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.


AA said...

Wowzers! Thanks for explaining all that!

I think I'll have to make an effort to memorize these and employ them in my daily life: "So I had a great 90807 this week. I'm still working on finding a doctor who'll 90862 me, though."

Battle Weary said...

There is another variable to consider as well. Does the patient have a therapist they see regularly, or do they only see the psychiatrist? I see a psychologist weekly, with an occasional bi-weekly thrown in. I see my psychiatrist every 2-3 months. From here I will call them T and pdoc! My T provides depth psychotherapy with a lot of trauma work. My pdoc provides medication management AND brief, very focused psychotherapy (ie; how am I managing in school?). Both work in the same practice, T is an owner/partner, pdoc an employee. They both care whether or not the other will be paid by my insurance. My insurance will only pay for two visits for psychotherapy in one week with prior authorization...they will pay for psychotherapy and medication management from two separate providers without question. So my pdoc never bills for psychotherapy, except for the two week period when my T was in Europe and I saw pdoc specifically for psychotherapy instead!

As an I used to do billing/coding, I would have to agree that using 90862 definitely makes sense from a billing standpoint. If the documentation is there to bump a code up to 99214 or 90805, then I would do that. But since the documentation required for those is so very specific, it is much easier (and more cost effective)to use a code that requires less documentation but pays at a better rate than 99213.

Anonymous said...

I would be curious to know what the psychiatrists' perceptions are (survey), as to whether they are performing psychotherapy during those 15-minute 90862s.

From my perspective, medication management feels like a social call with prescriptions tacked on at the end. I wonder if my pdoc sees it differently? (Rhetorical)

Around here, I'm told most of the psychiatrists who formally offer psychotherapy have stopped taking insurance altogether. I can understand why, as it appears the insurance reimbursement rates are abysmal, even for med checks (mine pays 80% of 2/3 the billed amount-- Don't ask me to do the math.)

Anonymous said...

So I brought this journal home to post about the same article, and then I forgot. Good I have Roy to remind me. Only I had a different slant on it, here's what caught my eye:
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.

The stats are for psychiatrists who provide psychotherapy to ALL their patients. I'm surprised there are 10 percent of psychiatrists out there who provide psychotherapy to ALL their patients.

I wonder how this was asked. I consider myself a psychotherapist, but I see patients in a clinic, and even if I spend 25 minutes with them, well...if it's once every 90 days and they see a social worker therapist regularly, even if something happens in the session that's simply amazing, I just don't call this "psychotherapy." And there are patients I see who come in with a relative, answer all my questions saying they are fine, the relative confirms that things are going well, and I write a script. It seems that once you have One such patient, you can no longer say you treat ALL your patients with psychotherapy.

So how about a post telling us exactly what the documentation requirements are for the common codes.


Anonymous said...

Hey, just wandered over here after finding the podcast via SA Mind ... And I love the podcast, but this blog is -- there's no nice way to put this -- ugly. Garish colors. The reverse type is hard enough to read but when you mix it up with boldface that's so much bigger than regular bodytype it's visually painful. Very cluttered. Even this comment page is tough to read with the type so tiny.

Please redo the look -- even if that's just choosing a more placid template.

Anonymous said...

This caught MY eye also:

"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)."

This is how I interpreted it:

Traditional psychotherapy- specialist psychiatrists are retiring or dying. My own, fabulous, psychiatrist who I see once or twice a week, 50 minute sessions is OVER 65 YEARS OLD. When he retires there will not be a replacement for him coming up through the system who studied psychotherapy in the way he did.

Anonymous posted:
"answer all my questions saying they are fine, the relative confirms that things are going well, and I write a script. It seems that once you have One such patient, you can no longer say you treat ALL your patients with psychotherapy."

My psychotherapy-based psychiatrist would NOT HAVE a SINGLE patient like that because he is PSYCHOTHERAPY based. A patient comes for a 50 minute TALKING session and if there's a medication discussion it's extremely short (1-2 minutes). My psychiatrist would not ask a series of questions where the patient's answer would be that the patient is "fine". That's not psychotherapy is it? Surely there'd be more probing questions to analyze a patient's week in light of their psychological background and relative to changes they are trying to make in their life, wouldn't there be, if the psychiatrist were practicing psychotherapy? If a relative were along in my psychiatrist's office it would be to analyze the relationship between the two, not to get a "status report" from the relative.

My psychiatrist suggests that new patients try psychotherapy for a few weeks before starting anti-depressants (which they often request on initially seeing him), and suggests that patients self-evaluate after a few weeks of psychotherapy to decide if they REALLY still feel they need them. He says most do not need them after a few weeks of psychotherapy. I wonder how many of the newer breed of psychotherapists do that? I'd bet the hand is poised over the prescription pad with the question in mind WHAT to prescribe.

I think it's really sad that psychiatrists used to be the gold standard for "talking therapy" and now the large majority no longer are oriented towards providing that as a primary service. It's a tremendous loss to mankind.

Anonymous said...

