Tuesday, January 29, 2013

How's It Going: The New CPT Codes for Psychiatry for 2013

So our psychiatric society now has a separate listserv just for CPT code issues (not my idea) and the CPT posts on both listservs are flying in.  What codes to use, what codes insurers are denying, what rates insurers are paying.  I'm not sure anything has caused such confusion and angst in recent years.

How's it going for you?

My CPT YouTube Tutorials are still up if you'd like to watch, but with so much speculation going on among the professionals, I don't think anyone has any idea what we are supposed to be doing.  

For one patient back in December, I requested pre-authorization for psychotherapy with med management (the old 90807), I was sent authorization to see the patient for 20 visits for 99211 -- 5 minute visits (and they said that).  I re-submitted a Uniform Treatment Plan asking for authorization for more reasonable codes, but just the idea!  

So it's been just about a month: If you're a patient, are you getting reimbursed?  If you're a shrink: are you getting paid?  I'll ask again in a few weeks, but I'm assuming I'll be filling out many repeat statements for patients to submit.

Tell me your stories!

How's It Going? The NY SAFE Act and Mandatory Thought Police for Therapists

Oh, Clink is going to hate me for that provocative post title, but so it goes.  

There's so much going on that I'm going to put up a few posts in a row.  

This one is to ask for your feedback: How are people in New York feeling about the new law requiring therapists to report people they feel are likely to be dangerous? Read my views Here and Clink's view Here.

I'm watching legislation in Maryland carefully.  So far, our governor has proposed legislation that requires reporting all patients who have a continuous stay in a psychiatric facility for over 30 days, voluntary or not.  I figure this probably captures eating disordered patients, geriatric admissions, and forensic patients (--who mostly already get reported because the current law requires reporting involuntary patients in state hospitals for over 30 days).  You can later request your gun rights back by appealing with a letter from a psychiatrist certifying that you are safe.  I'll get you a list of psychiatrists who will be providing those, right along side those who will be prescribing medical marijuana, which is also back in the hopper again.  

We are expecting a bill to be proposed soon that will require therapists to report dangerous patients -- hopefully it will go nowhere.  Oddly enough, while there is legislation mandating that psych patients be reported to the government to curtail their access to guns, there is also legislation proposed by Delegate Don Dwyer proposing that ammunition sales people may not require identification in order to purchase ammunition and forbidding such information to be given to the government.  I may move to Delegate Dwyer's district just so I can vote against him.  The last time I had a cold, I was required to fill out forms and provide my drivers' license (taken to the back room for several minutes) before I could get a single box of decongestants.  I look like the Meth Lab type? (Oh, but I am enjoying Breaking Bad). 

So I want to hear from you, especially if you live in New York!

Saturday, January 26, 2013

Now is the Time: Sebelius, Hyde, and Insel Begin National Dialogue on Mental Illness

HHS Secretary Sebelius held a public phone call on Jan 16 regarding the expansion of mental health (MH) treatment, especially for kids. This was the day after President Obama's "Now is the Time" [pdf] plan was released. The recorded 30-minute phone call is available until Feb 15 and can be listened to by calling 888-568-0013 (no codes or anything).

Here are some of the points I noted while listening:
  • 60% of people with mental illness and 85% of people with substance use disorders do not receive help
  • failure to receive help is largely due to stigma and people not asking for help [umm, what about failure to access help due to insurance barriers and inadequate and inaccurate provider directories?]
  • Project AWARE to train 5000 MH professionals to help identify MH problems in school age kids
  • to help eliminate stigma, she will be initiating a year-long "national dialogue" about mental illness, focusing on young people
  • mentioned a Healthy Transitions program for young adults

Then SAMHSA Director Pam Hyde entertained questions from callers. My telegraphic notes are below:

