Psychiatry CPT Code Changes

[F0nzie]

For those of us interested in either a full-time or part-time private practice, we may have some good news in the near future:

http://www.psych.org/practice/news-and-alerts/cpt-coding-changes-for-psychiatry

There will be significant changes for coding and billing of psychiatric services beginning on January 1, 2013

As you'll note on the AMA chart, code 90862 (Pharmacologic Management) has been eliminated. We would like to remind you that even today the work currently described by 90862 can also be captured using the general evaluation and management codes (99xxx series) used by most physicians.

Justification for this? Here's a study I looked up that highlights the problems:

http://www.ncbi.nlm.nih.gov/pubmed/14645792

As indicated in t1, findings from the 2002 NSPP indicated that in terms of discounted fees, psychiatrists who provide one 45- to 50- minute outpatient psychotherapy session with medical evaluation and management (CPT code 90807) earn $74.52 less per hour, or 40.9 percent less, than do psychiatrists who provide three 15-minute medication management sessions (CPT code 90862 for each visit). This financial disincentive for psychotherapy was also seen when psychiatrists' undiscounted fees were examined; psychiatrists who provide one 45- to 50- minute psychotherapy session with medical evaluation and management earn $107.60 dollars less per hour, or 40.9 percent less, than do psychiatrists who provide three 15-minute medication management visits.

Despite the fact this data was collected in 2002, the pay discrepancy has not significantly changed over the last 10 years. I also did a bit of research into the CPT 99xxx series that may be replacing our current codes:

which are reimbursed at much higher rates than our current codes:

90862

90805

90807

Bottomline? The 15 minute med check will be abolished. We may get compensated higher for standard 30 + 45 minute follow ups.

Thoughts?

---

Members don't see this ad.

 

[nitemagi]

Hawt.

 

[F0nzie]

The CPT codes I used were taken from an average cost of living city in the US to keep it consistent. Expect the numbers to be 10-30% higher in cities with a very high cost of living.

You can use this site to see the average reimbursement in your State: https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do?submitbutton=accept

 

[F0nzie]

While changing the CPT codes may result in a global increase in Psychiatrist's salaries for various salaried positions (perhaps not as much if the salary is subsized by the county, State, or Federal Government), private practitioners that want a low key practice might benefit from this the most. By looking at the graph below, private solo practice only has a small financial edge over academics. And if these numbers are not substantially flawed, you are probably financially better off in academics in the long run. Rise of private practice?

 

[Chrismander]

Maybe I'm being dense, but how does this change the incentive to provide psychotherapy? The APA's online CPT crash course specifically mentions that psychotherapy does not count as "counseling" for the purposes of time based coding. So if you spend 45 minutes psychotherapizing a patient, you can't just automatically say "I spent >50% in counseling" and bill for a 45 minute E&M session.

It's awesome that we're no longer (quite) as ghettoized from other physicians now that we can use E&M (and in fact have to use E&M as far as I can see now that 90862 is gone). From my point of view it's going to lead to a lot of psychiatrists using the extra time in their new 30 minute slots to listen for heart murmurs and use precious time from an intake to ensure that ALL 14 points of ROS are documented to death to capture the maximum E&M possible.

Again, maybe I'm missing something and 3 X 15 minute visits of E&M's will provide less total RVU's than some new unicorn of a 45 minute psychotherapy code... but it seems unlikely? at least to me.

Please explain if I'm wrong... again, I'm still fumbling around this CPT world myself.

 

[F0nzie]

Maybe I'm being dense, but how does this change the incentive to provide psychotherapy? The APA's online CPT crash course specifically mentions that psychotherapy does not count as "counseling" for the purposes of time based coding. So if you spend 45 minutes psychotherapizing a patient, you can't just automatically say "I spent >50% in counseling" and bill for a 45 minute E&M session.

It's awesome that we're no longer (quite) as ghettoized from other physicians now that we can use E&M (and in fact have to use E&M as far as I can see now that 90862 is gone). From my point of view it's going to lead to a lot of psychiatrists using the extra time in their new 30 minute slots to listen for heart murmurs and use precious time from an intake to ensure that ALL 14 points of ROS are documented to death to capture the maximum E&M possible.

Again, maybe I'm missing something and 3 X 15 minute visits of E&M's will provide less total RVU's than some new unicorn of a 45 minute psychotherapy code... but it seems unlikely? at least to me.

Please explain if I'm wrong... again, I'm still fumbling around this CPT world myself.

Apparently the APA is helping out with the development of new codes for mental health. Child psychiatry in particular definitely needs a helping hand.

 

[F0nzie]

The APA's online CPT crash course specifically mentions that psychotherapy does not count as "counseling" for the purposes of time based coding.

This is backwards on all sorts of levels. I hope they fix this.

 

[F0nzie]

If they plan on dropping our current code:

It seems they would replace it with this 99XXX code:

We would like to remind you that even today the work currently described by 90862 can also be captured using the general evaluation and management codes (99xxx series) used by most physicians.

