In yesterday's NY Times, there's an Invitation to a Dialogue about Gender Identity, by Jack Drescher, with a request for responses from readers by tomorrow.
Dr. Drescher writes about Coy Mathis, a 6-year-old, born a boy, now identifying as a girl. He discusses Gender Identity, and the fact that it is unclear what, if anything, to do with or for young Coy, or similar children.
He admonishes, "Currently experts can’t tell apart kids who outgrow gender dysphoria (desisters) from those who don’t (persisters), and how to treat them is controversial."
And finally, he offers some advice:
I would advise parents to learn all they can about the different approaches so they can understand the limitations and how they are sometimes guided by personal beliefs about gender rather than by good research data.
Is this supposed to be helpful? How? What kind of dialogue does the Times expect this to generate?
It's like saying, "No one knows what to do, so as the expert, I'm advising you to educate yourselves." What's the point of being an expert?
I'm not implying Dr. Drescher ought to know what to do, or that parents ought not to educate themselves. But if your best advice is, "Study up!", then you don't need to write about it in the Times.
So why am I writing this post? Not sure. Maybe it's to point out the hype anything related to DSM-5 gets. Or maybe I'm annoyed by the final blurb:
The writer, a psychiatrist and psychoanalyst, served on the D.S.M.-5 Workgroup on Sexual and Gender Identity Disorders. He is co-editor of “Treating Transgender Children and Adolescents.”
Oh, so that's the advice! If you want answers, buy my book!
An unpaid ad in the NY Times.
Showing posts with label psychiatry. Show all posts
Showing posts with label psychiatry. Show all posts
Wednesday, June 26, 2013
Monday, May 27, 2013
Open Source-Please Comment
I have an idea, in very rudimentary form, and I'd like to get peoples' opinions on it.
But first, an amusing anecdote:
The attending who taught me ECT was a character. He'd been doing ECT forever, and his approach was quite old-school. When the patient started to seize, as noted by the twitching toe, he would determine the length of the seizure by counting, 1-Mississippi, 2-Mississippi, 3 Mississippi...
One time, I suggested we look at the clock, and he said, "No, no, this is better." 1-Mississippi was his definition of clinical rigor. Clearly, this was not science.
I read somewhere, some time ago, that the DSM (3?) committee voted on the criteria for MDD. "Those in favor of worthlessness/guilt? Approved! Those in favor of helplessness/hopelessness? Not approved!"
Clearly, this was not science.
But here's the interesting part. How was it determined that 126 was the cutoff for diabetes? I'm not going to look up the history, but I imagine it started with the idea that diabetes was a disease, whose symptoms included ketosis, polyuria, polyphagia, polydypsia, etc. And after seeing many patients with this condition, some clever person figured out that it had something to do with glucose. And later, they realized that if a patient's glucose level is too high, that patient has diabetes. And then "too high" needed to be defined. Presumably, they took a lot of patients who had known diabetes and compared them with normal controls by testing glucose levels. And eventually, they figured out that most patients with diabetes had glucose levels > 126, and most patients without diabetes had levels < 126.
That is science. And it involved a lot of data over a long period of time. Now, granted, they had a test they were looking at-plasma glucose concentration. And there are no convenient lab tests in psychiatry. But there is data.
Not the data you get from a drug-company-sponsored study, where fancy statisticians are hired to produce any desired reality (see, for example, this post). And not the data you get from a 20 person committee voting on a diagnosis.
But what if it was a 200 person committee? Or 2000? Or 20,000? Imagine 20,000 mental health practitioners chiming in on which symptoms they've seen the most. Or which meds they've found most effective. Or least. Or what type of therapy works best for what type of patient. One anecdote is meaningless. But 20,000 anecdotes? Not so meaningless.
I'm talking about the power of the internet. There was a time when the largest number of clinicians you could get in one place was at an APA meeting. Or a survey sent out by snail mail. Now, there's worldwide access at all times. Who needs the DSM when there's the possibility of open source psychiatric data and unlimited discussion?
Would this do anything to determine etiology? No. Not in and of itself, anyway. Would it be valid or accurate? Who knows? People are skeptical about Wikipedia, but is there any more cause for skepticism there than in an old-fashioned encyclopedia article written by one biased individual? Or one closeted committee?