  • peer specialists (Pam called them "peer professionals")
  • surrogate parents and their MH needs
  • workforce issues
  • correlation of violence w psych meds; toxic practices w/in MH; stigma of coercive treatment; fear guns removed w/o reason 
  • veterans' advocate in Michigan: how do we determine who is at risk and who is not; removing vets' guns; how to reach people in gangs
  • APRN public health nurse: expanding nurses' scope of practice to treat people with mental illness can improve access
  • hope for expansion of voluntary, and not involuntary, treatment; "open dialogue" concept from Finland
  • ACLU: training police to deal better w MH symptoms, esp in kids, so they don't enter the justice system
  • NFFMH: concerns about cuts to existing programs for families

NIMH Director Tom Insel was also present, and said additional questions and comments can be sent to this email: externalaffairs@hhs.gov.

The Bodies Under the Floorboards

The subtitle for this post is: No Crystal Balls Here.

I know ClinkShrink disagrees with me and thinks the NY State gun legislation requiring psychiatrists to report people who, in the judgement of the mental health professional, are likely to be dangerous, is not so bad.  She has pointed out that the information gets reported to another mental health professional employed by the state, and that official makes a decision about moving it to another agency.  Maybe that official will go out and meet all the patients this will include and review their records and examine them.  That would be good.  But I think it will be a lot of individuals -- presumably everyone seen in an ED for a serious suicide attempt, and many people admitted to a psychiatric unit. We'll have to see what that ends up meaning and how that Director of Community Services decides who gets reported on.  I don't think that many outpatient clinicians will be reporting their patients unless they are really, really worried, and reporting someone who tells you that they are stockpiling arms and planning to kill a lot of people, well, that person should get reported.  We really don't think that psychiatrists should keep silent if a very psychotic person is talking about killing the neighbors because they are aliens who have cameras watching him and he knows this because something on his desk was in a different position than where he left it.

Periodically over the years, I've met patients who fit the profile of someone I'd find worrisome.  Male, loner, no social contacts, a little odd, who has expressed some aggressive thoughts.  Decades ago, I remember telling a colleague, "No one will be surprised when they find bodies under his floorboards."  In none of these cases has their been anything to report.  The persons in question have not had histories of violence, they haven't mentioned owning weapons, there is nothing specific other than their inability to relate normally and they have all been actively (and voluntarily) engaged in their  mental health care.  To the best that I can tell, my predictive powers with such individuals has been exactly Zero.  I have never seen an article in the paper that any of them have committed any crimes, that bodies have been dragged up from under their floorboards.  It's a different story if there is a history of violence,  then my predictive power goes up (a little) , and often alcohol and drugs are involved.  And sometimes someone does something that is a complete surprise, that I could not possibly have seen coming.  No guns, one power saw. Ugh.

I don't like guns for anyone.  Perfectly sane people get drunk or angry and if there's a gun there, they may shoot the person who provokes them.  I prefer a good fistfight any day.  Many people start to commit suicide and change their minds.  Many, many people and swallowing pills may let you change your mind, guns generally don't.  And if you read the papers in Baltimore, it's not an unusual event to take out someone else as you go, murder-suicides are not infrequent.  I do realize that criminals have illegal guns that legislation doesn't touch, but I still just don't like guns, even if you're using them to shoot animals for sport.  No stuffed heads hanging over the door in my office.  