Then whoever wrote this article in the APA website is misinformed as it does not appear to exist as an option for us. It seems if they revamped our codes to fit in with the 99XXX series, it would only make sense that we would also get the option for 30 + 45 minute visits.

 

[F0nzie]

Just spoke with one of the coders in our department that keeps up to date with these issues. Her impression was that the 15 minute med management code was to be dropped and that we would continue with our standard 90805 and 90807. If this ends up happening, I anticipate insurance based private practices that serve low-middle income families will take a substantial hit in revenue.

I just recently interviewed with a group practice that had physicians seeing patients every 15 minutes. Some physicians were apparently grinding patients every 10 minutes using the 90862 code. The director was straight up with me "if you're only seeing patients every 30 minutes, you may as well save yourself the hassle of private practice and work for the county. They will pay you more".

The discrepancies in reimbursements for other physicians frustrate me because they just further the stigma that mental health treatment is somehow "different". Maybe insurers think psychotherapy does not work, or there is an oversupply of therapists so they can undercut the therapy portion of it. I don't know. It really upsets me not knowing and understanding why these judgments are made.

 

[Chrismander]

Fonzie, do you have raw RVU data? The numbers above are in dollar amounts, which as you point out varies across the country. Right now a 15 minute 90862 is 0.95 RVU... roughly 4 RVU/hour. how does a 20 minute psychotherapy E&M visit compare?

 

[vistaril]

I just recently interviewed with a group practice that had physicians seeing patients every 15 minutes. Some physicians were apparently grinding patients every 10 minutes using the 90862 code. The director was straight up with me "if you're only seeing patients every 30 minutes, you may as well save yourself the hassle of private practice and work for the county. They will pay you more".

The discrepancies in reimbursements for other physicians frustrate me because they just further the stigma that mental health treatment is somehow "different". Maybe insurers think psychotherapy does not work, or there is an oversupply of therapists so they can undercut the therapy portion of it. I don't know. It really upsets me not knowing and understanding why these judgments are made.

1) insurers are never going to make it revenue-equal for psychiatrists to do therapy(vs meds) on a per hr basis. you knew this going in. Im baffled by why you are upset by it. If you want to do therapy you can......insurance just isn't going to pay you a bunch to do it.

2) mental health treatment is different. Anyone can see that the model is obviously different. I dont know that this is a stigma; it;'s just a reality. What....do you want the same billing codes as GI or something?

3) In the real world it's not uncommon for groups that hustle to average 5+ pts an hour. A lot of local psychs here in large groups see 45 pts a day if they are mostly repeats.....to get to that volume you need to be able to make up for time you go over on difficult pts by taking time away from brainless med checks that can be done in your sleep and you wonder why they are even there

note that Im not making a judgement to the above. It's just what happens at high volume practices.

 

[F0nzie]

Bumping the thread. New update:

http://www.psych.org/practice/manag...reimbursement/changes-to-psychiatry-cpt-codes

Changes to Psychiatry CPT Codes

Getting Ready for 2013


Background
Almost all of the codes in the Psychiatry section of CPT (the 908xx series of codes) will be changing next year. We are not permitted to provide specific information about the new CPT codes that will be used for psychiatry services beginning in 2013 until they are published by the AMA this fall. However, starting right now, there are a number of things a practice can do to prepare for the code changes that will help you be ready when the new codes go into use.

The APA is aware that some psychiatrists have contracts with payers that limit the codes they will be reimbursed for to those in the Psychiatry section of CPT. We will be doing outreach to major payers to ensure that they are aware the codes are changing and will be making the necessary accommodations so there will not be a hold-up with reimbursement when the new codes go into effect.

Practical Steps
The one specific we are able to provide about the changes is that code 90862, pharmacologic management, will no longer exist in 2013. Even now, it is appropriate to use a medical evaluation and management (E/M) code (i.e., 99212 or 99213) in place of 90862.)

Start familiarizing yourself with E/M codes for medication management and other patient encounters that are not primarily for psychotherapy. Unlike the psychotherapy codes, which are almost all timed codes, E/M codes are generally chosen based on the complexity of the presenting problem, the intensity of the examination required, and the difficulty of the medical decision making involved (as well as the setting where the service takes place and whether the patient is new or established). There are, however, typical times attached to the codes, and coding can be based on time if more than half of the patient encounter was spent in counseling the patient and providing coordination of care.

The Centers for Medicare and Medicaid Services (CMS) has a well written guide to E/M coding available on its website along with two sets of documentation guidelines for E/M coding – one from 1995 and the other from 1997. These guidelines are used by most payers when auditing E/M coding. The 1997 guidelines are the most appropriate ones for psychiatrists to use since they include a single-system psychiatric exam. We have posted an abridged version of the 1997 documentation guidelines (scroll to CMS Resources) on the APA website that just contains the information relevant to psychiatrists. The APA also has an online CME course that provides an introduction to E/M coding at www.apaeducation.org.