Facebook changed the world by recognizing that a huge collection of connected individuals is a very powerful thing. Why can't we make that idea work to our patients' benefits?
Please comment on this post. I'd like to get a sense of what people imagine this could be like.
But first, an amusing anecdote:
The attending who taught me ECT was a character. He'd been doing ECT forever, and his approach was quite old-school. When the patient started to seize, as noted by the twitching toe, he would determine the length of the seizure by counting, 1-Mississippi, 2-Mississippi, 3 Mississippi...
One time, I suggested we look at the clock, and he said, "No, no, this is better." 1-Mississippi was his definition of clinical rigor. Clearly, this was not science.
I read somewhere, some time ago, that the DSM (3?) committee voted on the criteria for MDD. "Those in favor of worthlessness/guilt? Approved! Those in favor of helplessness/hopelessness? Not approved!"
Clearly, this was not science.
But here's the interesting part. How was it determined that 126 was the cutoff for diabetes? I'm not going to look up the history, but I imagine it started with the idea that diabetes was a disease, whose symptoms included ketosis, polyuria, polyphagia, polydypsia, etc. And after seeing many patients with this condition, some clever person figured out that it had something to do with glucose. And later, they realized that if a patient's glucose level is too high, that patient has diabetes. And then "too high" needed to be defined. Presumably, they took a lot of patients who had known diabetes and compared them with normal controls by testing glucose levels. And eventually, they figured out that most patients with diabetes had glucose levels > 126, and most patients without diabetes had levels < 126.
That is science. And it involved a lot of data over a long period of time. Now, granted, they had a test they were looking at-plasma glucose concentration. And there are no convenient lab tests in psychiatry. But there is data.
Not the data you get from a drug-company-sponsored study, where fancy statisticians are hired to produce any desired reality (see, for example, this post). And not the data you get from a 20 person committee voting on a diagnosis.
But what if it was a 200 person committee? Or 2000? Or 20,000? Imagine 20,000 mental health practitioners chiming in on which symptoms they've seen the most. Or which meds they've found most effective. Or least. Or what type of therapy works best for what type of patient. One anecdote is meaningless. But 20,000 anecdotes? Not so meaningless.
I'm talking about the power of the internet. There was a time when the largest number of clinicians you could get in one place was at an APA meeting. Or a survey sent out by snail mail. Now, there's worldwide access at all times. Who needs the DSM when there's the possibility of open source psychiatric data and unlimited discussion?
Would this do anything to determine etiology? No. Not in and of itself, anyway. Would it be valid or accurate? Who knows? People are skeptical about Wikipedia, but is there any more cause for skepticism there than in an old-fashioned encyclopedia article written by one biased individual? Or one closeted committee?
Facebook changed the world by recognizing that a huge collection of connected individuals is a very powerful thing. Why can't we make that idea work to our patients' benefits?
Please comment on this post. I'd like to get a sense of what people imagine this could be like.
Monday, May 13, 2013
CPT-New and Improved?
In response to my recent CPT article, CPT: A Primer, in The Carlat Report, I received an email from Joel Shield, MD. I don't know Dr. Shield, but I want to share some of the content, and I have his permission to do so.
Dr. Shield writes about the real CPT coding, as opposed to what's being presented as CPT coding, which is really the Center for Medicare Services' (CMS) version, the version I've researched and written about because I didn't realize there was a difference.
What is the difference? Basically, the CMS version is a checklist, with, for example, 1-3 elements of HPI, at least 6 elements on exam, and 1 pertinent ROS for a 99213 (see my post).
But the version from the CPT 2013 manual is much more descriptive. You have to meet the same standard-providing enough information to qualify your coding, but it's much less of a checklist.
I'm not getting into too much detail because that might involve purchasing the manual so I could figure out what goes into it. Dr. Shield forwarded two articles he wrote up about the coding, and I'd like to include them, but I haven't figured out how to attach a pdf to a post. If anyone knows, by the way, please comment and tell me how.
