How Medicare will devalue the work of psychiatrists

For the first 20 years of practice, assigning a code to the services I offer has been easy. I see most patients for “90807” – a 50 minute psychotherapy session with medication management.  It all gets mushed together, a patient may talk about an upsetting event in their lives (psychotherapy) and then mention they are having trouble sleeping or a side effect to a medication (medication management), then go on to talk about their future goals (psychotherapy), and the session may end with a prescription for a refill, a new medication, or a suggestion to take make a lifestyle change (medical management).  These codes, submitted by either the patient of the doctor to third party payers allow for reimbursement for services.

For 2013, the codes that all mental health professionals use are changing.

The coding for an evaluation of a new patient is fairly simple, there is one code that includes medical services, to be used by psychiatrists, and another code to be used by social worker and psychologists.  (I’m not sure what codes get used by physician assistants or nurse practitioners).

For regular appointments, the new codes are not so simple.  For those who prescribe medications and manage medical conditions, we will be moving to the same Evaluation and Management codes that other physicians use – the 99211 to 99215 range based on the medical complexity of the problem.  These codes, as you may know, require very specific levels of documentation to determine exactly how complex a problem is.  There’s the history, the interval history, the review of systems, the exam, and the complexity of medical decision making .  But it can all be summarized below.    For the history, we need only document the following: location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms

HPI is considered “brief” if it includes 1-3 of these elements, and “extended” if it includes > 4 elements or 3 stable conditions.

To determine the actual level of care, the following chart makes this clear:

Level Of care requirements (2 out of 3 needed)
Level of Care
Problem Focused
Extended Problem Focused
Low Complexity
12 from 2 or more organ systems
Moderate Complexity
2 from each of 9 organ  systems
High Complexity

What’s nice about this method, and why it was advocated for by both the American Medical Association and the American Psychiatric Association, is that it treats psychiatrists like every other physician.  It emphasizes the medical aspects of what we do compared to other mental health professionals, differentiates our work, and highlights the complexity and diversity of what psychiatrists do.   The hope is that reimbursements will improve (psychiatrists are on a very low rung of the physician pay scales), encourage parity such that insurers will not be able to offer lower co-pays, limit appointment coverage, or have higher or separate deductibles for psychiatric care.  We also hope that by treating psychiatric appointments the same as every other medical appointment, the stigma of mental illness will disappear.

So what’s the problem?  It’s all good, right?

Well, it’s all complicated.  Many psychiatrists see patients for psychotherapy, sometimes every week, and these requirements for specific elements of the history and exam are not about offering the best possible individualized care to the patient in the room, they are about documentation for reimbursement.  And in the case of a psychotherapy patient, they take time away from the work of psychotherapy and may create an irrelevant distraction to therapy.

Under the new system, psychotherapy that occurs during a psychiatric appointment must be timed separately from medical management.  Psychotherapy is one thing, and discussions about medical issues are another.  So the psychiatrist first must determine which Evaluation and Management service he provided, document and code this, and then he must use an “add-on” code for the psychotherapy, based on time.  But even time is not a simple thing: there are 30 minute, 45 minute, and 60 minute sessions.  And if time should be clear, it’s not, a 30 minute session lasts for 16-37 minutes; a 45 minute session is 38-52 minutes, and a 60 minute session lasts for over 53 minutes.  In this new system, there are 15 possible combinations to code the old 50 minute psychotherapy session with medication management.  Unless, of course, there is a crisis intervention, a difficult family situation with a disruptive member in the session, or requirements to report a sentinel event like child abuse, in which case there are more “add-on” codes.

So what’s the problem?  It’s a little confusing, but we hope reimbursements will be better and this captures what we do and lets us be “real doctors” (was I ever not a real doctor?)

So, in some bullet points, let me share my outrage:

1. This change has all occurred very rapidly, over the past 2 months, and mental health professionals do not know how to code these new changes.  They aren’t obvious or easy to learn and multi-hour courses are being offered, but January promises to see some chaos when the wrong codes are submitted and reimbursement is denied.  This could be a problem if one has a mortgage or bills to pay.

2.  What was quite simple has now become unnecessarily complex.  Why do we need 17 different codes to describe a psychotherapy session with medication management?

3. The documentation requirements are onerous and will use time that would be better spent on meaningful patient care geared to the individual patient.

In terms of the financial aspects of the new codes:

1. Psychiatrists have contracts with insurance companies based on the CPT codes they have been using.  It is not clear that there will be time to renegotiate all these contracts with new codes by January 1st.

2. Patients will not know the cost of a session before it occurs.  And this may leave room for the patient and doctor to disagree on exactly what transpired in a session if the cost or reimbursement would change: Were 36 minutes devoted to psychotherapy or 38 minutes? It will make a difference in the fees.