Contracts
You should review any contracts you have with insurers to see if they limit you to the current codes in the Psychiatry section of CPT (most of which will no longer exist in 2013). The APA will be contacting the major payers to alert them to the code changes, but it would also make sense for you to contact them to inquire about what will be done to revise the contract to accommodate the coding changes. Under HIPAA (the Health Insurance Portability and Accountability Act) all insurers are required to use the current CPT codes, which means they will be required to use the new coding schema and will need to update any contracts to take into account the new codes that psychiatrists will be using and also to ensure that psychiatrists will be reimbursed for providing evaluation and management services as the Parity Act requires.

Conclusion
Since there may only be three months between when the new psychiatry CPT codes are made public and when they will go into effect, it’s good to be doing everything you can to prepare for the changes now. Keep watching the APA website for new information and contact the Practice Management HelpLine—800.343.4671, [email protected] —if you have any questions.

 

[toothless rufus]

Bumping the thread. New update:

http://www.psych.org/practice/manag...reimbursement/changes-to-psychiatry-cpt-codes

So this is bad and decreases reimbursement and prevents one from seeing the usual number of patients per hour that are eligible for your usual billing, right?

Who makes up these rules, why are we forced to follow them without recourse, and why can't they leave well enough alone?!

If you are billing on "complexity" vs "time" the goal of whomever makes this stuff up is to decrease overall reimbursement, driving down incomes, correct?

Infuriating.

And correct me if I'm wrong, but as I understand it, physician salaries are not the problem anyway.

 

[BS81]

So this is bad and decreases reimbursement and prevents one from seeing the usual number of patients per hour that are eligible for your usual billing, right?

Who makes up these rules, why are we forced to follow them without recourse, and why can't they leave well enough alone?!

If you are billing on "complexity" vs "time" the goal of whomever makes this stuff up is to decrease overall reimbursement, driving down incomes, correct?

Infuriating.

And correct me if I'm wrong, but as I understand it, physician salaries are not the problem anyway.

Learn how to document and code properly and you should be making MORE

 

[toothless rufus]

Learn how to document and code properly and you should be making MORE

Really? That sounds promising. I must admit I have absolutely NO CLUE how all this billing stuff works. It is frightfully boring and appears time consuming. I guess the best time to learn is in residency. Is there a handbook or something?

 

[nitemagi]

Really? That sounds promising. I must admit I have absolutely NO CLUE how all this billing stuff works. It is frightfully boring and appears time consuming. I guess the best time to learn is in residency. Is there a handbook or something?

Try looking up codes here:

https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do

 

[toothless rufus]

Try looking up codes here:

https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do

Thanks!

 

[Chrismander]

BUMP!

So what is everyone's thoughts now? The guidelines are out. 90862 not being replaced by anything. Psychotherapy codes basically gone for M.D.'s, now an appendage to an E&M code. Can a dynamic psychiatrist doing weekly scheduled psychotherapy and taking insurance even do it anymore (if they ever could). I mean, wouldn't the insurance balk that they're billing E&M every week?

More importantly, what does this mean for the rest of us? Once a psychiatrist seeing 3-4 pts per hour switches to E&M, can they bill straight 99214 for 1.5 RVU's a pop (.95 for the old 90862) and really increase their income by 50%? Or is that pure fantasy?

 

[F0nzie]

BUMP!

So what is everyone's thoughts now? The guidelines are out. 90862 not being replaced by anything. Psychotherapy codes basically gone for M.D.'s, now an appendage to an E&M code. Can a dynamic psychiatrist doing weekly scheduled psychotherapy and taking insurance even do it anymore (if they ever could). I mean, wouldn't the insurance balk that they're billing E&M every week?

More importantly, what does this mean for the rest of us? Once a psychiatrist seeing 3-4 pts per hour switches to E&M, can they bill straight 99214 for 1.5 RVU's a pop (.95 for the old 90862) and really increase their income by 50%? Or is that pure fantasy?

Can you please provide a link for the official changes? I'm going to run this info by my billing department to see what they think.

 

[vistaril]

BUMP!

So what is everyone's thoughts now? The guidelines are out. 90862 not being replaced by anything. Psychotherapy codes basically gone for M.D.'s, now an appendage to an E&M code. Can a dynamic psychiatrist doing weekly scheduled psychotherapy and taking insurance even do it anymore (if they ever could). I mean, wouldn't the insurance balk that they're billing E&M every week?

More importantly, what does this mean for the rest of us? Once a psychiatrist seeing 3-4 pts per hour switches to E&M, can they bill straight 99214 for 1.5 RVU's a pop (.95 for the old 90862) and really increase their income by 50%? Or is that pure fantasy?

I think so....the bottom line is when doing med mgt you dont have to spend any min time with a pt and *something* has to be checked......

this looks like it is going to be good for outpt people who want to do high volume med mgt.

 

[michaelrack]

BUMP!

So what is everyone's thoughts now? The guidelines are out. 90862 not being replaced by anything. Psychotherapy codes basically gone for M.D.'s, now an appendage to an E&M code. Can a dynamic psychiatrist doing weekly scheduled psychotherapy and taking insurance even do it anymore (if they ever could). I mean, wouldn't the insurance balk that they're billing E&M every week?