However, a nice summary was included with the email I received:
In summary, the CPT manual and the CMS guidelines use the same categories for coding E&M services (the four levels of history, examination, and medical decision making), but differ significantly in some of the details of those categories (for example, the CMS guidelines specifying psychiatric, constitutional, and musculoskeletal parts of the psychiatric examination) and, most importantly, in adding a sub-basement level of very detailed requirements for what defines the levels of history, examination, and medical decision making. While the descriptions of the levels in the CPT manual are, in general terms, the same as those of CMS, because they are more descriptive they can be satisfied more flexibly and more easily.
Now here's the rub: If you document more descriptively, you can be less freaked out about what goes into your documentation. You might even be able to write the kind of note you're accustomed to, one that has something to do with patient care. But, if you ever get audited, or need to justify your services to someone who may or may not have graduated from high school, someone who is simply going to count the number of bullet points you did or didn't include in your documentation, then you're better off having bullet points to be counted.
To be honest, I'm bugging out a little over all the recent changes. You need to bill differently, and learn how to bill differently. You need to diagnose differently, and learn how to diagnose differently. It's too much. I'd really like to get back to my day job.
Dr. Shield writes about the real CPT coding, as opposed to what's being presented as CPT coding, which is really the Center for Medicare Services' (CMS) version, the version I've researched and written about because I didn't realize there was a difference.
What is the difference? Basically, the CMS version is a checklist, with, for example, 1-3 elements of HPI, at least 6 elements on exam, and 1 pertinent ROS for a 99213 (see my post).
But the version from the CPT 2013 manual is much more descriptive. You have to meet the same standard-providing enough information to qualify your coding, but it's much less of a checklist.
I'm not getting into too much detail because that might involve purchasing the manual so I could figure out what goes into it. Dr. Shield forwarded two articles he wrote up about the coding, and I'd like to include them, but I haven't figured out how to attach a pdf to a post. If anyone knows, by the way, please comment and tell me how.
However, a nice summary was included with the email I received:
In summary, the CPT manual and the CMS guidelines use the same categories for coding E&M services (the four levels of history, examination, and medical decision making), but differ significantly in some of the details of those categories (for example, the CMS guidelines specifying psychiatric, constitutional, and musculoskeletal parts of the psychiatric examination) and, most importantly, in adding a sub-basement level of very detailed requirements for what defines the levels of history, examination, and medical decision making. While the descriptions of the levels in the CPT manual are, in general terms, the same as those of CMS, because they are more descriptive they can be satisfied more flexibly and more easily.
Now here's the rub: If you document more descriptively, you can be less freaked out about what goes into your documentation. You might even be able to write the kind of note you're accustomed to, one that has something to do with patient care. But, if you ever get audited, or need to justify your services to someone who may or may not have graduated from high school, someone who is simply going to count the number of bullet points you did or didn't include in your documentation, then you're better off having bullet points to be counted.
To be honest, I'm bugging out a little over all the recent changes. You need to bill differently, and learn how to bill differently. You need to diagnose differently, and learn how to diagnose differently. It's too much. I'd really like to get back to my day job.
Sunday, May 5, 2013
Bereavement
Bereavement was the winner-the DSM-5 change that those who took my survey believe has the potential to do the most harm.
This feels especially relevant to me, since I lost a parent a couple months ago. (Life goes on, gotta keep blogging through).
To review, in DSM-4, Bereavement gets a V-code (other conditions that may be a focus of clinical attention): V62.82:
This category can be used when the focus of clinical attention is a reaction to the death of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss). The bereaved individual typically regards the depressed mood as "normal", although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of "normal" bereavement vary considerably among different cultural groups The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss. However, the presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. these include 1) guilt about things other than actions taken or not taken by the survivor at the time of death; 2) thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person; 3) morbid preoccupation with worthlessness; 4) marked psychomotor retardation; 5) prolonged and marked functional impairment; and 6) hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person. (DSM-4 TR Desk Reference, Pp. 311-12).
And don't forget, in the DSM-4 definition of a Major Depressive Episode (ibid. p. 169), criterion E specifies that the symptoms are not better accounted for by Bereavement:
Considering this in light of the imminent publication of DSM-5 (incidentally, I thought it would be published on the 3rd, but Amazon doesn't have it til the 27th, B&N the 22nd ), it doesn't seem like that much of an improvement. Two months is not a very long time following a loss. And functional impairment and psychomotor retardation sound like the kinds of things that might linger for a while.
