Shrink Rap News

Last month, I wrote about the Mental Health Parity and Addiction Equity Act (MHPAEA) and its impact on how the new psychiatry CPT codes were being used (and misused) by commercial payers. On Jan. 16, the Centers for Medicare and Medicaid Services (CMS) issued a Dear State Health Officer (SHO) letter that provided guidance to state Medicaid directors regarding the applicability of MHPAEA to Medicaid.

This is also the same date that President Obama stated – and HHS Secretary Sebelius quickly confirmed – that the final regulations for MHPAEA would be completed this year. (Despite the passing of MHPAEA in 2008, payers were not required to be compliant until 2010. Yet a “final rule” has not been issued, resulting in confusion about how the law must be applied.)

The SHO letter, issued by Director Cindy Mann, explains in its six pages what is expected of Medicaid. While maybe not great for beach reading, it is exciting to read that the spirit of MHPAEA will be alive and well in Medicaid. The enumerated requirements apply to Managed Care Organizations (MCOs) that contract with states to provide Medicaid services. For example:

• “Medical management techniques used by the MCO, such as pre-authorization requirements, which are applied to mental health or substance use disorder benefits must be comparable to and applied no more stringently than the medical management techniques that are applied to medical/surgical benefits.”

•  The “criteria for medical necessity determinations made under the plan for mental health or substance use disorder benefits must be made available by the plan administrator to any current or potential participant, beneficiary, or contracting provider upon request.”

• “When out-of-network coverage is available for medical/surgical benefits, it also must be available for mental health or substance use disorder benefits.”

Finally, the letter also makes it clear that states should review their MCO contracts “to assure that plans comply with the provisions of MHPAEA.” “MCOs that are not in compliance with the parity requirements described above should take steps to come into compliance with those requirements.”

The SHO letter also addresses compliance of state Alternative Benefit Plans and CHIP (Children’s Health Insurance Programs) plans.

While there is no deadline stated as to when state Medicaid plans must become compliant nor does the letter indicate the penalties for noncompliance, this is clearly a warning shot putting state Medicaid directors on notice. I expect we will see further clarification once the Final Rule is issued later this year.

What it means in Maryland so far is that Medicaid has become one of the better payers for the new CPT codes for mental health services. This is in part because of commercial payers’ noncompliance with MHPAEA, paying combined E&M plus psychotherapy services on par with 90805 and 90807 rates from last year, rather than paying E&M codes at the same rates as for primary care physicians.

As complaints from patients and psychiatrists continue to pile up – to state insurance commissioners, MCO medical directors, state district branches, the APA, state attorneys general offices, and the Department of Labor – commercial payers also will begin to come in line across the country.

There will be challenges to riding out this national transition, but it seems clear that a new day is dawning for people who expect mental health and addiction care to be treated like any other medical service.

 —Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmailDOTcom.

Last month, I wrote about the Mental Health Parity and Addiction Equity Act (MHPAEA) and its impact on how the new psychiatry CPT codes were being used (and misused) by commercial payers. On Jan. 16, the Centers for Medicare and Medicaid Services (CMS) issued a Dear State Health Officer (SHO) letter that provided guidance to state Medicaid directors regarding the applicability of MHPAEA to Medicaid.

This is also the same date that President Obama stated – and HHS Secretary Sebelius quickly confirmed – that the final regulations for MHPAEA would be completed this year. (Despite the passing of MHPAEA in 2008, payers were not required to be compliant until 2010. Yet a “final rule” has not been issued, resulting in confusion about how the law must be applied.)

The SHO letter, issued by Director Cindy Mann, explains in its six pages what is expected of Medicaid. While maybe not great for beach reading, it is exciting to read that the spirit of MHPAEA will be alive and well in Medicaid. The enumerated requirements apply to Managed Care Organizations (MCOs) that contract with states to provide Medicaid services. For example:

• “Medical management techniques used by the MCO, such as pre-authorization requirements, which are applied to mental health or substance use disorder benefits must be comparable to and applied no more stringently than the medical management techniques that are applied to medical/surgical benefits.”

•  The “criteria for medical necessity determinations made under the plan for mental health or substance use disorder benefits must be made available by the plan administrator to any current or potential participant, beneficiary, or contracting provider upon request.”

• “When out-of-network coverage is available for medical/surgical benefits, it also must be available for mental health or substance use disorder benefits.”

Finally, the letter also makes it clear that states should review their MCO contracts “to assure that plans comply with the provisions of MHPAEA.” “MCOs that are not in compliance with the parity requirements described above should take steps to come into compliance with those requirements.”

The SHO letter also addresses compliance of state Alternative Benefit Plans and CHIP (Children’s Health Insurance Programs) plans.

While there is no deadline stated as to when state Medicaid plans must become compliant nor does the letter indicate the penalties for noncompliance, this is clearly a warning shot putting state Medicaid directors on notice. I expect we will see further clarification once the Final Rule is issued later this year.

What it means in Maryland so far is that Medicaid has become one of the better payers for the new CPT codes for mental health services. This is in part because of commercial payers’ noncompliance with MHPAEA, paying combined E&M plus psychotherapy services on par with 90805 and 90807 rates from last year, rather than paying E&M codes at the same rates as for primary care physicians.

As complaints from patients and psychiatrists continue to pile up – to state insurance commissioners, MCO medical directors, state district branches, the APA, state attorneys general offices, and the Department of Labor – commercial payers also will begin to come in line across the country.

There will be challenges to riding out this national transition, but it seems clear that a new day is dawning for people who expect mental health and addiction care to be treated like any other medical service.

 —Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmailDOTcom.

Last month, I wrote about the Mental Health Parity and Addiction Equity Act (MHPAEA) and its impact on how the new psychiatry CPT codes were being used (and misused) by commercial payers. On Jan. 16, the Centers for Medicare and Medicaid Services (CMS) issued a Dear State Health Officer (SHO) letter that provided guidance to state Medicaid directors regarding the applicability of MHPAEA to Medicaid.

This is also the same date that President Obama stated – and HHS Secretary Sebelius quickly confirmed – that the final regulations for MHPAEA would be completed this year. (Despite the passing of MHPAEA in 2008, payers were not required to be compliant until 2010. Yet a “final rule” has not been issued, resulting in confusion about how the law must be applied.)

The SHO letter, issued by Director Cindy Mann, explains in its six pages what is expected of Medicaid. While maybe not great for beach reading, it is exciting to read that the spirit of MHPAEA will be alive and well in Medicaid. The enumerated requirements apply to Managed Care Organizations (MCOs) that contract with states to provide Medicaid services. For example:

• “Medical management techniques used by the MCO, such as pre-authorization requirements, which are applied to mental health or substance use disorder benefits must be comparable to and applied no more stringently than the medical management techniques that are applied to medical/surgical benefits.”

•  The “criteria for medical necessity determinations made under the plan for mental health or substance use disorder benefits must be made available by the plan administrator to any current or potential participant, beneficiary, or contracting provider upon request.”

• “When out-of-network coverage is available for medical/surgical benefits, it also must be available for mental health or substance use disorder benefits.”

Finally, the letter also makes it clear that states should review their MCO contracts “to assure that plans comply with the provisions of MHPAEA.” “MCOs that are not in compliance with the parity requirements described above should take steps to come into compliance with those requirements.”

The SHO letter also addresses compliance of state Alternative Benefit Plans and CHIP (Children’s Health Insurance Programs) plans.

While there is no deadline stated as to when state Medicaid plans must become compliant nor does the letter indicate the penalties for noncompliance, this is clearly a warning shot putting state Medicaid directors on notice. I expect we will see further clarification once the Final Rule is issued later this year.

What it means in Maryland so far is that Medicaid has become one of the better payers for the new CPT codes for mental health services. This is in part because of commercial payers’ noncompliance with MHPAEA, paying combined E&M plus psychotherapy services on par with 90805 and 90807 rates from last year, rather than paying E&M codes at the same rates as for primary care physicians.

As complaints from patients and psychiatrists continue to pile up – to state insurance commissioners, MCO medical directors, state district branches, the APA, state attorneys general offices, and the Department of Labor – commercial payers also will begin to come in line across the country.

There will be challenges to riding out this national transition, but it seems clear that a new day is dawning for people who expect mental health and addiction care to be treated like any other medical service.

 —Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmailDOTcom.

One of the more interesting aspects of our Accessible Psychiatry Project is that as colleagues, we don’t always agree. Sometimes we argue in person; other times by text or e-mail, and other times we argue in more public forums: on our blogs and podcast, where we present viewpoints that are different. At times, we persuade each other to see a new point of view, but sometimes we agree to disagree, and move on with our work and our friendships. Having said that, please do read Anne Hanson’s post on why you shouldn’t worry about the mandates of the New York SAFE Act on doctor-patient confidentiality, published on this website a few days ago. I’ll move on to tell you why I think you should be concerned, and why I hope the APA will be a vocal objector to the portion of the Act that infringes on confidentiality and suggests that mental health professionals may be able to prevent violence.

Last Tuesday, the New York State Assembly passed the New York SAFE Act, which includes a requirement that mental health professionals notify the state about any patient who represents a likely danger.  The exact wording of the legislation reads: 

“Not withstanding any other law to the contrary, when a mental health        professional currently providing treatment services to a person determines, in the exercise of reasonable professional judgment, that such person is likely to engage in conduct that would result in serious harm to self or others, he or she shall be required to report, as soon as practicable, to the director of community services, or the director’s designee, who shall report to the division of criminal justice services.”    

While I am an avid proponent of stricter gun control regulation, as a psychiatrist, I find the mandate to report patients to the state quite troubling. Confidentiality requirements extend to very few relationships: physicians, religious leaders, and attorneys, and it is the trust in this confidentiality that makes those relationships possible. This law annihilates psychiatrist-patient confidentiality in the most egregious of ways: by inserting the government into a situation where a violent act has not yet even occurred – it mandates government intrusions into our fantasies, and it sets a precedent to end the confidentiality that is necessary to allow for psychiatric treatment.

I’d like to point out a few things.

Procedures are already in place that address treatment of imminently dangerous people. Often, we hospitalize people when the threat is immediate, and our current mental health system has difficulty addressing the needs of those who are “imminently” dangerous, much less those who are dangerous without a given time frame.  

Notably, this law addresses all patients who convey they are dangerous – either suicidal or homicidal to a mental health professional, not just gun owners. The law does not just pertain to the “mentally ill” – whoever that may mean, given that roughly half of all people will experience an episode of mental illness during their lifetime and psychiatric patients don’t neatly divide into “us” and “them” categories.  People see therapists and talk about suicide, and even homicide, for reasons that don’t originate in a psychiatric disorder.  The hope might be that more funds will be funneled into both the administrative tangle of following up on all those who are identified as dangerous, reclaiming their guns, and overseeing the gun storage methods of their family members and roommates.  And then, we’d certainly want increased funding to allow for treatment of those identified as dangerous, but it remains to be seen if such funding will follow these measures, especially in times when psychiatric hospitals are closing, medical reimbursements are decreasing, paperwork burdens are shifting doctor time away from patient care, and psychiatric services are difficult to access.  

This legislation was inspired by the tragic Newtown massacre, yet we’ve seen nothing in the media that indicates the shooter would have fallen into a category that would have brought him to the attention of authorities, even if such laws had been in place. We’ve heard he had an autism spectrum illness, but there have been no reports that he’d been violent or ever told a mental health professional that he was planning a school shooting.

The most concerning issue with such legislation, however, is that it sets in motion a barrier to getting help for those who most need it. Who would willingly seek treatment, tell their clinician their dark thoughts, knowing such thoughts will be reported to an agent of the state, one who then decides (based on what?) whether he or she should be reported to the legal authorities? Certainly no gun owner, and certainly no troubled law enforcement officer. This legislation appears to require that those who voluntarily seek treatment because they are suicidal must be reported. It’s an interesting quandary, since insurers often permit hospital admission only if a patient is imminently dangerous, meaning this could possibly extend to nearly all persons admitted to  psychiatric units.  Perhaps they just won’t seek help. 

And for someone who is delusional,  this may be one more reason not to trust psychiatrists and not to get treatment. The New York SAFE Act may well have the unintended consequence of increasing suicide rates and violence, and there is no doubt that other states will follow suit with similar legislation if we don’t reconsider the quick response of New York state.

While other laws have overridden doctor-patient confidentiality – for example, requirements to report sexually transmitted diseases and abuse of vulnerable populations – those laws address illnesses and acts that have already happened.  These laws require clinicians to report their suspicions and beliefs about a patient’s intentions, and they set the stage to require state-mandated reporting of any number of fantasies told to a therapist. Violent ideas are very common, and mental health professionals are not particularly good at predicting who will act on them. What else might we extend reporting requirements to include?  The sexual activities of patients with HIV?  The financial behaviors of those running Ponzi schemes?