More importantly, what does this mean for the rest of us? Once a psychiatrist seeing 3-4 pts per hour switches to E&M, can they bill straight 99214 for 1.5 RVU's a pop (.95 for the old 90862) and really increase their income by 50%? Or is that pure fantasy?

A psychiatrist seeing 3-4 patients an hour would probably bill a mixture of 99213 (straightforward cases) and 99214 (more complex cases with more documentation, especially documentation of the higher level of medical decision making).

 

[F0nzie]

A psychiatrist seeing 3-4 patients an hour would probably bill a mixture of 99213 (straightforward cases) and 99214 (more complex cases with more documentation, especially documentation of the higher level of medical decision making).

99213 is a 10-15% bump in reimbursement compared with 90862 (our old med management code). It isn't much, but at least it accounts for inflation over the last 5 or so years. Salaries are still very good, but with agencies hiring for 40 hours a week with no call, it makes private practice hardly seem worth the time and effort.

How does one objectively document complex medical decision making in Psychiatry if most of what we do is keep people on meds, change meds, or d/c meds? If it simply involves getting vital signs, I'd hire a nurse for that any day to bump my reimbursements by 40%. Highly doubt that is the case though. If we could bill 99214 for all follow ups, I'd be taking Medicare patients in a private practice.

And just as an update, the billing person in our department has absolutely no clue about the upcoming CPT changes. Apparently this issue has not been brought up in their meetings.

 

[billypilgrim37]

Dunno if this is helpful (my eyes glaze over any time I see a 5 digit number).

http://www.aacap.org/cs/business_of_practice/reimbursement_for_practitioners

 

[michaelrack]

How does one objectively document complex medical decision making in Psychiatry if most of what we do is keep people on meds, change meds, or d/c meds? If it simply involves getting vital signs, I'd hire a nurse for that any day to bump my reimbursements by 40%. Highly doubt that is the case though. If we could bill 99214 for all follow ups, I'd be taking Medicare patients in a private practice.

.

99213 "sleeping ok. tolerating prozac. No SI. cont prozac for depression".

99214. "s/p suicide attempt 10 days ago....now on prozac 10 mg/day... some pscyhomotor agitation... denies SI today but his family reports some islolative behavior... will add lamictal 25 qhs and f/u in one week, discussed what to do if suicidal thoughts return..." (might need a little more detail for a 99214)
Many cases of treating psychosis, especially if you document monitoring for TD or DM, would qualify for 99214.

 

[OldPsychDoc]

99213 "sleeping ok. tolerating prozac. No SI. cont prozac for depression".

99214. "s/p suicide attempt 10 days ago....now on prozac 10 mg/day... some pscyhomotor agitation... denies SI today but his family reports some islolative behavior... will add lamictal 25 qhs and f/u in one week, discussed what to do if suicidal thoughts return..." (might need a little more detail for a 99214)
Many cases of treating psychosis, especially if you document monitoring for TD or DM, would qualify for 99214.

Our billing folks have told us that as long as we document a medical ROS we're good to bill a 99214--I'm always checking in with pts re; their pain, diabetic control, thyroids, etc, anyway.

 

[F0nzie]

Dunno if this is helpful (my eyes glaze over any time I see a 5 digit number).

http://www.aacap.org/cs/business_of_practice/reimbursement_for_practitioners

Thanks for the link Billy!

Chapter 3 Video 45 seconds in....

laughed so freaking hard....

 

[Chrismander]

Our billing folks have told us that as long as we document a medical ROS we're good to bill a 99214--I'm always checking in with pts re; their pain, diabetic control, thyroids, etc, anyway.

So just to get this straight, if you see a q3month (or even q6month) rock stable totally remitted MDD pattient, and just continue their SSRI or whathaveyou at each visit after checking and shooting the breeze a bit, make sure you get a ROS (does it have to be comprehensive i.e. every organ system, or just a certain number), you just automatically bill a 99214 no questions asked?

If so, that's pretty sweet. Are you billing nearly 100% 99214's then? Do you have to use certain catchphrases or prepackaged sentences/paragraphs to help justify the medical decision making component?

Thanks & gratitude for any input you can give. I'm in the same boat as F0nzie above, our billing folks and admin have never heard of psychiatry using E&M and are totally silent right now. Here's praying 3 months is enough lead time for them.

 

[Chrismander]

... If it simply involves getting vital signs, I'd hire a nurse for that any day to bump my reimbursements by 40%.

Can someone please tell me where this vital sign meme came from and if it's true? If I'm reading the 1997 guidelines correctly, vitals are only necessary if trying for a "Comprehensive" single system exam, which is only necessary for a 99215. So if I'm correct (A huge 'if', i'm crazy out of my element here) you could fire your nurse and still bill straight 99214's (as long as you can justify medical decision making) for 1.5 RVU's a pop.

MichaelRack & OPD: is that right? Can you do 99214's without doing vitals as a matter of course?