I would like the option to report someone I think is dangerous.  I have that option now, I can have them brought to an emergency room for an assessment -- the police will do this for me if I fill out the right form.    In the clinic, we can call hospital security to take someone to the emergency room -- it's not always pretty,  but it doesn't involve the state, at least not a my level.  If the government would like to expand my options by saying I can report someone I believe might be potentially dangerous without being imminently dangerous, that's fine.  There might be times it would be nice to have that option so that if I'm losing sleep over someone where I'm just not sure, it might be a little easier to get them evaluated for hospitalization.  What  I don't want is the government mandating that I am REQUIRED to report someone based on my thoughts of what they might do, because my predictive powers are Zero, and honestly, my thoughts are none of anyone's business.  I'm not sure why the APA and NY Psychiatric Association aren't making more noise about this.  I'm not sure the legislation is awful -- it depends on how it actually plays out -- but I still think it's a slope I don't want to be on.  And regardless of the implications, I worry that people who need help won't get it because of the perception it creates.  We have commenters writing in to say they won't see a psychiatrist because they think they will be reported to a data bank which will prevent them from getting jobs.  Or they're worried their psychiatrist will misinterpret something and report them (--believe me, outpatient psychiatrists are NOT going to be rushing to report their patients and will ask if this is a fantasy or an intention before calling authorities).  Still, regardless of the wording of the legislation, the New York Times has reported that mental health professionals are required to report people who are likely to be dangerous, and even if that doesn't capture the nuances of the NY SAFE Act, that perception is now out there. 

New York mental health professionals: I want to hear from you! 
APA officials : Wake up.

Oh, and while I'm talking about crystal balls, there  great op-ed piece in the NY Times by Elyn Saks.  See Schizophrenic, Not Stupid.  And for the record, I have never told anyone they shouldn't work upon receiving a diagnosis.  Plenty of people pop back from psychotic disorders, and we just don't what someone can achieve until they try.     
Please also see our last post and the comments on The NY SAFE Act, and the articles we wrote on the Clinical Psychiatry News Website.  
Dinah's piece on CPN is also available on Psychology Today without the password.

Tuesday, January 22, 2013

The NY SAFE Act : Should Therapists Worry About Mandatory Reporting Requirements?

Last week, when New York legislators approved the New York SAFE Act on gun control, several people wrote in asking us to comment on mandatory reporting of dangerous persons to state authorities.  Of course we couldn't keep quiet about such a topic, but interestingly, Clink and I had somewhat different interpretations and opinions about the legislation.  We've both written articles over on Shrink Rap News on the Clinical Psychiatry Website and I'll invite you to surf over there to read:


Monday, January 21, 2013

Take My Gun Rights, Please

I think we assume that those with a mental disorder don't want to be told they can't own a gun.  Maybe it's stigma, maybe it's simply the fact that no one wants to be told they don't have the same rights as anyone else.  My personal problem with the idea of keeping guns from people with mental illnesses is that we really haven't clearly defined who those "mentally ill" out there are and it's not an "Us" and "Them" issue.  If someone has been hospitalized for dangerous behavior arising from a mental disorder, requires medications for chronic difficulties with mood or perceptions, and are on governmental disability for a psychiatric disorder, then they are certain in the category of  people with mental illnesses.  But half of all people will have a mental illness of some kind at some point in their life, many people without defined psychiatric disorders will behave in impulsive and dangerous ways, and people who do not have mental illnesses will obtain guns and later become ill, or will live with others who become dangerous. 

So this article caught my attention because the writer thinks about obtaining a gun after someone tried to crash into her home.  I thought she was going to be glad she didn't end up shooting some intoxicated guy.  Instead, she talks about her own depression and how she decided not to purchase a gun because she is afraid she will use it to commit suicide if she has another episode of depression.  She doesn't think it's a bad idea for the government to forbid people with her condition from buying guns.  A link, and a quote, and I'll leave it at that.  Comment as you like.

Please Take Away My Right To A Gun
from The New York Times, by Wendy Button.

My depression appeared for the first time in the late ’90s, right before I began writing for politicians. It comes and goes like fog. Medicine can help. I have my tricks to manage and get through it. Sometimes it sticks around for a day or a week, and sometimes it stays away for a couple of years. But it never leads me to sleep all day, cry and wear sweat pants like the people in the commercials. You’d look at me and never know that sometimes my fight against the urge to die is so tough the only way I get through it is second by second; I live by the second hand. 

