Can Psychoanalysis be Coded with the New CPT, E/M Codes?

The blogger -Psych Practice- who posted on how to figure out an E/M code which I stole below, did  a wonderful  job of giving a clear set of directions on how to do this, though I have to say that I got nauseous half-way through because it is so long and complex with so many charts, but it does explain it.

  S/he wrote a follow-up blog post on how to code for a psychoanalytic session with Socrates as an example (I was a little confused about the Speech: Greek, Appearance: Toga, but I then I got it).  Anyway, it's very clever, and it makes the process seem a little less intimidating, and it does a wonderful job of incorporating the E/M portion of the session into what naturally flows without requiring the therapist to collect irrelevant data for the sake of documentation.  I hope it's right. So here's the link to the how to code E/M + add on therapy for the psychoanalysis of Socrates: http://psychpracticemd.blogspot.com/2012/11/em-psychoanalysis-note-monday.html

What this writer doesn't seem to take into account is the proclamation by AMA that the time spent on E/M must be completely distinct from the time spent on psychotherapy. Any one who has ever conducted or had psychotherapy knows, this is not possible.  It's like the AMA decided the sky is now purple with orange polka dots.  People come in and talk about what's important to them, and if they are depressed and have questions about that Abilify stuff they saw on TV, or are undergoing cancer treatments, or are about to have their knees replaced, that's what they talk about and it's not possible to define one part of a session as "psychotherapy" and instruct them to limit concerns about illnesses & treatments to a specific, time-distinct, portion of the session that is not "psychotherapy."  I believe that we have to say that regardless of what Insurers, the AMA, or the APA believe, that it's simply not possible to disentangle the time devoted to the two.  The stickiness of the issue is whether insurers/medicare are going to claim that if you have a 53 minute session and document a 99213 E/M code with a 90838 (60 minute psychotherapy add on) that you can't have done that much work seeing patients every hour and are going to insist that the therapy code be for the 45 (38-52 actually) minute shorter, session.  For medicare, there is a $45 dollar pay increase if the psychotherapy session goes from 52 minutes to 53 minutes. I'm not the only one who thinks this is all nuts, right?   

I am going to attempt to Live Tweet the 12/4 MPS CPT seminar with the hashtag #cpt.  There's no WiFi at the Sheppard Pratt conference center, so I will be doing it from my phone's touchscreen, typos and all, to the extent that my stamina holds out.  I practiced yesterday by tweeting Vani Rao's Grand Rounds at Hopkins on Traumatic Brain Injury (no, I didn't tweet the patient presentation). I know, I'm repeating myself, but I copied this from a email I put up on the psychiatric society's listserv.

Book Review: Psychotherapy Lives Intersecting

There's a bit of a formula to writing a book review, and here, I'm planning to break from that formula.  I recently had the pleasure of reading Louis Breger's new book, Psychotherapy Lives Intersecting and I'd like to tell you how I felt, and what things I thought about, while I was reading it.  The book is about psychoanalysis, so instead of reviewing, I'll be free associating.  You'll bear with me on this?  I did have a positive transference to Dr. Breger


Okay, so Louis Breger is a psychologist in California.  He's not just a psychologist, he's also a psychoanalyst, at Caltech, no less.  Caltech has psychoanalysts?  I thought Caltech had math geniuses and computer geeks.  I thought this because my brother went to Caltech, and one of my good friends from high school also went there.    My brother has written such books as Computer-Aided Financial Analysis, and my friend is a physicist in a linear accelerator (SLAC, to be precise).  Neither has ever mentioned a word about Oedipal complexes, ids, egos, pleasure principles, or psychoanalytic anything.  Okay, so apparently there is a psychoanalyst at Caltech.


In the introduction, Dr. Breger starts by talking about how Marsha Angell says anti-depressants don't work.  My feelings?  Annoyed.    Then he mentions that they've helped some of his patients, he's neither for or against them.  I kept reading.   