We have RN's but they're super busy with intakes & telephone calls and only do vitals on new patients, and returning stimulant & effexor patients, or else when specifically asked. No way to do 100% vitals without significantly retooling our practice...so we're praying the vitals are not mandatory in any way for 99213/99214's.

Thanks guys!

 

[F0nzie]

There will be multiple add-ons to E/M. Psychotherapy will be an add-on. "Interactive complexity" will also be an add-on for difficult patients described as "high anxiety, high reactivity, repeated questions, and disagreement". Presence of family members or legal guardians may be included in this add-on. You can also code for 2 intake evaluations on separate days to interview family members. Seems like a huge win for all of us, especially for Child psychiatry and Geri Psych!

 

[Chrismander]

There will be multiple add-ons to E/M. Psychotherapy will be an add-on. "Interactive complexity" will also be an add-on for difficult patients described as "high anxiety, high reactivity, repeated questions, and disagreement". Presence of family members or legal guardians may be included in this add-on. You can also code for 2 intake evaluations on separate days to interview family members. Seems like a huge win for all of us, especially for Child psychiatry and Geri Psych!

So who is this bad for then? If anyone. Just curious.

 

[BS81]

So who is this bad for then? If anyone. Just curious.

They added a +90863 add on code which is the same as the old 90862 med management code but only allowed to be billed by Rx Psychologists. Since they can't do medical evaluation and management they can't bill E&M codes. Nice way to further delineate the two professions from a coding standpoint. I think RxP's will hurt from this and maybe they'll stop pushing for prescribing rights.

 

[michaelrack]

.

MichaelRack & OPD: is that right? Can you do 99214's without doing vitals as a matter of course?

!

yes, you need 2/3 elements for the 9921x series, so you can skip Physial exam and vitals.

Please note that no matter how much you document and how much ROS you obtain, you can't bill that level if you don't meet the criteria for complexity of medical decision making (although that isn't too hard to do).

 

[Chrismander]

yes, you need 2/3 elements for the 9921x series, so you can skip Physial exam and vitals.

Please note that no matter how much you document and how much ROS you obtain, you can't bill that level if you don't meet the criteria for complexity of medical decision making (although that isn't too hard to do).

My contention is that a Physical Exam could still count as "Detailed" just not "comprehensive" if it didn't have vitals but still had all the psychiatric elements, and therefore would count for 1 of the 2 required elements for a 99214, even without vitals. Is that incorrect?

 

[digitlnoize]

Maybe this will help: http://www.aafp.org/fpm/1999/0700/fpm19990700p32-rt1.pdf

So, we need 2/3 of:

1. Detailed History
2. Physical Exam (12 bullets from 2 systems)
3. Moderate Complexity MDM

1. For the "Detailed History" section, you need 4 HPI elements of acute problems or to address 3 chronic problems (which I would bet most of our patient would have. You also need 2-9 ROS (med side effects should cover this) and 1 PFSH (so ask about smoking).

2. For physical exam, we need 12 approved bullets from 2 systems. The "psychiatric exam" only counts these four items:
• Describe patient's judgment and insight
• Assess orientation to time, place and person
• Assess recent and remote memory
• Assess mood and affect

Hurray. Checking 3 of the 7 vital signs counts for 1 bullet. So, to meet this requirement we would have to do at least a cursory physical exam. A quick version might be:

Constitutional: Middle aged M/F, appears stated age, NAD. (1 bullet)
EMNT: Hearing normal, external appearance of ears and nose intact, (2 bullets)
Neck: Neck supple.
Resp: Normal respiratory effort. (1 bullet)
MSK: Normal gait, full ROM upper and lower extremities (2 bullet)
Psych: A&Ox3, good judgement/insight, recent and remote memory intact, mood stated as "good", affect euthymic. (4 bullets)

Total bullets = 11

So, we either need vitals, or some other PE component like using a stethoscope. Quickly listening to chest and lungs would get us 2 more bullets. Alternately, vitals would get us one more bullet. Thyroid check would get a bullet. You could probably claim CN II-XII grossly intact and get a bullet, eh? But that might be fudging it if you don't actually break out your penlight and make them say "ah" and what not.

3. Moderate MDM: There are 3 categories. Dx/Management, Data, Risk. Need 2 of 3.
A: D/M: 3 points needed. Established stable problem gets 1 point each. So pt would need 3 stable problems. Any new problem is automatically 3-4 points. A worsening problem is 2 points, so would need one worsening and 1 stable to get 3 points.

B: Data: 3 points needed. Labs is 1 point. Old records is 1 point. Collateral is 1 point. This one will be difficult for us to get after first visit, I think.

C: Risk: Only one thing needed. Any rx counts. 1 chronic illness that's worsened counts. 2 stable chronic illnesses (i.e. depression, anxiety).

