The quest for CPT understanding, continued

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.