According to the Centers for Disease Control and Prevention, 38,364 Americans lost that fight in 2010 and committed suicide; 19,392 used a gun. No one ever attempted to break down my door in the early morning again, but I had an episode when my depression did come back in full force in the early winter of 2009, after I made a career-ending decision and isolated myself too much; on a January night in 2010; and again in May 2012, after testifying in the federal criminal trial of John Edwards, my former boss. If I had purchased that gun and it had been in my possession, I’m not sure I would have been able to resist and would be here typing these words.

Sunday, January 20, 2013

Shrink Rappers Top Clinical Psychiatry News

The list of the top ten most frequently viewed articles for 2012 in Clinical Psychiatry News just came out, and the Shrink Rappers are well represented with three posts by each of us. Here they are, in the order of "most viewed":

1. Is Ketamine the Next Big Thing for Depression? (by Roy)

2. The Aurora Shootings: Why The Mental Health Community Must Show Restraint (by me)

3. It's Time to Stop Strip Searching Patients (by Dinah)

I thought that given our blog readers' input and thoughts on our various posts over the years, I should let you guys know that your comments have helped shape what we write about as well as our opinions over the years. Apparently, the psychiatric community at large is listening too, if the Clinical Psychiatry News stats are any indication.

So....keep reading, keep commenting and thank you for helping us write.


Wednesday, January 16, 2013

A New Computer and A Nice Book Review Found in the Middle of the Night

So with all the CPT code nonsense, I've decided to computerize my practice and do my own billing in a different way.  I bought a computer -- an All-in-One thing with the computer in the screen, and a printer, and a desk to put them on.  I got the password for the WiFi from one of my office mates and am now chipping in for the Verizon bill (well, sort of).  So, yes, if you're wondering, I didn't have a computer, or a desk, in my office until last week.  Before I had a smart phone, I was e-unaccessible while I worked, and I thought the office as my haven, a place where I sit and actually speak to people without the distraction of screens.  If I could serve wine and cheese, my job would be perfect.  Ummm, some days.  So the new computer is fine, it has a really big screen that I can actually see without glasses, but I don't like Windows 8 at all, and you can be sure that Clink and Roy have already thrown up their arms in geeky exasperation because I didn't buy a MacBook.  The insurance form program I've used for years doesn't work with Mac's, but to my geek friends....oy. 

So CPT codes, and mental health issues all over the news, a new computer, new ways of billing, and the inevitable busy-ness of before and after vacation.  Last night, I realized that I had my novels floating out there and I've never checked to see if anyone's saying anything about them.  I Googled Double Billing, and realized it was mentioned in my college alumni magazine (which was also sitting next to my laptop), and that one of my neighbor's books (Concussions and Our Kids) was also in that same "In Brief" review.  But then I stumbled upon a blogger who had written the nicest comments weeks ago. Do check out Tee Bee H's blog "about the non-commercial things we do." I borrowed her graphic above.  Since I was surfing because I couldn't sleep, this was just the nicest thing to read:

The book was a page-turner because of elegant structure and pacing.  The language was often interesting and otherwise non-jarring.  I really cared about the author’s take on things –because she is a psychiatrist? because I’ve followed  her blog for a while?– which meant that I was interested in the protagonist’s thoughts, feelings and actions.  At times I ached for the mess her life was in, at others I wanted to shake her into action, and then she’d find her backbone again, just in the nick.  And there was nothing saccharine about the happy ending – a fine achievement, seriously.

Sunday, January 13, 2013

Pick Your Insanity Test

Here's my followup to the post I started yesterday.

If the insanity defense were reformed (again), you'd have to decide which new legal test you'd use. A legal "test" is a written definition or standard. In general, there are two insanity tests in common use: the ALI test and various derivations of the McNaughton test. The McNaughton test states that a defendant is insane if he is unable to understand the nature or quality of the act, or---if he did understand the nature of his actions---that he didn't understand that they were wrong. In 1955 the American Law Institute (A.L.I.) wrote the Model Penal Code in an effort to make criminal laws uniform across the country. The Model Penal Code's insanity test, also called the ALI test, states that a defendant is insane if he "lacks substantial capacity to appreciate the criminality of one's conduct or to conform one's conduct to the requirements of the law". It has two parts, a cognitive standard and a volitional or behavioral standard.