-----------------

The answer is that it depends on the patient. If it's someone who is only there for well-controlled MDD only, you probably aren't going to get a 99214. This patient wouldn't qualify for the "Detailed History" as they don't have an acute problem or 3 chronic ones. You could easily get the Exam by doing a good physical. But MDM would be tough. You'd get 1/3 MDM for risk for writing an Rx. Likely wouldn't get data unless you're calling collateral, ordering labs, and reviewing old records at each visit, so fail. Pt only has one stable problem so only get 1 point for D/M part of MDM, so you have 2 MDM sections, but need 3.

Bottom line is that if you want to get a 99214 on everyone, you better make sure you're addressing 3 problems at each visit. Does that depressed patient smoke? Do they drink? Anxiety? Personality D/O? Find something else wrong with them!

 

[vistaril]

So who is this bad for then? If anyone. Just curious.

one big thing a lot of you guys are missing from this is that there are some cases where the pt is going to wonder why he was billed for a 'higher level of care' when he comes in stable just wanting his zoloft refilled......not everyone has the same copay for every office visit. Sometimes there are graduated copays, sometimes it is a percentage(admittedly less common now), and oftentimes there is a deductible that must be met before insurance kicks in. Taken as a whole, these situations are quite common.

 

[Chrismander]

Digitnoize: you missed the boat on the 1997 CMS "single organ system" specialist physical exams. It's posted on the APA (members only section) website. The rest of your post on MDM and History/PFSH was helpful for me, thank you. Have had absolutely minimal coding experience.

The main question I still continue to have is whether the Detailed Physical (single system) exam through the 1997 CPT regulations is truly sufficient with 9 bullet points of psychiatric info from the following list, even without vitals/musculoskeletal exam (both of which seem to be REQUIRED for a Comprehensive physical exam). Then the key followup question, if this 9 bullet point psych exam indeed counts as the entirely of a Detailed Exam, can we just do a ROS / PFSH and skip MDM entirely and still arrive at the mythical 99214? Come on folks, I feel like we've crowdsourced ourselves half the way there already!

Psych single system bullets from 1997 CMS E&M guidelines (allegedly 9 required for Detailed exam; ALL required + vitals & musculoskeletal exam for Comprehensive):
• Description of speech, including rate, volume, articulation,
coherence, and spontaneity with notation of abnormalities (e.g.,
perseveration, paucity of language)
• Description of thought processes, including rate of thoughts; content
of thoughts (e.g., logical vs. illogical, tangential); abstract reasoning;
and computation
• Description of associations (e.g., loose, tangential, circumstantial,
intact)
• Description of abnormal or psychotic thoughts, including
hallucinations, delusions, preoccupation with violence, homicidal or
suicidal ideation, and obsessions
• Description of the patient's judgment (e.g., concerning everyday
activities and social situations) and insight (e.g., concerning
psychiatric condition)
Complete mental status examination, including
• Orientation to time, place, and person
• Recent and remote memory
• Attention span and concentration
• Language (e.g., naming objects, repeating phrases)
• Fund of knowledge (e.g., awareness of current events, past history,
vocabulary)
• Mood and affect (e.g., depression, anxiety, agitation, hypomania,
lability)

 

[digitlnoize]

Digitnoize: you missed the boat on the 1997 CMS "single organ system" specialist physical exams.

Considering I was still rocking out in clubs back then, that doesn't surprise me. I'm only an intern now, ya know...Thanks though! Great to know!

Then the key followup question, if this 9 bullet point psych exam indeed counts as the entirely of a Detailed Exam, can we just do a ROS / PFSH and skip MDM entirely and still arrive at the mythical 99214?

I would say yes. We need 2 of the 3 criteria, and if what you are saying is true, that a good mental status exam basically counts for the "exam" criteria for E&M, then all we need is EITHER the "Detailed History" or the MDM.

The problem I described still remains. If our mythical patient does not have 1 ACUTE problem or THREE chronic problems...we still likely won't be able to bill a 99214 under the "Detailed History" criteria OR the MDM criteria, which both basically require 3 chronic problems or 1 new problem to meet this criteria...which basically renders the examination meaningless! Hurray!!!

The good news is that I bet most of our patients will have 3 problems. All we have to do is document them. My question: Do they have to be "DSM" problems. For example, if we counseled the depressed patient about their obesity problem, can that count as a chronic problem billable as such by us? Or HTN? Diabetes? You get the idea...

 

[toothless rufus]

Maybe this will help: http://www.aafp.org/fpm/1999/0700/fpm19990700p32-rt1.pdf

Shouldn't there be a psych-specific version?

 

[Chrismander]

.we still likely won't be able to bill a 99214 under the "Detailed History" criteria OR the MDM criteria, which both basically require 3 chronic problems or 1 new problem to meet this criteria...which basically renders the examination meaningless! Hurray!!!

The good news is that I bet most of our patients will have 3 problems. All we have to do is document them. My question: Do they have to be "DSM" problems. For example, if we counseled the depressed patient about their obesity problem, can that count as a chronic problem billable as such by us? Or HTN? Diabetes? You get the idea...

I think this is the crux then, and why I really need to find a good coder / E&M specialist to bounce this stuff off of before Jan 1.