Is this really what we want? Interestingly, in New York, you can still tell your internist or dermatologist that you’re feeling suicidal, and that doesn’t need to be reported to the state.
       
—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011)

One of the more interesting aspects of our Accessible Psychiatry Project is that as colleagues, we don’t always agree. Sometimes we argue in person; other times by text or e-mail, and other times we argue in more public forums: on our blogs and podcast, where we present viewpoints that are different. At times, we persuade each other to see a new point of view, but sometimes we agree to disagree, and move on with our work and our friendships. Having said that, please do read Anne Hanson’s post on why you shouldn’t worry about the mandates of the New York SAFE Act on doctor-patient confidentiality, published on this website a few days ago. I’ll move on to tell you why I think you should be concerned, and why I hope the APA will be a vocal objector to the portion of the Act that infringes on confidentiality and suggests that mental health professionals may be able to prevent violence.

Last Tuesday, the New York State Assembly passed the New York SAFE Act, which includes a requirement that mental health professionals notify the state about any patient who represents a likely danger.  The exact wording of the legislation reads: 

“Not withstanding any other law to the contrary, when a mental health        professional currently providing treatment services to a person determines, in the exercise of reasonable professional judgment, that such person is likely to engage in conduct that would result in serious harm to self or others, he or she shall be required to report, as soon as practicable, to the director of community services, or the director’s designee, who shall report to the division of criminal justice services.”    

While I am an avid proponent of stricter gun control regulation, as a psychiatrist, I find the mandate to report patients to the state quite troubling. Confidentiality requirements extend to very few relationships: physicians, religious leaders, and attorneys, and it is the trust in this confidentiality that makes those relationships possible. This law annihilates psychiatrist-patient confidentiality in the most egregious of ways: by inserting the government into a situation where a violent act has not yet even occurred – it mandates government intrusions into our fantasies, and it sets a precedent to end the confidentiality that is necessary to allow for psychiatric treatment.

I’d like to point out a few things.

Procedures are already in place that address treatment of imminently dangerous people. Often, we hospitalize people when the threat is immediate, and our current mental health system has difficulty addressing the needs of those who are “imminently” dangerous, much less those who are dangerous without a given time frame.  

Notably, this law addresses all patients who convey they are dangerous – either suicidal or homicidal to a mental health professional, not just gun owners. The law does not just pertain to the “mentally ill” – whoever that may mean, given that roughly half of all people will experience an episode of mental illness during their lifetime and psychiatric patients don’t neatly divide into “us” and “them” categories.  People see therapists and talk about suicide, and even homicide, for reasons that don’t originate in a psychiatric disorder.  The hope might be that more funds will be funneled into both the administrative tangle of following up on all those who are identified as dangerous, reclaiming their guns, and overseeing the gun storage methods of their family members and roommates.  And then, we’d certainly want increased funding to allow for treatment of those identified as dangerous, but it remains to be seen if such funding will follow these measures, especially in times when psychiatric hospitals are closing, medical reimbursements are decreasing, paperwork burdens are shifting doctor time away from patient care, and psychiatric services are difficult to access.  

This legislation was inspired by the tragic Newtown massacre, yet we’ve seen nothing in the media that indicates the shooter would have fallen into a category that would have brought him to the attention of authorities, even if such laws had been in place. We’ve heard he had an autism spectrum illness, but there have been no reports that he’d been violent or ever told a mental health professional that he was planning a school shooting.

The most concerning issue with such legislation, however, is that it sets in motion a barrier to getting help for those who most need it. Who would willingly seek treatment, tell their clinician their dark thoughts, knowing such thoughts will be reported to an agent of the state, one who then decides (based on what?) whether he or she should be reported to the legal authorities? Certainly no gun owner, and certainly no troubled law enforcement officer. This legislation appears to require that those who voluntarily seek treatment because they are suicidal must be reported. It’s an interesting quandary, since insurers often permit hospital admission only if a patient is imminently dangerous, meaning this could possibly extend to nearly all persons admitted to  psychiatric units.  Perhaps they just won’t seek help. 

And for someone who is delusional,  this may be one more reason not to trust psychiatrists and not to get treatment. The New York SAFE Act may well have the unintended consequence of increasing suicide rates and violence, and there is no doubt that other states will follow suit with similar legislation if we don’t reconsider the quick response of New York state.

While other laws have overridden doctor-patient confidentiality – for example, requirements to report sexually transmitted diseases and abuse of vulnerable populations – those laws address illnesses and acts that have already happened.  These laws require clinicians to report their suspicions and beliefs about a patient’s intentions, and they set the stage to require state-mandated reporting of any number of fantasies told to a therapist. Violent ideas are very common, and mental health professionals are not particularly good at predicting who will act on them. What else might we extend reporting requirements to include?  The sexual activities of patients with HIV?  The financial behaviors of those running Ponzi schemes?

Is this really what we want? Interestingly, in New York, you can still tell your internist or dermatologist that you’re feeling suicidal, and that doesn’t need to be reported to the state.
       
—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011)

One of the more interesting aspects of our Accessible Psychiatry Project is that as colleagues, we don’t always agree. Sometimes we argue in person; other times by text or e-mail, and other times we argue in more public forums: on our blogs and podcast, where we present viewpoints that are different. At times, we persuade each other to see a new point of view, but sometimes we agree to disagree, and move on with our work and our friendships. Having said that, please do read Anne Hanson’s post on why you shouldn’t worry about the mandates of the New York SAFE Act on doctor-patient confidentiality, published on this website a few days ago. I’ll move on to tell you why I think you should be concerned, and why I hope the APA will be a vocal objector to the portion of the Act that infringes on confidentiality and suggests that mental health professionals may be able to prevent violence.

Last Tuesday, the New York State Assembly passed the New York SAFE Act, which includes a requirement that mental health professionals notify the state about any patient who represents a likely danger.  The exact wording of the legislation reads: 

“Not withstanding any other law to the contrary, when a mental health        professional currently providing treatment services to a person determines, in the exercise of reasonable professional judgment, that such person is likely to engage in conduct that would result in serious harm to self or others, he or she shall be required to report, as soon as practicable, to the director of community services, or the director’s designee, who shall report to the division of criminal justice services.”    

While I am an avid proponent of stricter gun control regulation, as a psychiatrist, I find the mandate to report patients to the state quite troubling. Confidentiality requirements extend to very few relationships: physicians, religious leaders, and attorneys, and it is the trust in this confidentiality that makes those relationships possible. This law annihilates psychiatrist-patient confidentiality in the most egregious of ways: by inserting the government into a situation where a violent act has not yet even occurred – it mandates government intrusions into our fantasies, and it sets a precedent to end the confidentiality that is necessary to allow for psychiatric treatment.

I’d like to point out a few things.

Procedures are already in place that address treatment of imminently dangerous people. Often, we hospitalize people when the threat is immediate, and our current mental health system has difficulty addressing the needs of those who are “imminently” dangerous, much less those who are dangerous without a given time frame.  

Notably, this law addresses all patients who convey they are dangerous – either suicidal or homicidal to a mental health professional, not just gun owners. The law does not just pertain to the “mentally ill” – whoever that may mean, given that roughly half of all people will experience an episode of mental illness during their lifetime and psychiatric patients don’t neatly divide into “us” and “them” categories.  People see therapists and talk about suicide, and even homicide, for reasons that don’t originate in a psychiatric disorder.  The hope might be that more funds will be funneled into both the administrative tangle of following up on all those who are identified as dangerous, reclaiming their guns, and overseeing the gun storage methods of their family members and roommates.  And then, we’d certainly want increased funding to allow for treatment of those identified as dangerous, but it remains to be seen if such funding will follow these measures, especially in times when psychiatric hospitals are closing, medical reimbursements are decreasing, paperwork burdens are shifting doctor time away from patient care, and psychiatric services are difficult to access.  

This legislation was inspired by the tragic Newtown massacre, yet we’ve seen nothing in the media that indicates the shooter would have fallen into a category that would have brought him to the attention of authorities, even if such laws had been in place. We’ve heard he had an autism spectrum illness, but there have been no reports that he’d been violent or ever told a mental health professional that he was planning a school shooting.

The most concerning issue with such legislation, however, is that it sets in motion a barrier to getting help for those who most need it. Who would willingly seek treatment, tell their clinician their dark thoughts, knowing such thoughts will be reported to an agent of the state, one who then decides (based on what?) whether he or she should be reported to the legal authorities? Certainly no gun owner, and certainly no troubled law enforcement officer. This legislation appears to require that those who voluntarily seek treatment because they are suicidal must be reported. It’s an interesting quandary, since insurers often permit hospital admission only if a patient is imminently dangerous, meaning this could possibly extend to nearly all persons admitted to  psychiatric units.  Perhaps they just won’t seek help. 

And for someone who is delusional,  this may be one more reason not to trust psychiatrists and not to get treatment. The New York SAFE Act may well have the unintended consequence of increasing suicide rates and violence, and there is no doubt that other states will follow suit with similar legislation if we don’t reconsider the quick response of New York state.

While other laws have overridden doctor-patient confidentiality – for example, requirements to report sexually transmitted diseases and abuse of vulnerable populations – those laws address illnesses and acts that have already happened.  These laws require clinicians to report their suspicions and beliefs about a patient’s intentions, and they set the stage to require state-mandated reporting of any number of fantasies told to a therapist. Violent ideas are very common, and mental health professionals are not particularly good at predicting who will act on them. What else might we extend reporting requirements to include?  The sexual activities of patients with HIV?  The financial behaviors of those running Ponzi schemes?

Is this really what we want? Interestingly, in New York, you can still tell your internist or dermatologist that you’re feeling suicidal, and that doesn’t need to be reported to the state.
       
—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011)

This week, the state of New York passed the Secure Ammunition and Firearms Enforcement (SAFE) Act of 2013 in response to the December shooting at Sandy Hook Elementary School in Newtown, Conn. This act, which was promptly signed into law by Gov. Andrew M. Cuomo, is one of the earliest legislative responses to this incident but it surely won’t be the last. Many people are scrutinizing it in anticipation of their own pending legislation.

I’ve heard a lot of discussion among my colleagues about what a law like this might mean for clinical practice, so I thought I would review it for myself. I’m not an attorney, and I’m sure some nuances of the law may eventually be addressed through the court system, but here are my initial impressions.

First, many of the provisions seem pretty reasonable: a limit on who can purchase weapons, or a revocation of licensure, for anyone convicted of certain violent offenses or for anyone against whom a protective order was granted. Some of the listed crimes, such as stalking and violation of a protective order, seem particularly geared toward domestic violence offenders.

In what I suspect will be a plus for abuse victims, the law now requires protective order respondents to surrender their weapons and the judge granting the order to revoke the firearm license of the respondent. Although laws vary between states, some states currently don’t grant police the authority to confiscate the weapons of domestic violence offenders pending a conviction. I think limiting access to weapons in a household with this level of conflict is probably a good thing. It also might save a few people from getting shot at the door of the courthouse following a custody hearing.

Consistent with other states, New York now will revoke the license of anyone placed under guardianship due to psychiatric or developmental disability, as well as for anyone civilly or criminally committed to a psychiatric hospital. What was unclear to me was the mechanism by which the authorities would ensure that the weapon(s) were in fact removed, but maybe those are details that remain to be worked out.

The aspect of the law that has drawn the most attention from my psychiatric colleagues, as well as from the media and the general public, is the requirement that mental health practitioners report suspected dangerous patients to authorities. This raised an obvious degree of alarm along with attendant fears of further stigmatization of psychiatric patients.

Here’s what Mental Health Law 9.46 actually says:

   “Notwithstanding any other law to  the  contrary,  when  a  mental
   health  professional  currently providing treatment services to a person
   determines, in the exercise of reasonable  professional  judgment,  that
   such person is likely to engage in conduct that would result in serious
   harm to self or others, he or she shall be required to report,  as  soon
   as practicable, to the director of community services, or the director’s
   designee, who shall report to the division of criminal justice services
   whenever he or she agrees that the person is likely to  engage  in  such
   conduct.” (emphasis added)

OK, there's a little more nuance to this than what has been reported in the traditional media. The clinician is not required to report patients directly to the police, and in spite of the apparent mandatory language might not be required to report to the firearms regulators at all. The “mandatory report” must be to the clinician’s director, who then reviews the case and determines, using reasonable professional judgment, whether the risk is sufficient to warrant a revocation of a licensed firearm. The language of the immunity clause additionally supports this permissive interpretation:

   “The decision of a mental health professional to disclose or not to
   disclose in accordance with this section, when made reasonably and in
   good faith, shall not be the basis for any civil or criminal liability
   of such mental health professional.” (emphasis added)

In either case, the law is clear that the only information to be disclosed is non-clinical, identity-based information. The agency receiving the information is required to destroy it after 5 years, or upon restoration of legal gun ownership rights. This is not a label that will be placed upon someone forever. Before I read the law I shared the concerns of my colleagues that this would lead to a tremendous expansion of a Tarasoff duty, but it appears that it stayed more true to the original New York Tarasoff law than I expected. The New York medical confidentiality laws permit disclosure of patient information to the police when the danger is “serious and imminent,” but does not mandate disclosure.