While I'm trying to make the argument that even DSM-4 pathologized grief, I think I'm only succeeding in making the argument that grief, or bereavement, may be hard to differentiate from Major Depression. And this, I believe, is the force behind the removal of the exclusion criterion.
Reading up on this topic just made me more confused than I already was. So I'll try to stick to my basic questions, and share with you what I've learned so far.
1. How can I tell if my patient is depressed, or simply grieving following a loss?
2. How important is the time factor, (i.e. 2 months)?
Since the road to understanding should be paved with clarity, I think we need some working definitions. These are from:
Zisook, S; Shear, K; Grief and bereavement: what psychiatrists need to know; World Psychiatry. 2009 June; 8(2): 67–74.
Bereavement is the actual loss-the death of a loved one. Grief is the emotional reaction to the death. And mourning describes some of the typical behaviors associated with the death, like funerals or religious practices.
The same paper also differentiated between Uncomplicated Grief, Complicated Grief, and Grief-Related Major Depression.
For me, these are useful concepts, because they point to the difference between what is and isn't expectable following a bereavement. You can read the specifics in the paper, but the idea is that, in uncomplicated grief, there is an intense, acute phase, followed by a resolution into a less intense phase, "integrated grief". In complicated grief, seen in 10% of grieving individuals, the transition to an integrated state never occurs. And grief-related major depression is neither uncomplicated nor complicated grief. It is a major depressive episode that occurs following a bereavement.
Now the question is, if a patient meets criteria for a major depressive episode within 2 months of a death, is this really grief disguised as depression, is it depression in addition to grief, or is it depression brought on by the loss that caused the grief, or by the grief, itself?
According to the Zisook paper, between 24% and 42% of recently bereaved subjects met criteria for a major depressive episode within the first 2 months following a bereavement. And 16% were still depressed at 12 or 13 months (depending on the study). Most importantly, the best predictor for depression at 13 months was depression at 1 or 2 months. A past history of major depression also predicted depression at 1 year following bereavement. And bereaved persons are also at risk for lingering subsyndromal depressive symptoms. In addition, bereavement, itself, can precipitate a depressive episode.
This paper, along with others by the same author(s) concludes that bereavement related depression is similar to non-bereavement related depression, which implies the removal of the bereavement exclusion is valid: If it looks like depression, then it IS depression, and should be treated as such.
Well, maybe.
Another paper,
Mojtabai, R; Bereavement-Related Depressive Episodes Characteristics, 3-Year Course, and Implications for the DSM-5; Arch Gen Psychiatry. 2011;68(9):920-928, has a different take. I found this paper clearer and more convincing than the previous one, although this may not be evident from my description (read 'em!).
This study looked at a very large sample and compared the characteristics and outcomes of 5 different groups: 1. Those with a single, brief (<2 months) episode of depression following a bereavement; 2. Those with a single, brief episode of depression not following a bereavement;
3. Those with a single, non-brief (> 2 months) episode; 4. Those with recurrent depressive episodes; and 5. Those with no lifetime history of depression.
In terms of baseline characteristics, group 1 (single brief episode following bereavement) was more likely than group 2 to be 50 or older and to be non-Hispanic Black. Group 1 was less likely than group 2 to have impairment in functioning, to have onset in their 20's, to have a co-morbid anxiety disorder, to have sought treatment, or to have been prescribed medication for depression.
Compared with group 4, group 1 was less likely to have a family history of depression, comorbid alcohol dependence, and onset before the age of 20 years.
In terms of symptom profiles, group 1 was less likely than group 2 to experience feelings of worthlessness, suicidal ideations, increased sleep, or fatigue.
And as far as follow up goes, "Participants with bereavement-related, single, brief depressive episodes were not more likely than participants without a lifetime history of depression at baseline to experience a depressive episode during the 3-year follow-up... However, participants with bereavement-unrelated, single, brief depressive episodes had an elevated risk of experiencing a depressive episode at follow-up compared with participants without a history of depression..., and compared with those with bereavement-related depressive episodes (14.7% vs 8.2%, adjusted odds ratio [AOR], 1.88; 95% CI, 1.05-3.38; P = .04). Participants with single, nonbrief depressive episodes also had an increased risk of new depressive episodes in follow-up compared with participants with bereavement-related, single, brief depressive episodes..., as did participants with recurrent depressive episodes compared with those with bereavement-related, single, brief depressive episodes..."