Here is a link I posted last year to a state-by-state break down of insanity standards. It's a little out of date; Kansas is listed as using the McNaughton test but they have since abolished the insanity defense.

Frontline did a nice series a while ago about the insanity defense and they have a summary of the historical tests here.

Saturday, January 12, 2013

Reforming the Insanity Defense

Over on Peter Earley's blog there is a post entitled "How Fair Is The Insanity Defense" that you should all go over and read. I thought about writing a comment there but quickly released this would require a post of its own, so here it is.

He starts out with a case description of a man with an undoubtedly severe mental illness who either shot or assaulted many people while delusional. In 1992, after a failed attempt at civil commitment, he shot and killed two people. At trial state psychiatrists testified that he knew killing was wrong, even though motivated by delusion---in other words, a legally sane crime by the McNaughten test of insanity (which Mr. Earley describes well, I won't be repetitive here). He was sentenced to death and eventually executed in spite of a recommendation for commutation by the Texas Board of Pardon and Paroles.

Mr. Earley is critical of the McNaughten test and feels that we should rethink the legal definition of insanity. He also advocates to end the use of private forensic experts, a point I'll return to later.

First, I think the public should understand there is a certain logic to when and how a defense attorney decides to file an insanity plea. Mr. Earley is appropriately critical of attorneys who file the plea "when their client is obviously guilty and they don't have any other rational explanation to fall back on." It's true that there is sometimes a hidden agenda for requesting a sanity evaluation: there may be a chance that an evaluation could turn up mitigating information that could be used at sentencing, or as leverage in a plea bargain.

Setting aside the hidden agenda, the fact of the matter is that insanity pleas are filed rarely compared to the overall number of offenses that happen every year. This is particularly true of misdemeanors. That's because an insanity plea, if successful, could lead to the defendant ending up under court or health and mental hygiene supervision for years. A simple guilty plea could get a client out of jail, with or without supervision, in months. The attorney is obligated to act in the stated wishes of his client, and that wish is obviously going to be to get out as soon as possible. Thus, we usually only see insanity pleas filed in very serious, felony cases.

So how rare is it? In Maryland, an insanity plea is filed in fewer than one-half of one percent of all crimes commited in a year, both in Circuit and District Court. Out of all crimes committed in Maryland, only 0.032% end in a successful insanity verdict. This certainly doesn't suggest that the defense is being abused.

Regarding the proposal to use court appointed experts (please see also my previous post on private evaluations):

We're already doing that. Most jurisdictions have individual psychiatrists or psychologists working on behalf of the court, either in a court-affiliated medical clinic or under contract with the state's department of health. As the system usually works, this independent court-appointed evaluator completes an assessment and sends a report with an opinion about sanity back to the judge who ordered the evaluation, with a copy sent to the defense attorney who filed the plea and to the prosecution. (Exact details of who gets the report, when they get it and how it can be used may vary between states. I'm speaking in very general terms here.)

Then and only then will a private expert get involved, mainly because one side or the other won't be happy with the independent expert's opinion. In my experience, this usually takes place when the independent expert thinks a defendant is sane and the defense wants to challenge the report. In Maryland, if the court's expert finds someone insane that opinion is almost never challenged by the prosecution because both sides recognize, and agree, that this person is very very sick. (I think the number is somewhere near 90% agreement on insanity but I don't have the study in front of me.)

In short, the insanity defense is hardly ever used and private forensic expert involvement is even less common than that. Out of a few hundred evaluations done every year in our forensic hospital, only a handful will involve a private opposing expert.

Whether or not the legal test of insanity should be changed is an issue that arises regularly throughout history, most recently in 1984 following the assassination attempt on Ronald Reagan. Then, Congress passed the Insanity Defense Reform Act which changed the test on a Federal level. It excluded any category of mental illness from serving as the basis of an insanity plea unless the diagnosis was a "serious" mental illness. Many states, including Maryland, revised their insanity statutes following the Hinckley verdict. Four states have completely abolished the insanity defense.

