Tuesday, January 29, 2013

How's It Going: The New CPT Codes for Psychiatry for 2013


So our psychiatric society now has a separate listserv just for CPT code issues (not my idea) and the CPT posts on both listservs are flying in.  What codes to use, what codes insurers are denying, what rates insurers are paying.  I'm not sure anything has caused such confusion and angst in recent years.

How's it going for you?

My CPT YouTube Tutorials are still up if you'd like to watch, but with so much speculation going on among the professionals, I don't think anyone has any idea what we are supposed to be doing.  

For one patient back in December, I requested pre-authorization for psychotherapy with med management (the old 90807), I was sent authorization to see the patient for 20 visits for 99211 -- 5 minute visits (and they said that).  I re-submitted a Uniform Treatment Plan asking for authorization for more reasonable codes, but just the idea!  

So it's been just about a month: If you're a patient, are you getting reimbursed?  If you're a shrink: are you getting paid?  I'll ask again in a few weeks, but I'm assuming I'll be filling out many repeat statements for patients to submit.

Tell me your stories!

37 comments:

Anonymous said...

Gauche and boring. Figure this stuff out for yourself and then actually do something of importance for your patients. Why not tell me how much money was streaming into your wallet before and then after the new codes? That would be even more boring and stupid and trite. Say something of interest, please. Not just how much or little insurance companies are paying you. But maybe that is your sole obsession?

HarrietMD said...

Dinah,
Would it be possible for outsiders to have access to the list serves you are referring to. The only one I belong to is mostly non-physicians, and they have had little interest in CPT issues at all.
I haven't billed for January yet because I am confused/upset/oppositional.
Thanks,
BTW, to the anonymous posting, for many psychiatrists these CPT coding changes are not about making more or less money; they are about whether or not we are going to be able to continue to practice psychiatry in a way that we feel is ethical and in which we can have genuine relationships with our patients. Many of us believe that our professional organizations, along with the health insurance companies that so notoriously discriminate against and fraudulently take advantage of psychiatric patients, have rigged a new system so that we will not be able to do of anything except administer medicines that make pharmaceutical companies rich. If that is the function of psychiatric care, you don't need psychiatrists and pretty soon you are not going to have any.

Dinah said...

Anon (aka Lester?):
I absolutely agree with you on all fronts, this is gauche and boring. And every conversation I have had with other psychiatrists for weeks now (maybe 2 months) has included at least a glancing reference to this. I feel like our heads have been hijacked, the essence of these new codes includes separating what portion of the session is "psychotherapy" from what is "evaluation and management" and counseling is not therapy. It's an impossible task, and suddenly I find myself thinking about what I'm supposed to be coding, and what is happening in the sessions in this weird way, and the demand that we document X number of factors and review of X number of symptoms. And will we do it right and will we be audited and accused of fraud, and even if we do it right, will the patient get reimbursed or will the insurance company simply say they aren't paying for those codes. And I get paid by the patient, so it's not my money, it's the patient's and one option is just to code very low so little documentation is required, and the patient just won't be reimbursed well. I wish I could go back to having my undivided attention on the patient's problems. Now if I'm thinking this is complicated, and I should bill a higher code so patient gets reimbursed more, I'm thinking about how exam points I've done, when the patient said they were more depressed, did I remember to document for how long and what the mitigating factors were? And suddenly it's like we're being told that these are the things that make us good doctors: weighing the patient, taking their blood pressure, reviewing their medical issues (good, I know all your bowel habits but you're seeing your GI doctor for your Crohn's disease tomorrow) and most of my patients are hooked up with good medical care, they don't need me as their primary or gatekeeper or referral service (which is good because I'm terrible at all of them).

And yes, for those who participate with insurance, it's about the money, one wrote in today her care was reimbursed at $57 for an hour of work (for Harriet: 99213, +90836), and if you're making $9 an hour, I truly understand why you would have no sympathy for this.

I am sorry to hijack the blog with this gauche topic (and I agree it's totally gauche), but it is what's on every shrink's mind (except ClinkShrink) these days, it's causing a lot of paperwork, anxiety, uncertainty, and angst, and it's absolutely detracting from psychiatric care.

