Monday, December 10, 2012

They'll Come Knocking

Behind all the anxiety of new CPT codes-- because change is hard-- there is not just the angst of more paperwork, or the question of whether gathering specific data distracts from the work of caring for the individual patients.  We wonder whether the burden of new billing systems and more documenting for the sake of being able to code like "real doctors" will actually translate to higher reimbursements.   More than that, though, there is the fear, which lately does not go unspoken: the fear of doing it wrong and being accused of insurance fraud.  Our presenter at a CPT training seminar warned that down-coding is just as fraudulent as  up-coding, and my feeling is that we should accurately code the work we do within the confines of the very complex Evaluation and Management schedule, such that our services do get higher reimbursement --- it's difficult to follow but it's either about collecting the right number of bullet points in each category or it's about spending more than 50% of time counseling and coordinating care.  Funny, now psychiatrists have to talk more than they listen.   Yet everyone I've spoken to says they code low because they don't want to draw attention to their work and don't want to be accused of fraud.  I suggested that this is wrong when the doctor is paid a salary and so the hospital collects lower fees.  I also think it's wrong when the doctor is out-of-network and the patient's reimbursement, from their health insurance company with those very high premiums and very low reimbursement for expensive psychiatric services, depends on the code. 

 Some docs are just trying to ignore the upcoming changes, especially those in small private practices.  Insurance companies don't typically audit charts of solo practioners who are not in their networks.  It's likely rare that Medicare does either, unless perhaps something looks fishy?  So some say, "they won't bother me."  Others say, they're coding low to stay off the radar, and at least 2 docs I know are opting out of Medicare, because Medicare audits are scary with their $10,000 per claim fines.  (Am I right about this?)

Emailed to me today, with the actually title, "They'll Come Knocking":

Subscribe to Compliance Watch to Steel Against Investigations and Unnecessary Penalties 
Do you know the new definition of fraud? Are you up to snuff on changes to CPT codes? Big changes are on the horizon. Are you ready for how they will affect your day-to-day and business practices? To survive in our new healthcare environment, staying current on mandates and preparing adequately for investigations and audits is crucial.

Of course this company is selling their services and they are doing it through scare techniques, but still.  


SteveBMD said...


I really have to commend you for the outstanding work you've done in summarizing the new CPT codes for us.

You are absolutely correct that "gathering specific data [might] distract from the work of caring for individual patients," but we must also consider the preparation and education time that we must put in to learn these codes.

For instance, I would feel much more confident in my patient-care skills if I spent my free time browsing journals, attending talks, obtaining CME credits, reviewing my charts, or reading books to help make me a better psychopharmacologist and/or psychotherapist, rather than learning how to use proper billing codes. Something tells me my patients would agree.

As it happens, I work in a cash-only private practice, so (at least for now) I don't have to worry about billing codes or even documenting the "right" diagnosis. But in every other setting I've worked (as with the vast majority of psychiatric providers), the demands of documentation and bureaucracy had more of an impact on how I practiced than my own education, skill, enthusiasm, or interest.

It's incredibly demoralizing, and it's sad to see that it continues, while doctors grit their teeth and accept it. When is the revolution?

Dinah said...

What's a "cash only" practice? No checks? They stop off at the ATM? And you don't provide a statement that patients can submit to their health insurance companies if they'd like reimbursement? Or do you only see those without any insurance?

I think on this side of the country, we refer to it as a fee-for-service or out-of-network services and we still give patients a statement or form they can submit for reimbursement, so even the No Insurance docs are taking courses and learning to code this and wondering if they can be audited.

SteveBMD said...

By "cash," I mean the way my patients and I pay for just about every other service, from yoga and massage to carpet cleaning and dog grooming. (And yes, checks and credit cards are OK too.). I can also make adjustments to my fees to accommodate people's specific situations.

You're right, I'll have to learn the codes to represent what I most often do with my patients (at least those who request a form for OON reimbursement-- although technically I'm not obligated to provide that), but one of the reasons I chose this path is so that I can spend more time developing my practice and serving my patients' needs, rather than some payer's.

Joel Hassman, MD said...

This CPT process was not changed to help psychiatry, don't let anyone with a straight face say otherwise. It was done, in my opinion, with one of two agendas, and the first is the more likely one: to try to legitimize psychiatrists as somatic colleague doctors, which is the faux agenda of the DSM 5 as well, and the second, which is harsh to opine but I sense has legitimacy to offer, to further sabotage the profession, what is disturbing is it includes those in our profession!

Yes, I earned an MD degree, keep up with my CMEs and do my best to keep somatic care interventions in my conscious, but, we don't do medical care in the office, and this post may allude that those who stupidly start to do physical care in the office without justification, thanks for ruining it for those of us who responsibly WON'T!

Again, private practice is essentially dead within two to three years overall. Even cash practices will take a hit, because our non psychiatric colleagues will continue to underprice the care, like they've been doing to now for the past 15 years anyway.

Oh, and by the way, I read and hear more and more PCPs are either resigned, but more frightening, some are eager to take on more psych patients. This seems to be easy money to PCPs and others.

Wow, you hear the lie enough and it becomes truth, how unsettling!

By the way, Dinah, these codes we are to type are getting more incoherent and illegible with every post I offer of late.

jesse said...