And I guess that's the trick when it comes to opening the bag of worms of insanity reform: there's always the chance, particularly given the outrage following the Connecticut shooting, that the defense could be thrown out altogether. And then where would my seriously mentally ill forensic patients be? The Supreme Court recently had the opportunity to hear a case that would have challenged the constitutionality of a state statute barring the defense, but they turned the case down.

OK, that's wraps up my response. I just wanted to provide a little more background and factual information to the topic since it is going to be discussed a lot in the news as certain high profile cases come to trial.

Wednesday, January 09, 2013

Results of the Survey on the New CPT Codes

101 responses
What is your profession?
Nurse Practioner
Physician's Assistant
Prescribing Psychologist
Are you ready to begin using the new CPT codes next week?
I'm not sure if I'm ready
I didn't know I had to change how I code.
What have you done to learn the new codes?
Taken a real-life course
Taken the APA's online course
Read the E/M manual pertaining to psychiatry
Asked colleagues
Watched Dinah's YouTube tutorial series
Taken another (not APA) course
Nothing, I am not at all ready
People may select more than one checkbox, so percentages may add up to more than 100%.
Has Updating to the New Codes Cost You Money?
$0 to $250
$250 to $500
$500 to $1000
$1000 to $1500
More than $1500
I have not yet spent any money, but I intend to soon
Are you hopeful that the new coding will result in higher reimbursements to you or your patients?
I am uncertain
Do you see the changes to using the 99 series E/M codes as being positive for psychiatry?
I am uncertain
Are you concerned that the new requirements for documentation will be a burden?
Were you already using the 99 series E/M codes in your practice before these changes?
Are you confident you know how to use and document the new codes in a way that your bills will be accepted by insurers?
How do you feel about the APA's support of the new billing codes?
Good: It's about time -- psychiatrists should bill like other doctors
Good: I am hopeful this will help destigmatize psychiatry
Bad: I wish APA did not support these changes
I am ambivalent -- I see good and bad to the process
I have no feelings about this
I am angry: this adds a large burden to my practice
People may select more than one checkbox, so percentages may add up to more than 100%.
Do the new coding documentation requirements change how much you worry about having your charts audited by insurers?
Yes --I worry more
Yes: I am less worried then I was with the old ways of coding
No: I wasn't worried before and I'm not worried now
What percentage of your patients do you also see for psychotherapy?
None, or less than 5%

Ah, Technology

I'm in the generation that straddles techo-life.  I want to say "I remember when..."  but that does sound so very old.  Okay, I remember when you stayed home to wait for a phone call, stood up to change channels,  went to the neighbors' because they had a color TV, Smith-Corona typewriters with the carriage return, carbon paper for duplicates, teachers handed out mimeos they'd cranked out that smelled of fresh ink, libraries had microfilm, people wrote and mailed letters to communicate.  For my 5th grade "invention," I wrote about a device that you could talk in to and it would type out your words -- Mr. Shannon liked it, but said such a thing would never exist.  In college, I thought word processing was awesome (until the computer crashed with your paper on it), in med school I got an answering machine, and no, I don't remember my first remote control.  I do remember my first experience with e-mail, I asked Clink to show me, and the only person on her address list I knew was a mutual friend across the country-- I sent him an email and he wrote back to say that he and his wife and two children would be visiting and could they stay at my place for a week?  That was enough email for me for a while, but I did enjoy his visit (and his wife, and his kids...).  And Clink has spent 20 years telling people that I thought the dial-up site I used to look at houses --( after all,  if people were going to come visit like this, we needed a bigger place) -- was much too slow and the Internet would never catch on. 

