Psychiatry CPT Code Changes

[michaelrack]

. I'm not going to be feeling for a pheo anytime soon (and I think the diagnostic sensitivity of that is really really low), but labs should be a part of psychiatric treatment, as appropriate.

agree. The diagnosis of pheochromocytoma is a biochemical diagnosis (the diagnosis is based on labs drawn to work up symptoms suggestive of pheo). If I remember from my recent IM MOC course correctly; serum metanephrines or urine catecholamines/metanephrines are the usual tests.

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[vistaril]

Not if you're doing it for billing purposes, sure. But if your patient is a smoker and you're the only doctor he sees regularly (not an unusual situation), it's reasonable.

If you're doing it just for billing purposes, that's questionable. But if the billing is just there to provide some incentive for you to be thorough, that's different.

It's reasonable to hire a nurse to take vital signs, and you're already doing an MSE. Beyond that, it's probably good for your patient to just do some basic physical examination depending on the drug they're on - i.e. check for anticholinergic effects and/or serotonergic effects, get the nurse to do periodic ECGs on the patients that need them, get the nurse to draw blood for lithium levels or valproate levels, check for the classic side effects of the mood stabilizers, check for Parkinsonism in anybody on an antipsychotic, etc. And then throw in a thyroid exam, a neuro exam, etc. Only when there's an indication... not for every patient. But it'll mean that a lot of patients will get bumped up to that higher billing code (if they're not paying out-of-pocket), and you might actually pick up some things that you wouldn't have otherwise caught.

Plus, you don't even need the physical exam to bump up the billing code, as long as you have "moderate complexity decision making."

look, I dont care if you bill the pt for the most complex visit possible and don't do any of it. I could care less. Whether he or his insurance could also care less I don't know or care.

But no, I stand by my point there is absolutely no indication for an outpt psychiatrist on return pt med mgt visits to be auscultating lungs in an asymptomatic pt. This 'you may be his only dr' bs is just that-bs. That excuse may fly on an inpatient unit where someone is admitted and hasnt had access to outpt care or seen any physician, and we do in fact do cursory PE's on admission on inpatient units. But in the private outpt world, that is not likely to be the case. think about it- he probably came to you from a referral by his......wait for it....primary care physician! And if he self referred, what are the chances of a smoker self referring to psychiatry who has no pcp? 1 in 10000000000000?

if you guys want to watch sanford and son reruns with pts and then bill a 999999999999999, go for it. But don't tell me you're going to go around trying to play internist for people coming in for psych outpt visits....thats embaressing. and not therapeutic.

 

[vistaril]

I keep a stethoscope, BP cuff, portable mini pulse ox, and a breathalyzer in my office. I think it's quite reasonable to do targeted physical exam when appropriate.

yes, and several of these examples have already been given......ROM and cogwheel testing on pts on dopamine blocking agents for example if they look stiff or have complaints.

But that is a FAR different thing than what one person said earlier about listening to EVERY pt's heart and lungs on EVERY visit.

I dont carry my stethoscope when I do outpt, although I guess I could track one down within 10 seconds if I needed it. But it's not unreasonable for a psychiatrist to have one tucked away somewhere I guess. It is unreasonable to be doing PE's with your stethoscope on every outpt that walks in.

 

[F0nzie]

Renting medical offices equipped with sinks and examination rooms are substantially more expensive than simple executive office suites. From a financial standpoint, minimizing overhead costs and referring to PCPs seems more resourceful for both the psychiatrist and the patient. From a patient care perspective, rather than striving for a higher level code, perhaps the add-on psychotherapy and interactive complexity codes will make 30-45 minute follow ups more financially viable.

 

[vistaril]

Renting medical offices equipped with sinks and examination rooms are substantially more expensive than simple executive office suites. From a financial standpoint, minimizing overhead costs and referring to PCPs seems more resourceful for both the psychiatrist and the patient.From a patient care perspective, rather than striving for a higher level code, perhaps the add-on psychotherapy and interactive complexity codes will make 30-45 minute follow ups more financially viable.

doubtful......if anything in the future the trend is going to increasingly be in the other direction- volume, volume, volume and more volume.

 

[michaelrack]

But in the private outpt world, that is not likely to be the case. think about it- he probably came to you from a referral by his......wait for it....primary care physician! And if he self referred, what are the chances of a smoker self referring to psychiatry who has no pcp? .

he may have come by referral by way of his primary care nurse (practitioner). Self-referrals to psychiatry aren't that rare, especially for "I think I have ADHD". I occasionally have patients who try to self-refer to me for psych issues (usually the intake person is able to intercept and explain that I practice sleep).