There's a whole lot more, obviously, but to summarize what I've learned so far:
Post-bereavement, it's appropriate to assess the grieving patient for depression, in addition to, or as a result of, or instead of, grief. Within the first 2 months, if the patient does not have 5 of the 9 criteria for a major depressive episode, then the patient is not experiencing a major depressive episode, and is assumed to be grieving.
What if the patient does have 5 of the 9 criteria? It depends who you ask:
What will be the effect of the removal of the bereavement exclusion? Will fewer treatable depressions be missed? Will morbidity increase from treating conditions that don't require treatment, or from pathologizing normal processes?
The answer is the same as the solution to grief, itself. To quote Viola from Twelfth Night:
This feels especially relevant to me, since I lost a parent a couple months ago. (Life goes on, gotta keep blogging through).
To review, in DSM-4, Bereavement gets a V-code (other conditions that may be a focus of clinical attention): V62.82:
This category can be used when the focus of clinical attention is a reaction to the death of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss). The bereaved individual typically regards the depressed mood as "normal", although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of "normal" bereavement vary considerably among different cultural groups The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss. However, the presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. these include 1) guilt about things other than actions taken or not taken by the survivor at the time of death; 2) thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person; 3) morbid preoccupation with worthlessness; 4) marked psychomotor retardation; 5) prolonged and marked functional impairment; and 6) hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person. (DSM-4 TR Desk Reference, Pp. 311-12).
And don't forget, in the DSM-4 definition of a Major Depressive Episode (ibid. p. 169), criterion E specifies that the symptoms are not better accounted for by Bereavement:
I.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked funcional impairment, ... worthlessness, suicidal ideation, psycho(sis), or psychomotor retardation.
So, same as above.Considering this in light of the imminent publication of DSM-5 (incidentally, I thought it would be published on the 3rd, but Amazon doesn't have it til the 27th, B&N the 22nd ), it doesn't seem like that much of an improvement. Two months is not a very long time following a loss. And functional impairment and psychomotor retardation sound like the kinds of things that might linger for a while.
While I'm trying to make the argument that even DSM-4 pathologized grief, I think I'm only succeeding in making the argument that grief, or bereavement, may be hard to differentiate from Major Depression. And this, I believe, is the force behind the removal of the exclusion criterion.
Reading up on this topic just made me more confused than I already was. So I'll try to stick to my basic questions, and share with you what I've learned so far.
1. How can I tell if my patient is depressed, or simply grieving following a loss?
2. How important is the time factor, (i.e. 2 months)?
Since the road to understanding should be paved with clarity, I think we need some working definitions. These are from:
Zisook, S; Shear, K; Grief and bereavement: what psychiatrists need to know; World Psychiatry. 2009 June; 8(2): 67–74.
Bereavement is the actual loss-the death of a loved one. Grief is the emotional reaction to the death. And mourning describes some of the typical behaviors associated with the death, like funerals or religious practices.
The same paper also differentiated between Uncomplicated Grief, Complicated Grief, and Grief-Related Major Depression.
For me, these are useful concepts, because they point to the difference between what is and isn't expectable following a bereavement. You can read the specifics in the paper, but the idea is that, in uncomplicated grief, there is an intense, acute phase, followed by a resolution into a less intense phase, "integrated grief". In complicated grief, seen in 10% of grieving individuals, the transition to an integrated state never occurs. And grief-related major depression is neither uncomplicated nor complicated grief. It is a major depressive episode that occurs following a bereavement.
Now the question is, if a patient meets criteria for a major depressive episode within 2 months of a death, is this really grief disguised as depression, is it depression in addition to grief, or is it depression brought on by the loss that caused the grief, or by the grief, itself?
According to the Zisook paper, between 24% and 42% of recently bereaved subjects met criteria for a major depressive episode within the first 2 months following a bereavement. And 16% were still depressed at 12 or 13 months (depending on the study). Most importantly, the best predictor for depression at 13 months was depression at 1 or 2 months. A past history of major depression also predicted depression at 1 year following bereavement. And bereaved persons are also at risk for lingering subsyndromal depressive symptoms. In addition, bereavement, itself, can precipitate a depressive episode.
