The quest for CPT understanding, continued

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.