I have been working hard to get it into a system where it just is, I don't worry about it, and I don't resort to sitting in front of a screen while I'm with patients (as many of my colleagues have suggested) or using checkbox forms for notes which leave me unable to follow my own work for later clinical use, spending time asking questions that are irrelevant to the patient.

Bear with us, it's a process, and it will get done. And this is my blog, and this is what's on my mind, even if you don't approve.

Harriet, the listservs are for state members. If NYSPA doesn't have one, please start one for them!!!

Laura1019 said...

Hi Dinah,

I am also anxious to hear how it is going for others with all the changes. I haven't received any EOB's yet for January, so I'm still waiting to see how it is going to be. I did call several times in December to ask one of the insurance companies if they could tell me anything about how best to proceed, but I never received any calls back. When I decided at the end of December to go off the panel and called to accomplish that, I did get a confirmation only after I called again, and as of yesterday my patients have started telling me they have received a letter from this insurance company that I will be off panel by a certain date.
I have no idea so far if I'm coding correctly or not. I do know I'm spending quite a lot more time, obsessively writing up the documentation, and struggling not to let that stuff intrude in my thoughts while I'm in the sessions with patients.
I felt pretty offended by Anonymous's comments, and if I could take the making a living part out of the equation, that would make me very happy.

Laura said...

Still too early to see how insurance companies are reimbursing on the patient end. January billing is not out (unless you are perhaps only utilizing med. management and pay on a per-visit basis (as opposed to monthly?) and there's usually a lag time of about (minimum) 2 weeks before the claims are processed and checks sent back out.

Also, many (most?) insurances with deductibles start over on the calendar year, further complicating things.

Joel Hassman, MD said...

I don't see the issue as a hijack, I see it as probably the final straw in how insurers will enforce psychiatry as a bare bones meds only practice.

WHEN colleagues start getting audited, probably not until next year, and auditors find true fraudulent claims and then try to generalize that psychiatry as a whole is dishonest, then the excrement hits the fan and watch non psychiatrists be made primary psychotropic providers for all.

PPACA, otherwise known as Obamacare, (and I hate that latter term as it just keeps Obama front and center for the legislation) will be the demise of psychiatry. You as providers just do not want to see the future.

What is most disturbing is we get to be slammed twice by watching the Governor of this state think he can emulate the current occupant of the White House to think he will become President in 2016. Wow, this legislative onslaught being entertained as part of gun control matters for Maryland, it is beyond frightening.

And don't be holding your breaths waiting for the APA to step in and take a stand. They will be too busy holding up their newborn child of DSM 5 to care about the state of affairs for the profession.

2013 will be a very painful year for providers who tried to care about mental health care needs.

Laura1019 said...

OK, Just opened today's mail, and got the first shock. I don't know if it's kosher to put actual figures out there, but for a combo of 99212+90836 (instead of 90807) I was reimbursed about $63 and for same exact service last year under the old code I was reimbursed $106. Wow. No wonder they wouldn't return my calls.

Laura1019 said...

Can anyone explain to me why I would get reimbursed a lower amount for doing psychotherapy and medication management than a therapist doing psychotherapy only? I don't understand. I just called the APA to ask this question and the voice mail says they are too busy to return calls but I can watch a Q & A session on the website. Really?

I am not very politically astute, but I really would like to know.

Dinah said...

Laura,
I posted this on our listserv, one of the members of APA responded:

"It is clear to me that insurers are attempting to capitalize on the coding changes, pay less under the new codes, and save their companies monies. Certainly we are all intelligent enough to understand this attempt by them. I certainly did not think they were going to roll over and pay us what we are worth. On the other hand, perhaps being a bit naive about this I did not envision that they would game it to this extent, specifically addressing the change from paying $106 last year and now $63!

I know that the APA has been dealing with so many calls that they can't always answer all the calls. Given my being on the committee of the APA and working with staff at the APA level I will try to bring this to the attention of the APA as well. I will need more details from Laura - who is the payer? being the major question. "

Laura1019 said...