This paper, along with others by the same author(s) concludes that bereavement related depression is similar to non-bereavement related depression, which implies the removal of the bereavement exclusion is valid: If it looks like depression, then it IS depression, and should be treated as such.
Well, maybe.
Another paper,
Mojtabai, R; Bereavement-Related Depressive Episodes Characteristics, 3-Year Course, and Implications for the DSM-5; Arch Gen Psychiatry. 2011;68(9):920-928, has a different take. I found this paper clearer and more convincing than the previous one, although this may not be evident from my description (read 'em!).
This study looked at a very large sample and compared the characteristics and outcomes of 5 different groups: 1. Those with a single, brief (<2 months) episode of depression following a bereavement; 2. Those with a single, brief episode of depression not following a bereavement;
3. Those with a single, non-brief (> 2 months) episode; 4. Those with recurrent depressive episodes; and 5. Those with no lifetime history of depression.
In terms of baseline characteristics, group 1 (single brief episode following bereavement) was more likely than group 2 to be 50 or older and to be non-Hispanic Black. Group 1 was less likely than group 2 to have impairment in functioning, to have onset in their 20's, to have a co-morbid anxiety disorder, to have sought treatment, or to have been prescribed medication for depression.
Compared with group 4, group 1 was less likely to have a family history of depression, comorbid alcohol dependence, and onset before the age of 20 years.
In terms of symptom profiles, group 1 was less likely than group 2 to experience feelings of worthlessness, suicidal ideations, increased sleep, or fatigue.
And as far as follow up goes, "Participants with bereavement-related, single, brief depressive episodes were not more likely than participants without a lifetime history of depression at baseline to experience a depressive episode during the 3-year follow-up... However, participants with bereavement-unrelated, single, brief depressive episodes had an elevated risk of experiencing a depressive episode at follow-up compared with participants without a history of depression..., and compared with those with bereavement-related depressive episodes (14.7% vs 8.2%, adjusted odds ratio [AOR], 1.88; 95% CI, 1.05-3.38; P = .04). Participants with single, nonbrief depressive episodes also had an increased risk of new depressive episodes in follow-up compared with participants with bereavement-related, single, brief depressive episodes..., as did participants with recurrent depressive episodes compared with those with bereavement-related, single, brief depressive episodes..."
There's a whole lot more, obviously, but to summarize what I've learned so far:
Post-bereavement, it's appropriate to assess the grieving patient for depression, in addition to, or as a result of, or instead of, grief. Within the first 2 months, if the patient does not have 5 of the 9 criteria for a major depressive episode, then the patient is not experiencing a major depressive episode, and is assumed to be grieving.
What if the patient does have 5 of the 9 criteria? It depends who you ask:
- According to DSM-4, if less than 2 months have passed since the death, AND there is no evidence of marked funcional impairment, ... worthlessness, suicidal ideation, psycho(sis), or psychomotor retardation, then the patient is not depressed, but rather grieving. But if more than 2 months have passed, OR any of these symptoms is present, regardless of the time frame, then the patient is depressed.
- According to DSM-5, the patient is depressed.
- According to the Zisook paper, the patient should probably be treated for depression, since post-bereavement depression is similar to bereavement unrelated depression.
- According to the Mojtabai paper, the patient is likely to fare better than one with a bereavement-unrelated depression, with fewer sequelae and less severity, and this should be factored into the decision to treat.
I am now more educated and less certain about this topic than I was when I started to research it. One question I haven't really taken up is, why 2 months? Why not 2 weeks, if we're talking about criteria for major depression? Or longer than 2 months?
What will be the effect of the removal of the bereavement exclusion? Will fewer treatable depressions be missed? Will morbidity increase from treating conditions that don't require treatment, or from pathologizing normal processes?
The answer is the same as the solution to grief, itself. To quote Viola from Twelfth Night:
O time! thou must untangle this, not I;
It is too hard a knot for me to untie!
Sunday, April 28, 2013
And The Winner Is...
