Wednesday, September 02, 2009

Diagnostic Stability

I have a question: How do people put down diagnosis on insurance forms over time?
Okay, it's easy to start-- a patient walks in with Major Depression, recurrent, moderate in severity. 296.32
The patient takes medications and gets better. No more symptoms. They come once a month. Let's say they come for a 50 minute session once a month because....
But they aren't coming in and spending 50 minutes talking about their symptoms. They aren't having any. Maybe they spend 5 minutes talking about medication-related issues...needing refills, lab work, side effects. And then, they spend 45 minutes talking about the events and activities in their life and their relationships with others. Maybe one of those relationships is having some difficulty and this is what they spend the bulk of the session talking about.
So what's the code? Does it still code as a 296.32 (this is what they sought help for) or does it now go on the wonderful form as Major Depression, in remission. Oh, but they're only in remission because they are on meds.
And the next visit, the primary topic is a panic attack. But they don't have enough symptoms or enough frequency of panic attacks to actually meet criteria for panic disorder. Or maybe they do. Do you change the diagnosis to panic disorder, or do you leave it 296.32?
The following visit, what do you know, the patient is feeling a little depressed. Does the diagnosis change to major depression, mild?

And what about coding those sessions? If the patient doesn't talk about symptoms or medications, is it coded as a psychotherapy session (90806) or as a psychotherapy session with medication management (90807)? I always code a 90807 on the theory that I'm a doctor, and at some level, I always consider from what I hear whether the medications are working...enough, not enough, what ever. If someone's on medicine, there's no way I can know before they walk through the door whats med management and what's therapy. I know one psychiatrist who said he codes therapy sessions as 90806 (no med management and it's often reimbursed to the patient at a lower rate)....I wondered, if the patient walks in and wants their medications changed, does he tell them they have to come back for a different visit? Or does he wait to see how the session goes and then decide what to code (and what to charge?)

There are things they don't ever teach us in a formal way. And there's not a great way to ask (ah, who do you ask?)- I thought I'd ask you!