Shrink Rap Today

Three psychiatrists explain their work

The End of The 50 Minute Hour?

Will the new CPT codes change mental health practices?

  On January 1, 2013, new coding procedures will go into effect for mental health services. Our Current Procedural Terminology (CPT) codes are used to bill insurers for services, and psychiatry coding has not changed since 1998. The existing codes are self-explanatory. For example, psychiatrists often bill with the CPT code “90807” which stands for a 45-50 minute outpatient psychotherapy session with medication management. Everyone know what this means.

Psychiatry has changed since 1998 and the current codes are not felt to capture the complexity or diversity of what psychiatrists now do. In addition to the basic CPT codes, there are more specific Evaluation and Management (E/M) codes which require specific elements to the exam and documentation, but many psychiatrists -- myself included -- have practiced without ever using these E/M codes.

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The new CPT codes include a level of complexity that mental health clinicians and their support staff are only now just beginning to learn. The new codes were announced by the American Medical Association in mid-September, and which new codes mental health professionals should use is not entirely obvious; it requires training. The National Council for Community Behavioral Healthcare hosted a two hour webinar and showed 99 slides to begin the educational process. Their webinar reached maximum capacity and would-be registrants were turned away. In mid-November, the American Psychiatric Association held a meeting to teach district branch leaders how to do the coding, and in my state, the Maryland Psychiatric Society will begin offering seminars in December.

The new codes, like the old ones, allow psychotherapy to be billed according to time, but as increments of 30, 45, and 60 minutes. Presumably, the longer sessions will result in higher reimbursement, but under the new guidelines, a 50 minute session – or any psychotherapy session running 38-52 minutes -- would be coded as 45 minutes. The code for a 60 minute session will require that the session last a minimum of 53 minutes.

If this isn’t confusing enough, for those who prescribe medications, E/M codes will now be required for every appointment and the code for pharmacologic management will be abolished. The time involved for medication and education issues must not be included in the overall psychotherapy time if the psychiatrist does both, so two codes will be used for one visit and the services, offered in the same appointment, must be distinct. You’ve got that, right? The E/M codes will allow for five different levels of complexity, and will require the psychiatrist to provide specific documentation regarding the history, examination, and medical decision making. Having reviewed all this, I still have not figured out the E/M codes, and don’t know what codes to use for my usual 50 minute psychotherapy session, which I believe will now be 53 minutes, or maybe 38 minutes -- which can be billed as 45 minutes -- plus the added, undefined period of time it takes to perform the E/M medication-related service, after determining what level of complexity that is. There will also be codes for crisis management and difficult family situations. To put it simply, there will now approximately 17 different ways to code a 50 minute psychotherapy session with medication management, depending on precisely what gets said in the session, and each combination will yield a different fee. There doesn’t seem to be a code for the time spent figuring out the right code for each session, or any concern that these issues might distract clinicians from patient care issues.

So what does this mean for mental health practioners and for the patients who receive treatment? I think the changes will end up being fairly straightforward for those who offer only psychotherapy or only medication management. For psychiatrists, the hope is that the coding will better capture what it is we actually do and will allow for an appreciation of the complexity that differentiates psychiatry from other mental health specialties. The fear is that these changes will create a lot of confusion, especially at first, and they promise to increase the paperwork burden, and anxiety about inadvertantly fraudulent claims.

With six weeks to implementation, tens of thousands of individual clinicians, administrative staffers, and institutions still need to be trained, and then to adjust the ways in which in which they practice, document, and bill.

I suspect that we’re in for a time of transition, and that appointments will be submitted with incorrect codes only to be rejected. Ultimately, the kinks will get worked out, but the new system promises to be more cumbersome.

For the physician who participates in health insurance networks, perhaps payments will rise, and for those who don’t participate, these changes may allow their patients to receive better reimbursement for out-of-network services. So far, however, that’s not looking good, at least not for Medicare providers and recipients. The 2013 Medicare fee schedule released last week reveals that reimbursement for psychiatric evaluations with medical services – those done by psychiatrists – will be lower than reimbursements for psychiatric evaluations done by social workers and psychologists. And timed psychotherapy provided by psychiatrists who also provide E/M services will be reimbursed at a lower rate than psychotherapy provided by those who are not managing medical issues. This makes no sense, and seems to run counter to the premise that creating a comprehensive system of coding services would create an appreciation for the complexity of the medical aspects of treating mental disorders, address parity, and decrease the stigma to seeing a psychiatrist.

I talked about this in a bit more detail with the pros and cons on KevinMD, here.

Your 38 minutes are up now.

 

Dinah Miller, M.D. is a psychiatrist in Baltimore. She is co-author of Shrink Rap: Three Psychiatrist Explain Their Work

 

Dinah Miller, M.D., is a psychiatrist and writer in Baltimore, Maryland. She is co-author of the book Shrink Rap: Three Psychiatrists Explain Their Work.

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