Thursday, November 8, 2012

Prepare for the Coding Cliff

Meeting with a bunch of psychotherapists in my building the other day I asked how they planned to prepare for the changes in Current Procedural Terminology (CPT) codes scheduled to take effect on January 1. (CPT codes allow payers to reimburse for medical claims based on a numerical code.) None of them acknowledged any awareness of the change and its likely impact.

CPT codes have become one of the few remaining reasons for existence of the American Medical Association, which profits considerably from their publication, still a monopoly despite the fact that only a small minority of physicians still belong. Do not expect AMA to help you unless you belong. They make money selling the information you need.

I understand that new codes will replace all the old psychiatric codes, including initial evaluation, psychotherapy, and medical management. Do not expect payers to help you. If you submit an outdated code, they get to delay payment.

Psychotherapists may have it relatively easy. Just figure out what new codes replace the old codes.

Psychiatrists who provide what we used to call medical management will, however, start to use the same evaluation and management (E/M) codes internists and other primary care physicians have used for years. More complex than psychotherapy coding, each level of "procedure" requires performance of different services. For example, you may expect a sudden explosion in psychiatrists checking vital signs (pulse, blood pressure, etc.) at every encounter with patients who somehow survived all those past years without.

The devil may be in the documentation. Someday a payer may audit your records and have you sent to jail for fraud if your notes fail to support the procedure you claimed.

The American Psychiatric Association seems all excited at the prospect of psychiatrists obtaining reimbursement more commensurate with services provided. I will believe that when I see it. Do not expect APA to help unless you belong. APA retains few other benefits of membership. Notice I wrote reimbursement, not payment. This change means nothing to patients who pay you directly for your services. Do not expect them to jump for joy at the prospect of paying you more for the same service so your insured patients get better reimbursement. Ask them how much they want to pay for you to check blood pressure on every visit. Will we risk breaking some law if we continue to bill cash patients the old fashioned way while claiming new codes for those insured? Possibly.

How to prepare: I plan to look for online courses, ask my internist friends, and borrow a copy of one of the coding manuals published by AMA from a library. Good luck. Stay out of jail: only code for what you actually did.


  1. For every psychiatrist to consider urgently sending over his/her signature:

    (Rough draft)

    To whom it may concern at the AMA and the APA:

    This letter, though originally not composed by me, represents my viewpoints exactly. I urgently request you take immediate action regarding a problem that threatens the integrity of our profession of psychiatry and the health and lives of our patients, related to changes occurring regarding coding of our procedures.

    Psychotherapy is a recognized, accepted, and needed medical practice, that has been a part of our training as psychiatrists. We have also been trained to evaluate our patients' needs for medications and other "biological" treatments. We have a responsibility to be aware of our patients' medical status in general, and of the need to refer our patients to their primary care providers and/or to specialists as indicated. Thus, we are expected by our profession and society to maintain all of this concern and awareness throughout the interaction with a psychotherapeutic patient, as an integral part of being a physician.

    The psychotherapeutic relationship is considered to be especially important in our patient's lives. Anything that distorts that relationship, and introduces into it any element of artificiality or deception, can be quite disastrous for such patients, destroying their ability to communicate genuinely with confidence in our concern for their welfare, and introducing complex transference/countertransference processes detrimental to certain kinds of psychotherapy, thus presenting a health risk to the patient, even perhaps a life-threatening one.

    For unclear reasons, there have been changes in the coding for psychotherapy, affecting reimbursement in extremely significant ways, that do not appear to be based upon an adequate understanding of the nature of psychotherapy and that can predictably bring about the impairment and possible destruction of some psychotherapeutic relationships, with consequent negative and perhaps even tragic consequences.

    We psychiatrists who are providing psychotherapy for our patients, often on a weekly basis, in order to be reimbursed for our work will now be required either to code just for psychotherapy, and receive about one half of the amount that we had previously been receiving (perhaps resulting in closure of some practices), or, in order to be paid more appropriately, to code for E&M with the psychotherapy simply being an "add-on" code. Then, in order to document the E&M code, we must report that we have carried out certain procedures. Although the possible selections of procedures are multiple, ultimately they consist of ones that are usually not necessary or even appropriate to be done on a weekly basis.

