Five key events in 2013 will leave a longlasting mark on psychiatry. Here: a look at the impact that CPT coding, DSM-5, sunshine laws, a shrinking market for “shrinks,” and I-STOP are likely to have on our field.
CPT coding and the re-medicalization of psychiatry
Starting January 1, 2013, psychiatrists adopted the E&M (evaluation and management) billing codes used by medical colleagues. These billing codes affect more than money and mean more than promises of “parity” with other medical specialties. Learning coding is confusing and time-consuming—but CPT codes redirect our “gaze” and change the way psychiatrists think. This may be one of many steps toward ending the supposedly “separate but equal” categories of “mental illness” and “medical illness.”
Back in 1977, then-president of the APA Mel Sabshin, MD, urged psychiatrists to return to their medical roots—roots that were frayed by psychoanalysts who deemed medical training unnecessary and accepted “lay analysis” instead. Change takes time, however. The power and prestige of psychoanalysis faded slowly but surely, but still leaves its legacy. In 2013, the AMA elected a psychiatrist, Jeremy Lazarus, MD, as its president.
APA and AMA presidential pronouncements aside, the substance of CPT coding shifts the attention of psychiatrists. Higher CPT codes include the same “review of systems” as medical examinations. They require notation of basic neurological observations (gait, station, tremor, muscle strength, pupil size, orientation, memory tests, etc), plus vital signs, weight, girth, and possible comments about skin, hair, respiration, etc. The standard mental status findings (speech patterns, relatedness, affect, unusual perceptions, etc) remain. Coding rules let us choose among 9 items from a preset menu. In short, psychiatry is treated like ophthalmology, another “single-system specialty,” rather than psychology.
Many psychiatrists already perform these functions. When we prescribe lamotrigine, for example, we inspect skin for rashes and signs of Stevens-Johnson syndrome. Lithium prescribers check for tremor, ataxia, and acne, as well as lithium and lymphocyte levels and thyroid and kidney function. The Abnormal Involuntary Movement Scale is subspecialists or not, we instinctively look for track marks or new tattoos. The examples are endless—but now we organize our impromptu physical examinations better. As for checking drug-drug interactions or possible pregnancies—how could we not?
To qualify for higher payments, we make more observations and more notations (provided that such detail is essential to our patient’s problems at that visit). Conferring with relevant medical specialists or generalists—not just with therapists— also boosts the code. We know that money motivates most people— and that “contingency management” (cash rewards) even motivates previously untreatable substance users. We can expect higher-paying CPT codes to motivate MDs and DOs to change their behavior.
That’s only one-third of the story. These CPT codes force psychiatrists to assess the specifics of their patients’ subjective complaints, evaluate objective signs and symptoms systematically, and consider differential diagnoses (which include “medical mimics”). Psychiatrists are no longer passive listeners; they are active assessors.
Documenting CPT codes reminds psychiatrists to choose treatment modalities after the evaluation. If psychotherapy is added, it earns an “add-on code” and gets extra reimbursement as a “procedure.” Psychotherapy is not the automatic outcome of every psychiatric visit. Psychopharmacology, transcranial magnetic stimulation, electroconvulsive therapy, breathing techniques, dietary changes and (in theory) even psychosurgery can be prescribed. Referrals to specialists or requests for tests may be ordered before proceeding.
Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, Bronx, NY. She is also in private practice in New York City. She reports no conflicts of interest concerning the subject matter of this article.
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