I often wonder how, as a somewhat extroverted, easily distracted person, if life would have been much different for me if there had been cell phones and texting and Facebook back when I was a teenager.  Would I have had a broader social life, would I have ever been able to study?  Would I have had more fun?  Would I have ever been able to do the work I needed to do to get into medical school with so many other distractions available?  Would I have had a blog back then?  

Monday, January 07, 2013

We're Still Talking About Those Damn CPT Codes

Over on Clinical Psychiatry News, my dear co-blogger, Roy, has an article on the value of organized medicine and the good things about the big picture of using E/M codes for psychiatry. He's a fan. Check out his article HERE

Roy discusses why people (like me) don't like the new CPT coding and lists some reasons.  He's a big advocate of parity, and mental illness like any other disorder, so I do understand why he likes E/M coding, it's what the other docs do.  I also understand that it makes no sense to pay one fee for a 'med check' no matter how long or complex it is, and why E/M rates may make sense for psychiatrists who do nothing but med management.  

In the context of psychotherapy, it still makes no sense, and Roy didn't cover all the bases.
Here's what he missed:

People plan for the expense of psychotherapy.  Doctors treat by their time.  If you're feeling well, and you come to spend an hour talking about how your mood's been good and how you've successfully managed some difficult relationship issues this week, you generally don't get a break on the price.  And if you show up in crisis, it's generally the same 50-60 minutes, you don't get charged more because the doc has to thing harder.  And it's good if the fee is predictable, how else can you know if you can even afford treatment?

The new codes require that specific things be documented, so if you're having a rough time, and the doctor needs to listen to what's going on in your life (I'll call that therapy, if no one minds), figure out if you're having a reaction or an exacerbation of illness, review your medications, talk with the distressed family you brought along who are hanging out in the waiting room, call your pharmacy, order tests, call your primary care doc, etc...okay, now the doctor has to add a few more steps: first, to call it a complex visit, he must do a more complete history and exam, including reviewing at least 10 or 14 bodily systems.  So in addition to the usual, you're getting asked about coughing and pooping and shortness of breath and weakness and easy bruising, and temperature sensitivity, and does it hurt when you pee?  And that may not be irrelevant, but even if it is, those systems need to be reviewed and documented as bullet points.  And the exam needs more bullet points, and these bullet points don't have to have anything to do with you.  I know at least 3 psychiatrists who are now taking blood pressure of every patient at every visit.  Does that make sense, for weekly psychotherapy in a patient with no history of hypertension?    And presumably, this all takes away from therapy time, and adds to Evaluation and Management time, but in fact, that may DECREASE the amount the psychiatrist gets paid.  With the current Medicare fees, the psychiatrist gets paid MORE for a 60 minute therapy session (53 minutes, actually) with a 99212 -- a low level E/M which requires almost no bullet points and documentation, then he gets if there are only 52 minutes of psychotherapy (therefore a 45 minute session is billed if the therapy is 38-52 minutes) and a 99213 E/M service which requires a bit more of an exam.  The bullet points just have to be there, they don't have to be medically relevant.  And, in fact, if a patient comes in with so much distress that psychotherapy can't be done and the only thing that occurs in a session is evaluation and management, but no actual therapy, the doctor gets paid notably less.  I won't speak for private insurances because I don't know what they are doing -- I hear that some are simply not allowing E/M codes, a clear parity violation, but this is only a week old, so we'll see.

As Roy points out, using E/M codes has always been an option for psychiatrists, what's new is that they are now forced to do so, and while it may make sense for med checks, it's a distraction to care that's given when therapy and med management are combined.  The templates are flying, they are pages long, and they don't include space to write why a medication was started or stopped, but of course they do allow space for review of the urinary tract.  It pretends to be precise, as if anyone could differentiate 37 from 38 minutes of psychotherapy, but instead, it makes liars of us all and encourages psychiatrists to ask questions or perform procedures they didn't see as relevant 10 days ago for the sake of higher reimbursements (either to themselves or to the patients).  