The SAFE Act may actually be more protective of patient confidentiality in that it specifically limits disclosure to non-clinical information. The Tarasoff law has no such limitation.

Finally, one aspect of the law might be more problematic for clinicians but has been given no media attention. The SAFE Act requires the Office of Mental Health to develop an administrative process by which a gun owner can have his or her rights restored. The standard of review is that the individual “will not be likely to act in a manner dangerous to public safety and where the granting of the relief would not be contrary to public safety.” I’m sure there will be a few vigorous debates and sleepless nights over the determination of exactly what “not likely” means and how someone will prove that he or she is really safe. Assessment of competency to own and use a weapon is one thing I was not taught in residency.

The act also extends the current assisted outpatient treatment law, closes some loopholes in the law, and adds additional steps to identify eligible patients, but the specifics of this are beyond the scope of this column. The act modifies nine previously existing laws and these complicated pieces of legislation sometimes result in unanticipated contradictions that will get litigated over time. Until then, I think clinicians have some breathing room to know the law might not be as onerous as was first reported.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

This week, the state of New York passed the Secure Ammunition and Firearms Enforcement (SAFE) Act of 2013 in response to the December shooting at Sandy Hook Elementary School in Newtown, Conn. This act, which was promptly signed into law by Gov. Andrew M. Cuomo, is one of the earliest legislative responses to this incident but it surely won’t be the last. Many people are scrutinizing it in anticipation of their own pending legislation.

I’ve heard a lot of discussion among my colleagues about what a law like this might mean for clinical practice, so I thought I would review it for myself. I’m not an attorney, and I’m sure some nuances of the law may eventually be addressed through the court system, but here are my initial impressions.

First, many of the provisions seem pretty reasonable: a limit on who can purchase weapons, or a revocation of licensure, for anyone convicted of certain violent offenses or for anyone against whom a protective order was granted. Some of the listed crimes, such as stalking and violation of a protective order, seem particularly geared toward domestic violence offenders.

In what I suspect will be a plus for abuse victims, the law now requires protective order respondents to surrender their weapons and the judge granting the order to revoke the firearm license of the respondent. Although laws vary between states, some states currently don’t grant police the authority to confiscate the weapons of domestic violence offenders pending a conviction. I think limiting access to weapons in a household with this level of conflict is probably a good thing. It also might save a few people from getting shot at the door of the courthouse following a custody hearing.

Consistent with other states, New York now will revoke the license of anyone placed under guardianship due to psychiatric or developmental disability, as well as for anyone civilly or criminally committed to a psychiatric hospital. What was unclear to me was the mechanism by which the authorities would ensure that the weapon(s) were in fact removed, but maybe those are details that remain to be worked out.

The aspect of the law that has drawn the most attention from my psychiatric colleagues, as well as from the media and the general public, is the requirement that mental health practitioners report suspected dangerous patients to authorities. This raised an obvious degree of alarm along with attendant fears of further stigmatization of psychiatric patients.

Here’s what Mental Health Law 9.46 actually says:

   “Notwithstanding any other law to  the  contrary,  when  a  mental
   health  professional  currently providing treatment services to a person
   determines, in the exercise of reasonable  professional  judgment,  that
   such person is likely to engage in conduct that would result in serious
   harm to self or others, he or she shall be required to report,  as  soon
   as practicable, to the director of community services, or the director’s
   designee, who shall report to the division of criminal justice services
   whenever he or she agrees that the person is likely to  engage  in  such
   conduct.” (emphasis added)

OK, there's a little more nuance to this than what has been reported in the traditional media. The clinician is not required to report patients directly to the police, and in spite of the apparent mandatory language might not be required to report to the firearms regulators at all. The “mandatory report” must be to the clinician’s director, who then reviews the case and determines, using reasonable professional judgment, whether the risk is sufficient to warrant a revocation of a licensed firearm. The language of the immunity clause additionally supports this permissive interpretation:

   “The decision of a mental health professional to disclose or not to
   disclose in accordance with this section, when made reasonably and in
   good faith, shall not be the basis for any civil or criminal liability
   of such mental health professional.” (emphasis added)

In either case, the law is clear that the only information to be disclosed is non-clinical, identity-based information. The agency receiving the information is required to destroy it after 5 years, or upon restoration of legal gun ownership rights. This is not a label that will be placed upon someone forever. Before I read the law I shared the concerns of my colleagues that this would lead to a tremendous expansion of a Tarasoff duty, but it appears that it stayed more true to the original New York Tarasoff law than I expected. The New York medical confidentiality laws permit disclosure of patient information to the police when the danger is “serious and imminent,” but does not mandate disclosure.

The SAFE Act may actually be more protective of patient confidentiality in that it specifically limits disclosure to non-clinical information. The Tarasoff law has no such limitation.

Finally, one aspect of the law might be more problematic for clinicians but has been given no media attention. The SAFE Act requires the Office of Mental Health to develop an administrative process by which a gun owner can have his or her rights restored. The standard of review is that the individual “will not be likely to act in a manner dangerous to public safety and where the granting of the relief would not be contrary to public safety.” I’m sure there will be a few vigorous debates and sleepless nights over the determination of exactly what “not likely” means and how someone will prove that he or she is really safe. Assessment of competency to own and use a weapon is one thing I was not taught in residency.

The act also extends the current assisted outpatient treatment law, closes some loopholes in the law, and adds additional steps to identify eligible patients, but the specifics of this are beyond the scope of this column. The act modifies nine previously existing laws and these complicated pieces of legislation sometimes result in unanticipated contradictions that will get litigated over time. Until then, I think clinicians have some breathing room to know the law might not be as onerous as was first reported.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

This week, the state of New York passed the Secure Ammunition and Firearms Enforcement (SAFE) Act of 2013 in response to the December shooting at Sandy Hook Elementary School in Newtown, Conn. This act, which was promptly signed into law by Gov. Andrew M. Cuomo, is one of the earliest legislative responses to this incident but it surely won’t be the last. Many people are scrutinizing it in anticipation of their own pending legislation.

I’ve heard a lot of discussion among my colleagues about what a law like this might mean for clinical practice, so I thought I would review it for myself. I’m not an attorney, and I’m sure some nuances of the law may eventually be addressed through the court system, but here are my initial impressions.

First, many of the provisions seem pretty reasonable: a limit on who can purchase weapons, or a revocation of licensure, for anyone convicted of certain violent offenses or for anyone against whom a protective order was granted. Some of the listed crimes, such as stalking and violation of a protective order, seem particularly geared toward domestic violence offenders.

In what I suspect will be a plus for abuse victims, the law now requires protective order respondents to surrender their weapons and the judge granting the order to revoke the firearm license of the respondent. Although laws vary between states, some states currently don’t grant police the authority to confiscate the weapons of domestic violence offenders pending a conviction. I think limiting access to weapons in a household with this level of conflict is probably a good thing. It also might save a few people from getting shot at the door of the courthouse following a custody hearing.

Consistent with other states, New York now will revoke the license of anyone placed under guardianship due to psychiatric or developmental disability, as well as for anyone civilly or criminally committed to a psychiatric hospital. What was unclear to me was the mechanism by which the authorities would ensure that the weapon(s) were in fact removed, but maybe those are details that remain to be worked out.

The aspect of the law that has drawn the most attention from my psychiatric colleagues, as well as from the media and the general public, is the requirement that mental health practitioners report suspected dangerous patients to authorities. This raised an obvious degree of alarm along with attendant fears of further stigmatization of psychiatric patients.

Here’s what Mental Health Law 9.46 actually says:

   “Notwithstanding any other law to  the  contrary,  when  a  mental
   health  professional  currently providing treatment services to a person
   determines, in the exercise of reasonable  professional  judgment,  that
   such person is likely to engage in conduct that would result in serious
   harm to self or others, he or she shall be required to report,  as  soon
   as practicable, to the director of community services, or the director’s
   designee, who shall report to the division of criminal justice services
   whenever he or she agrees that the person is likely to  engage  in  such
   conduct.” (emphasis added)

OK, there's a little more nuance to this than what has been reported in the traditional media. The clinician is not required to report patients directly to the police, and in spite of the apparent mandatory language might not be required to report to the firearms regulators at all. The “mandatory report” must be to the clinician’s director, who then reviews the case and determines, using reasonable professional judgment, whether the risk is sufficient to warrant a revocation of a licensed firearm. The language of the immunity clause additionally supports this permissive interpretation:

   “The decision of a mental health professional to disclose or not to
   disclose in accordance with this section, when made reasonably and in
   good faith, shall not be the basis for any civil or criminal liability
   of such mental health professional.” (emphasis added)

In either case, the law is clear that the only information to be disclosed is non-clinical, identity-based information. The agency receiving the information is required to destroy it after 5 years, or upon restoration of legal gun ownership rights. This is not a label that will be placed upon someone forever. Before I read the law I shared the concerns of my colleagues that this would lead to a tremendous expansion of a Tarasoff duty, but it appears that it stayed more true to the original New York Tarasoff law than I expected. The New York medical confidentiality laws permit disclosure of patient information to the police when the danger is “serious and imminent,” but does not mandate disclosure.

The SAFE Act may actually be more protective of patient confidentiality in that it specifically limits disclosure to non-clinical information. The Tarasoff law has no such limitation.

Finally, one aspect of the law might be more problematic for clinicians but has been given no media attention. The SAFE Act requires the Office of Mental Health to develop an administrative process by which a gun owner can have his or her rights restored. The standard of review is that the individual “will not be likely to act in a manner dangerous to public safety and where the granting of the relief would not be contrary to public safety.” I’m sure there will be a few vigorous debates and sleepless nights over the determination of exactly what “not likely” means and how someone will prove that he or she is really safe. Assessment of competency to own and use a weapon is one thing I was not taught in residency.

The act also extends the current assisted outpatient treatment law, closes some loopholes in the law, and adds additional steps to identify eligible patients, but the specifics of this are beyond the scope of this column. The act modifies nine previously existing laws and these complicated pieces of legislation sometimes result in unanticipated contradictions that will get litigated over time. Until then, I think clinicians have some breathing room to know the law might not be as onerous as was first reported.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

For those of you who are not on LinkedIn, I recommend joining if only to be able to participate in the APA members-only group there, which has more than 2,000 APA members in it and has new discussions going on frequently. This column was adapted from a discussion I started over there.

I’ve seen quite a bit of distress about the CPT coding changes, and hearing about long-time APA members talking about dropping out over this. A commenter on Shrink Rap wrote: “I’ve been in APA since residency (20 years), and I feel betrayed. I know things need to change, but this is the most stressed and unsupported I’ve ever felt in my career.”

The anger seems to mostly be about four points:

1. Not enough time to learn and implement the changes;

2. Psychiatrists providing regular psychotherapy will need to charge different amounts (if using insurance) based on what they talk about. [As another commenter noted, “A patient being charged more for (and therefore dissuaded from) sharing serious information”];

3. The valuation of the Psych Eval and Psychotherapy codes without E&M being higher than the codes used with E&M. Nonphysicians getting paid MORE for the same service as higher-trained physicians is not passing the sniff test (90791 vs. 92, 90832 vs. 33);

4. Needing to learn and document using the AMA’s “count up the points” E&M schema is perceived as a lack of support from the APA.

To be clear, I generally support the changes, though some aspects do not make sense. An evaluation with E&M should reimburse more than one without.

If psychotherapy is separate from the E&M component, then it should be paid the same whether an E&M component is used or not. I do understand that the “count up the points” philosophy behind E&M has been part of every other medical provider’s life for more than a decade, so we are simply finally joining the pack (though many of us, including myself, have been using these codes for years).

Insurance companies have gotten away with paying us flat rates for “med management” for years, regardless of how much or little time it takes.

