The launch of the new Current Procedural Terminology (CPT) coding system in 2013 has thrown many psychiatrists into a quandary. It has challenged us to think in entirely new ways about describing what we do. Always available to us, the evaluation and management (E&M) codes were seldom used by psychiatrists, although they have been the essential codes used by other physicians since 1992. Now psychiatrists have no choice but to use them and the new add-on therapy codes. The challenges for psychiatrists include:
• Learning the complexities of the E&M Chinese-menu–style coding system
• Accepting the idea of an add-on “procedure code” for therapy
• Embracing the distinctions between “counseling” and “therapy” (defined differently in CPT )
• Disentangling “medical thinking” activity from “therapy” activity in order to code them separately
Besides the philosophical implications of this last point for further extending an already widening mind-body split, this new system sharply highlights ethical conundrums that have always lurked in fee-for-service medicine, though more subtly in the past. This article focuses on 2 ethical issues that the new CPT coding raises to higher stakes: the increased potential for conflict of interest in billing and the erosion of confidentiality.
Conflict of interest
Consider these 2 cases from my experience.
Case 1. In my fee-for-service practice, Joan started our last session with a question: “Last month’s bill had different CPT codes than the month before, and my insurance paid different amounts for the codes. We met for a half hour each time. Can’t you always use the same code, like last year, for our half-hour sessions? Can it be the one that gives me the higher reimbursement?”
During one appointment, I measured Linda’s blood pressure and weight, tested her balance when she told me about some dizziness, and discussed her stomach pain and the chronic pain in her neck. After reviewing the interim history (all the while performing a mental status examination), I “counseled” her about how her psychiatric medications might or might not be related to the physical symptoms, the optimal timing for taking them, and other choices of medication. We met for a total of 25 minutes. I coded 99214 (Table).
During another visit, after asking about a number of interim psychiatric symptoms, I did not check blood pressure or balance; I did order a lithium level test because I was concerned about a tremor. We then spent approximately 18 of 25 minutes going over cognitive techniques for managing her increasing anxiety at work. For that visit, I coded 90813 with an add-on psychotherapy code of 90833.
These code sets reimburse the patient quite differently. In the Baltimore, Maryland, suburbs where I practice, the average Medicare payment for 90814 averages $114 and 90813 + 90833 = $121 ($78 + $43). For patients with private insurance, the differences have ranged as high as $40.
Case 2. A colleague called me for an ethics consultation. She was treating patients with medication and therapy. In some cases, the E&M activity encompassed about 5 minutes, and the therapy about 45 minutes: the total time spent with the patient was 50 minutes. She took 10 minutes between cases. She used to bill 90807 before the code changes. “I so often feel there is more work to do in a session and have thought about taking more time. I’d like to spend 8 to 10 more minutes on the therapy, move right on to the next patient, and take a break every few hours to write notes. In the past, I’d get paid the same if I spent the extra 10 minutes. Now, if I spend those extra minutes on therapy, I can code the 90838 add-on rather than 90836 and get paid more by insurance. Now that there is an extra reward to me for doing so, is it ethical for me to make this change, which in the past would help patients more than me? Is that a conflict of interest?”
Dr Komrad is Chair of Ethics for the Sheppard Pratt Health System in Maryland and a member of the APA Ethics Committee. He is also the author of You Need Help: A Step-by-Step Plan to Convince a Loved One to Get Counseling. He reports no conflicts of interest concerning the subject matter of this article.
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