The premise of the book is that after decades as a psychotherapist, Dr. Breger contacted his former patients and asked them to fill out a questionnaire.  He wanted to get their feedback on their psychotherapy.  If you know me at all, you know this is an exercise I'd find very cool.  Who writes to their patients 30 years after the end of psychotherapy and asks What did this mean to you?  What a great idea, it inspired my admiration, and the positive transference began.


It seems that most of Dr. Breger's patients are in multiple times a week therapy for years.  Okay, that's what analysis is, but who can afford that?  My feeling: a little jealous.  Maybe it's something I would have wanted to check out, but with my medical school debts, then childcare/tuition/etc, it wasn't an option back then.  And now-- still too expensive, terribly time consuming, and hard to rationalize putting this degree of resources into something for the sake of intellectual curiosity.  It's a mixed kind of envy, however-- one psychiatrist I know spent 11 years in analysis conducted at 6:15 every morning, and as someone who is not a 'morning person' such an endeavor would be unthinkable.


Many, if not most, of Breger's patients are psychotherapists themselves (or in training), and many had been in therapy before and had experienced unsatisfying, if not traumatizing, relationships with therapists who sounded to be rigidly engaged in a therapeutic stance that lacked empathy, warmth, and any degree of kindness or humanity.  Dr. Breger broke that mold and his patients seemed to all comment on his kindness, attention, non-judgmental stance, and that he cared about them.  These were the qualities they found healing, and few seemed to mention great insights or spectacular interpretations.  He brought one patient cookies.  My thoughts: What a nice guy.  I think I'd like talking to him.  And if not, I do love cookies.  It presents therapy as a corrective healing response, often good for those who've had critical and damaging childhood relationships.


After a bit, it felt repetitive: the patients said the same things--- they all thanked him, they all appreciated him, they all contrasted him to the prior therapists who were personally related to the devil.  He has no patients that didn't like him?  That weren't full of gratitude?  Even wonderful psychotherapists aren't wonderful for everyone, there's some chemistry there, and there are some very particular patients out there who manage to find fault with everyone.  I went through a brief phase of feeling annoyed with Dr. Breger.  Is he a narcissist?  Why write about all the kudos?  Ah, but he redeemed himself later in the book-- he tells us he only wrote to his long-term patients where psychotherapy seemed helpful, that he didn't want to trouble people who would be distressed by the request or communication, and he mentions that some people left therapy early on, and one even got better with medications and didn't want psychotherapy.  So it's not a research study in the double-blind, placebo-controlled, all results are fair game for publication, type of project.  Knowing that such patients existed and were acknowledged as such, in reasonably respectful terms, left it more realistic and honest.  I liked the book again.


There were some intensely personal moments.  The author talks about his own childhood, including his insecurities, his mother's mental illness which included hospitalizations and repeated suicide attempts, and his father's fatal heart attack.  His grandmother also suffered from depression and had a lost a child, one his mother was born to replace.    I enjoyed getting to know him and his family.


At one point, Breger talks about allowing patients to call him while he was sick in the Intensive Care Unit.  While I might like to feed my patients cookies, and I certainly try to be responsive and available, this was a degree of availability and patient-first mind set that made me uncomfortable.  For my own sense of sanity and boundaries, I'd like to think that if I'm ever so unfortunate as to be in an ICU, that I could simply be sick, fight for my life, and be 100% patient, without having to remain as anyone's doctor, at least until I was healed enough to be released from the hospital.  While it's nice to be able to reassure patients, it seems that having a colleague cover should be enough, and I never want to be this indispensable.
  
Dr. Breger is a psychoanalyst-- a training analyst at that-- and this shows in the way he looks at problems as the result of childhood (or at least long-ago) events.  There's little room in his paradigm that allows for genetics or biology, or illness.  He's not shy, however, about discussing his disdain for psychoanalytic practice-- for it's abstinence, rigidity, coldness, and adherence to a theory that leaves little room for individual differences.  The theory, he asserts, can be practiced in such a way that it is thrust upon patients, and if they don't buy the interpretation, they are "resistant." He seems to have found a way to draw out positive and helpful aspects of psychoanalysis while abandoning the parts that make it impersonal, rigid, and even mean. 