And there's something unsettling to me that select proponents of these changes are charging to teach how to use them.  And the AMA certainly makes a bit of money selling their manuals for these codes.

Time-based psychotherapy with medication management should be reimbursed based on time, not bullet points.

Please do take my poll, I'll publish results soon.

Friday, January 04, 2013

Why You Should Care About FISA

I know everybody's been concerned about the fiscal cliff lately, but meanwhile something important has slipped under the radar that could be more serious than that for all of us.

Last week both houses of Congress overwhelmingly passed a five year extension to the Foreign Intelligence Surveillance Act (FISA), the law which allows warrantless eavesdropping, wiretapping and monitoring of anyone who may represent a threat to national security. The renewal has been signed into law already by President Obama.

Under this act, government investigators can datamine telephone, email and other online communications pretty much at will. Congress voted down proposed amendments to allow mandatory annual reporting of how often this is done or who this is being done to.

I know this sounds a bit histrionic, but consider this statement from Rand Paul last week:

“Some may ask well, why go to such great lengths to protect records? Isn’t the government just interested in the records of bad people?” Paul said. “Well, to answer this question, you must imagine your Visa statement and imagine what information is on your Visa statement. From your Visa statement, the government may be able to ascertain what magazines you read, whether you drink and how much, whether you gamble and how much, whether you’re a conservative, a liberal, a libertarian, whom do you contribute to, who is your preferred political party, whether you attend a church, a synagogue or a mosque, whether you see a psychiatrist, what type of medication do you take.” (emphasis added)

So this isn't something that, as a mental health professional, you can just shrug off since you're not 'one of the bad guys.'  Particularly now since the public and the government have pressing interests in liberalizing the flow of information between public safety and mental health systems in light of all the recent shootings. The FISA extension grants that authority. If a mental health patient could be deemed a general threat to public safety (read: national security)...well..think about it. Read the full Rand Paul link.

I know everybody is concerned about CPT code changes and impending reimbursement issues, but there's other stuff going on too right now. If you would like to know how your Congressman voted on this issue, you can read the roster here.

[My first post about this topic was in April 2006. It was the seventh of nearly 2000 blog posts we've put up. Seven years later, nothing much has changed.]

Thursday, January 03, 2013

2007 Connecticut AG Report Critical of MH Access for Kids

The 2007 Connecticut Attorney General report on access to mental health care for children [PDF] was quite critical of the role that managed care had on shrinking access to mental health services for children and adolescents. Among the conclusions were:
The results of this survey, both the data collected and the written remarks of child and adolescent psychiatrists, show that countless children and adolescents are receiving inadequate psychiatric treatment, or no treatment at all. Although some patients may be adequately served by psychiatric care focused on the use of medication, a significant proportion of children and adolescents may need treatment that is more intensive, and more expensive, than therapy restricted to the use of drugs. Loss of access to this type of care, what psychiatrists call “relationship-based psychiatric care,” has been happening out of public sight.   
Using low reimbursement rates and bureaucratic hurdles to discourage the delivery of relationship-based care, managed care companies appear to be forcing many Connecticut child and adolescent psychiatrists out of managed care, making it increasingly difficult for many middle income children and adolescents to have adequate access to psychiatric care or to receive the relationship-based treatment that was formerly the standard of care. For many young people, the psychiatric care available appears to be either drugs, or nothing.
One of the four recommended actions included:
Plans must be required to canvas participating providers regularly to determine those providers who are actually available to see enrollees seeking to begin treatment. This information must be made easily available to enrollees so that they are not required to telephone their way through the provider list only to be told that participating psychiatrists are not participating after all, or are not seeing new patients.
Unfortunately, it is common for payers to inflate the apparent size of their network by not keeping them accurate and up-to-date and including providers who no longer accept new patients or who do not take certain age groups or clinical problems. This report found that some payers had advertised networks that were 2, 3, and 4 times their actual effective size. (Is that fraud?)

Homework for the future: How many psychiatrists are in your network? How accurate is it?