The payer I was referring to is Anthem. Apparently, I could have been payed a little more up to about $70 for the combo (99212 + 90836) if I had set my fee a little higher for the 99212. They allowed only $27 for the 90836. I would have been paid $88 for simply billing for psychotherapy only (the 90834 code). I honestly don't mind fees being readjusted to allow more care for more people, but I am doing medical work in addition to good psychotherapy work, and I just don't understand how this can be. I guess it would be much more lucrative to see 2 or 3 patients an hour for med management, but I'm stubborn about using my psychotherapy skills and I went into psychiatry with the intent of having a broad skill set to offer. Is this really about insurance companies trying to save money or is there something else going on here?

Laura1019 said...

Sorry, I know I'm hogging the blog right now, but I have one more thing to say. What Anthem and other insurers may not realize is that I have actually saved them a lot of money because of the way I practice, which means I know my patients well and follow them closely etc. I know I have at least a couple of patients I kept out of the hospital last year when they became psychotic or severely depressed because of my combination of skills. Why don't they take that into account!!!

jesse said...

@Laura - you upset is well founded. I think you may be assigning reasonable and thoughtful motives to the indsurers rather than realizing that they do not value what we do for our patients. I think they just do the thing that they can do to pay the least - nothing in it more complicated than that.

Joel Hassman, MD said...

Two points to the above several comments from today:

1. It is painfully obvious that the change in coding is NOT to benefit psychiatrists, especially since the coding changes for other providers have really little changes, and
2. Why is the author of this post turning to the APA for answers? Really, did Caesar ask Brutus what he was doing with the knife, perhaps Jesus really had no issue with Judas's choices? The APA supported this CPT coding matter, is overtly profiting from it with these inane "seminars" how to understand and maximize the coding, so, they are really going to help rectify the very outcomes at hand now.

HELLO!? Are people paying attention here?! Psychiatry is being marginalized, minimized, and being slowly put to death these past 15 years, am I truly the only one seeing the writing on the wall?! You all keep rationalizing and hoping for responsible, caring minds and supports to come rushing in to stop the insanity.

As things stand, private practice psychiatry will be extinct in another couple of years, tops. Start looking for those "coveted" positions we are being forced into.

Hey, you can write me off as a crank, over the top, or just ludicrous, or, are the signs worth ignoring further. You be the judge.

Anonymous said...

With the CPT code talk for the past 2 months, I think you have driven away your main readership - mental health patients. We get that your stressed. You are very vocal about that. On all issues. But it does make one less likely to come back.

Dinah said...

Anon, that's fine. My mind is on CPT codes and how new gun legislation will effect people with mental illnesses. If you don't want to read, that's fine, check out the other psychiatry blogs instead, come back and check on us in a few months when the insurance stuff settles down (it will). But I write about what's on my mind and no one pays me for this.

My cpt story for now: coded as session as 99212 and +90838 (low level medical management and 60 minutes of psychotherapy). The patient was reimbursed just over $7.
We're starting to hear that insurance companies are not allowing 60 minutes of therapy. The reasonable thing might be for insurers to say "We aren't reimbursing for 60 minute therapy codes, so here is the payment based on our fees for a 45 minute session." Instead they bounce them back with a "not allowed" so the patient has to find out what codes are needed, contact the doc, get another statement, remail it, and wait.

HarrietMD said...

Joel,
It was painful to read your entry, and for what it is worth, I agree with you that the psychiatric leadership has behaved treacherously.

I have a different take, I think, however on what this moment in time means for psychiatry as a field. I think it can be an opportunity to redefine ourselves, because this moment has been coming for a very long time. We have been lead into a dead end ally for years. So, this is a crisis, and the gun law issues make it more so. Everyone is telling us what to be, and what to do--the government, the pharmaceutical companies, the APA--and they have agendas that are incompatible with emotional well-being---ours or our "patients", or our country's for that matter--and it will be necessary to set a different agenda if we are to emerge from this.

I think that psychiatrists will always be "needed", because we set the path for all other disciplines in mental health: what we believe, and what we embrace is used as the paradigm for how the society views mental illness and health.

I believe that the paradigm that we have embraced since the 1990s has turned out to be a bust--emotional illness has been neither cured nor clarified since the onset of intensive psychopharmacological treatments. Every day I think more and more psychiatrists are aware of the limitations of the drugs that we use. Maybe it is embarrassing to admit that this approach has not led where we wanted it to, that it turns out that we were hopeful but now we are skeptical, and we need a new model.