Changing to a tiered pricing level makes total sense and provides better incentives for managing complex conditions. The challenge will be in preventing payers from essentially doing the same thing as before by, for example, requiring prior authorizations for 99213 or higher, or only paying for 99212, or paying the same for either code.

This will require aggressive action on our part (individuals, district branches, APA, AMA) in speaking out when these discriminatory practices occur – and they will – by complaining to the insurance companies’ medical directors, state insurance commissioners, Health & Human Services, Department of Labor, Office of Civil Rights, accrediting bodies (for example, URAC, NCQA), and to the APA so that they can help us track and fight these practices.

Paying psychiatric physicians a different amount from other physicians for the same CPT service code, or applying more stringent conditions for payment, is a violation of the Mental Health Parity Act, plain and simple. It has been going on for years by using codes that ONLY psychiatrists use (for example, 90862, 90807).

Now that we are using some of the same codes as other physicians, this discriminatory reimbursement practice can no longer be ignored. These changes are in many ways a stroke of genius, and the APA and AMA deserve acclaim for their courageous support of professionalism and fairness in the face of members angry about the transitional struggles.

I suspect that it will take a couple years or so for the transition to be complete. It will go faster if we refuse to sign discriminatory contracts that violate the parity law. If we file complaints with state and federal regulatory agencies. If we expose these practices to the light of day. And if we support organizations to fight for us on our behalf.

Health care is changing rapidly, and physicians need to get involved or be marginalized as cogs in the health care machine. I quit the AMA back in the 1990s after I perceived it was not listening to us. I recently rejoined because we need to stick together and help solve the health care challenges our nation faces.

Now is the time to get MORE involved in organized medicine, not less. And hang on for the ride.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmailDOTcom.

For those of you who are not on LinkedIn, I recommend joining if only to be able to participate in the APA members-only group there, which has more than 2,000 APA members in it and has new discussions going on frequently. This column was adapted from a discussion I started over there.

I’ve seen quite a bit of distress about the CPT coding changes, and hearing about long-time APA members talking about dropping out over this. A commenter on Shrink Rap wrote: “I’ve been in APA since residency (20 years), and I feel betrayed. I know things need to change, but this is the most stressed and unsupported I’ve ever felt in my career.”

The anger seems to mostly be about four points:

1. Not enough time to learn and implement the changes;

2. Psychiatrists providing regular psychotherapy will need to charge different amounts (if using insurance) based on what they talk about. [As another commenter noted, “A patient being charged more for (and therefore dissuaded from) sharing serious information”];

3. The valuation of the Psych Eval and Psychotherapy codes without E&M being higher than the codes used with E&M. Nonphysicians getting paid MORE for the same service as higher-trained physicians is not passing the sniff test (90791 vs. 92, 90832 vs. 33);

4. Needing to learn and document using the AMA’s “count up the points” E&M schema is perceived as a lack of support from the APA.

To be clear, I generally support the changes, though some aspects do not make sense. An evaluation with E&M should reimburse more than one without.

If psychotherapy is separate from the E&M component, then it should be paid the same whether an E&M component is used or not. I do understand that the “count up the points” philosophy behind E&M has been part of every other medical provider’s life for more than a decade, so we are simply finally joining the pack (though many of us, including myself, have been using these codes for years).

Insurance companies have gotten away with paying us flat rates for “med management” for years, regardless of how much or little time it takes.

Changing to a tiered pricing level makes total sense and provides better incentives for managing complex conditions. The challenge will be in preventing payers from essentially doing the same thing as before by, for example, requiring prior authorizations for 99213 or higher, or only paying for 99212, or paying the same for either code.

This will require aggressive action on our part (individuals, district branches, APA, AMA) in speaking out when these discriminatory practices occur – and they will – by complaining to the insurance companies’ medical directors, state insurance commissioners, Health & Human Services, Department of Labor, Office of Civil Rights, accrediting bodies (for example, URAC, NCQA), and to the APA so that they can help us track and fight these practices.

Paying psychiatric physicians a different amount from other physicians for the same CPT service code, or applying more stringent conditions for payment, is a violation of the Mental Health Parity Act, plain and simple. It has been going on for years by using codes that ONLY psychiatrists use (for example, 90862, 90807).

Now that we are using some of the same codes as other physicians, this discriminatory reimbursement practice can no longer be ignored. These changes are in many ways a stroke of genius, and the APA and AMA deserve acclaim for their courageous support of professionalism and fairness in the face of members angry about the transitional struggles.

I suspect that it will take a couple years or so for the transition to be complete. It will go faster if we refuse to sign discriminatory contracts that violate the parity law. If we file complaints with state and federal regulatory agencies. If we expose these practices to the light of day. And if we support organizations to fight for us on our behalf.

Health care is changing rapidly, and physicians need to get involved or be marginalized as cogs in the health care machine. I quit the AMA back in the 1990s after I perceived it was not listening to us. I recently rejoined because we need to stick together and help solve the health care challenges our nation faces.

Now is the time to get MORE involved in organized medicine, not less. And hang on for the ride.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmailDOTcom.

For those of you who are not on LinkedIn, I recommend joining if only to be able to participate in the APA members-only group there, which has more than 2,000 APA members in it and has new discussions going on frequently. This column was adapted from a discussion I started over there.

I’ve seen quite a bit of distress about the CPT coding changes, and hearing about long-time APA members talking about dropping out over this. A commenter on Shrink Rap wrote: “I’ve been in APA since residency (20 years), and I feel betrayed. I know things need to change, but this is the most stressed and unsupported I’ve ever felt in my career.”

The anger seems to mostly be about four points:

1. Not enough time to learn and implement the changes;

2. Psychiatrists providing regular psychotherapy will need to charge different amounts (if using insurance) based on what they talk about. [As another commenter noted, “A patient being charged more for (and therefore dissuaded from) sharing serious information”];

3. The valuation of the Psych Eval and Psychotherapy codes without E&M being higher than the codes used with E&M. Nonphysicians getting paid MORE for the same service as higher-trained physicians is not passing the sniff test (90791 vs. 92, 90832 vs. 33);

4. Needing to learn and document using the AMA’s “count up the points” E&M schema is perceived as a lack of support from the APA.

To be clear, I generally support the changes, though some aspects do not make sense. An evaluation with E&M should reimburse more than one without.

If psychotherapy is separate from the E&M component, then it should be paid the same whether an E&M component is used or not. I do understand that the “count up the points” philosophy behind E&M has been part of every other medical provider’s life for more than a decade, so we are simply finally joining the pack (though many of us, including myself, have been using these codes for years).

Insurance companies have gotten away with paying us flat rates for “med management” for years, regardless of how much or little time it takes.

Changing to a tiered pricing level makes total sense and provides better incentives for managing complex conditions. The challenge will be in preventing payers from essentially doing the same thing as before by, for example, requiring prior authorizations for 99213 or higher, or only paying for 99212, or paying the same for either code.

This will require aggressive action on our part (individuals, district branches, APA, AMA) in speaking out when these discriminatory practices occur – and they will – by complaining to the insurance companies’ medical directors, state insurance commissioners, Health & Human Services, Department of Labor, Office of Civil Rights, accrediting bodies (for example, URAC, NCQA), and to the APA so that they can help us track and fight these practices.

Paying psychiatric physicians a different amount from other physicians for the same CPT service code, or applying more stringent conditions for payment, is a violation of the Mental Health Parity Act, plain and simple. It has been going on for years by using codes that ONLY psychiatrists use (for example, 90862, 90807).

Now that we are using some of the same codes as other physicians, this discriminatory reimbursement practice can no longer be ignored. These changes are in many ways a stroke of genius, and the APA and AMA deserve acclaim for their courageous support of professionalism and fairness in the face of members angry about the transitional struggles.

I suspect that it will take a couple years or so for the transition to be complete. It will go faster if we refuse to sign discriminatory contracts that violate the parity law. If we file complaints with state and federal regulatory agencies. If we expose these practices to the light of day. And if we support organizations to fight for us on our behalf.

Health care is changing rapidly, and physicians need to get involved or be marginalized as cogs in the health care machine. I quit the AMA back in the 1990s after I perceived it was not listening to us. I recently rejoined because we need to stick together and help solve the health care challenges our nation faces.

Now is the time to get MORE involved in organized medicine, not less. And hang on for the ride.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmailDOTcom.

Recently, French psychiatrist Daniele Canarelli was convicted of manslaughter for failing to protect the public from a seriously ill patient who went on to kill an elderly man with an ax.

The patient had a history of involuntary admissions for increasingly dangerous behavior, and had eloped from a consultation with Dr. Canarelli 20 days before the offense. Although Dr. Canarelli notified the police about the elopement and the potential risk, the French court criticized the doctor for failing to refer the patient to another medical team and alleged that she was “blind” to the risk he represented.

She was given a 1-year suspended prison sentence and fined 8,500 euros, or about $11,000. The victim’s son was pleased with the outcome and hoped the case would set a precedent. The French state psychiatrist’s union protested the action and called it a “dark day” for clinicians.

Here in the United States, clinicians and patients alike expressed concern that the case would lead to harsher treatment of the mentally ill and an increase in civil commitments. Others felt that the case might lead to a new wave of criminalization of psychiatry similar to laws passed for boundary violations or mandatory reporting of child abuse.

Presently, 39 states have made failure to report child abuse a misdemeanor criminal offense, and many have laws that criminalize sexual contact between patients and therapists. While most states have Tarasoff laws that impose a duty to protect or warn third parties when a patient is dangerous, to date no states have created any criminal penalties for failure to carry out this duty.

The conviction of Michael Jackson’s physician notwithstanding, here in the United States, very few physicians are ever criminally prosecuted for clinical care. This is because the level of culpability, or the required mental state, for a criminal conviction is higher than that required for civil liability. In order to be guilty of criminal negligence, the behavior must show that the defendant deliberately disregarded a significant risk of serious injury to another. Drunk driving is a typical example of criminally negligent behavior, and a drunk driver could be prosecuted if someone dies as a result.

In order for a physician to be guilty of criminal negligence, the doctor must have been aware that a risk of harm existed and have deliberately ignored the risk. Most malpractice claims are based on a lower level of culpability than that and typically do not involve an intent to cause harm. Mere carelessness is not a criminal act.

In America, the distinction between carelessness and intentional harm is maintained by our two separate criminal and civil procedures with their differing levels of proof. A criminal conviction requires proof beyond a reasonable doubt, while civil liability only requires proof by a preponderance of the evidence. This is why O.J. Simpson could be acquitted of murder but found civilly liable for the killing in a separate hearing.

The French legal system co-mingles civil and criminal procedures, and the alleged victim plays a larger role. While the decision to prosecute a case lies with the state’s attorney in America, in France, an alleged victim has the opportunity to appeal a decision not to pursue criminal charges. French criminal procedure is a non-adversarial system in which the judge or magistrate acts as a lead investigator, and both the defense and the prosecution act in support of that role. The goal is to seek the truth, for the benefit of the victim.

French victims also have a higher level involvement in criminal proceedings than American victims. Under the Federal Crime Control Act of 1990, American victims have a right to receive notice of the trial and the trial outcome, and to be present at trial. However, victims cannot call witnesses or compel the production of evidence, and they have no right to testify.

While the facts or the Canarelli case are not publicly known, it’s possible that what started out as a civil matter was later determined by the magistrate to be more serious than that, once the investigation was complete.

As a forensic psychiatrist working in corrections, I have a reason to be concerned about new liability risks related to dangerous patients. However, I do not see the Canarelli case as a cause for alarm.

DR. ANNETTE HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, French psychiatrist Daniele Canarelli was convicted of manslaughter for failing to protect the public from a seriously ill patient who went on to kill an elderly man with an ax.

The patient had a history of involuntary admissions for increasingly dangerous behavior, and had eloped from a consultation with Dr. Canarelli 20 days before the offense. Although Dr. Canarelli notified the police about the elopement and the potential risk, the French court criticized the doctor for failing to refer the patient to another medical team and alleged that she was “blind” to the risk he represented.

She was given a 1-year suspended prison sentence and fined 8,500 euros, or about $11,000. The victim’s son was pleased with the outcome and hoped the case would set a precedent. The French state psychiatrist’s union protested the action and called it a “dark day” for clinicians.

Here in the United States, clinicians and patients alike expressed concern that the case would lead to harsher treatment of the mentally ill and an increase in civil commitments. Others felt that the case might lead to a new wave of criminalization of psychiatry similar to laws passed for boundary violations or mandatory reporting of child abuse.

Presently, 39 states have made failure to report child abuse a misdemeanor criminal offense, and many have laws that criminalize sexual contact between patients and therapists. While most states have Tarasoff laws that impose a duty to protect or warn third parties when a patient is dangerous, to date no states have created any criminal penalties for failure to carry out this duty.