I, too, am concerned about these new codes, but not about the possibility of being audited (being a fee-for-service psychiatrist not in any networks). More worrisome is that the new codes will become the standard of what notes should be.

A psychiatrist could be asked in court whether his notes meet the format published by the AMA. "Doctor, are you aware of these codes? Your notes do not conform to them?"

Then licensing boards, the state accrediting boards from which we obtain our licenses) could start judging a psychiatrist's practice by whether he adheres to the new format.

So I share the above concerns, perhaps taking them to an even more worrisome level.

ClinkShrink said...

Oh, I've been staying away from this topic as much as I can (CPT codes have been haunting me lately, vicariously, through the blog and other venues). Now I feel like I need to chime in.

I have never used a CPT code, haven't talked to an insurance company in 20 years and I work in what could be considered the ultimate in a managed care environment. In other words: take what I'm about to say with a grain of salt.

Nevertheless, I think some concerns now are getting overblown.

With regard to CPT codes becoming the standard of care for progress notes and medicolegal liability:

Billing codes never have been, and won't be, the standard of care. In 20 years of forensic practice I have yet to ever hear of or see a billing code cited as a basis for a deviation in standard of care. Standard of care is determined by expert testimony, the medical literature, professional guidelines and other sources. None of these sources address billing codes.

As far as getting dinged medicolegally from progress note content, I can tell you that after reviewing mental health practitioner notes from practices all over the state while doing pretrial evaluations, that the current state of affairs is pretty abysmal in some places. And I'm not talking about places where people are forced to use medical record systems designed to make them think in categorical checkbox terms with no opportunity to document rational thought.

Nobody looks over the shoulder of someone in solo private practice to make sure that notes are "up to snuff." (I'm not advocating for this either, I'm just saying that even SOME set standard for progress notes would be better than the zero-standard accountability I've seen in some documentation.) Requiring practitioner to adhere to a format of SOME type would be an improvement.

And now I apologize to Dinah for re-activating her CPT code trauma. I've said almost nothing about it up to now so this will count as my only rant on the topic.

jesse said...

Hi Clink, I was not talking medicolegal liability, but first, how a psychiatrist testifying could be embarrassed in a trial by an opposing lawyer (they will do anything) and second, that the licensing boards could start expecting a psychiatrist keep such notes, once they have become commonplace. Already the boards expect that a psychiatrist's notes have more in common with other medical notes than was ever the case in the past.

Dinah said...

So the APA has now published templates for notes on their website. Might that change things? The notes are 2 pages long, and do not include psychotherapy (you need to write a separate note for that). They have space for review of 14 bodily systems. Like many of the notes I've been required to use in clinics, there is not a space to write why you are using a specific treatment (or there's a little space). Clinically I find it useful to be able to what symptoms I am targeting with a medication, to write what other options I may have discussed with a patient for treatment, and to write exactly why a medicine was stopped, so if I think to use it again, I know why I stopped (ineffective, life-threatening allergy, side effects at a high dose but maybe worth re-trying at a low dose, etc.)

So it the APA sends out templates for notes --- I'm not aware this has been done before --- might they have a place in medico-legal world, or might they be used to say "You didn't fill out this so we're not paying?" What I read is that the most cited problem with audits was not having enough bullet points on the review of symptoms. And honestly, a careful review of symptoms is not part of routine treatment with psychotherapy.

Okay, so people are saying that Medicare and others don't and won't audit solo providers. If that's the case, why bother with all this documentation at all?

I'm annoyed that it's become unnecessarily complicated for no obvious reason. If psychiatrists wanted to bill with E/M codes, they could, why force this upon everyone?

Joel Hassman, MD said...

"If psychiatrists wanted to bill with E/M codes, they could, why force this upon everyone?"

Very good and simple question. Like Occam's Razor, the most direct and likely answer, for me at least, is just another way to MAKE MONEY!

But, the idiots who formulate this policy forget one thing, the more things change, the more they stay the same. And the same for us is just another way to marginalize psychiatry. Face it, auditing will happen, and there will be enough greedy and reckless colleagues out there to justify it.

And for it to be introduced right at the end of the year. Classic and reckless. Oh, and the APA coming out with templates, just inane!

Ravi C said...

I'm glad to stumble on this blog of sanity amidst this CPT insanity. IMHO, they are making life difficult for us all in order to be able to justify "taking back" money through audits, etc. Not for one minute is this about GOOD PATIENT CARE.

This is a complete disaster. Organized medicine has failed us.

Are we supposed to spend more time worrying about which code to use? Most of us will be tempted to get familiar with a few codes and stick with those. It's not worth the time and effort to "get it right" every time. For 90807 and 90805, it all basically averages out. Most of us seemed happy getting paid for our time; perhaps some of our colleagues thought they could get more money this way, because they think they are 'doing more' or are treating 'more complex' cases.

Psychotherapy, done properly, is complex in itself. I have literally seconds between patients to figure out a billing code.

This does not help.

Is there an app that can do this automatically? If someone sells a 99 cent app, they will be rich within a few months.

Joel Hassman, MD said...

Just thought I would add my comment about this issue, if anyone here is reading and interested. Just hit my name and read on.

Happy New Year.