ICertainly, we have been conned and lied to by pharmaceutical companies and the rest, and there were other social pressures that tore down the existing systems of mental health care. But my point is that since this approach does not work--,we are not magicians, and these pills are not magic, and we do no have anything like "cures", it is in everyone's interest to acknowledge that now.

If we continue to live by the notion that psychotropic medications are essential to treating mental illnesses, we will die by that notion. It simply turns out not to be true, and we need to stop endorsing and promoting a fantasy.

The price tag for Abilify alone in New York State for medicaid recipients is something like $2 billion/year. And there is no evidence that it works particularly well, and no evidence that it works better than Haldol, or the earlier neuroleptics. There is not enough money in the system to pay for both Abilify, and other new "medication" like it, and for institutional care, and for us. If Abilify, et al, really worked, that would be one thing: as it is, it does not.

We need to stop equating medications with care. When we can do that, we can begin to organize a different response to the forces that are controlling us and using us for profits, and through us promoting tranquilization of a very upset and angry society as if it is caring for their emotional distress.

We should stop dispensing medications in the way that we currently do, for one big thing. We need to start explaining some of the potential dangers and risks of psychotropic medications, and the limitations that we have found in them. We need to start expanding our thinking about "genetics" and start integrating neuroscience into our models, which actually points to far more complex interactions between environment and genetics and emphasizes attachment.

More money is made on psychotropic medications than any other medicines in the world. Period. We have a lot of power; these companies depend on us to survive, though we feel that it is the other way around. We need to change this. And we need to let the APA know that we are done with where they are taking us. . We need to start reading neuroscience and thinking about attachment issues, and social issues. And we having to start having the courage to put up a fight.

Laura1019 said...

Well said HarrietMD. I agree very much with your thoughts, here, and I have to say that this process is causing me to reflect on what we do as psychiatrists and what is effective for healing psychological problems and pain.

Prozac came on the market when I was in medical school, and thus began the era of the schism between the “biologically” vs the “psychologically” focused psychiatrist. I have a master’s degree in organic chemistry and you would think, I would worship at the feet of the pharmaceutical industry for making these drugs. But like you, I have seen over the years that meds have limited usefulness most of the time, and occasionally are very useful. ( Also, I never took samples from drug reps or let them in my office, so I would hopefully not be caught up in undue influence). The thing that helps the most from my experience, is the therapeutic relationship, no matter what type of therapy you practice.

I just read some of Jonathan Shedler’s work on the efficacy of psychodynamic psychotherapy (which is my basic theoretical orientation) and comparing the efficacy outcome studies of that type of therapy with CBT and outcome measures of pharmacotherapy. I have found that information helpful to me personally in these recent days as I think about my future, and how I want to continue to practice.

I agree that there is a great deal of pain, confusion, and anger in the broader culture, as economic structures have changed, and uncertainty is growing. People don’t feel safe, economically, or even just sending their kids to school.

I agree that as psychiatrists we are in an important and unique position to be the leaders for how to proceed in articulating and trying to heal the terribly painful issues going on in our culture.

I am so glad to have found this forum (thank you Dinah) to express my thoughts and feelings and to hear those of others who are struggling with the same concerns.

Maza said...

Wow, Harriet MD!!
You will have to fight hard to implement such a vision. I don't see it happening although it ought to. We would have fewer polls on the trauma of involuntary hospitalization because people might actually stop feeling that it was a place of re-traumatization. Are you suggesting something along the lines of the Sanctuary model? That costs big bucks to implement and probably not less than drugging patients so I can't see it gaining gov support. It would make a huge difference if people had that kind of care. What we have now cannot really be called care. It is control and that keeps a vicious cycle going. Of all my psych stays, I got better faster with fewer meds when there was someone who understood why I might have developed psych issues and who approached me in a calm and humane way as opposed to forced restraint, physical or chemical. It is amazing the power a human being has to connect with people who are quite psychotic and to bring them to a place of safety (not a "safe room").
It boggles the mind that instead of reaching out to humans as humans, the psych prof first drugs the H out of us and then expects us to trust them. I do take the drugs but only because there is no safe place to go. I have read of places that cost a ton of dough where people can access outpatient programs that they can go to instead of being locked up, where meaningful things happen instead of waiting for your five minutes with the shrink, getting your meds and going back into a zombified drug induced state.
Those places are for the very wealthy. Not even someone with a good income could afford to blow it all on such a luxury. Harriet MD, how many of you are there out there do you think? Not enough. That is very sad. I hope you also train young docs.