 

[shan564]

look, I dont care if you bill the pt for the most complex visit possible and don't do any of it. I could care less. Whether he or his insurance could also care less I don't know or care.

But no, I stand by my point there is absolutely no indication for an outpt psychiatrist on return pt med mgt visits to be auscultating lungs in an asymptomatic pt. This 'you may be his only dr' bs is just that-bs. That excuse may fly on an inpatient unit where someone is admitted and hasnt had access to outpt care or seen any physician, and we do in fact do cursory PE's on admission on inpatient units. But in the private outpt world, that is not likely to be the case. think about it- he probably came to you from a referral by his......wait for it....primary care physician! And if he self referred, what are the chances of a smoker self referring to psychiatry who has no pcp? 1 in 10000000000000?

I don't know what it's like in your practice setting, but I've seen a lot of patients, including smokers, who either (1) self-refer to psychiatry for one of many possible reasons, (2) see a random PCP (including a student health center, staff health center, etc.) for a psychiatry referral and then rarely follow up with that PCP because they don't have many other debilitating medical problems, or (3) are referred to follow up with psychiatry after an inpatient admission. And I'm just a medical student, so my experience is very limited.

if you guys want to watch sanford and son reruns with pts and then bill a 999999999999999, go for it. But don't tell me you're going to go around trying to play internist for people coming in for psych outpt visits....thats embaressing. and not therapeutic.

Maybe it's embarrassing if your physical examination skills are weak. I don't see any reason to be embarrassed about a doctor examining a patient. People with bipolar disorder and schizophrenia have a significantly shorter life expectancy, largely due to smoking/drugs and lack of PCP care. I think it's a bit negligent to send your patient away to suffer from general health conditions just because it's not your specialty. You went to medical school, and even after you got into psychiatry, they made you do a general medical internship. You have a medical license. You're not just a psychologist with prescribing privileges.

Also, what I'd find much more embarrassing would be if I grossly misspelled the word "embarrassing" on a public forum.

 

[digitlnoize]

also, some EP cardiologists can't pick up 'conduction abnormalities' by auscultation, and you're going to start doing it??

You will note that I never said you can "pick up conduction abnormalities by auscultation." I said that our drugs often cause heart problems, so maybe we should examine our patients...hearts! It's not rocket science people...also just a example (although perhaps a poor one.)

I seem to have hit a nerve. I wonder what it is that makes psychiatrists so defensive about NOT doing physical exams...Do we have an inferiority complex about this? They are done regularly on inpatient units, for the exact reasons I described: Because we are doctors and we should do an examination to evaluate the health of our patient. This is done via physical exam. Why are we so lax about them in the outpatient world? Because as soon as our patients are discharged from the inpatient psych ward, they are somehow magically healthier and no longer need a physical exam?

I'm sorry guys, I get that everyone's having a good laugh at the silly intern's examples, and that's fine, but never examining a patient doesn't make sense.

Also...would you need a sink? How about those wall mounted hand sanitizers the hospitals use? Also, don't you have a bathroom with a sink?

 

[shan564]

I seem to have hit a nerve.

No, you didn't hit a nerve... he's always like that.

 

[ratched]

Will psychiatrists be unable to bill 90805, 90807, and 90847 billing codes in the near future?

If so, will there be new billing codes that specifically use the terms "psychotherapy" or "counseling" in the description?

I'm thinking that these new CPT codes (and elimination of the old ones), if I'm getting it right, will allow outpatient psychiatrists to remain in insurance networks to do psychopharm follow-ups and will allow these same psychiatrists to bill pts out-of-pocket for psychotherapy, even if the psychiatrist is in-network for a particular pt. (The logic being that the psychiatrist is offering a service that is non-reimbursible or "not medically necessary" -- not unlike offering life coaching.)

Does anyone see holes in this logic? I'm not looking to commit fraud, just hoping to continue practicing a mixture of psychotherapy and psychopharm, not leave insurance panels, and maximize income.

 

[michaelrack]

. You went to medical school, and even after you got into psychiatry, they made you do a general medical internship. .

It is not a general medical internship; it's a few months of a primary care specialty. A majority of the 1st year is psychiatry.

 

[shan564]

Yeah, I guess I was vague - I should have said an "abbreviated" general medical internship.

 

[F0nzie]

Why are we so lax about them in the outpatient world?

In the hospital setting, the primary team has already performed a physical exam. As consultants we can review their findings and perform our own focused physical if necessary. A full repeat physical examination is rarely necessary unless you are following a protocol for medical clearance. Definitely do you physical examinations for serotonin syndrome, NMS, delirium, hepatic encephalopathy, neurologic disease etc. Probably not necessary for the 21 year old with SI because they broke up with their ex.

