Wednesday, September 02, 2009

Diagnostic Stability

I have a question: How do people put down diagnosis on insurance forms over time?
Okay, it's easy to start-- a patient walks in with Major Depression, recurrent, moderate in severity. 296.32
The patient takes medications and gets better. No more symptoms. They come once a month. Let's say they come for a 50 minute session once a month because....
But they aren't coming in and spending 50 minutes talking about their symptoms. They aren't having any. Maybe they spend 5 minutes talking about medication-related issues...needing refills, lab work, side effects. And then, they spend 45 minutes talking about the events and activities in their life and their relationships with others. Maybe one of those relationships is having some difficulty and this is what they spend the bulk of the session talking about.
So what's the code? Does it still code as a 296.32 (this is what they sought help for) or does it now go on the wonderful form as Major Depression, in remission. Oh, but they're only in remission because they are on meds.
And the next visit, the primary topic is a panic attack. But they don't have enough symptoms or enough frequency of panic attacks to actually meet criteria for panic disorder. Or maybe they do. Do you change the diagnosis to panic disorder, or do you leave it 296.32?
The following visit, what do you know, the patient is feeling a little depressed. Does the diagnosis change to major depression, mild?

And what about coding those sessions? If the patient doesn't talk about symptoms or medications, is it coded as a psychotherapy session (90806) or as a psychotherapy session with medication management (90807)? I always code a 90807 on the theory that I'm a doctor, and at some level, I always consider from what I hear whether the medications are working...enough, not enough, what ever. If someone's on medicine, there's no way I can know before they walk through the door whats med management and what's therapy. I know one psychiatrist who said he codes therapy sessions as 90806 (no med management and it's often reimbursed to the patient at a lower rate)....I wondered, if the patient walks in and wants their medications changed, does he tell them they have to come back for a different visit? Or does he wait to see how the session goes and then decide what to code (and what to charge?)

There are things they don't ever teach us in a formal way. And there's not a great way to ask (ah, who do you ask?)- I thought I'd ask you!


crystal said...

In my internship at a prison setting the qualifier "symptoms currently medication controlled" worked. As I am not practicing yet, I do not know if this is "insurance ok'd" so I am interested to hear answers to this post!

ItsTheWooo said...

From my experience with psychiatrists they generally diagnose you and bill you for the most expensive things possible.

E.G. first visit, I tell them my symptoms and history and within ten minutes she says I have bipolar II (???ten minutes so sure???)

Next few visits, additional information leads her to consider schizoaffective disorder (I definitely don't have that, I am high functioning)

The last, and final visit, after going off my medication (which wasn't helping much) and being admittedly distraught, agitated, and perhaps somewhat symptomatic (assuming I am even having symptoms)... she codes me as bipolar I mixed state severe. (which was obviously wrong as I wasn't in a mental institution so it couldn't be severe... and I don't think she thought that was true either, because she was only going to give me a low dose depakote which probably wouldn't make a dent in a "severe mixed state")

After that visit, I decided it was all a load of crap and never went back.

Maybe some psychiatrists are better than this but I got the impression her goal was to diagnose me with SOMETHING, ANYTHING, and the worse the better ($$$)

Anonymous said...

Mine uses different codes depending on the length of visit. I checked my copies of some recent claims forms and they were 90862, 90805, 90807, for, respectively, 30, 45, or 60 minute appointments. Although I think have seen a couple of other codes (maybe 90804 and/or 90806) on my bills in the past. I am on meds and we do always review those.

I don't know if he rethinks the diagnosis for billing purposes each time or not. Probably not, since the forms are filled in in advance of my visit. So I guess it is for what I am being treated for, not my current state.

a psychiatrist who learned from veterans said...

In the case you outline, the first f/u visit would be coded a 296.35, MDD in partial remission. The appropriate diagnosis even if the patient is weller than you is, by DSM-4 rule following a 296.1 or .2 or .3 or .4, a .5 for the first 3 months. If the primary effort subsequent visit was to R/O Panic disorder then I would make it a 300.01 or 300.21, panic disorder, for that visit. Later you might have 296.36, MDD recurrent in remission.

Dinah said...

Crystal: it's a good idea, but the insurance companies don't buy it.

ItsTheWoo: Some diagnoses are reimbursed and some aren't, but the actual fee depends only on the time and whether medications are involved. 50 minutes to treat anxiety gets reimbursed the same as 50 minutes to treat bipolar disorder or schizophrenia.

shrink who learned from vets: sounds like you re-consider the diagnosis with every visit.

Others ?