Joel Hassman, MD said...

To HarrietMD & Laura 1019:

I hear your comments fully. The fact remains, and this will greatly annoy some other readers and commenters here, that too many of our colleagues are whores and cowards. I think they make up over 50% of practicing clinicians. And don't even talk about what composes the APA and academic leadership as a whole. They sold out about the time I finished residency, that being 1993.

Hey, I practice what I preach, and I will not stop pursuing the level of care I was trained to provide, it will just be at salaried levels hereon for now. Because as sad as it is with our colleagues, trying to be respectful to those patients who have heard and followed my recommendations and seen progress, there are equally those who have not wanted nor tried to listen but just insisted, if not at times badgered me to consider the quick fix mantra. Even worse, sold irresponsibly, in my opinion, by some therapists.

I want truth and efficacious treatment to prevail. It won't be by working with insurers, pharma, and colleagues who are focused on their wallets/purses first.

It starts with making the APA irrelevant. How? Anyway you can legitimately and respectfully shame colleagues who are still members is a start. When DSM 5 comes out, a majority rejection of it is another slap in the hierarchy face. And not waiting for alleged leadership organizations to step in to reject poorly conceived political legislation to mandate psychiatric interventions should be handled by the people who are outraged. I still believe group protests do have an impact. Unfortunately, a group infers a sizeable amount of people coming out on a work day, so you will not be paid that day.

Really, can doctors handle that last sentence!?

Finally, Dinah's last comment about the reimbursement of $7 is vague to me, $7 above what the patient paid to you for the session, or was just paid $7 for the visit? If the latter, that is beyond shameful for a payment, it is insult and injury simultaneously!

Until something of substance that is legitimate and reflects consistent progress from where things are now, 2013 is going to be a bad year for psychiatry. And note when I say private practice is doomed, it will be for those who accept insurance and depend on a majority referral base from therapists and physician colleagues who also depend on insurance.

But even out of pocket practices, I have to ask this: you are going to spend more time on resubmitting claims for your patients and dealing with authorizations for medications legitimately written, isn't that going to have some impact on subtle resentment and annoyance if it continues on a weekly basis for months? If you honestly answer "no", then you are quite the provider. Personally, if you answer "yes", I think you are realistic. The intrusions stink, and they are going to not just continue, but risk exponential rise.

Yeah, if you look up "jaded", "cynical", and "pessimistic" along with "the future of psychiatry" as a group on Google, my name and picture will be choice 1.

By the way, if you go to my blog today, I sense today's post will not humor and enlighten. But it is what I see it to be.

Ravens win on Sunday? Caw caw caw!!!

Harriet MD said...

To Joel,
I didn't know you had a blog; I will certainly enjoy reading it no matter how bleak.
I do wish to say, again in response to your comments, that I don't think we should be fighting with one another as we do; I am tired of the psychotherapy vs. pharmacological wars as I am tired of all of the wars that occur in this quite disgraceful country of ours, including the real wars that noone is willing to talk about overseas. I wish other psychiatrists were less conservative; I wish they were versed and sophisticated politically. I think it is, no matter how you practice, excruciatingly painful and difficult work. I think it is hard to maintain a health state of mind doing it.
If there are 50% of us who you believe are good-willed, that is a lot of people to work with. Maybe we can be persuasive; and frankly, if the other side has a losing hand. Eventually psychiatrists will have plenty of time to actually protest as things come apart.
I know also what you mean about feeling compelled to medicate. We should be talking about this. We are all, for multiple reasons. But if we were to begin to consider writing for Haldol instead of Risperdal or ability, boy would we hesitate. We have bought the advertising...we don't have to and when we start to consider what we are doing, we will learn how to begin to change it.

Anonymous said...

Doctors,

You have been insulted beyond measure. It is ludicrous to think the US average to minimum wage pays higher for your time than what insurance considers reimbursement. If you do not speak up for yourselves where will that leave you and your patients who rely on you.