The conviction of Michael Jackson’s physician notwithstanding, here in the United States, very few physicians are ever criminally prosecuted for clinical care. This is because the level of culpability, or the required mental state, for a criminal conviction is higher than that required for civil liability. In order to be guilty of criminal negligence, the behavior must show that the defendant deliberately disregarded a significant risk of serious injury to another. Drunk driving is a typical example of criminally negligent behavior, and a drunk driver could be prosecuted if someone dies as a result.

In order for a physician to be guilty of criminal negligence, the doctor must have been aware that a risk of harm existed and have deliberately ignored the risk. Most malpractice claims are based on a lower level of culpability than that and typically do not involve an intent to cause harm. Mere carelessness is not a criminal act.

In America, the distinction between carelessness and intentional harm is maintained by our two separate criminal and civil procedures with their differing levels of proof. A criminal conviction requires proof beyond a reasonable doubt, while civil liability only requires proof by a preponderance of the evidence. This is why O.J. Simpson could be acquitted of murder but found civilly liable for the killing in a separate hearing.

The French legal system co-mingles civil and criminal procedures, and the alleged victim plays a larger role. While the decision to prosecute a case lies with the state’s attorney in America, in France, an alleged victim has the opportunity to appeal a decision not to pursue criminal charges. French criminal procedure is a non-adversarial system in which the judge or magistrate acts as a lead investigator, and both the defense and the prosecution act in support of that role. The goal is to seek the truth, for the benefit of the victim.

French victims also have a higher level involvement in criminal proceedings than American victims. Under the Federal Crime Control Act of 1990, American victims have a right to receive notice of the trial and the trial outcome, and to be present at trial. However, victims cannot call witnesses or compel the production of evidence, and they have no right to testify.

While the facts or the Canarelli case are not publicly known, it’s possible that what started out as a civil matter was later determined by the magistrate to be more serious than that, once the investigation was complete.

As a forensic psychiatrist working in corrections, I have a reason to be concerned about new liability risks related to dangerous patients. However, I do not see the Canarelli case as a cause for alarm.

DR. ANNETTE HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, French psychiatrist Daniele Canarelli was convicted of manslaughter for failing to protect the public from a seriously ill patient who went on to kill an elderly man with an ax.

The patient had a history of involuntary admissions for increasingly dangerous behavior, and had eloped from a consultation with Dr. Canarelli 20 days before the offense. Although Dr. Canarelli notified the police about the elopement and the potential risk, the French court criticized the doctor for failing to refer the patient to another medical team and alleged that she was “blind” to the risk he represented.

She was given a 1-year suspended prison sentence and fined 8,500 euros, or about $11,000. The victim’s son was pleased with the outcome and hoped the case would set a precedent. The French state psychiatrist’s union protested the action and called it a “dark day” for clinicians.

Here in the United States, clinicians and patients alike expressed concern that the case would lead to harsher treatment of the mentally ill and an increase in civil commitments. Others felt that the case might lead to a new wave of criminalization of psychiatry similar to laws passed for boundary violations or mandatory reporting of child abuse.

Presently, 39 states have made failure to report child abuse a misdemeanor criminal offense, and many have laws that criminalize sexual contact between patients and therapists. While most states have Tarasoff laws that impose a duty to protect or warn third parties when a patient is dangerous, to date no states have created any criminal penalties for failure to carry out this duty.

The conviction of Michael Jackson’s physician notwithstanding, here in the United States, very few physicians are ever criminally prosecuted for clinical care. This is because the level of culpability, or the required mental state, for a criminal conviction is higher than that required for civil liability. In order to be guilty of criminal negligence, the behavior must show that the defendant deliberately disregarded a significant risk of serious injury to another. Drunk driving is a typical example of criminally negligent behavior, and a drunk driver could be prosecuted if someone dies as a result.

In order for a physician to be guilty of criminal negligence, the doctor must have been aware that a risk of harm existed and have deliberately ignored the risk. Most malpractice claims are based on a lower level of culpability than that and typically do not involve an intent to cause harm. Mere carelessness is not a criminal act.

In America, the distinction between carelessness and intentional harm is maintained by our two separate criminal and civil procedures with their differing levels of proof. A criminal conviction requires proof beyond a reasonable doubt, while civil liability only requires proof by a preponderance of the evidence. This is why O.J. Simpson could be acquitted of murder but found civilly liable for the killing in a separate hearing.

The French legal system co-mingles civil and criminal procedures, and the alleged victim plays a larger role. While the decision to prosecute a case lies with the state’s attorney in America, in France, an alleged victim has the opportunity to appeal a decision not to pursue criminal charges. French criminal procedure is a non-adversarial system in which the judge or magistrate acts as a lead investigator, and both the defense and the prosecution act in support of that role. The goal is to seek the truth, for the benefit of the victim.

French victims also have a higher level involvement in criminal proceedings than American victims. Under the Federal Crime Control Act of 1990, American victims have a right to receive notice of the trial and the trial outcome, and to be present at trial. However, victims cannot call witnesses or compel the production of evidence, and they have no right to testify.

While the facts or the Canarelli case are not publicly known, it’s possible that what started out as a civil matter was later determined by the magistrate to be more serious than that, once the investigation was complete.

As a forensic psychiatrist working in corrections, I have a reason to be concerned about new liability risks related to dangerous patients. However, I do not see the Canarelli case as a cause for alarm.

DR. ANNETTE HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

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.

Every year, my hospital requires me to complete training in the management of patient aggression. This is particularly good training to have for anyone working with forensic patients. Sometimes, I have to work with patients who are dangerous or angry for a variety of reasons, and frontline staff like nurses, nursing aides, and security attendants are particularly at risk for patient assault.

The training covers topics like basic self-defense techniques, “take-down” and escort procedures, and both individual and environmental causes of patient violence. Of course, the most important teaching point is that communication skills and verbal de-escalation are the most crucial tools in the violence prevention toolbox.

I had an opportunity to appreciate these skills recently when a local “citizen journalist” and blogger was involved in a prolonged standoff with police. He was wanted for a violation of probation and for failure to appear in court. Several hours before the warrant was served, he tweeted that he was a “bad bad” and “dangerous” man, and he put up a blog post suggesting that his life would be short and that he would “die free.” Unknown to police, there was also a weapon with ammunition in the home.

What made this situation unusual was the fact that the blogger in question had his own Internet-based radio show, a large Twitter following and a chat room hosted on his website. When police arrived to serve the warrant, he refused to come out of the house, and the standoff began. The blogger recorded his conversation with the police negotiator and broadcast it in real time through the Internet. The conversation lasted close to 2 1/2 hours, and drew listeners from around the world. At one point as many as 8000 people listened, and many more joined in through Twitter and the chat room. I was able to follow this conversation and the public response to it.

While both the negotiator and the defendant had clear moments of tension and frustration, I was impressed overall by the level of calm rationality demonstrated on both sides. Here are a few de-escalation teaching points I came away with: The defendant was preoccupied with past grievances and injustices involving the police. He felt unfairly targeted, and thought the presence of the SWAT team was excessive and unnecessary. He had many complaints about the local police department’s response to crime in general and his past experience in the local detention center.

The negotiator allowed him time to list and discuss past events in detail, and expressed appreciation for this information. He frequently emphasized the need to resolve the standoff in order to move beyond the past. This emphasis upon the future implicitly suggested that recovery was possible and that the situation was not a catastrophe.

In addition, the negotiator admitted any problems with miscommunication or misunderstanding and gave the defendant an opportunity to clarify his statements. He encouraged the defendant to continue the conversation and didn’t press for early resolution. He emphasized points of agreement, particularly the fact that neither side wanted a bad outcome. He recognized and specifically commented on the defendant’s skills, strengths, and experience. He used humor judiciously, and overlooked insults and degrading comments.

Public comment throughout the standoff showed the effectiveness of these interventions. Early in the standoff, there was general sentiment that the defendant was being treated unfairly or disproportionately, but as time passed this opinion changed. Tweeters questioned his motives for prolonging the standoff, suggested that he was grandstanding to build his following and also questioned his judgment. A few directly called on the defendant to come out and give himself up, which he did eventually.

Shortly before coming out the defendant himself complimented the negotiator, and they were able to share a brief joke. When the defendant said he was going to “wrap this (broadcast) up in time for the networks” the negotiator lent a hand by adding, “To our listeners … thank you for listening.”

This event illustrates that although health care professionals and police obviously have different roles, priorities, and duties, safety is a priority for both, and there are skills we can learn from each other.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Every year, my hospital requires me to complete training in the management of patient aggression. This is particularly good training to have for anyone working with forensic patients. Sometimes, I have to work with patients who are dangerous or angry for a variety of reasons, and frontline staff like nurses, nursing aides, and security attendants are particularly at risk for patient assault.

The training covers topics like basic self-defense techniques, “take-down” and escort procedures, and both individual and environmental causes of patient violence. Of course, the most important teaching point is that communication skills and verbal de-escalation are the most crucial tools in the violence prevention toolbox.

I had an opportunity to appreciate these skills recently when a local “citizen journalist” and blogger was involved in a prolonged standoff with police. He was wanted for a violation of probation and for failure to appear in court. Several hours before the warrant was served, he tweeted that he was a “bad bad” and “dangerous” man, and he put up a blog post suggesting that his life would be short and that he would “die free.” Unknown to police, there was also a weapon with ammunition in the home.

What made this situation unusual was the fact that the blogger in question had his own Internet-based radio show, a large Twitter following and a chat room hosted on his website. When police arrived to serve the warrant, he refused to come out of the house, and the standoff began. The blogger recorded his conversation with the police negotiator and broadcast it in real time through the Internet. The conversation lasted close to 2 1/2 hours, and drew listeners from around the world. At one point as many as 8000 people listened, and many more joined in through Twitter and the chat room. I was able to follow this conversation and the public response to it.

While both the negotiator and the defendant had clear moments of tension and frustration, I was impressed overall by the level of calm rationality demonstrated on both sides. Here are a few de-escalation teaching points I came away with: The defendant was preoccupied with past grievances and injustices involving the police. He felt unfairly targeted, and thought the presence of the SWAT team was excessive and unnecessary. He had many complaints about the local police department’s response to crime in general and his past experience in the local detention center.

The negotiator allowed him time to list and discuss past events in detail, and expressed appreciation for this information. He frequently emphasized the need to resolve the standoff in order to move beyond the past. This emphasis upon the future implicitly suggested that recovery was possible and that the situation was not a catastrophe.

In addition, the negotiator admitted any problems with miscommunication or misunderstanding and gave the defendant an opportunity to clarify his statements. He encouraged the defendant to continue the conversation and didn’t press for early resolution. He emphasized points of agreement, particularly the fact that neither side wanted a bad outcome. He recognized and specifically commented on the defendant’s skills, strengths, and experience. He used humor judiciously, and overlooked insults and degrading comments.

Public comment throughout the standoff showed the effectiveness of these interventions. Early in the standoff, there was general sentiment that the defendant was being treated unfairly or disproportionately, but as time passed this opinion changed. Tweeters questioned his motives for prolonging the standoff, suggested that he was grandstanding to build his following and also questioned his judgment. A few directly called on the defendant to come out and give himself up, which he did eventually.

Shortly before coming out the defendant himself complimented the negotiator, and they were able to share a brief joke. When the defendant said he was going to “wrap this (broadcast) up in time for the networks” the negotiator lent a hand by adding, “To our listeners … thank you for listening.”

This event illustrates that although health care professionals and police obviously have different roles, priorities, and duties, safety is a priority for both, and there are skills we can learn from each other.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Every year, my hospital requires me to complete training in the management of patient aggression. This is particularly good training to have for anyone working with forensic patients. Sometimes, I have to work with patients who are dangerous or angry for a variety of reasons, and frontline staff like nurses, nursing aides, and security attendants are particularly at risk for patient assault.

The training covers topics like basic self-defense techniques, “take-down” and escort procedures, and both individual and environmental causes of patient violence. Of course, the most important teaching point is that communication skills and verbal de-escalation are the most crucial tools in the violence prevention toolbox.

I had an opportunity to appreciate these skills recently when a local “citizen journalist” and blogger was involved in a prolonged standoff with police. He was wanted for a violation of probation and for failure to appear in court. Several hours before the warrant was served, he tweeted that he was a “bad bad” and “dangerous” man, and he put up a blog post suggesting that his life would be short and that he would “die free.” Unknown to police, there was also a weapon with ammunition in the home.