TP-- It's good there are docs like your psychiatrist, but the reality is that his model leaves no room for patients who really do not want psychotherapy, those who can't afford a psychiatrist for psychotherapy (many mentally ill patients have Medical Assistance or MA which does not reimburse well) or for those who are not particularly able to participate in therapy and who have conditions that we know do not respond to therapy alone-- for example a patient with schizophrenia and mental retardation, where the goal (presumably met with meds) is to keep them out of the hospital by eliminating disruptive behaviors.

It's good to have all kinds of psychiatrists. --Dinah

Dr. Pink Freud said...

another variable to consider is population density. In areas with a relatively low (let's say the rural south) pop. density, there are very few psychiatrists, as well as other health-care resources. One can imagine that medication management is about the only real option a psychiatrist has where there is great need, but a paucity of resources (time to see patients obviously constituting a resource.)

Roy said...

@battle weary: excellent points. I find it interesting that T & pdoc coordinated so well.

@anon #1: I think a good psychiatrist can do an assessment and therapy without making one feel they are on an examination table. And most psychiatrists doing therapy in the context of a 15-30 min med mgmt visit are probably doing supportive psychotherapy, much less so than, say, psychodynamic psychotherapy or CBT or Interpersonal psychotherapy (IPT).

@dinah: a post on documentation... hmm, I might just do that... I'll add it to my list.

@anon#3: ugly, huh? I resemble that. Seriously, I guess templates are a matter of personal taste. I prefer cleaner templates, good use of whitespace, and that Aqua look. But, this template "897" didn't seem to be used a lot and was one of the less garish ones out there when we started 2 years ago. Maybe some day we'll try a makeover. Thanks for the input.

@pink freud: agreed; a lone shrink in a small town might have limited time to do classic psychotherapy, but I think it is unwise to do plain med mgmt without a certain amount of supportive psychotherapy so that you know what is going on in the pt's life and can better interpret what they are telling you (verbally and nonverbally).

Anonymous said...

I have a question...

Can "regular" MDs use these billing codes if they are doing "psych" services? Or is there a different code for regular MDs who provide treatment.

Anonymous said...

Can we bill for a new, non-credentialed psychiatrist under a Family Practice or Internal Medicine physician?

Billing Mama said...

I am the Billing Manager for large primary care group. We are thinking of adding a psychiatrist to our group.

1)Can we bill for a new, non-credentialed psychiatrist under one of our credentilled MDs?

2) Are the problems billing for certain codes?

3)Are there special pitfalls to watch out for?

4) Are there payors who are especially difficult to work for?

Any and all other advice/help is certainly much appreciated!!!

Sideways Shrink said...

Billing Mama,
You may have already found out this information or "discovered" it the hard way. I worked in a multi-specialty group practice and due to the low reimbursement of psychiatric services versus the administrative costs of this kind of group practice, you are wise to ask questions like this. Due to previous financial debt owed to the county by the organization, the organization had to provide psychiatric care and psychotherapy (financially best done by MSWs) to Medicare, Medicaid, and "indigent" patients. My work was limited to medication management work--more bag for the hourly buck (typical in group practices like this) and my fees were used (it finally dawned on me) to subsidize the therapy work of the social workers because given the overhead the therapy work was a financial losing proposition. The organization wouldn't honor the productivity based contract they signed with me so and so I left to run my own shop to have enough income to cover my student loans.
So having seen both sides and now having dropped some companies because they are too difficult or poorly reimbursing, here is what I think.

1)Can we bill for a new, non-credentialed psychiatrist under one of our credentilled MDs?
I THINK THERE IS A WAY TO DO THIS, but only if the other physician is a psychiatrist and literally on site. Otherwise, in a Medicare audit, Lord help you.

2) Are the problems billing for certain codes?
SHRINKS ARE CREDENTIALED COMPLETELY separately from other physicians and literally can not bill for physical assessment/diagnostic codes. Almost all psych codes are time based NOT based on the severity of the illness of the patient. There are codes for billing telephone calls BUT NO COMPANY WILL pay for them. This extends the time spent by your psych and if you are serving the acutely mentally ill with no other psychiatric staff--nurses or social workers--the daily and on call burden of your psych is going to make it rough.
3)Are there special pitfalls to watch out for?
To make it pay you need to have a no show fee in place that patient's have agreed to and I would say your shrink is going to need to do at least 3 medication management visits per hour. Your organization needs to have someone on staff to specifically schedule and take messages for your psych--even if the staff person is an experienced LPN or MA. Otherwise, the workload on the psych is going to be too high and you run into liability issues with poor or no triaging done by front office staff who schedule for, say, primary care or some other specialty.
4) Are there payors who are especially difficult to work for?
Watch out for 3rd party carve out companies that manage the psych visits and pay poorly. Magellan won't pay; United Healthcare (AKA United Behavioral Health now rebranded as Optum Health) are frequently used as carve outs and manage the care to death and PAY BADLY; Aetna pays poorly, but does pay and don't manage the care in general. If you see Medicaid and Medicare patients you will need to set a percentage cap for your psych practice if you want to be financially viable. It's a shame, but Congress made a bunch of decisions 26 and 16 years ago that made these reimbursement rates the case...