3. Psychiatrists who do not participate in insurance networks typically code sessions so that the patient can get maximal reimbursement, with 15 options, and each insurer reimbursing differently, this is going to be very confusing.  And those who don’t participate charge by their time, not by the service, so this creates a whole new structure which may either lead to under-reimbursement of patients, or concerns about fraud if coding is done incorrectly.

4.  It’s all way too complicated.

With respect to Medicare, the 2013 fees were released last week and the following issues became evident regarding fees for the mid-Atlantic states:

1. A psychiatric evaluation done with medical services (so one done by a psychiatrist) is reimbursed at a substantially lower fee than a psychiatric evaluation done by someone who is not a physician.

2. The timed psychotherapy part of the appointment is reimbursed at a lower rate if medical services are also provided, even though the new codes mandate that the time appropriated for psychotherapy be distinct.  Therefore, 30 minutes of a psychiatrist’s time used for psychotherapy is reimbursed less then 30 minutes of a psychotherapy time done by someone who may have much less training.  The psychiatrist is paid more for the appointment because of the additional E/M code, but the time spent on evaluation and management must be distinct from psychotherapy, so the per-minute fees paid for psychotherapy are higher to those who don’t provide medical services.  This is especially notable for the 60 minute code, where 53 minutes of therapy, distinct from medical management, must be done. (Psychiatrists are no longer allowed to use the bathroom).

3. In theory, paying psychiatrists less than other mental health clinicians for the time devoted to psychotherapy may eliminate Medicare’s financial incentive for split therapy – the psychiatrist is now the cheapest way to obtain psychotherapy services within the Medicare network.  If psychiatrists are willing to accept these fees, other mental health professionals may find their services are no longer needed.

4. If no medical services are provided (for example, if a psychiatrist’s patient is not taking medications), then a psychiatrist can submit for the higher, non-medical psychotherapy fees, but this means the reimbursement is higher for  doing psychotherapy on less complex patients, and this makes no sense.

5. Because physicians worry about charges of fraud related to inaccurate Medicare documentation, the new and complex coding requirements are likely to cause even more psychiatrists to opt out of Medicare.  As is, Medicare patients often have trouble finding network psychiatrists to provide treatment.

6.  Medicare patients are often on fixed incomes and it seems unreasonable to tell patients that their fees may vary widely and can not be determined until the session is over.

7. Anyone who has ever done psychotherapy or been in psychotherapy knows that it’s not possible to treat a mental illness and segregate medical issues to a separate time and not discuss them during psychotherapy.  Patients talk about what is important to them, and if they are depressed, having trouble functioning, having cancer treatments, or about to have a joint replacement, this is what they talk about in therapy.  Saying that evaluation and management must be done in a time period distinct from psychotherapy is like the AMA declaring that the sky is now orange with purple polka dots.  You can say it, but it just doesn’t happen that way.

For all patients, there may a reluctance to tell the psychiatrist if they are having medically related symptoms for fear of driving the cost of the appointment up, and psychiatrists may shift the emphasis of their work so that sessions are used to question and exam patients in ways that maximize what they can charge, rather than what is in the best interest of the patients.

In short, it’s not all good, and it’s difficult to understand why our professional organizations have promoted a system with so many complexities, or why the Centers for Medicaid and Medicare Service would set fees that devalue the work of psychiatrists.

Please note you can watch a video on the new codes.

And I took the E/M chart from a blog called Psych Practice.

Dinah Miller is a psychiatrist who blogs at Shrink Rap and co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

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  • Dinah

    Thanks to Kevin for posting this! The title is a little different, and I don’t believe it is Medicare’s INTENT to devalue psychiatry. There is so much confusion about what the new coding rules are, and I have gotten so much conflicting information from different sources about whether psychotherapy and E/M services can be combined or must be done separately (–APA and the National Council say services must be timed and provided as distinct), others have said they can be interspersed. For something that is going to implemented in weeks, there should be more consensus on how exactly it will work. Again, thanks for the air-space!

    • Rob Burnside

      One of Walt Whitman’s favorite sayings was, “Define the moment, or the moment will define you!” and it seems the process has begun, though right now it’s more of the later than the former. Eventually,a balance will be struck, there will be changes to the changes, and what is now disconcerting primarily because of its newness will become “old hat.” The important thing is that dialogue continues, thanks to Dinah and Kevin, and all who comment here. While concern is presently focused on billable moments, may you never lose sight of the fact that, above all else, effective patient/provider interaction promotes true healing.