What made this situation unusual was the fact that the blogger in question had his own Internet-based radio show, a large Twitter following and a chat room hosted on his website. When police arrived to serve the warrant, he refused to come out of the house, and the standoff began. The blogger recorded his conversation with the police negotiator and broadcast it in real time through the Internet. The conversation lasted close to 2 1/2 hours, and drew listeners from around the world. At one point as many as 8000 people listened, and many more joined in through Twitter and the chat room. I was able to follow this conversation and the public response to it.

While both the negotiator and the defendant had clear moments of tension and frustration, I was impressed overall by the level of calm rationality demonstrated on both sides. Here are a few de-escalation teaching points I came away with: The defendant was preoccupied with past grievances and injustices involving the police. He felt unfairly targeted, and thought the presence of the SWAT team was excessive and unnecessary. He had many complaints about the local police department’s response to crime in general and his past experience in the local detention center.

The negotiator allowed him time to list and discuss past events in detail, and expressed appreciation for this information. He frequently emphasized the need to resolve the standoff in order to move beyond the past. This emphasis upon the future implicitly suggested that recovery was possible and that the situation was not a catastrophe.

In addition, the negotiator admitted any problems with miscommunication or misunderstanding and gave the defendant an opportunity to clarify his statements. He encouraged the defendant to continue the conversation and didn’t press for early resolution. He emphasized points of agreement, particularly the fact that neither side wanted a bad outcome. He recognized and specifically commented on the defendant’s skills, strengths, and experience. He used humor judiciously, and overlooked insults and degrading comments.

Public comment throughout the standoff showed the effectiveness of these interventions. Early in the standoff, there was general sentiment that the defendant was being treated unfairly or disproportionately, but as time passed this opinion changed. Tweeters questioned his motives for prolonging the standoff, suggested that he was grandstanding to build his following and also questioned his judgment. A few directly called on the defendant to come out and give himself up, which he did eventually.

Shortly before coming out the defendant himself complimented the negotiator, and they were able to share a brief joke. When the defendant said he was going to “wrap this (broadcast) up in time for the networks” the negotiator lent a hand by adding, “To our listeners … thank you for listening.”

This event illustrates that although health care professionals and police obviously have different roles, priorities, and duties, safety is a priority for both, and there are skills we can learn from each other.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In case you missed the big news, last weekend, the American Psychiatric Association’s Board of Trustees voted on and approved the final diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual, or DSM-5, paving the way for publication next year.

I know, you are shocked. The DSM-5 has been 14 years in the making, with more than 1,500 expert reviewers, multiple committees, work groups, meetings, revisions, and $25 million spent when all is said and done. So, there was little surprise when the board met on Dec. 1 and made the final approvals for publication in May 2013. I am on the APA Assembly, which is its deliberative body. We met in November to vote affirmatively on the recommendations of the Assembly DSM-5 Task Force to approve the new manual to date. At that time, most of the criteria sets had been finalized.

The scientific reviews began in 1999 across 13 NIH-supported conferences, followed by a prelude to the DSM-5 website in 2004 for additional input and development. Specific work groups began meeting 5 years ago for more focused reviews, and in 2010 the first draft was publicly released, with two subsequent revisions leading up to the present. In addition to the extensive scientific review, there were reviews based on effects on clinical practice, public health, and forensics.

I won’t provide an exhaustive review of the DSM-5 changes; you will get plenty of these in the months leading up to the May publication date. I will share the aspects that stand out for me so far.

First, you will notice that the multi-axial system is going away. No more dividing things up into Axis I (mental illness), Axis II (personality and developmental), Axis III (“medical”), Axis IV (essentially social problems), and Axis V (global assessment of functioning or GAF). This system was the embodiment of the “biopsychosocial” formulation.

In today’s era of integration of psychiatry into mainstream medicine and attempts to destigmatize, it makes sense to me to include mental illnesses among all the other conditions a person might have rather than setting them off in their own special section. I found the GAF to not be very useful, as it had turned into an unreliable metric for many reasons.

The number of diagnoses will remain about the same, but some of the names, organization, and criteria will have been revised based on the latest research and conceptualizations. Newly distilled diagnoses include autism spectrum disorder, binge eating disorder, hoarding disorder, and skin-picking disorder. The dementia diagnoses have been reworked.

The old diagnoses of substance abuse and substance dependence were restructured and combined into substance use disorder. I found that differentiation between abuse and dependence was not terribly useful, and that these things existed along a spectrum that changes over time for each specific person.

The new, broader diagnosis emphasizes impairment combined with elements of abuse, including overuse, trouble quitting, craving, negative consequences, dangerous use, tolerance, and withdrawal. A modifier can indicate whether physiological dependence is present. Severity modifiers based on number of symptoms have replaced the less useful prior modifiers of episodic and continuous.

Disruptive mood dysregulation disorder has simultaneously been criticized as pathologizing temper tantrums in kids and lauded as a mechanism to reduce the growing percentage of kids with a bipolar diagnosis. The criteria do specify that the outbursts must be inconsistent with developmental level, so that should mute the above criticism, although it will be helpful to know what are the levels of “severe recurrent temper outbursts” that are consistent with a given developmental level. This is probably a bell-shaped curve so an agreed-upon cut point will be required.

There have some changes to the mood disorders. Dysthymia has been renamed persistent depressive disorder. Major depression has some notable changes.  Separate diagnoses of Single episode and Recurrent have been reduced to modifiers, while a new modifier of Persistent (greater than 2 years) was added. Another modifier, “with anxious distress,” was added to help identify comorbid anxiety symptoms, rather than create a separate diagnosis called “anxious depression,” which was considered but rejected.

Previously, there was a brighter line between depressive symptoms accountable to loss-related grief versus major depression, whereas now it is left more to clinical judgment. A very useful footnote goes into detail about how to think this through.

There has been some controversy regarding the interrater reliability of diagnosing major depression. The field trials for this diagnosis showed a much lower level of agreement when two clinicians examine the same person. This was brought up as one of the main points of contention during the Assembly discussion. My impression is that this diagnosis has become used with less attention to the criteria over the years, with this effect spilling over into the field trial results. But I’d like to hear what the depression experts have to say about this problem.

Overall, the DSM-5 has been long-awaited and will be out in a few months. Instead of having such long periods between DSM revisions, we will see shorter periods with bite-size revisions, for example, DSM-5.1, 5.2, 5.3, etc. This will make it more of a living document that can change more frequently based on new research and conceptualizations.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmail.com.

In case you missed the big news, last weekend, the American Psychiatric Association’s Board of Trustees voted on and approved the final diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual, or DSM-5, paving the way for publication next year.

I know, you are shocked. The DSM-5 has been 14 years in the making, with more than 1,500 expert reviewers, multiple committees, work groups, meetings, revisions, and $25 million spent when all is said and done. So, there was little surprise when the board met on Dec. 1 and made the final approvals for publication in May 2013. I am on the APA Assembly, which is its deliberative body. We met in November to vote affirmatively on the recommendations of the Assembly DSM-5 Task Force to approve the new manual to date. At that time, most of the criteria sets had been finalized.

The scientific reviews began in 1999 across 13 NIH-supported conferences, followed by a prelude to the DSM-5 website in 2004 for additional input and development. Specific work groups began meeting 5 years ago for more focused reviews, and in 2010 the first draft was publicly released, with two subsequent revisions leading up to the present. In addition to the extensive scientific review, there were reviews based on effects on clinical practice, public health, and forensics.

I won’t provide an exhaustive review of the DSM-5 changes; you will get plenty of these in the months leading up to the May publication date. I will share the aspects that stand out for me so far.

First, you will notice that the multi-axial system is going away. No more dividing things up into Axis I (mental illness), Axis II (personality and developmental), Axis III (“medical”), Axis IV (essentially social problems), and Axis V (global assessment of functioning or GAF). This system was the embodiment of the “biopsychosocial” formulation.

In today’s era of integration of psychiatry into mainstream medicine and attempts to destigmatize, it makes sense to me to include mental illnesses among all the other conditions a person might have rather than setting them off in their own special section. I found the GAF to not be very useful, as it had turned into an unreliable metric for many reasons.

The number of diagnoses will remain about the same, but some of the names, organization, and criteria will have been revised based on the latest research and conceptualizations. Newly distilled diagnoses include autism spectrum disorder, binge eating disorder, hoarding disorder, and skin-picking disorder. The dementia diagnoses have been reworked.

The old diagnoses of substance abuse and substance dependence were restructured and combined into substance use disorder. I found that differentiation between abuse and dependence was not terribly useful, and that these things existed along a spectrum that changes over time for each specific person.

The new, broader diagnosis emphasizes impairment combined with elements of abuse, including overuse, trouble quitting, craving, negative consequences, dangerous use, tolerance, and withdrawal. A modifier can indicate whether physiological dependence is present. Severity modifiers based on number of symptoms have replaced the less useful prior modifiers of episodic and continuous.

Disruptive mood dysregulation disorder has simultaneously been criticized as pathologizing temper tantrums in kids and lauded as a mechanism to reduce the growing percentage of kids with a bipolar diagnosis. The criteria do specify that the outbursts must be inconsistent with developmental level, so that should mute the above criticism, although it will be helpful to know what are the levels of “severe recurrent temper outbursts” that are consistent with a given developmental level. This is probably a bell-shaped curve so an agreed-upon cut point will be required.

There have some changes to the mood disorders. Dysthymia has been renamed persistent depressive disorder. Major depression has some notable changes.  Separate diagnoses of Single episode and Recurrent have been reduced to modifiers, while a new modifier of Persistent (greater than 2 years) was added. Another modifier, “with anxious distress,” was added to help identify comorbid anxiety symptoms, rather than create a separate diagnosis called “anxious depression,” which was considered but rejected.

Previously, there was a brighter line between depressive symptoms accountable to loss-related grief versus major depression, whereas now it is left more to clinical judgment. A very useful footnote goes into detail about how to think this through.

There has been some controversy regarding the interrater reliability of diagnosing major depression. The field trials for this diagnosis showed a much lower level of agreement when two clinicians examine the same person. This was brought up as one of the main points of contention during the Assembly discussion. My impression is that this diagnosis has become used with less attention to the criteria over the years, with this effect spilling over into the field trial results. But I’d like to hear what the depression experts have to say about this problem.

Overall, the DSM-5 has been long-awaited and will be out in a few months. Instead of having such long periods between DSM revisions, we will see shorter periods with bite-size revisions, for example, DSM-5.1, 5.2, 5.3, etc. This will make it more of a living document that can change more frequently based on new research and conceptualizations.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmail.com.

In case you missed the big news, last weekend, the American Psychiatric Association’s Board of Trustees voted on and approved the final diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual, or DSM-5, paving the way for publication next year.

I know, you are shocked. The DSM-5 has been 14 years in the making, with more than 1,500 expert reviewers, multiple committees, work groups, meetings, revisions, and $25 million spent when all is said and done. So, there was little surprise when the board met on Dec. 1 and made the final approvals for publication in May 2013. I am on the APA Assembly, which is its deliberative body. We met in November to vote affirmatively on the recommendations of the Assembly DSM-5 Task Force to approve the new manual to date. At that time, most of the criteria sets had been finalized.

The scientific reviews began in 1999 across 13 NIH-supported conferences, followed by a prelude to the DSM-5 website in 2004 for additional input and development. Specific work groups began meeting 5 years ago for more focused reviews, and in 2010 the first draft was publicly released, with two subsequent revisions leading up to the present. In addition to the extensive scientific review, there were reviews based on effects on clinical practice, public health, and forensics.

I won’t provide an exhaustive review of the DSM-5 changes; you will get plenty of these in the months leading up to the May publication date. I will share the aspects that stand out for me so far.

First, you will notice that the multi-axial system is going away. No more dividing things up into Axis I (mental illness), Axis II (personality and developmental), Axis III (“medical”), Axis IV (essentially social problems), and Axis V (global assessment of functioning or GAF). This system was the embodiment of the “biopsychosocial” formulation.

In today’s era of integration of psychiatry into mainstream medicine and attempts to destigmatize, it makes sense to me to include mental illnesses among all the other conditions a person might have rather than setting them off in their own special section. I found the GAF to not be very useful, as it had turned into an unreliable metric for many reasons.

The number of diagnoses will remain about the same, but some of the names, organization, and criteria will have been revised based on the latest research and conceptualizations. Newly distilled diagnoses include autism spectrum disorder, binge eating disorder, hoarding disorder, and skin-picking disorder. The dementia diagnoses have been reworked.

The old diagnoses of substance abuse and substance dependence were restructured and combined into substance use disorder. I found that differentiation between abuse and dependence was not terribly useful, and that these things existed along a spectrum that changes over time for each specific person.