Your point is quite salient... probably >50% of my patients are overweight or obese, which is super-relevant when prescribing atypicals/depakote/etc and therefore obesity (or hyperlipidemia, or DM2, or whatever) probably counts (or should count) as a "stable" diagnosis in those cases, because it's clearly relevant. But what about a condition being handled entirely by another specialist or PCP that has no clear-cut impact on my prescribing or the patient's mental state... hyperlipidemia/obesity and on an SSRI for anxiety. osteoarthritis and personality disorder. anemia and ADHD. I mean can we still count these by virtue of thinking about them at some point in the interview?

The other side of the coin is what psych stuff counts as a diagnosis, whether stable or unstable? "296.80, stable. 301.83, stable. 300.14, stable." So what happened there? DId I see someone with 3 different diagnoses who met the MDM & History criteria, or did I just divide one set of symptoms into three diagnoses?

This is enough to make me throw up my hands and demand to be socialized. I want a salary!

 

[digitlnoize]

I think this is the crux then, and why I really need to find a good coder / E&M specialist to bounce this stuff off of before Jan 1.

Your point is quite salient... probably >50% of my patients are overweight or obese, which is super-relevant when prescribing atypicals/depakote/etc and therefore obesity (or hyperlipidemia, or DM2, or whatever) probably counts (or should count) as a "stable" diagnosis in those cases, because it's clearly relevant. But what about a condition being handled entirely by another specialist or PCP that has no clear-cut impact on my prescribing or the patient's mental state... hyperlipidemia/obesity and on an SSRI for anxiety. osteoarthritis and personality disorder. anemia and ADHD. I mean can we still count these by virtue of thinking about them at some point in the interview?

My guess is that we could count them. I mean, we're freaking physicians after all, right?

The other side of the coin is what psych stuff counts as a diagnosis, whether stable or unstable? "296.80, stable. 301.83, stable. 300.14, stable." So what happened there? DId I see someone with 3 different diagnoses who met the MDM & History criteria, or did I just divide one set of symptoms into three diagnoses?

This is enough to make me throw up my hands and demand to be socialized. I want a salary!

I think that example would fit 99214 criteria. Those ARE 3 different diagnoses. It's not like you're dx-ing pt with Bipolar, MDD, and Mood NOS...that probably wouldn't fly. But BPAD, BPD, and DID would all fit okay, I think...

The family docs do the same thing when they have a patient with HTN, Obesity, DM, and Hyperlipidemia. 4 problems. 99214. Done.

 

[vistaril]

So, we either need vitals, or some other PE component like using a stethoscope. Quickly listening to chest and lungs would get us 2 more bullets. Alternately, vitals would get us one more bullet. Thyroid check would get a bullet. You could probably claim CN II-XII grossly intact and get a bullet, eh?
!

another thing to consider is...you know....that little thing called rapport, therapeutic alliance, respecting the patient, etc.......

if you have a typical high functioning GAD or dysthymia or OCD pt and they are coming in for a med check and refills and you start doing portions of a meaningless and fake PE with instruments they are going to catch on and lose a lot of respect for you. It will appear so contrived and out of place that they will know you just view them as a $ sign and are trying to check boxes...they may not be familar with medical coding but they will know it has something to do with that.....why else would their outpt psychiatrist start tapping on their belly or listening for bruits.....heck their medical dr/internist probably doesnt do those things.....lmfao....

 

[digitlnoize]

another thing to consider is...you know....that little thing called rapport, therapeutic alliance, respecting the patient, etc.......

if you have a typical high functioning GAD or dysthymia or OCD pt and they are coming in for a med check and refills and you start doing portions of a meaningless and fake PE with instruments they are going to catch on and lose a lot of respect for you. It will appear so contrived and out of place that they will know you just view them as a $ sign and are trying to check boxes...they may not be familar with medical coding but they will know it has something to do with that.....why else would their outpt psychiatrist start tapping on their belly or listening for bruits.....heck their medical dr/internist probably doesnt do those things.....lmfao....

I disagree 1000% (as usual) and actually think we should be doing at least cursory physical exams on patients. The differential for anxiety is quite large, and before assuming it's all in their head, it wouldn't be a bad idea to do an abdomen exam for, say, pheo.

I caught hemochromatosis presenting as depression and anxiety in a FM patient as a med student. Of course, I could've just skipped the physical and given him a refill on his Zoloft. Fortunately for him, I didn't (although the psychiatrist he'd been referred to apparently did), and I felt his enlarged liver, noted his nice winter tan, and asked if he had heart arrythmias (he did), and now he's getting good old fashioned blood letting, and likely not getting liver cancer.

Maybe we should listen to hearts more regularly since most of our drugs can cause inc QTc and other conduction abnormalities. Or, maybe we should do it because for many psych patients we may be the only doctor they see. Or, because a second set of ears keeping a lookout for warning signs never hurts. Why NOT take a second and listen for a murmur. It takes 2 seconds and could be an important finding.

Also, if you look at my "fake PE" listed above, you'll notice that it's pretty much all done with observation. No exam table, instrumentation, or palpation required in that version.

