Thursday, April 04, 2013

The Irony of "Medical Necessity."

In the state of Maryland, regulations require that patients seen in community mental health centers must see a physician every 90 days for a review, unless they are not taking medications, in which case they must see a physician once every 6 months.  It seems reasonable to me to say that a patient with a chronic disorder on medications should be seen 4 times a year to have their status, medications, lab work, health issues, mental status exam, all reviewed and to make sure the medications are still working and indicated and not causing undo side effects.  At the psychiatrist's discretion, patients can be seen more often, and patients who are having a problem are seen sooner.  Every patient has an assigned therapist and it's not unusual for a therapist to schedule someone to come in sooner than the 90 day review if they aren't doing well.  When I see someone, I often start my note with "Here for 90 day review."  It's code to myself that it's a routine visit to assess the continued necessity of the medications, and it's a bit different than if I write "Seen for an emergency -- sister notes was walking naked on the golf course and the patient is complaining of auditory hallucinations."  

So today I received an email informing me that the clinic is auditing charts to be sure the documentation fits with the CPT codes that are billed.  It's a problem, we're told, if the note says that the patient is being seen for a 90 day review.  It implies that the visit is for paperwork, and that there is no medically necessary reason for the visit and I shouldn't do this.

So wait, the law requires that I see the patient every 90 days, but if I write that that's why the patient is here today, that's a problem, because it's legally required but doesn't make the bar for being "medically necessary"?    


jesse said...

Not sure I understand. What is the code that you use for the 90 day review? Does that code require that the review is done for some reason other than a routine and proper check? If it is good practice to see every patient every 90 days, then does not that then make it "medically necessary"? For instance, when my internist checks my blood pressure on my yearly exam, given that I have not complained (there's that word) about any symptoms, is it not medically appropriate and necessary to do that to make the exam valid and useful? And do not insurance companies pay for that blood pressure reading without question?

Steven Reidbord MD said...

There's an irony, yes, but it's not irresolvable. You seem to agree that such a visit at least every 90 days really is medically necessary. Then don't document that you're doing it because it's required, document that you're doing it for the good reasons you admit there are.

Insurance makes a mockery of documentation. I recall working on an inpatient unit many years ago, and having to carefully chart that each patient was still terribly ill (so they wouldn't be de-funded prematurely for not needing treatment), and yet showing improvement (so they wouldn't be de-funded for wastefully consuming a valuable resource). Whether patients were actually improving, stable, or getting worse was an entirely separate issue. We paid a lot of attention and concern to patients' actual status, but we didn't dare chart it.

It's a lot better now that I shun insurance in my private practice and chart in ways that help me work with my patients.

Dinah said...

Jesse, It's a clinic, the appointments are billed to the insurance (usually Medicare and Medicaid) and these aren't therapy sessions, so each visit is billed according to what was actually done. Often, I end up using the time based code of 99214 (I think that's 25 minutes). If the patient spends a lot of time talking about personal issues unrelated to meds/symptoms/side effects, there may be a shorter time code and add-on therapy.

Steven: It's not unresolvable, but I don't like the whole mockery of charting issue. I know that "here for 90 day review" means : "Here to review continued need for medications, efficacy, side effects, and to assess medical monitoring needs"...the appointment needs to be documented on a two page color-specific form which includes a zillion things, so it seems the auditors/reviewers could also know that these multitude of issues are reviewed every 90 days and that this is medically necessary/reasonable.

And Jesse, the physical is reimbursed, but the blood pressure part doesn't not get reimbursed separately.

jesse said...

The annual APA meeting is in San Francisco in May. The Golden Gate Bridge and the Transamerica Tower. Telegraph Hill. Noe Valley.

it's medically necessary and does not require a code.

jesse said...

Thinking about this further, Dinah, who has determined that the 90 day check does not clear the bar for being medically necessary? As Dr. R noted you think it is medically necessary. Is more needed?

It is often the case that honest people with strong consciences (read Dinah) who can see different viewpoints create a problem for themselves by essentially arguing against themselves. Their strong superego does them in. This is one reason blogs like this, talking with peers, conferences (like the one in San Francisco) are so valuable. They can let us see that at times the convenient road and the honest road coincide.

Joel Hassman, MD said...

Speaking for one who works at a CMHC, what is the issue, if state MA alone sets the bar? And, you don't mention that patients have to see someone every 3 months for a therapy/case mngmt type visit as well, which over the years working at various clinics some docs do not hold patients to honoring. But, it seems the consequences of accepting this new CPT coding system are coming to fruition even earlier than I saw happening.

Gee, the APA thought this would benefit the profession. Maybe time for another seminar?

Mary K Parker said...

Looking at it from a Utilization Review/Utilization Management (UR/UM) perspective, your auditor is simply making sure you use the proper language to ensure maximum reimbursement for what you do.

Medicare (and insurance compancies, consequently) change the verbiage every year (making it necessary for UR/UM staff to attend regular update training). If changing the wording while the content and facts remain unchanged means you're reimbursed at a 2.56 rate versus a 1.88 rate, then I'd just go along. Good UR/UM staff can make their salaries back and more by alerting providers to changes in wording that result in better reimbursements of care.

It's unfortunate we live in such an Orwellian society....

HIGurl said...


Gotta love the challenge here! I honestly feel that the decision to dispense drugs (in each of these dilemmas) comes down to ethics. Bottom line.

The impasse is that we tend to take a look at the whole picture and then decide 'yae' or 'nae'. Does the risk outweigh the benefits?

For example, let's take the patient requesting the Valium. Is he healthy? Why is he asking for a specific drug, is there a hidden reason? Did he have this particular drug or a similar one before? Does he seem like the kind of person to sell his prescription? Will he be back for more meds? Can it contribute to more anxiety later? What if I decide not to prescribe it? (BTW, if this scenario what genuine, I think this person would ask for two pills, not one - because he needs to fly back).

In this case, I would ask him to go she his primary care physician. I mean, you don't see any presentable mental health issues, right? Be like some politicians/legislators and throw the responsibility/liability to someone else! Lol. Well, you could contact his previous physician who prescribed it before and decide then dispense (if applicable).

Again, a scenario such as this presents much dilemma. It's like being a Becker's MD patient with great cholesterol and blood pressure numbers who needs a new heart or defibrillator implant - "Do I want a donut or a fruit salad for dessert?" Isn't life full of choices? Decisions, decisions, decisions...

a psychiatrist who learned from veterans said...

APA guidelines are with the initiation of an antidepressant for the pt to be seen 3 times including the first visit in the first 3 months. That pace or nearly that pace hardly needs to be maintained as a routine. Ideally, we have too much real work to do and that is what is embedded in the new procedure codes.