The new, broader diagnosis emphasizes impairment combined with elements of abuse, including overuse, trouble quitting, craving, negative consequences, dangerous use, tolerance, and withdrawal. A modifier can indicate whether physiological dependence is present. Severity modifiers based on number of symptoms have replaced the less useful prior modifiers of episodic and continuous.

Disruptive mood dysregulation disorder has simultaneously been criticized as pathologizing temper tantrums in kids and lauded as a mechanism to reduce the growing percentage of kids with a bipolar diagnosis. The criteria do specify that the outbursts must be inconsistent with developmental level, so that should mute the above criticism, although it will be helpful to know what are the levels of “severe recurrent temper outbursts” that are consistent with a given developmental level. This is probably a bell-shaped curve so an agreed-upon cut point will be required.

There have some changes to the mood disorders. Dysthymia has been renamed persistent depressive disorder. Major depression has some notable changes.  Separate diagnoses of Single episode and Recurrent have been reduced to modifiers, while a new modifier of Persistent (greater than 2 years) was added. Another modifier, “with anxious distress,” was added to help identify comorbid anxiety symptoms, rather than create a separate diagnosis called “anxious depression,” which was considered but rejected.

Previously, there was a brighter line between depressive symptoms accountable to loss-related grief versus major depression, whereas now it is left more to clinical judgment. A very useful footnote goes into detail about how to think this through.

There has been some controversy regarding the interrater reliability of diagnosing major depression. The field trials for this diagnosis showed a much lower level of agreement when two clinicians examine the same person. This was brought up as one of the main points of contention during the Assembly discussion. My impression is that this diagnosis has become used with less attention to the criteria over the years, with this effect spilling over into the field trial results. But I’d like to hear what the depression experts have to say about this problem.

Overall, the DSM-5 has been long-awaited and will be out in a few months. Instead of having such long periods between DSM revisions, we will see shorter periods with bite-size revisions, for example, DSM-5.1, 5.2, 5.3, etc. This will make it more of a living document that can change more frequently based on new research and conceptualizations.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmail.com.

Warning: tongue-in-cheek alert 

The executive director of our district branch sent out an email: New CPT Codes are Coming. Read more on the APA’s website! At first I ignored it – after all, coding is boring. Eventually, though, I clicked through to the APA’s website, and in order to read the information, I had to log in. Log in? I didn’t remember my APA username or password and I went to click on “Forgot your username?” and was told I needed to call the APA. Call? Like on a telephone? Here was the first sign that this was not going to be a smooth process.

I found my log in details, and I didn’t have to call. A good omen, I decided, and I proceeded to read through the APA slide show about the new CPT codes.  90801, soon gone, would now be 90792. I assumed that as a physician, I should use the code that included “with medical services,” whatever that might mean. Since I only bill 90801, 90805, and 90807 in my private practice, this wasn’t looking so bad; in a manner of minutes, I had figured out one-third of my coding issues. I work at a clinic where my services are billed as 90862 for pharmacologic management, but I figured they would tell me what code to use for the soon-to-be defunct 90862.

It was downhill from there. I flipped through the slides quickly and realized that there was one set of psychotherapy codes if there were no medications involved, another if medications are involved, and I now had to learn to use the five levels of complexity for the dreaded Evaluation and Management (E/M) codes that I have successfully avoided for years. One appointment, two codes with many possible variations, more documentation, and the slides didn’t tell me exactly how to use the E/M codes. I Googled and Googled, and nothing got better. And then I decided that someday I would figure this out and be the one to write about it. That day has not yet come, and if you’re reading to find out how to use the new CPT codes, you can stop now and come back in a few weeks.
I called the man I think of as the “CPT god,” Dr. Chester W. Schmidt, or more officially, the Consultant to the Committee on Codes and Reimbursements. “The AMA CPT editorial panel insisted there be revisions because of the need to differentiate medical-psychiatric services from nonmedical psychological services,” Dr. Schmidt noted. “We jumped on the opportunity to revise the psychiatry codes to give our practitioners the opportunity to more flexibly capture the work we do and to improve reimbursement.” 

Dr. Schmidt suggested I buy a manual on how to use E/M codes and noted, “There probably is not a way to make learning this easy.” The truth be told, I want a way for this to be easy.
 

From there, I went to Amazon.com to look for an Evaluation and Management manual. I figured I would buy a Kindle version so that I could read it on my computer and on my phone. Funny, but in a world where physicians are being told we must embrace e-prescribing and electronic medical records, Amazon does not sell a kindle version of the AMA’s CPT manual for 2013. For the moment, I decided to hold off on buying this 600-page volume. It’s single Amazon reviewer noted that it was printed on paper “comparable to Russian toilet paper” and something about this imagine was not appealing.

My fellow Shrink Rapper, Steve Daviss, knows more about CPT codes than I do. He sent an e-mail saying, “For E&M, ‘counseling’ is not psychotherapy, it is essentially education, telling them about med effects and side effects, educating about sleep hygiene, about diagnosis, about treatment options, stuff like that. Coordination would be things like calling the therapist, writing a letter to the PCP, getting a prior authorization for a med, arranging for admission.”

It was early on a Saturday morning, I had not yet had a single drop of coffee, and I e-mailed back a caustic response about how counseling and education get peppered throughout a psychotherapy session; one would have to sit with a stopwatch to account for how many minutes of each type of communication there are, and that this would be distracting to the process of patient care. It would require different fees for every session, which the patient would not know in advance, and I ended my rant by saying that perhaps I would opt out of Medicare and by the time I finished, I’d threatened to quit my clinic job and announced I’d be forced into commit billing fraud. 

It wasn’t until my private response to Steve came back to my own e-mail in-box that I realized our conversation was not private, but that I had posted my temper tantrum to the 190 psychiatrists on our psychiatric society’s listserv. It’s just not the best way to start a weekend.  

The Maryland Psychiatric Society will be holding seminars to teach the new codes, and perhaps after that first session on Dec. 4, I will have something more helpful to say. As I was lamenting the fact that it would take me 2.5 hours to learn to code a psychotherapy session, a Facebook post came in from a colleague in another state where the training session took 6 hours.   

I’ll be sharing the rest of my quest to understand the new CPT codes here and on our main Shrink Rap blog. Please do subscribe to my Twitter feed and if I can, I will live tweet the Dec. 4 session, scheduled for 6 p.m., using hashtag #cpt.  If you’d like to register for one of the Maryland Psychiatric Society’s five CPT coding seminars, you can contact the staff at [email protected] or 410-625-0232.  

—Dinah Miller, M.D.

DR. MILLER is co-author of Shrink Rap: Three Psychiatrists Explain Their Work.  She is prone to occasional ranting.

Reply Reply to all Forward

Warning: tongue-in-cheek alert 

The executive director of our district branch sent out an email: New CPT Codes are Coming. Read more on the APA’s website! At first I ignored it – after all, coding is boring. Eventually, though, I clicked through to the APA’s website, and in order to read the information, I had to log in. Log in? I didn’t remember my APA username or password and I went to click on “Forgot your username?” and was told I needed to call the APA. Call? Like on a telephone? Here was the first sign that this was not going to be a smooth process.

I found my log in details, and I didn’t have to call. A good omen, I decided, and I proceeded to read through the APA slide show about the new CPT codes.  90801, soon gone, would now be 90792. I assumed that as a physician, I should use the code that included “with medical services,” whatever that might mean. Since I only bill 90801, 90805, and 90807 in my private practice, this wasn’t looking so bad; in a manner of minutes, I had figured out one-third of my coding issues. I work at a clinic where my services are billed as 90862 for pharmacologic management, but I figured they would tell me what code to use for the soon-to-be defunct 90862.

It was downhill from there. I flipped through the slides quickly and realized that there was one set of psychotherapy codes if there were no medications involved, another if medications are involved, and I now had to learn to use the five levels of complexity for the dreaded Evaluation and Management (E/M) codes that I have successfully avoided for years. One appointment, two codes with many possible variations, more documentation, and the slides didn’t tell me exactly how to use the E/M codes. I Googled and Googled, and nothing got better. And then I decided that someday I would figure this out and be the one to write about it. That day has not yet come, and if you’re reading to find out how to use the new CPT codes, you can stop now and come back in a few weeks.
I called the man I think of as the “CPT god,” Dr. Chester W. Schmidt, or more officially, the Consultant to the Committee on Codes and Reimbursements. “The AMA CPT editorial panel insisted there be revisions because of the need to differentiate medical-psychiatric services from nonmedical psychological services,” Dr. Schmidt noted. “We jumped on the opportunity to revise the psychiatry codes to give our practitioners the opportunity to more flexibly capture the work we do and to improve reimbursement.” 

Dr. Schmidt suggested I buy a manual on how to use E/M codes and noted, “There probably is not a way to make learning this easy.” The truth be told, I want a way for this to be easy.
 

From there, I went to Amazon.com to look for an Evaluation and Management manual. I figured I would buy a Kindle version so that I could read it on my computer and on my phone. Funny, but in a world where physicians are being told we must embrace e-prescribing and electronic medical records, Amazon does not sell a kindle version of the AMA’s CPT manual for 2013. For the moment, I decided to hold off on buying this 600-page volume. It’s single Amazon reviewer noted that it was printed on paper “comparable to Russian toilet paper” and something about this imagine was not appealing.

My fellow Shrink Rapper, Steve Daviss, knows more about CPT codes than I do. He sent an e-mail saying, “For E&M, ‘counseling’ is not psychotherapy, it is essentially education, telling them about med effects and side effects, educating about sleep hygiene, about diagnosis, about treatment options, stuff like that. Coordination would be things like calling the therapist, writing a letter to the PCP, getting a prior authorization for a med, arranging for admission.”

It was early on a Saturday morning, I had not yet had a single drop of coffee, and I e-mailed back a caustic response about how counseling and education get peppered throughout a psychotherapy session; one would have to sit with a stopwatch to account for how many minutes of each type of communication there are, and that this would be distracting to the process of patient care. It would require different fees for every session, which the patient would not know in advance, and I ended my rant by saying that perhaps I would opt out of Medicare and by the time I finished, I’d threatened to quit my clinic job and announced I’d be forced into commit billing fraud. 

It wasn’t until my private response to Steve came back to my own e-mail in-box that I realized our conversation was not private, but that I had posted my temper tantrum to the 190 psychiatrists on our psychiatric society’s listserv. It’s just not the best way to start a weekend.  

The Maryland Psychiatric Society will be holding seminars to teach the new codes, and perhaps after that first session on Dec. 4, I will have something more helpful to say. As I was lamenting the fact that it would take me 2.5 hours to learn to code a psychotherapy session, a Facebook post came in from a colleague in another state where the training session took 6 hours.   

I’ll be sharing the rest of my quest to understand the new CPT codes here and on our main Shrink Rap blog. Please do subscribe to my Twitter feed and if I can, I will live tweet the Dec. 4 session, scheduled for 6 p.m., using hashtag #cpt.  If you’d like to register for one of the Maryland Psychiatric Society’s five CPT coding seminars, you can contact the staff at [email protected] or 410-625-0232.  

—Dinah Miller, M.D.

DR. MILLER is co-author of Shrink Rap: Three Psychiatrists Explain Their Work.  She is prone to occasional ranting.

Reply Reply to all Forward

Warning: tongue-in-cheek alert 

The executive director of our district branch sent out an email: New CPT Codes are Coming. Read more on the APA’s website! At first I ignored it – after all, coding is boring. Eventually, though, I clicked through to the APA’s website, and in order to read the information, I had to log in. Log in? I didn’t remember my APA username or password and I went to click on “Forgot your username?” and was told I needed to call the APA. Call? Like on a telephone? Here was the first sign that this was not going to be a smooth process.

I found my log in details, and I didn’t have to call. A good omen, I decided, and I proceeded to read through the APA slide show about the new CPT codes.  90801, soon gone, would now be 90792. I assumed that as a physician, I should use the code that included “with medical services,” whatever that might mean. Since I only bill 90801, 90805, and 90807 in my private practice, this wasn’t looking so bad; in a manner of minutes, I had figured out one-third of my coding issues. I work at a clinic where my services are billed as 90862 for pharmacologic management, but I figured they would tell me what code to use for the soon-to-be defunct 90862.

