the patients, will fit neatly in our templates. I also realize that many psychiatrists, at least in the APA leadership, see this as a victory, and say it will all be quickly simplified and that we’ll all be valued and paid more. Even I have moments of wondering if they might be right.

Nevertheless, at this moment, it mostly feels like a tremendous and unnecessary burden that diverts us from issues of patient care. I feel strongly that APA should be protecting us from this type of burden, not advocating for it.  
I do hope you’ll find the CPT Coding Tutorial for Outpatient Psychiatrists helpful. I’ve divided into four short segments, and think it may help you to begin to organize how you might think about this.  To access the training videos, please click here. You’re also welcome to share them to your own blog or Facebook page. Happy Holidays.

—Dinah Miller, M.D.