Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, February 9, 2014

Starting to Think about Medical Necessity

I thought it was all over when I cracked the CPT code. I felt liked I had accessed the secrets of the universe, and there was nothing more to do but sit back and let my patients enjoy their reimbursement.

But times change, tides roll in and out, and insurance companies find new ways to be, well, they're not even A-holes. They're B-holes.

It's no longer sufficient to document  1-3 presenting problems, 6 exam elements, and 1 ROS,  code a 99213, and call it a day.

This is from Magellan Health, their Medical Necessity Criteria Guidelines 2014. Incidentally, how do you think Ferdinand Magellan, the original, would feel about having a health insurance company named after him?

There seem to be 2 categories to qualify for outpatient psychiatric care: Severity of Need, and Intensity and Quality of Service.

Severity of Need requires criteria A,B,C,D, E to be met, so you can see where this is headed.

A-DSM-5 diagnosis, or evaluation for one.
It doesn't say anything about ICD-9 or 10.

B-Presenting impairment consistent with the DSM-5 diagnosis.

C. (This is a quote)

One of the following:
1) the patient has symptomatic distress and demonstrates impaired functioning due to
psychiatric symptoms and/or behavior in at least one of the three spheres of functioning
(occupational, scholastic, or social), that are the direct result of a DSM-5 diagnosis. This is
evidenced by specific clinical description of the symptom(s) and specific measurable
behavioral impairment(s) in occupational, academic or social areas. or
2) the patient has a persistent illness described in DSM-5 with a history of repeated admissions
to 24-hour treatment programs for which maintenance treatment is required to maintain
community tenure, or
3) there is clinical evidence that a limited number of additional treatment sessions are required
to support termination of therapy, although the patient no longer has at least mild
symptomatic distress or impairment in functioning. The factors considered in making a
determination about the continued medical necessity of treatment in this termination phase
are the frequency and severity of previous relapse, level of current stressors, and other
relevant clinical indicators. Additionally, the treatment plan should include clear goals
needing to be achieved and methods to achieve them in order to support successful
termination (such as increasing time between appointments, use of community resources,
and supporting personal success).

So, measurable impairment, or repeated admissions to 24-hour programs (what about longer?), or needs a specific number of additional sessions to terminate.

D. The patient does not require a higher level of care.
Magellan specifies at the beginning of the document that the least restrictive care is always the most desirable.  

E. The patient appears to be motivated and capable of developing skills to manage symptoms or make behavioral change. 
What if they're not? And how can you tell? 

That's just "Severity of Need". Intensity and Quality of Service has criteria A through L, which take up two whole pages. You can check them out, yourself-they're on pages 103-104 of the document. But they include things like: 
*documentation (extensive) of symptoms 
*medically necessary and appropriate treatment plan (How do you establish a medically necessary plan to determine medical necessity?) 
*9 required components of the treatment plan
*patient is motivated
*patient is adherent
*patient is showing progress
*no duplication of services 

And a couple of my favorites:

*Treatment is effective as evidenced by improvement in SF-BH, CHI, and/or other valid outcome measures. 
*Visits for this treatment modality are recommended to be no greater than one session per week, except for: (i) acute crisis stabilization, or (ii) situations where the treating provider demonstrates more than one visit per week is medically necessary. 

*As the patient exhibits sustained improvement or stabilization of a persistent illness, frequency of visits should be decreased over time (e.g., once every two weeks or once per month) to reinforce and encourage self-efficacy, autonomy, and reliance on community and natural supports. 

Okay. Clearly these guidelines were developed by people who have not gone anywhere near a patient in a very long time or have never treated a patient, period. This is the kind of thing you'd come up with if you had to figure out how to make money from a field you know nothing about.

And this is just Magellan.

What about Anthem?

Well, Anthem, the most recent update I could find, anyway, from October 2013, lets you use DSM-IV or ICD diagnoses. And they refer to "Severity of Illness (SI)", rather than need.

All of the following must be present:
  1. Specific symptoms or disturbances of mood and/or behavior are present, with functional impairment, which are consistent with the DSM/ICD diagnosis listed, and these disturbances/symptoms are likely to improve with treatment; AND
  2. The Covered Individual demonstrates motivation for treatment and is capable of benefiting from the treatment approach planned.
Then they talk about "Intensity of Service (IS)":

All of the following must be present:
  1. Treatment goals target resolution of specific symptoms or stabilization of mood and/or behavior consistent with the DSM/ICD diagnoses listed and also target specific domains of functional impairment; AND
  2. Medication is being used for conditions where indicated, and if not, documentation of the reason and treatment interventions addressing the omission of this treatment; AND
  3. If substance abuse/dependence is a diagnosis or indicated to be present, a substance use evaluation has been performed when appropriate and treatment is being provided; AND
  4. Community/natural supports and resources are identified and utilized or skills to develop community/natural supports is  a treatment goal, including school/work interventions, self-help or diagnosis specific support groups, spiritual/religious, and community recreational activities; AND
  5. Coordination of care with other clinicians providing care to the Covered Individual or family members, including psychiatrist/therapist and primary care physician (PCP) is documented; AND
  6. For children/adolescents, family participation in treatment or family therapy is documented unless contraindicated with documentation of the reason; AND
  7. Treatment is not duplicative of services being provided by another clinician for the same reasons/diagnoses;AND
  8. Provider must be properly licensed to provide the treatment requested
And then there's the issue of frequency, if treatment is being provided more than once a week:

Frequency Criteria: for treatment that occurs more frequently than once per week (excluding Medication Management) must have all of the following (1 - 3) to qualify:
  1. Either the Covered Individual has been discharged from an inpatient, residential or partial hospitalization program (PHP) service and more frequent outpatient (OP) treatment is required as a transition for the purposes of stabilization while returning to the community or the Covered Individual is in crisis as evidenced by suicidal ideation or high risk behavior that is manageable on an OP basis, or an unexpected increase in symptoms and/or behaviors or worsening in mood where the treatment goals are focused on stabilization of the crisis;AND
  2. The symptoms/behaviors or mood that represent the crisis can be stabilized with more frequent treatment as evidenced by urgent psychiatric contact and medication changes if indicated and reports of progress with resolving the crisis; AND
  3. The condition has not stabilized to the point where less frequent treatment which targets less critical symptoms/behaviors is equally appropriate.
In other words, the only reason to meet more than once a week is if there's an acute crisis just shy of requiring hospitalization.

I'm getting a little too irked to write anymore, so I'm gonna stop for now, but please do check out the documents, and let me know if you have any idea how to integrate this into regular notekeeping, and how to tailor the content to a specific patient's insurance requirements.


  1. There is a rationale approach to all of this Business Necessity to maximize profits and exploit physicians. The APA needs to step in an set the standard for both care and documentation and take the higher ground on this issue. No physicians stands a chance debating nonsensical criteria (like B, C, D, E of the Magellan "standard"). It is written in legalese for a reason. We know the reason is either to deny care prospectively or (even worse) in a retrospective Department of Justice manner so that the practitioner can be "penalized" by the managed care cartel. We all know how that works - disallow certain charges and then extrapolate that across the entire population of patients seen from that payer. The end result is tens of thousands needing to be paid back based on purely subjective determinations.

    I am not holding my breath on the APA doing anything proactively, but I think that this degree of harassment is the evidence why psychiatrists are the least likely to accept private insurance. I would hope that we could get to a point where nobody does but I realize that the cartel has many people who need our services in its grasp.

  2. Have the insurance companies asked for your notes?

  3. All this talk of coding is stirring up my PTSD -- awfully darned happy I work in corrections now!