      • Dinah

        My fear is that all this complexity in multiple codes per session (I think you can have 3, med management, psychotherapy, complexity issues) and being sure you’ve me the documentation requirements for the E/M code you’ve used, that good patient care, which in psychiatry often has to do with the interpersonal elements, will get lost. Funny, but I don’t think 3rd party reimbursers care about true healing.

        • Rob Burnside

          One of my fears is that 3rd party reimbursers may soon care *too much*about healing, given the large number of newly-insured patients bursting
          onto the treatment scene, and that time may be “value-engineered” out of the formula. Ironically, this is where complex codes can become the practitioner’s ally, essentially buying the extra time necessary for a patient to improve. In other words, I’m seeing the potential for greater flexibility where others see less, in the hope that we’re not simply re-arranging deckchairs. That might be the worst outcome of all. In any case, thank you, Dinah!

  • Jason Simpson

    “What was quite simple has now become unnecessarily complex. Why do we need 17 different codes to describe a psychotherapy session with medication management?”

    It is ABSOLUTELY the purpose of Medicare and all insurance companies to make coding as complicated as possible so they can block claims and pay out less money.

    Medicare and insurance executives have meetings where they discuss this very thing. An actuary or accountant will get up in a meeting and say “we project that if we add one extra layer of coding complexity that we will spend X% less on reimbursements because physicians wont code their documents correctly and we can therefore refuse payment.”

    Wake up, doctors, thats what these scoundrels do for a living and they are VERY good at it. It is no mistake that ICD-10 has more than double the codes of ICD-9. Its not the doctors making that decision, it is the Medicare/Medicaid/insurance executives playing you like puppets.

  • ninguem

    I claim no expertise on psychiatry billing. Forgive me if I’m making a rookie mistake.

    50 minutes with a patient, counseling and medication management, I say that’s a 99215 by the “regular” medical fee schedule. for “E+M” (evaluation and management). For established patients, it’s 99211, 99212, 99213, 99214, and 99215.

    99211 is typically the nonphysician visits, sees a nurse, gets blood pressure checked or some basic thing.
    99212 a very basic physician visit.
    99213 the typical average physician visit
    99214 a more complicated visit
    99215 complex visit

    There are rules for “simplicity” or “complexity” of office visits, but there’s also time-based rules.

    99213-15 minutes
    99214-25 minutes
    99215-40 minutes

    Oversimplifying but there you are.

    I don’t have much reason to bill psychiatry codes.

    I would say you could bill 99215 based on time spent, I say don’t bother with documenting “complexity” (though I’m sure you could easily justify that billing), but just document time.

    Medicare payment for that billing code is a public document from your regional Medicare carrier. The actual payment varies a little by region.

    When I glance at payment for 90807 and 99215 I see it’s about the same in my area. I think it will be a wash for you.

    My advice, and a dime, won’t even get you a cup of coffee anymore. I could be dead wrong. Criticism welcome.

    • Dinah

      Oh, it would be nice if it was that simple, but they are requiring two codes for psychotherapy and medication management, so a 99213, for example, plus a time based psychotherapy code. And the time can’t ‘overlap” (as if that were possible). Can you just bill a 99215 based on time if here is notihing complex going on? F/u for depression, psychotherapy session discussing issues patient is having at work, or with spouse, stable on current medication regimen?

  • Patricia Kelly

    PAs use the physician codes; for Medicare they are reimbursed at 85% of the physician rate.

    • Dr. Jeff

      For a physician who has 7 years of postgraduate training versus PA’s 2 years that 15% difference amounts to a professional insult. Why go through 4 years of expensive medical school and three years of a hard residency when you can make 85% for a lot less expense

  • doc99

    Psychiatrists should be paid for their time – not arcane CPT/ICD codes. It really is THAT simple.

  • Kolin H Bennett PA

    Our group has spent tons of time, money and sweat getting these what if add on codes intergrated so our MDs arent spending more time clearing a note than actually visiting the client. There is no way to “break out” a medical issue on a psych session. AMA is lost on this one. Just fatigue, was it the SSRI, are they too anxious to sleep? Then you hear about their thyriod symptoms and maybe apnea.
    We need to be paid for what we do. I am
    a PA and I work with super docs. 90862 visits were always complicated by something. If they were perfect on the med check and roll them out the door too fast, you get slammed on pt survey.
    Rant is done, I am very open to ideas.

  • Doccupy

    Ain’t it awful.

    Keep complaining, and see where it gets you.

    AMA and APA have betrayed us, as evidenced by their decision to get in bed with payers. If you want to DO something, start with resigning from these worthless organizations, then fire all patients who have Medicare or Medicaid, and get out of all contracts with insurance companies. If you don’t have the guts for it, stop accepting new Medicare patients and opt out, or at least restrict the number of new Medicare patients you take.