If I may make a suggestion - you will probably never find a time when mental health issues are more in the forefront of the media and on the minds of the populace. You have a captive audience. Use it for the benefit of your profession. Hasn't everyone seen those heartbreaking commercials depicting the needs of animals? They grab your attention and you would be speaking on behalf of human beings in great need. You are indispensable for those of us with mental illness. Everyone of us that pays good money for our health insurance has been screwed by their insurance company in some fashion. So again, you have the populace on your side already. I am, by no means, suggesting that you parade someone with mental illness for this purpose, but rather show some of us that you have helped relieve their burden to lead much more satisfying lives. If it were not for my psych, I would not be steady enough to write this post.

Please do not wait for the APA. What have they done for you lately? Do not wait for insurance companies to pony up. They should be publicly shamed and discredited for their policies. You have the "bona fides". You worked hard to arrive and maintain your role in an esteemed position in the medical field.

PS - Please do not retaliate to me as I love animals and support an organization with my time and dollars.

Dinah said...

Ah, there's a story in the New York Times about how the problem with out of net work practice is that the doctors are over charging. The story focuses on a man who needs an emergency gall bladder operation, the surgeon is out of network and charges $30,000 and the insurance company pays their percentage of Usual and Customary which is $2000. The patient gets screwed (big time, and in emergency surgery, you don't get to shop around like you might in psychiatry).

Okay, so my story above, the patient pays me and got reimbursed $7.65 cents.

Anonymous said...

Your above scenario is ill-informed. Since it was an emergency, it's on the admitting hospital to provide a surgeon who will accept the person's insurance in network, and if not, the person has redress: contact the insurance company. Yes it'll take time and effort, but the insurance company will swallow the rest of the cost (minus whatever deductible is present.) Been there, done that, as have numerous colleagues and relatives. But that makes for only some annoyance, definitely doesn't make for a good story....Hey, we all know a newspaper has a slant.....

The major difference is that a psychiatrist is self-selected. The person has an option to go out of network or stay within. I personally see an out of network shrink and am anxiously waiting to see what my insurance will do. But, it is true that I have the choice to say in-network and pay only a copay (yes, I get that screws you more. But apparently it's a choice between patient or dr being screwed, and since you take only private pay, the choice is actually patient or patient. Your income is not directly affected at all.)

Anonymous said...

I am happy to find this blog. I am in private practice and an fee for service based. I am confused by how to code for e/m + psychotherapy visits. As each will be a separate code do I also need to come up with a breakdown cost for each code? Ie- if my normal fee for a 90807 was 100.00, now would I have to divide - 99213 ($30) + 90836 ($70.00)? Though my patients pay out of pocket I would still like to correctly code so they get the appropriate reimbursement. Thank you.

Anonymous said...

Also going through the tutorials, am I correct to code for a e/m 99214 solely based on time when I see med management patients for 30 minutes of which greater than 50% of the time was spent in coordination of care and counseling?

Dinah said...

Anon, 3 up, Just repeating what the NYTimes said.

Anon 2 up: I don't know the breakdown, and since I coded a session in a way that my patient got reimbursed $7.65 for a hour-long session, I may be the wrong person to ask! (coded as 99212 +90838).
There are two issues: How do you do the coding in a way that reflects the work you've done (I believe you'd have to analyze every sentence and sit with a stop watch and first test with inter-rater reliability) and then what codes do you submit that will be reimbursed, which appears to be a complete mystery. Each insurance company has it's own rules.

Laura1019 said...

I have a question, that I'm sure no one knows the answer to yet, but here it is anyway. Should I code my session (50-55 minutes) as 90834, even though it's really 99212+90836 so that I am reimbursed at a more fair rate, and patient is too when I am out of network? Would that be considered insurance fraud? Why do I get paid less for providing medical care along with psychotherapy?

I am so confused, angry, and demoralized by this whole thing. If anyone has a rationale for how to code at this point that is legal and fair, I would like to hear it.

Ann M. Childers, MD said...

I am in an office with one other psychiatrist. We are getting paid, so far. We submitted our billing to the clearing house late in January because we did not know what to charge, but now money is coming in and most charges are accepted (I made a few mistakes coding psychiatric assessments initially because I could not believe the reimbursement for 90792 and thought it required an additional e/m code--sadly, I know better now).

