Journal of Psychiatric Practice
Psychotherapy Column
March, 2013
New Medical Psychotherapy CPT Coding: The Tail Wagging the Dog?
Norman A. Clemens, M.D.
Abstract: The author discusses the implications of the 2013 revised CPT system
for coding psychotherapy with medical evaluation and management (E&M.) He
expresses concern about a potential devaluing of psychotherapy because of the
required order of reporting combined codes with E&M as the primary code.
Procedural and documentation requirements for using the standard medical E&M
codes challenge psychiatrists to be systematic and efficient in order not to
interfere with time and attention essential to effective psychotherapy process.
Insensitive use of computers when working with patients can damage rapport
and progress. The trend towards sharing personal health information in large
systems calls for heightened discretion. Using HIPAA-protected psychotherapy
notes for highly sensitive personal information is essential to preserve patient
privacy. Journal of Psychiatric Practice 2013;XX:XXX-XXX
The 2013 Current Procedural Terminology1 (CPT) introduces a new set of numerical
codes for psychotherapy. Time frames for psychotherapy sessions are altered and more
specific, but in general the change requires only the learning of new numeric codes for
units of psychotherapy itself. However, for physicians the coding for psychotherapy with
medical evaluation and management (E&M) is radically different. This is not the space
for a primer on using the new codes, but I wish to comment briefly on some implications
of the change and the way I hope psychiatrists will view and use the new system.
What I have heard about the rationale for the coding change suggests multiple motives.
One is to bring psychiatry closer to the rest of medicine and eliminate idiosyncratic
procedures that are seen to stigmatize and isolate psychiatry. Another is that more
detailed and specific coding may allow more precise study and management of the
utilization of services, aided by the more elaborate documentation that is necessary to
support the codes. A third argument that I heard advanced by an attorney who was
involved in furthering the change is that physicians are de facto more vulnerable to
malpractice claims for overlooking serious medical problems than non-medical
therapists and therefore this vulnerability warrants using the medical E&M codes for
every psychotherapeutic encounter with a patient. It is not merely incidental that using
the standard E&M codes rather than the previous unique fee pattern for psychotherapy
with medical E&M would increase psychiatric income and consequently the disparity in
income between medical and non-medical psychotherapists. Regardless of motivations,
the new codes are here to stay.
The feature that is most jarring on first acquaintance with the codes is that codes are to
be reported with the medical E&M code first and the psychotherapy code second. While
this may be consistent with the use of E&M codes in general, it symbolically may be felt
as a statement that the primary service is medical E&M and psychotherapy is incident to
that. I hope that such a mind-set that devalues the evidence base and highly developed
technical skills of psychotherapy can be avoided.
Psychotherapy is an entity with a process all its own, just as any surgical procedure
would be. It takes place in units over time – sometimes as frequently as several times a
week over months or years. In every session we tacitly observe the patient, actively
assess his or her condition, and make decisions accordingly, so that as physicians we
are doing medical evaluation and management. But the more frequently the patient is
seen, the more that process is seamlessly integrated into the therapeutic work itself.
With such patients one does not ordinarily spend a certain number of minutes doing
E&M, then distinctly shift gears and start the therapy. Unless the patient’s condition has
suddenly changed or new medical or psychiatric symptoms have emerged, it is unlikely
that we would be coding the E&M above a level 1 service – but an unusual development
or intervention could justify a higher level. The division of time elements between
psychotherapy and E&M for coding would likely be arbitrary estimates.
Documentation is another challenge. In its efforts to help members adjust to the new
system, the American Psychiatric Association’s web site offers some templates for
documentation. They involve check lists for a complete psychiatric history and mental
status examination. Presumably one can develop templates tailored to individual
patients that can be copied session by session and filled out as indicated. The attorney
mentioned earlier advises having each session on a separate page so that if audited
one can submit only the requested sessions (as in a court room, never provide more
than is asked for.)
I hope psychiatrists and the organized systems many of them work in can develop
patterns of writing documentation that are not unduly cumbersome. Templates and
check lists should facilitate efficient record-keeping, not act as prompts for scrupulously
filling in all the blanks. The worst-case scenario is the psychiatrist staring at the
computer and doggedly going down a list of questions while the patient, aching to tell
his or her story, glares into space and feels alone. No eye contact, no rapport. While it
may enhance the level of E&M that can be billed, that’s a formula for losing a disgusted
patient.
The larger world of health care is inexorably moving towards integrating individual
medical records with larger systems. Big community hospital systems and regional
health information exchanges may eventually be integrated into a national health
information system. These trends pose huge technical challenges to deal with
interoperability, security, and privacy of personal health information. Patient consent to
divulge information is a major issue2. Spectacular breaches are commonplace.
Depending on where psychiatrists work, they may have little choice about participating
in these systems. A patient’s diagnoses, major risk factors, medication regimes and side
effects, and chosen mode of psychotherapy (all E&M data) will inevitably be exposed to
the prevailing health information network, and the psychiatrist will have full access to the
patient’s general medical record. That much information-sharing is potentially an asset
to the patient’s overall medical care, in my view, though many colleagues would
disagree. However, the safeguards for protecting sensitive information from eyes that
have no business seeing it are far from perfected. Think potential employers or coworkers, ancillary personnel of all types, even jealous lovers in any big hospital
complex…
For that reason it is crucial that psychiatrists make full use of HIPAA –protected
psychotherapy notes for sensitive personal information. These are defined as notes
maintained “separated from the rest of the individual’s medical record.” Advisedly,
they are not recorded on a networked electronic system (or are fully encrypted in any
personal computer.) They can be divulged only with the patient’s specific, time-delimited
authorization (not the more general consent) with very few exceptions such as to
prevent imminent harm, or malpractice defense of the psychotherapist. The patient does
not have the right to see psychotherapy notes. The protection of psychotherapy notes is
unique in HIPAA and is the outgrowth of the privileged protection of psychotherapy
notes in the 1996 decision of the U.S. Supreme Court in Jaffee v. Redmond. For the
sake of our patients and their access to effective psychotherapy, sensitive personal
information belongs in psychotherapy notes, not the general medical record. And the
new system of procedure codes for psychotherapy with medical evaluation and
management must not be used in such a way that it is the tail that wags the dog.
1
American Medical Association. Current Procedural Terminology. 2013
Clemens NA. Privacy, Consent, and the Electronic Mental Health Record: The Person vs. the
System. Journal of Psychiatric Practice 2012;18:46–50
2