In outpatient psychiatry we make the assumption that the individual is medically stable and can see a pcp for a check up per our recommendations. Co-morbid medical conditions are better addressed by the expertise of the PCP for the purposes of detection, treatment, and maintenance. This strategy also limits our liability. Specific labs should be ordered regardless ie. TSH. I can see exceptions where you might want to have a blood pressure cuff available if bp altering medications are making your patient symptomatic. The current codes for psychiatric evaluations do not reimburse physical exams which also reduces our incentive to do them.

The bulk of our clinical work is also limited to dealing with patients with primary issues related to their emotional states. In most cases, these symptoms yield negative physical exams. Repeat physical examinations have limited value if nothing was discovered the first time. Even specialists in other fields have ultra focused physical examinations in their follow ups.

Also keep in mind, once you start outpatient work that physical examinations can be awkward and potentially disruptive to the therapeutic alliance. For example, if you are doing weekly dynamic psychotherapy and dealing with issues of transference on a seductive patient, it might not be such a good idea to start palpating the abdomen.

Hospitals and private groups are going to expect you to perform which leaves little to no time to waste doing complete or even focused physical exams in many cases (unless maybe you're a CL attending). However, if you can get recognition for your work in the field, you may get more leverage to negotiate more time to see your patients and practice the way you want. The idea is they would want you bad enough to take the financial hit to keep you. The alternative is to withdraw from employment and insurance contracts and practice your own philosophical approach and take responsibility for the financial ramifications.

Entering psychiatry and "letting go" of the physical exam is a loss. Losing the white coat in outpatient clinical work also feels like a loss which is why I tend to wear it every now and then in the hospital.

 

[F0nzie]

Will psychiatrists be unable to bill 90805, 90807, and 90847 billing codes in the near future?

If so, will there be new billing codes that specifically use the terms "psychotherapy" or "counseling" in the description?

I'm thinking that these new CPT codes (and elimination of the old ones), if I'm getting it right, will allow outpatient psychiatrists to remain in insurance networks to do psychopharm follow-ups and will allow these same psychiatrists to bill pts out-of-pocket for psychotherapy, even if the psychiatrist is in-network for a particular pt. (The logic being that the psychiatrist is offering a service that is non-reimbursible or "not medically necessary" -- not unlike offering life coaching.)

Does anyone see holes in this logic? I'm not looking to commit fraud, just hoping to continue practicing a mixture of psychotherapy and psychopharm, not leave insurance panels, and maximize income.

Interesting observation regarding the upcoming CPT codes changes which will essentially separate psychopharmacology from psychotherapy with respect to reimbursement. It seems if insurance companies are not willing to pay a physician rate for our psychotherapy services that we should have the negotiating power to opt out and provide medical services only. Once and IF that is established with the insurance company, the patient would have to understand that a super bill will not be paid for by their insurance company. My hypothesis is that insurance companies should be ok with this because the less money they have to pay out, the better off they are. My guess is 5-10% of insurance referred patients will be able to afford to pay out-of-pocket for psychotherapy. Still far more efficient than spending excessive amount of time with self-promotion/advertising if you were to opt out and do an exclusive cash practice.

 

[digitlnoize]

In the hospital setting, the primary team has already performed a physical exam.

Not in the hospitals I've worked in. At the state children's psych hospital each patient gets a full physical. At the state adult psych hospital, each patient, again, gets a full physical. At my University program, we do an abbreviated, but still complete physical on every consult patient. Obviously, this is deferred if there is a specific reason (such as the seductive patient you noted above).

I think part of the reason we do our own physicals is because you never know if the ED (or service X) is just trying to turf a patient to you. We've had more than a few patients who did not belong (medically) on the psych service, but would've wound up there if the psych team hadn't performed a good physical.

I agree that if you're doing therapy it gets weird. But, if you're provided medical management, I don't feel like we should be "assuming" things. You know what they say about "assuming..."

Anyways, I guess either way, the PE doesn't really matter. The patient basically needs 3 old or 1 new problem to meet a 99214 and that's that.

 

[vistaril]

Maybe it's embarrassing if your physical examination skills are weak. I don't see any reason to be embarrassed about a doctor examining a patient..

lmfao.....the medical students taking this "I'm a doctor...hear me roar" approach is hilarious. Again, you'll see what it is like out there when you actually start taking gigs outside of your residency program.

 

[vistaril]

You will note that I never said you can "pick up conduction abnormalities by auscultation." I said that our drugs often cause heart problems, so maybe we should examine our patients...hearts! It's not rocket science people...also just a example (although perhaps a poor one.)