Rather than use the psych eval code 90792 we use the E/M codes (usually 99204 for 45 min, even though we see patients for 60 min).

The typical coding we do for low acuity 30 min patients is 90833 + 99213 e/m.

We know we are getting all the elements into our notes because we use a psychiatric electronic medical record that keeps track of notes, ensures we include all pertinent elements then automatically codes for us.

So far I am optimistic that we will survive this, and perhaps thrive. Income looks very positive at this point, but not all charges have been paid on so we are waiting to see what happens.

To be candid, I don't know how anyone can manage this coding situation without a specialized electronic medical record. We pay between $300-400 per month for two psychiatrists and an office manager, and because of this system we need no outside billing agents (we connect directly to the clearing house). We saved money all last year and now we are weathering the code changes in good shape. 'My two cents.

Laura1019 said...

To Ann,

Sounds like you are doing mostly med management, and not seeing people weekly, so this model for reimbursement will work better for you than it does for me.

Ann M. Childers, MD said...

Laura,

Do you prescribe medications to your patients or do any medical investigations (bp, pulse, weight, medication reconciliation, e.g.)? You can code for 45-60 min for psychotherapy with E/M, and add an E/M code to that. In this case, 90836 (45 min) or 90837 (60 min) plus, for example, 99213 (low acuity) or 99214 (more acute) depending upon what elements you include in your note. Keeping track of the elements can be a challenge, but it has to be done to satisfy an audit, should that occur (I understand this is highly unlikely, but with the new system it's hard to know...). If you receive cash payments accurate coding can help your patients recoup expenses.

BTW, our clinic charges $125 for 99213 and $80 for a 90833 E/M code (these two are combined in one 30 min. slot), which is within a few dollars of what at least one major insurance company pays for these codes. These charges are for a 25-30 min service visit including medication management for a low acuity patient. A 45 min psychotherapy visit with E/M for low acuity is 90836 $125 plus 99213 $125 = $250. This is more than we could expect from insurance companies last year.

Laura1019 said...

Ann,

It sounds like your insurance payors are more generous than what I'm dealing with. Yes, almost all my patients are on medication that I prescribe or have medical issues I have to pay attention to, and I see many of them weekly for psychotherapy. Last year most of the sessions were coded 90807 and the major insurer I am paneled with allowed about $106 for that.

This year, the same insurer is only allowing $41.71 for a 99212 and $69.51$ for 99213, and $27.89 for 90836, for a total of $69.60 and $97.4 respectively for same service I was doing last year. They are allowing $88.19 for 90834 (psychotherapy only with no E/M). Does this make sense to you?

I am assuming also that you are not seeing the same patients weekly for ongoing psychotherapy, so are less likely to be questioned or audited about using a 99213 code on a weekly basis.

I did try an EHR for a brief time, but the notes all sounded alike and I decided to come up with my own template, simpler but based on the one recommended by the APA.

Laura1019 said...

Just received this link from one of my patients

http://vitals.nbcnews.com/_news/2013/02/07/16842490-therapists-change-in-medical-coding-threatens-mental-health-care?lite

Jarusha Kutz said...

I wonder if some of the reasons people haven't been reimbursed for certain codes that seem they should pay well, such as the E/M codes: 99213, 99214, 99215 has to do with not entering more than one diagnostic code for those patients who we say require higher medical decision making complexity. Without an audit, how can the insurance company see we are actually treating the number of problems we say we are, if we are not coding adequate diagnoses in our claims?

I don't know if that plays a role in if they pay, but I know that since the new codes have come out, I have felt the need to disclose more than I had previously being more specific in diagnoses. I am now listing more than one diagnosis per patient if I intend to used E/M codes such as 99213, 99214, 99215. I used to try to preserve the patient's privacy by tending more towards adjustment disorders as diagnoses, an never used to use more than one diagnosis. Now I feel I have to be more candid with the insurance companies in my billing as well as my documentation.

It is a scary rope to walk, privacy for our patients and helping them get the reimbursements they need. I hope the ban on denying people insurance benefits based on "pre-existing conditions" hurries up and goes into effect.

Jarusha

Jarusha Kutz said...