For me personally, I plan to at least listen get vitals (including weight, pulse, and BP), and listen to heart and lungs on each and every patient. Not for billing, but because I want to be a good doctor.

 

[Chrismander]

Maybe we should listen to hearts more regularly since most of our drugs can cause inc QTc and other conduction abnormalities.

Man, do I feel stupid now. Ordering expensive EKG after expensive EKG just for the QTc interval (calculated by the machine, natch). When all along my ears and stethoscope could have been doing it for free. Or even better than free, enriching me! So sort of like a BP check... the first sound you hear is the Q defection.. the second is the end of the T... just need a stopwatch... now just figure square root of the 60/heart rate... and done! Who said one semester of math for premeds was a waste of time!

OK, OK, I'm done. I actually agree with your general point that we don't do enough PE's... but I think Vistaril's winning here with the general notion that patients will rebel (and rightly so) unless the specific purpose of the PE is explained each time, and you have a compelling answer other than "Checking out your [Insert organ system here]". Like if you do a thyroid palp at each initial visit with depression or anxiety, mazel tov, though it's likely to be low yield, certain to be less sensitive/specific than the thyroid panel you'll run anyway, and will probably still freak your patient out even with proper explanation before and debriefing after. Little known fact, 99% of boundary violations start with "I'm gonna feel your thyroid baby, then check your neck and shoulders for...tension". [insert osteopath joke here]. And q-visit thyroid palpitation in someone with no thyroid history is insane... unless you take the causation in the ol' "a watched pot never boils" too seriously....

Routine checking [i.e. no symptom prompting the check, no med s/e we're specifically looking for] of even one or two organ systems will not go over well, nor should it.

Routine checking for cogwheeling rigidity is probaby indicated in someone on dopamine blockers... which you could probably explain each time as checking for s/e from the med they're on, and probably not lose their trust. But checking tone etc at every visit of someone on another kind of med is just stupid & greedy. Routine vitals (every visit) and weight (every few months) is a good idea, because it's a doctor's office, that's what happens at every other doctor's office even if you were just there a week ago, and many meds impact them, and many people have hypertension or obesity even without meds, and many of our patients don't have PCP's where this would be normally picked up on routine screening. Hell, my DENTIST checks my [totally normal] BP every visit... probably just an E&M billing device, but his explaination that many people don't go to their PCP's and it's now dental standard of care to screen for BP at the yearly visit because they pick up a bunch of new cases of HTN to refer to PCP is *just* plausible enough that I don't put up a fight over it. Nor do I when he insists on checking my neck for..."lymph nodes".

 

[F0nzie]

I can see doing a yearly physical for my patients but then I'd have to get an office suite with a sink.

 

[michaelrack]

Agree with Chrismander in general. It's fine,in my opinion, for a psychiatrist to do a general exam (if he is qualified) when initiating treatment and then do periodic focused (ie, neuro exam) when indicated.

Everything you do needs to be medically necessary. Doing an abdominal exam purely for billing purposes would be fraud- especially if done every visit.

 

[vistaril]

I disagree 1000% (as usual) and actually think we should be doing at least cursory physical exams on patients. The differential for anxiety is quite large, and before assuming it's all in their head, it wouldn't be a bad idea to do an abdomen exam for, say, pheo.

Maybe we should listen to hearts more regularly since most of our drugs can cause inc QTc and other conduction abnormalities.
For me personally, I plan to at least listen get vitals (including weight, pulse, and BP), and listen to heart and lungs on each and every patient. Not for billing, but because I want to be a good doctor.

lmfao...this is funny on so many levels. Curious- you've never been out in the 'real world' yet have you?

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

too funny....why stop there though? you're going to have your own cath suite too right?

once you get out into practice, you'll see what outpt psychiatry is like. Sometimes as we go through our first couple years in an academic setting we don't have a good understanding of this.

 

[vistaril]

Maybe we should listen to hearts more regularly since most of our drugs can cause inc QTc and other conduction abnormalities. Or, maybe we should do it because for many psych patients we may be the only doctor they see. .

if you are in a private outpt setting, you will most likely not be the only doctor they see. these patients are going to have insurance, and almost all have a primary care doctor(or medical specialists of some sort).....who are trained much better than you or me to do this sort of stuff. And your patients know this.

 

[vistaril]

For me personally, I plan to at least listen get vitals (including weight, pulse, and BP), and listen to heart and lungs on each and every patient..

there is absolutely no indication for an outpt psychiatrist on a routine visit to be listening to an asymptomatic pt's lungs on every visit. none.

 

[shan564]

there is absolutely no indication for an outpt psychiatrist on a routine visit to be listening to an asymptomatic pt's lungs on every visit. none.

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."

 

[nitemagi]

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. WHAT should be routine is a larger question, especially in a population with limited resources and engagement, and scrutiny at times for unnecessary physical contact with patients.

I think Shan's points are well taken, particularly if we conceptualize reimbursement drives thoroughness. 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.