Saturday, August 30, 2008

CPT Billing Codes for Psychiatrists and Psychotherapy

Joseph j7uy5 over at Corpus Callosum posted a review of some articles in the recent issue of Archives of General Psychiatry.  One of the articles was "National Trends in Psychotherapy by Office-Based Psychiatrists" by Ramin Mojtabai & Mark Olfson (Arch Gen Psychiatry. 2008;65(8):962-970).

He linked to an LA Times summary of the article, which suggested that medications were increasingly "replacing" psychotherapy.  Joseph's take on the newspaper article was right on the money... that the article did not address whether medications were "replacing" psychotherapy, but "Instead, what the study says, is that psychiatrists are, on average, spending a smaller proportion of their time doing psychotherapy. It is possible (indeed, likely) that other practitioners are doing the psychotherapy, while the psychiatrists are devoting more of their time to medication management."

I'm going to go one step further and say that it doesn't even say that (though it still is probably true).  What the study says is that psychiatrists are billing for fewer and fewer psychotherapy visits.  Click on the image above and it takes you to a .pdf of the form that survey participants used as part of the National Ambulatory Medical Care Survey, which is what this study is based on.  It's a lot to complete, and I'm guessing that participating psychiatrists had an office staffer complete these forms.  And the office staff probably decided whether to darken the psychotherapy square only for patients scheduled for 45 minutes or an hour.  Or, maybe based on the billing code used.  I doubt that they asked the doc after each visit if she "used psychotherapy" with the patient.

Anyway, here is what the study "found":
Results:  Psychotherapy was provided in 5597 of 14 108 visits (34.0% [weighted]) sampled during a 10-year period. The percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (P < .001). This decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications. At the practice level, the decrease in providing psychotherapy corresponded with a decline in the number of psychiatrists who provided psychotherapy to all of their patients from 19.1% in 1996-1997 to 10.8% in 2004-2005 (P = .001). Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits, and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often. 
Conclusions:  There has been a recent significant decline in the provision of psychotherapy by psychiatrists in the United States. This trend is attributable to a decrease in the number of psychiatrists specializing in psychotherapy and a corresponding increase in those specializing in pharmacotherapy—changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years.

I wasn't able to find my issue of AGP around the house, but I'm sure that these limitations of the study were discussed.  Nonetheless, I'm not here so much to critique an article I didn't read as I am to explain about how psychiatrists bill for their services.

So, anyway, I submitted a comment to Joseph's post, which wound up being so long I thought I'd post it here, regarding how psychiatrist office visits usually get coded, or billed. 

When psychiatrists submit a bill to an insurance company, there are generally 3 types of codes one can use, which are called CPT codes (for Current Procedural Terminology). One is called an E&M code (Evaluation & Management). This would mostly be one of these: 99211, 99212, 99213, 99214, 99215 (each one is more complex or time-consuming than the next, with escalating payments). Use of this code requires a specific type of documentation. A number of insurance companies may either not pay for this code for psychiatrists, or require a preauthorization.

The next are psychotherapy codes, which are based on time and the main ones are 90805 (20-30 min), 90807 (45-50 min), and 90809 (75-80 min). These also require some specific documentation and payments escalate.  (There are other codes which are used when there is no E&M component, such as 90804, 90806, 90808, but most psychiatrists actually do evaluate and manage treatment with each visit, though they may use these even codes if they don't want to bother with the documentation, which can be quite onerous.)

Finally, there is the medication management code, or 90862. There is no time attached to this one, so whether you spend one minute or one hour with a patient, you can use this one. It is paid about the same as a 99213 and a bit less than a 90805. There are very little documentation requirements and rarely requires a preauthorization, so it is the easiest one to use. Many psychiatrists will use this code, yet still provide psychotherapy to a patient during the session, commonly 15 to 30 minutes long (a few docs may only see pts for 5 or 10 minutes, if the pt is well-known to them, or in a busy clinic, but this is probably not the standard).

So, since the abstract was unclear on this matter, I thought I'd do some teaching about how it works. Given how the study was done, I think that it only truly speaks to the success of managed care policies in paying less and less for psychiatric treatment. Of course, you get what you pay for.