It was downhill from there. I flipped through the slides quickly and realized that there was one set of psychotherapy codes if there were no medications involved, another if medications are involved, and I now had to learn to use the five levels of complexity for the dreaded Evaluation and Management (E/M) codes that I have successfully avoided for years. One appointment, two codes with many possible variations, more documentation, and the slides didn’t tell me exactly how to use the E/M codes. I Googled and Googled, and nothing got better. And then I decided that someday I would figure this out and be the one to write about it. That day has not yet come, and if you’re reading to find out how to use the new CPT codes, you can stop now and come back in a few weeks.
I called the man I think of as the “CPT god,” Dr. Chester W. Schmidt, or more officially, the Consultant to the Committee on Codes and Reimbursements. “The AMA CPT editorial panel insisted there be revisions because of the need to differentiate medical-psychiatric services from nonmedical psychological services,” Dr. Schmidt noted. “We jumped on the opportunity to revise the psychiatry codes to give our practitioners the opportunity to more flexibly capture the work we do and to improve reimbursement.” 

Dr. Schmidt suggested I buy a manual on how to use E/M codes and noted, “There probably is not a way to make learning this easy.” The truth be told, I want a way for this to be easy.
 

From there, I went to Amazon.com to look for an Evaluation and Management manual. I figured I would buy a Kindle version so that I could read it on my computer and on my phone. Funny, but in a world where physicians are being told we must embrace e-prescribing and electronic medical records, Amazon does not sell a kindle version of the AMA’s CPT manual for 2013. For the moment, I decided to hold off on buying this 600-page volume. It’s single Amazon reviewer noted that it was printed on paper “comparable to Russian toilet paper” and something about this imagine was not appealing.

My fellow Shrink Rapper, Steve Daviss, knows more about CPT codes than I do. He sent an e-mail saying, “For E&M, ‘counseling’ is not psychotherapy, it is essentially education, telling them about med effects and side effects, educating about sleep hygiene, about diagnosis, about treatment options, stuff like that. Coordination would be things like calling the therapist, writing a letter to the PCP, getting a prior authorization for a med, arranging for admission.”

It was early on a Saturday morning, I had not yet had a single drop of coffee, and I e-mailed back a caustic response about how counseling and education get peppered throughout a psychotherapy session; one would have to sit with a stopwatch to account for how many minutes of each type of communication there are, and that this would be distracting to the process of patient care. It would require different fees for every session, which the patient would not know in advance, and I ended my rant by saying that perhaps I would opt out of Medicare and by the time I finished, I’d threatened to quit my clinic job and announced I’d be forced into commit billing fraud. 

It wasn’t until my private response to Steve came back to my own e-mail in-box that I realized our conversation was not private, but that I had posted my temper tantrum to the 190 psychiatrists on our psychiatric society’s listserv. It’s just not the best way to start a weekend.  

The Maryland Psychiatric Society will be holding seminars to teach the new codes, and perhaps after that first session on Dec. 4, I will have something more helpful to say. As I was lamenting the fact that it would take me 2.5 hours to learn to code a psychotherapy session, a Facebook post came in from a colleague in another state where the training session took 6 hours.   

I’ll be sharing the rest of my quest to understand the new CPT codes here and on our main Shrink Rap blog. Please do subscribe to my Twitter feed and if I can, I will live tweet the Dec. 4 session, scheduled for 6 p.m., using hashtag #cpt.  If you’d like to register for one of the Maryland Psychiatric Society’s five CPT coding seminars, you can contact the staff at [email protected] or 410-625-0232.  

—Dinah Miller, M.D.

DR. MILLER is co-author of Shrink Rap: Three Psychiatrists Explain Their Work.  She is prone to occasional ranting.

Reply Reply to all Forward

I have a lot of experience helping people deal with loss. In my prison clinic, many of my patients have experienced unimaginable losses. They’ve witnessed the murder of friends, the suicide of family members, been burned in house fires, or witnessed horrible crimes. They’ve lost homes, jobs, and spouses in addition to freedom.

I know what to say to them; it’s somewhat practiced by now, but it seems to help. I remind them what they haven’t lost: that last friend, the supportive ex-girlfriend, the young child in foster care. I advise them to stay in the present instead of dwelling on the worst conceivable future. I encourage them to take pride in their past accomplishments, even if those accomplishments seem small or insignificant to others. I tell them they will find a new purpose for their lives and a reason why events happened as they did.

Disaster and loss, trauma and recovery, are always easier to manage when it happens to someone else. When it hits closer to home, it can be a challenge to take your own advice.

I found myself thinking about this in late October as I attended the American Academy of Psychiatry and Law conference. This conference is notorious for bad weather stories; survivors of the infamous Denver conference remember the 3-foot snowstorm that shut down the airport and kept us stranded until the hotel ran out of food.

This year’s conference was no exception, and I stayed glued to weather forecasts as Hurricane Sandy crept up the East Coast. I was relieved that, contrary to my usual luck, my presentation was not the last session of the last conference day. I had a reasonable chance of leaving early if it was necessary.

I was impressed by the size of the storm, by the predictions of doom and disaster. I tracked the NOAA coastal flood advisories and fiddled with the online flood model of New York to see how bad things could get. I attended luncheon talks with my colleagues from New York, all the while thinking that the storm probably wouldn’t be as bad as the news was saying.

I was so wrong. Watching news stories about the evacuation of NYU Langone Medical Center and Bellevue Hospital, I thought about the people I knew there and the patients they were moving. I saw the devastation on Staten Island and heard stories of lives lost there. Suddenly, my prison advice seemed cliché and trite.

There is no easy way to salvage the remains of a past life. One can pick through the wreckage, create a monument to lost memories, or let go of the remnants determined to rebuild in new and better ways. There is no right way to deal with it, no better way, only ways that are less painful than others. The only certainty is that life will not be the same. As psychiatrists, the best we can do is instill faith in recovery.

I think the poet Elizabeth Bishop said it best in her poem, One Art:

The art of losing isn’t hard to master;
so many things seem filled with the intent
to be lost that their loss is no disaster.

Lose something every day. Accept the fluster
of lost door keys, the hour badly spent.
The art of losing isn’t hard to master.

Then practice losing farther, losing faster:
places, and names, and where it was you meant
to travel. None of these will bring disaster.

I lost my mother’s watch. And look! my last, or
next-to-last, of three loved houses went.
The art of losing isn’t hard to master.

I lost two cities, lovely ones. And, vaster,
some realms I owned, two rivers, a continent.
I miss them, but it wasn’t a disaster.

—Even losing you (the joking voice, a gesture
I love) I shan’t have lied. It’s evident
the art of losing’s not too hard to master
though it may look like (Write it!) like disaster.

DR. ANNETTE HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychi­atrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, in­cluding the Maryland Department of Health and Mental Hygiene or the Mary­land Division of Correction.

I have a lot of experience helping people deal with loss. In my prison clinic, many of my patients have experienced unimaginable losses. They’ve witnessed the murder of friends, the suicide of family members, been burned in house fires, or witnessed horrible crimes. They’ve lost homes, jobs, and spouses in addition to freedom.

I know what to say to them; it’s somewhat practiced by now, but it seems to help. I remind them what they haven’t lost: that last friend, the supportive ex-girlfriend, the young child in foster care. I advise them to stay in the present instead of dwelling on the worst conceivable future. I encourage them to take pride in their past accomplishments, even if those accomplishments seem small or insignificant to others. I tell them they will find a new purpose for their lives and a reason why events happened as they did.

Disaster and loss, trauma and recovery, are always easier to manage when it happens to someone else. When it hits closer to home, it can be a challenge to take your own advice.

I found myself thinking about this in late October as I attended the American Academy of Psychiatry and Law conference. This conference is notorious for bad weather stories; survivors of the infamous Denver conference remember the 3-foot snowstorm that shut down the airport and kept us stranded until the hotel ran out of food.

This year’s conference was no exception, and I stayed glued to weather forecasts as Hurricane Sandy crept up the East Coast. I was relieved that, contrary to my usual luck, my presentation was not the last session of the last conference day. I had a reasonable chance of leaving early if it was necessary.

I was impressed by the size of the storm, by the predictions of doom and disaster. I tracked the NOAA coastal flood advisories and fiddled with the online flood model of New York to see how bad things could get. I attended luncheon talks with my colleagues from New York, all the while thinking that the storm probably wouldn’t be as bad as the news was saying.

I was so wrong. Watching news stories about the evacuation of NYU Langone Medical Center and Bellevue Hospital, I thought about the people I knew there and the patients they were moving. I saw the devastation on Staten Island and heard stories of lives lost there. Suddenly, my prison advice seemed cliché and trite.

There is no easy way to salvage the remains of a past life. One can pick through the wreckage, create a monument to lost memories, or let go of the remnants determined to rebuild in new and better ways. There is no right way to deal with it, no better way, only ways that are less painful than others. The only certainty is that life will not be the same. As psychiatrists, the best we can do is instill faith in recovery.

I think the poet Elizabeth Bishop said it best in her poem, One Art:

The art of losing isn’t hard to master;
so many things seem filled with the intent
to be lost that their loss is no disaster.

Lose something every day. Accept the fluster
of lost door keys, the hour badly spent.
The art of losing isn’t hard to master.

Then practice losing farther, losing faster:
places, and names, and where it was you meant
to travel. None of these will bring disaster.

I lost my mother’s watch. And look! my last, or
next-to-last, of three loved houses went.
The art of losing isn’t hard to master.

I lost two cities, lovely ones. And, vaster,
some realms I owned, two rivers, a continent.
I miss them, but it wasn’t a disaster.

—Even losing you (the joking voice, a gesture
I love) I shan’t have lied. It’s evident
the art of losing’s not too hard to master
though it may look like (Write it!) like disaster.

DR. ANNETTE HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychi­atrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, in­cluding the Maryland Department of Health and Mental Hygiene or the Mary­land Division of Correction.

I have a lot of experience helping people deal with loss. In my prison clinic, many of my patients have experienced unimaginable losses. They’ve witnessed the murder of friends, the suicide of family members, been burned in house fires, or witnessed horrible crimes. They’ve lost homes, jobs, and spouses in addition to freedom.

I know what to say to them; it’s somewhat practiced by now, but it seems to help. I remind them what they haven’t lost: that last friend, the supportive ex-girlfriend, the young child in foster care. I advise them to stay in the present instead of dwelling on the worst conceivable future. I encourage them to take pride in their past accomplishments, even if those accomplishments seem small or insignificant to others. I tell them they will find a new purpose for their lives and a reason why events happened as they did.

Disaster and loss, trauma and recovery, are always easier to manage when it happens to someone else. When it hits closer to home, it can be a challenge to take your own advice.

I found myself thinking about this in late October as I attended the American Academy of Psychiatry and Law conference. This conference is notorious for bad weather stories; survivors of the infamous Denver conference remember the 3-foot snowstorm that shut down the airport and kept us stranded until the hotel ran out of food.

This year’s conference was no exception, and I stayed glued to weather forecasts as Hurricane Sandy crept up the East Coast. I was relieved that, contrary to my usual luck, my presentation was not the last session of the last conference day. I had a reasonable chance of leaving early if it was necessary.

I was impressed by the size of the storm, by the predictions of doom and disaster. I tracked the NOAA coastal flood advisories and fiddled with the online flood model of New York to see how bad things could get. I attended luncheon talks with my colleagues from New York, all the while thinking that the storm probably wouldn’t be as bad as the news was saying.

I was so wrong. Watching news stories about the evacuation of NYU Langone Medical Center and Bellevue Hospital, I thought about the people I knew there and the patients they were moving. I saw the devastation on Staten Island and heard stories of lives lost there. Suddenly, my prison advice seemed cliché and trite.

There is no easy way to salvage the remains of a past life. One can pick through the wreckage, create a monument to lost memories, or let go of the remnants determined to rebuild in new and better ways. There is no right way to deal with it, no better way, only ways that are less painful than others. The only certainty is that life will not be the same. As psychiatrists, the best we can do is instill faith in recovery.

I think the poet Elizabeth Bishop said it best in her poem, One Art:

The art of losing isn’t hard to master;
so many things seem filled with the intent
to be lost that their loss is no disaster.

Lose something every day. Accept the fluster
of lost door keys, the hour badly spent.
The art of losing isn’t hard to master.

Then practice losing farther, losing faster:
places, and names, and where it was you meant
to travel. None of these will bring disaster.

I lost my mother’s watch. And look! my last, or
next-to-last, of three loved houses went.
The art of losing isn’t hard to master.

I lost two cities, lovely ones. And, vaster,
some realms I owned, two rivers, a continent.
I miss them, but it wasn’t a disaster.

—Even losing you (the joking voice, a gesture
I love) I shan’t have lied. It’s evident
the art of losing’s not too hard to master
though it may look like (Write it!) like disaster.

DR. ANNETTE HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychi­atrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, in­cluding the Maryland Department of Health and Mental Hygiene or the Mary­land Division of Correction.