After the therapy is completed, the doctor-patient relationship is left to the patient.  In some cases, Breger becomes friends with his patients, they continue in various forms of contact, ranging from a holiday card to visits to each others' homes for meals.  In this sense, this is a different world from my professional life where it's hard to imagine purposeful on-going social relationships (including spouses) with my former patients.  Perhaps it's the difference between being a psychiatrist, a non-analyst, practicing in a different decade, and in a different state (California has it's own rules, right?). 


In thinking about this book as a teaching tool for young therapists-- or psychiatry residents in training-- I'm not sure that it's value lies in contrasting a warmer, more responsive therapy to traditional psychoanalysis.  I'm not aware of any young psychiatrists who are entering training in traditional psychoanalysis, but perhaps that's a function of where I practice,  Still, this book provides a historical perspective that is difficult to capture as psychoanalysis fades as a primary treatment of mental disorders. 


The biggest strength of this little book, however, is Breger's easy writing and warm, inviting, and caring style.  At just over 120 pages, it's a quick, compelling, and enjoyable read, written by a man whose masterful skill as a psychotherapist weaves through every page.

A Dangerous Method

 We are taking a break from our normal forensic programming to bring you this guest post from Jesse, a review of the film "A Dangerous Method."  ---Clink

Another psychiatrist and I went with our spouses. We all hated it. There were at least three levels on which I considered the film, the first being whether it in fact is a good film, the second relating to what it shows about Freud, Jung, and the birth of psychoanalysis, and the third what it shows about a psychiatrist getting involved with his patient.

A Dangerous Method purports to show Jung, the protagonist, treating a young (and of course beautiful, played by Keira Knightly) Russian Jewish woman named Sabina Spielrein, who was brought to his clinic for treatment of her hysteria. It is quite obvious from the outset that he will fall in love with her, and we are not disappointed, but the predictability and lack of drama in the film are striking. Spielrein gets better and wants to become a physician and analyst herself, which she does (historically, her most famous analysand was Jean Piaget).

We see a little of Freud, stiff and priggish, but quite adamant on maintaining the scientific stature of psychoanalysis and opposed to Jung’s efforts to bring in parapsychology. It is hard to imagine a less sympathetic picture of Jung, and as one who knows relatively little about him I can just say that I hope this film’s portrayal is a strong dramatization: unfeeling, narcissistic, and breaking every rule that has been standard in our field since its inception.

Sabina has been abused by her father by being beaten, which she acknowledges led to sexual arousal. Her symptoms remit as she became able to talk about it. Of course the very worst thing for this woman would be to reproduce that trauma with her psychiatrist, but that is exactly what Jung repeatedly does. The director switches (again quite predictably) between scenes of Sabina being beaten by Jung prior to sex to scenes of Jung’s beautiful and virginally white-clad wife, loyal and forgiving, who tells Jung haltingly that she disappointed him by having given birth to a girl, but will do better next time.

Of course Sabina falls in love with him. You do understand that it is transference. But he soaks it up and wallows in it. For a patient who has been sexually abused and beaten by her father everything Jung does is the worst it could be.

No viewer has any sympathy for him. He is without feeling except for himself. No guilt. No regrets.

Now, if the film really taught us something about psychoanalysis! But it doesn’t. It uses the language but throws off profoundly important concepts with the ease of a ten year old telling you that E = mc2, and with equivalent understanding. Spielrein herself made some important contributions, and Jung was one of the most famous psychologists in the world, but how he got that distinction (rather than ostracism and shame) is anyone’s guess.

So the more you know about psychoanalysis and good drama the more you will hate this film. The more you understand that a patient having a sexual relationship (and even more a perverted one) with a psychiatrist causes profound and lasting damage, the more you will feel that a film that makes the relationship appear harmless is itself causing serious harm.