Unlucky Number 90862
Unlucky Number 90862
You know, I don’t know the patient. I just prescribe meds.”
This is the most disappointing—and unfortunately, one of the most common—responses I receive from the psychiatrists I call from the psychiatric emergency department.
I often think that I would prefer the psychiatrist speak more frankly: “I do not really know much about the patient. I have a diagnosis here of ______NOS, which the patient has had for __ years. I give him powerful medication that can affect the way he thinks, feels, and behaves and can have harmful side effects, but I have never really thought it was important for me to get to know more about him. Once you discharge him, please let me know if you have made any medication changes so that I can continue them.”
I have also been disappointed by some of the responses I get when I tell people that I am a psychiatry resident. “I see, . . . a psychiatrist . . . you just prescribe medications. Psychologists do the therapy, right?” “Oh, so you’re a pill pusher?”
While these responses differ in levels of social grace, they each convey an unfortunate under-appreciation of the range of and potential treatment psychiatrists can offer.
I believe there is a small change we can take upon ourselves that would make the outpatient psychiatrist quoted in the opening line a rarity, and the response about psychiatrists being pill pushers history. Consider some of our most commonly used outpatient CPT codes1: Code 90805 for the patient who is treated with a combination of psychotherapy and medication management in 30 minutes, and 90807 for patients who receive similar services in 45 minutes. Each of these codes requires the psychiatrist to spend a certain amount of time with the patient, but they do not dictate the specific nature of that interaction.
On a single day, my coding of 90807 can represent a 6-year-old girl with ADHD who is working on a drawing of her family, a woman with OCD who is distressed because the various food items on her plate are touching each other, a disabled firefighter with PTSD who is reporting that he joined the fire department because he felt it would make him a “real man,” or even a resident with GAD who is describing his hopes and fears as his wife is expecting their first child.
While 90805, 90807, and every other billable outpatient code has a mandatory time minimum, 90862 alone requires none. Even the written description of this CPT code (“Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy”) appears removed from the essential point of every patient interaction—ie, that it should be in the patient’s best interest. A strict interpretation could lead to an absurd situation in which a psychiatrist tells a patient, “I am sorry, your visit does not include a discussion of that topic because it falls outside the bounds of minimal medical psychotherapy.” This particular situation could be avoided, of course, by billing a different code, but in cases of shared care, 90862 is often the only reimbursable code available to the psychiatrist.
As psychiatrists, we are trained to observe our patients quickly by considering aspects as diverse as time of arrival for an appointment, body position, use of language, and manner of dress. We are also taught that the same observation in different patients may signify vastly different meanings. Three consecutive patients may wear sunglasses indoors—one because she just came from the ophthalmologist, another because he is hiding a black eye his partner gave him a week earlier, and a third because she is concerned that people may be stealing government secrets by looking into her eyes. To make observations and to ascertain the meanings of these observations, time with the patient is essential.
I do not know the magic number of minutes that should be spent with our patients. But we should accept among ourselves that there is a certain minimum amount of time required for us to do our job appropriately. As a field, we should set a minimum amount of time it takes for us to interact with patients and to make appropriate plans with them for their well-being. If we don’t do this ourselves, others will make this decision for us. In fact, many state Medicaid programs have already instituted 15-minute minimums for code 90862.
I realize that as a resident, I have the advantage of having very few distractions from my clinical responsibilities. I am protected from having to spend time speaking with insurance companies to get authorization for sessions or medications. Furthermore, my income is set and the government mandates fixed limits for the hours I can work. I have no staff I can affect with unpopular but necessary decisions. Regardless, though, of how busy most practicing psychiatrists are (and I imagine I will be soon), not knowing all of one’s patients should either be a temporary state of affairs—or at least something to be admitted only with a degree of shame.
References
Reference
1. CPT 2010 Professional Edition. Spiral Edition. Chicago: American Medical Association; 2009.
I applaud Dr. Forman's call for professional ethics and responsibility. To put it bluntly: except in unusual circumstances [see below], prescribing medications for a patient one does not "know"is not just dangerous--it is unethical. Of course, we have all been faced with the pressure to "just prescribe." Some twenty-five years ago, I took over as the lone psychiatrist for a large outpatient mental health clinic. Almost the same day
I set foot in the place, I was told I needed to "write scrips" on over 100 patients whose prescriptions would be expiring soon--patients whom I had never met and truly did not "know"! This was a real ethical and medical bind.
If I didn't write out renewals, the patients would almost certainly suffer. But if I wrote them, I would be assuming responsibility for patients who might or might merit the medications, as written by the previous psychiatrist.
I wound up making an uncomfortable compromise: I reviewed the patients' charts briefly, explained my rationale for renewing the meds in a brief note (e.g., preventing relapse, withdrawal, etc.), and wrote prescriptions for only
a 2-week supply with one refill. I told the nursing staff I wanted to see each of the patients as soon as possible--which elicited rather quizzical looks and some raised eyebrows. I was told that it is "routine practice" to write such "en masse" prescriptions in clinic settings. I was very uneasy with this, though the APA's Manual of Psychiatric Quality Assurance does permit such refills in situations where the patient's physician is absent, and the refill is for a minimal amount of the medication. But in general, as Dr. Forman notes, there is no excuse for
"prescribing but not knowing"! --Ron Pies MD