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.