How do I code this?

[DD214_DOC]

There is a weird primary care consultation system setup where I'm at, and pretty much nobody actually knows how to code for what we do. Any feedback on what, if anything, I can code this under is much appreciated.

Essentially, a patient sees their PCP and there is some type of psychiatric concern. Usually, this is a positive result on PHQ-9 and PCL measures and some endorsement of related symptoms. The PCP then submits a, "referral" to this consultation program, almost always without any actual consultation question with it. A nurse case manager then picks it up and calls the patient to collect additional information and provide some education on resources. An encounter is created in the EMR by the NCM containing the information gathered. The NCM then calls me and, "staffs" the case over the phone (basically repeats what is written in the encounter). I utilize that information along with a review of records and provide recommendations to the PCP by documenting my portion of the encounter in the EMR. (as an aside, my reccs typically are things such as, "evaluate further", "clarify purpose of consultation", or outright reject the, "referral") The reccs are then either seen by the PCP when the patient is seen again or relayed to them by the NCM.

So, nobody knows how to code this. It appears the closest match is the 99446/7/8 codes, but from what I have read this applies only in the case of direct communication with the PCP? Since there is an intermediate person -- the NCM -- this can't be used?

My thoughts on the actual program would be a completely different topic.

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[F0nzie]

http://alert.psychnews.org/2016/07/cms-announces-medicare-coverage-of.html?m=1

Not sure who's winning... patients for being evaluated and treated via second hand information, psychiatrists for taking on extra liability, or PCPs for filling up their schedules treating psychiatric issues.... Collaboration is a winning word though!


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[nexus73]

This consultation service sounds like a curbside consult on steroids. Provide recommendations without ever seeing the patient. I know it is an expanding area of research and is obviously being implemented in various settings, but it seems frought with liability concerns.

 

[DD214_DOC]

This consultation service sounds like a curbside consult on steroids. Provide recommendations without ever seeing the patient. I know it is an expanding area of research and is obviously being implemented in various settings, but it seems frought with liability concerns.

I don't really know what it is. Half the time the PCP's treat it like a magical void that makes psych problems go away. They simply, "refer" to the program with no actual question or request, then proceed as if the psych issue is no longer their concern. I've seen so many things fall through the cracks and it's rare my reccs consist of anything more than further evaluation needed prior to further reccs.

 

[DD214_DOC]

I'll tag this onto the thread: under what conditions may one code an intake for an established patient? I know it's possible, but I don't really use it much and have probably undercoded a lot of things by not using it.

 

[keifernny2]

Established to who? A patient established to a primary care group is not established to psychiatry. You can't bill an intake unless you actually see the patient though. If the patient saw another psychiatrist in your group within the last 3 years, then it is a follow up. If they haven't (or it has been 3+ years), then it is a new pt. If the patient is technically a follow up (because they see another psychiatrist with your group ) but it takes longer for you to evaluate them (because, let's say, the other psychiatrist's notes are terrible), then you can code a level 5 e/m follow up based on time.


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[DD214_DOC]

Established to who? A patient established to a primary care group is not established to psychiatry. You can't bill an intake unless you actually see the patient though. If the patient saw another psychiatrist in your group within the last 3 years, then it is a follow up. If they haven't (or it has been 3+ years), then it is a new pt. If the patient is technically a follow up (because they see another psychiatrist with your group ) but it takes longer for you to evaluate them (because, let's say, the other psychiatrist's notes are terrible), then you can code a level 5 e/m follow up based on time.


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Already established with me. It was a completely separate topic that I just tagged onto this thread instead of creating another.

I swear I read somewhere you could code for a diagnostic eval on an established patient, but I can't remember the criteria. I think maybe a new presenting issue that requires a full evaluation?

 

[keifernny2]

You can do it once every 3 years for the same provider, but based on RVUs for an eval vs. an extended follow up visit, there is little to ever do it. I don't even bill with the diagnostic eval code, I only use e/m new patient codes (and e/m f/u codes with or without therapy).