    More simply and concretely, the new requirements for documentation for E&M make it most likely that a psychiatrist performing weekly psychotherapy would be expected to take the patient's blood pressure and pulse in every session, even if, for example, the patient was being followed quarterly by a primary care physician who was doing the same. It is exceedingly clear that such a procedure would often be totally unnecessary. And never in the history of the provision of psychotherapy has there ever been any expectation that such a set of procedures, carried out in every session, be a part of that psychotherapy.

    The introduction of these procedures into each weekly psychotherapy session makes it evident to the patient that the psychotherapist is performing a procedure that is unnecessary, simply in order to get paid more. In fact, if the psychotherapist is to be honest with his patient, that has to be the explanation given to the patient. Justifying this new procedure by giving some false rationale would easily be perceived as dishonesty, and alter the patient’s relationship to the treating psychiatrist, quite possibly profoundly affecting the patient’s perception of the psychotherapist’s integrity and trustworthiness, and reducing confidence in the treatment process.


  2. (Continued rough draft)

    All of the above has nothing to do with the general issue as to our public image with regard to integrity. The performance of unnecessary procedures in the service of getting paid more money is, I believe, bound ultimately to have a destructive effect on the image of our profession.

    There is a second issue of some importance.

    It should be noted that although we psychiatrist's do indeed prescribed medication, it is just as important a medical judgment to decide that a patient should discontinue medication, or not begin it in the first place. This is especially true because any of our medications have a certain risk for the patient that has to be weighed against the benefits of its use. Since we are physicians, we are indeed held responsible by our profession and by society for making such decisions any time we are treating our patients with psychotherapy.

    It would be especially troubling to see the introduction of any administrative procedures that would in any way tend to promote the prescribing of medication in order to make more money. A psychotherapist who is understood to have the patient's medical welfare in mind at all times, and is expected to make the judgment as to whether the patient also needs medication, should feel absolutely free to make the judgment in each session that the patient does not need psychotropic medication, and/or does not need any change in such medication.

    There is nothing inherent in the current coding requirements that would make the prescribing of medication necessary, of course, but I am concerned that the implication that psychotherapy is an "add-on" to a procedure that does not involve psychotherapy may indeed lead to a bias toward the prescribing of medication in order to justify the use of E&M codes. If anything, it should be understood that the provision of a psychotherapy session by a psychiatrist automatically includes the continuing, unceasing assessment of the patient with regard to need for medication. This should be the automatic expectation, the only exception being the explicit understanding between the psychiatrist performing psychotherapy and the patient that the patient's medication decisions would be made by another specific medical provider.

    Psychologists who are prescribing medication will now code for psychotherapy and, secondarily, for medication management (+98063), and thereby presumably get paid more. I have special concern that this could promote the prescribing of medication that might not be needed. I believe this separate code should be used for any psychologist performing psychotherapy who is authorized to prescribe medication, whether he or she prescribes it or not. I believe this should be made very clear.

    If an add-on code methodology is necessary for psychotherapy, I recommend that the model being used for psychologists be used also for psychiatrists, and that in both cases the code simply mean that the psychotherapist also is assuming the responsibility for decisions regarding psychotropic medication. There could be separate such codes for psychiatrists and psychologists, to reflect the greater breadth of medical responsibility assumed by psychiatrists. Documentation of such sessions could include a statement regarding the prescribing of medication or the consideration of doing so or the decision not to do so. Although in my opinion such a statement really should be assumed, this documentation would make it explicit. And such documentation would not interfere with the psychotherapeutic relationship.

    I urgently request that this matter be taken care of immediately. It is quite possible that the new coding requirements may drive some of us out of our professions, because of an unwillingness to have our integrity compromised.


  3. William V. Van Fleet, MDDecember 14, 2012 at 5:05 PM

    Is anyone going to take this action, send the letter in and share it with other psychiatrists to see if they wish to do so also?