    If you’re too much of a coward to act, you deserve what you get. You’re enabling what you claim to dislike.

    I don’t want to hear your complaining. Take it somewhere else.

  • joelfromreisterstown

    Sorry, when it comes to bureaucracy, I am as cynical and pessimistic one can possibly be. I see this at least as an effort of coming PPACA to further limit the role of psychiatry, if not eliminate the role of private practice practitioners by 2016 as able. I also see this as just complicating mental health to drive people away from treatment. Sure, I await the commenters to say otherwise or just label me unreasonable or crazy conspiracy accuser, but, where is the logic as seen as described above? And as noted, reimbursement rates will be affected for the worse, because let’s have a moment of brutal candor, as Medicare sets, so do private insurers.

    For me, yet another reason I am glad I do not belong to the AMA nor APA. Because what are these alleged representatives of physicians and psychiatrists respectfully thinking in approving this garbage? Certainly not for the profession! Hey, I read at a thread yesterday (and sorry I can’t link as can’t recall where it was), but, many of the commenters at the thread were trying to rationalize providing somatic services in a psychiatric office who are NOT internists, PCPs, or other legitimate source for medical services. Simply to legitimize those bullets. Careful what ya wish for, colleagues trying to make a buck, those ‘bullets’ may come back to harm ya!

    Watch for more audits too colleagues!!!

  • MeredithKendall

    Hey now, us mental health counselors do a bit of therapy, too. As well as psychoeducation.

    I think of the psychiatrists I’ve met who see 30 plus people for medication management over a nine hour day, and then have the joys of spending days and nights on psych unit duty. It’s tough, and there are quite a few doctors who could use a pay bump.

    On my end, therapists who work for agencies get at most a fourth of what the agency bills private insurance and public health systems, unless they have a supervisory role. Therapists in private practice can pay out 30% – 50% of their earnings to the owner of a group practice in order to pay for reception, insurance billing, HVAC, lighting, and a roof – marketing is typically done by the therapist, minus a profile page on the practice’s website.

    By no means should us Master’s level folks be getting paid as much as physicians for doing therapy (Though smart therapists find ways to make their income result in a more than comfortable living via teaching, publishing, etc. – well earned). We frequently can’t bill private insurance for hospital visits, home therapy, and going to court, which can eat up your time depending on what population you help. Overall, we take the hit due to the cost of doing business.

    I suspect the bulk of psychiatrists are in the same boat.

    I wish the clinical mental health professionals (psychiatrists, psychologists, social workers, and counselors) would band together, put our feet down, and say no to insurance entities completely controlling the way we work. It’s affecting our diagnostic criteria, it’s affecting our techniques, and it’s affecting the people we are trying to help. I can’t help but wonder if our desire to help people at almost every cost feeds into the way insurance entities treat us – we follow their terms with complacency out of fear that there won’t be money coming in. That is my observation from agency work, at least.

  • Linda Fogacci-Walker

    I’m a healthcare admin consultant and billing specialist and so happens mental health is my specialty. I think the biggest hurdle really is that all prescribers (not just Psychiatrists anymore) will need to 1) educate themselves, or obtain a coding specialists (preferably a CPC) and 2) expand their fee schedules to include the new and add on codes to account for the evaluation and management codes as well as the “add on ” psychotherapy codes.

    A patient shouldn’t be surprised at any change in price, because again, the provider should have a fee schedule. It’s also in the best interest of all physicians to have ONE fee schedule rather than various ones to coincide with insurance reimbursements. These universal fee schedules are used to create reimbursement fee schedules so a provider basing his billable fee on an allowable hurts the whole industry. ONE fee schedule, ONE fee for each CPT. This shouldn’t be new to any provider. Family practice’s have been doing this all along. They have ONE superbill laid out, cut and dry, doctor sees patient checks the appropriate codes and biller takes over from there. When in doubt a coder should go over the actual file to determine any coding inaccuracies. .

    As for the timing, let’s be fair. New coding changes are often announced right around October, the only difference this year is that there is no 90 day grace period, and these codes must be used as of 1/1/2013. I’m thinking mental health professionals are making much more of this than it has to be. Psychiatrist will undoubtedly will have the easiest of times as they have been able to use E/M when documentation permitted. Social workers and therapists really won’t have to do much aside change their psychotherapy codes and there’s only a minor change to the psychiatric evaluation.

    I think another thing lending to confusion is simply the deletion of the wording “Pharmacological Management” which used to be the simple 90862. CPT has done away with that terminology and instead replaces it with “medical services” A few words changed, added or deleted, can lead to a lot of confusion.

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