To answer Anonymous above,
Do not list your fees for E/M + psychotherapy add-on code as an amount to equal what you used to charge for 90807!
If you do this, the insurance will pay you less in total for that visit than before for a 90807.
Yes, you must figure out a fee schedule for those codes used in the claims you submit. Start out by figuring out a fee for the E/M codes you think you will use most. For me, I only see complex patients who would meet criteria for 99213 at the very least and often see patients who I would provide services of 99214 or 99215 for. I personally charge the same fee for each of those 3 E/M codes, nothing wrong with keeping it simple, just make sure whatever fee you list as your fee, is at least a high as what insurance companies are reimbursing those codes for. This is because if you say your fee is $150 for 99213 and you want to add a psychotherapy code of 90833 (30 min psychotherapy with E/M) and you decide you want to have your fee be a simple $25 for the 90833, you may be undercharging for the psychotherapy, but over charging for the E/M. You need to make sure your fees for each code are more or at least the same as what the insurance company allows. This is because the insurance will never pay you more than your stated fee per code! Even if they generally reimburse more for that particular code. The max they will pay you is what you say your fee is.

Now, no one wants to give themselves a raise they didn't want in the first place, so it may look like each visit you are charging more than ever before, especially if you combine E/M code with an add-on psychotherapy code, but you can see what reimbursements you get and adjust your fees down to what you feel is more reasonable at any point down the road. There is no rule that you cannot change your fees monthly, just keep them up to date on the claims.

I also like that when new patients call to make a new intake eval. appt and ask me how much do visits cost? I do not have to say, "It depends on how many problems you have." Or something more diplomatic but of that sort.

I spend a good deal of time with a patient in order to find out not only what is there, but also to find out what isn't there. And this is why my fees for 99213, 99214, and 99215 are all the same. Also, I spend more than 45 minutes with each patient if I am coding an E/M code plus any psychotherapy add on code, it just seems the right thing to do. I schedule each visit a 90 min block and use as much as I need to.
I will say that I have been more thorough and am finally getting to bill for the complexity of what I do. I have needed to weigh my patients on stimulants or atypicals more often, and now I have the incentive to do it. I have also been glad to take vitals more often as well. It gets me out of my chair. I know it is important to do with patients on stimulants every so often or when adjusting dosages, now I make sure to remember it.

If I saw certain patients weekly for an extended period and they were not struggling with med changes or emotional crises, I would be hard-pressed to take vitals more than at perhaps monthly intervals if they were taking meds that could cause that. And for these patients, I would likely code a lower E/M code plus psychotherapy. I may not make the same hourly rate, I haven't done the math, but I would be grateful to have patients so willing to come week after week even though they aren't in crisis. Currently as soon as my patients stabilize they move on, and come back whenever they feel they may be destabilizing or need a tune up for awhile.

This sure poses a challenge in many ways of how we do business.

It makes me wonder about how bizarre a mind or body of minds would have to be to come up with something so unnecessarily complicated.



Anonymous said...

Posted to a previous thread just before I saw this one, but here is more relevant, so please forgive a brief repost (as well as double-posting here, if it happens, I seem to be having some browser trouble - For anyone still struggling with these, I created a free web-based interactive training tool that will let you watch your code being built as you tick off data elements, see a "map" of how the code is built, and optimize your coding and documentation. I won't post the direct link so as not to appear to be spamming, but you can find it by under "Psychiatric Code Coach" on any search engine.

There are also lots of links to resources on the Maine Association of Psychiatric Physicians site (an APA DB, but 99% of the content is public), under the resources tab.

Regards,

M Price MD

Dinah said...

Thanks, Dr. Price. I tried your link in two browsers and couldn't work it easily, Firefox whatever and Safari.

Texas Doc said...

I was prepared for the new codes but baffled by the illogic. Medicare pays 21% more for non-medical evaluation than medical. At least Medicare has published fees; major private insurers have not done so, and many claims I have submitted in 2013 for E/M + psychotherapy are paid at absurdly low fees: I actually am paid more if I submit only a psychotherapy code (Medicare does pay more for combined services). I am being mugged by private insurers and my only option is to drop all contracts, which hurts patients, not insurance companies. This is one of the biggest debacles I have seen in 35 years of practice, and yes, this must be a bore for the non-professionals. We can move on shortly to DSM-V, which promises to move psychiatry even further from a profession centered on helping people toward an industrial profit center.