I seem to have hit a nerve. I wonder what it is that makes psychiatrists so defensive about NOT doing physical exams...Do we have an inferiority complex about this? They are done regularly on inpatient unitshospitals QUOTE]

yes, a cursory PE is typically done(and I mean cursory) after the pt is admitted. If anything abnormal is found the appropriate service is generally consulted. I think part of this is for instit billing purposes. Regardless, at most centers, unless it is a direct admit, the pt has already been 'medically cleared' by a non-psych md....

a lot of the longterm state hospitals that many training programs send pts to from their acute unit require that a NON-PSYCH MD/DO do a PE and medical clearance(at some point when they were admitted) before accepting the transfer.

I don't think most psychiatrists are defensive or not defensive about it. Most psychiatrists are just realistic. I'm not an internist...I spent a few months on internal medicine as an intern. The few months I spent on medicine were different in the sense that benchmarks didn't have to be made as they would with a categorical(or even some prelims) and as a result if there are glaring deficiencies they wont neccessarily be addressed.

Most psychiatrists more than a few years removed from residency DONT go around thinking they have 80% of the skills of an internist or whatever. For some reason it appears to be purely a thing specific to med students going into psych and some psych residents.

 

[splik]

for once i largely agree with vistaril! shock horror! actually the outpatient population is by definition healthier so doing screening physicals is low yield and largely a waste of time. american medical graduates are woeful at performing physical examinations regardless of specialty, and i cannot think of a cardiac side-effect of psych meds you would pick up through auscultation because there aren't any. that time spent wasted doing a physical examination, further erodes the time spent talking to your patient, which is the problem with psychiatry today is patients no longer expect their psychiatrist to engage with them in a meaningful way. OTOH doing thinks like checking BP, EKG, lipids, creatinine clearance etc may have some use. physical exam not so much.

Of course observation of the patient is part of your MSE and the most important part of the physical exam. There may be other reasons to lay hands on the patient, but as a routine screening, just like an annual physical it is a waste of time. By cutting into the brief time you actually have to speak with the patient, doing so could further undermine the relationship and miss important information actually relevant to their psychiatric care.

 

[shan564]

lmfao.....the medical students taking this "I'm a doctor...hear me roar" approach is hilarious. Again, you'll see what it is like out there when you actually start taking gigs outside of your residency program.

My point was that embarrassment is in the eye of the beholder. I'm not sure why you'd turn it into a personal thing.

 

[Baller MD]

So 3 years out, is this a good thing or a bad thing that has happened to psychiatry? I've seen differing opinions on my Google search.

ie someone viewing it as a con:

http://www.kevinmd.com/blog/2012/11/medicare-devalue-work-psychiatrists.html

 

[milesed]

It's mixed for me. I spent 6 months doing the level 99214 or 5 exams, documentation for those indicated to be told by my employer, " We are just billing everything at a level 3 visit." I wanted to pull my hair out. They said they did not want to risk possibly billing too high and having to pay anything back until the issues with our state were totally worked out. My understanding is that underbilling is just as bad as overbilling.

The problem is that parity really doesn't yet exist where I am and the state medicaid program has a law stating you can bill no more than two level 99214 or 5 visits per patient a year. Seems like federal parity laws will trump state laws to me.

Once we get true parity and state issues fixed, we should see a bump in gross billings. The downside is it takes longer to do a visit, you have to be very careful about all of your documentation, etc.

 

[PistolPete]

The problem is that parity really doesn't yet exist where I am and the state medicaid program has a law stating you can bill no more than two level 99214 or 5 visits per patient a year. Seems like federal parity laws will trump state laws to me.

Wow, this sounds awful! And as far as I know, yes, underbidding is just as bad as overfilling and could be considered fraud.

From what I understand, the new CPT codes changes have been good, paying more for the appropriate amount of work, assuming you are billing your 99214's accurately when you're doing 99214 level work and not being forced by your employer to bill 99213...

 

[Shikima]

Wow, this sounds awful! And as far as I know, yes, underbidding is just as bad as overfilling and could be considered fraud.

From what I understand, the new CPT codes changes have been good, paying more for the appropriate amount of work, assuming you are billing your 99214's accurately when you're doing 99214 level work and not being forced by your employer to bill 99213...

Only with Medicare... insurers will be happy you're underbilling. Only thing is that we cannot wave are the copay's....\

Oh, and 99214 repayments stink.

 

[Indodo]

What do you mean by REpayments? and how do they stink?

 

[Shikima]

What do you mean by REpayments? and how do they stink?

Payment via Medicare for 214 is kinda lousy IMO.