The results of my completely non-scientific and woefully under-sampled survey are in. Thanks to everyone who filled it out, and for those of you who didn't, I haven't lost faith in you for next time, whenever that turns out to be.
Drumroll, please (percentages rounded):
1. Which change in the new DSM-5 (as opposed to the old DSM-5) do you think will do the most harm?
Bereavement-66%
Binge Eating-11%
Disruptive Mood Regulation Disorder-11%
Removal of Multi-Axial System-11%
Others-0%
2. Which change in DSM-5 do you think will do the most good?
Chapter Rearrangement-33%
Gender Dysphoria-22%
Hoarding-22%
Substance-11%
Removal of Multi-Axial System-11%
Others-0%
3. Do you plan to buy the DSM-5 when it's released?
No-44%
Yes-33%
Unsure-22%
4. Do you think DSM-5 will change the way you practice?
No-78%
Yes, in a bad way-11%
Unsure-11%
Yes, in a good way-0%
Since I didn't ask people to explain their reasoning in the survey, I don't know why they feel the way they feel. However, I'm going to empathically place myself in the minds of those who voted for the winners, and try to write about why I, as them, would have chosen as I did, and also about what the literature shows. FYI, not all of the results agreed with my own opinion, but I think the occasional exercise in empathy is a good thing.
I'll cover Bereavement and Chapter Rearrangement in another post, but I just want to comment on the last two results. Think about it. Most people do not plan to buy the new DSM, and no one thinks it's publication, nay, existence, is a good thing.
Um, APA, you worked on this for years, with all the attendent Sturm und Drang, and no one thinks it'll do any good. What gives?
Drumroll, please (percentages rounded):
1. Which change in the new DSM-5 (as opposed to the old DSM-5) do you think will do the most harm?
Bereavement-66%
Binge Eating-11%
Disruptive Mood Regulation Disorder-11%
Removal of Multi-Axial System-11%
Others-0%
2. Which change in DSM-5 do you think will do the most good?
Chapter Rearrangement-33%
Gender Dysphoria-22%
Hoarding-22%
Substance-11%
Removal of Multi-Axial System-11%
Others-0%
3. Do you plan to buy the DSM-5 when it's released?
No-44%
Yes-33%
Unsure-22%
4. Do you think DSM-5 will change the way you practice?
No-78%
Yes, in a bad way-11%
Unsure-11%
Yes, in a good way-0%
Since I didn't ask people to explain their reasoning in the survey, I don't know why they feel the way they feel. However, I'm going to empathically place myself in the minds of those who voted for the winners, and try to write about why I, as them, would have chosen as I did, and also about what the literature shows. FYI, not all of the results agreed with my own opinion, but I think the occasional exercise in empathy is a good thing.
I'll cover Bereavement and Chapter Rearrangement in another post, but I just want to comment on the last two results. Think about it. Most people do not plan to buy the new DSM, and no one thinks it's publication, nay, existence, is a good thing.
Um, APA, you worked on this for years, with all the attendent Sturm und Drang, and no one thinks it'll do any good. What gives?
Sunday, April 21, 2013
Tele Me More
I want to pick up where I left off with the telepsychiatry post by looking at evidence in the literature.
One study, The Effectiveness of Telemental Health Applications: A Review
Canadian Journal of Psychiatry | Nov 2008, reviewed 72 papers. There was evidence of success with "Telemental health" (TMH) in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive–compulsive disorder were less convincing.
Another study, Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010, Psychiatric Services, 2012, compared number of inpatient psychiatric admissions and days of psychiatric hospitalization among patients who participated in remote clinical videoconferencing during an average period of six months before and after their enrollment in the TMH services. Psychiatric admissions of TMH patients decreased by an average of 24.2%, and days of hospitalization decreased by an average of 26.6%.
Yet another study of 494 subjects, Is Telepsychiatry Equivalent to Face-to-Face Psychiatry? Results From a Randomized Controlled Equivalence Trial, Psychiatric Services, June 2007, compared interactive videoconferencing with face to face treatment in psychiatric consultation with brief follow-up (monthly, up to 4 months), and found equivalent improvements in function in both groups, with similar levels of satisfaction with service. And TMH cost 10% less than face-to-face treatment.
A study of 297 individuals, published in The Lancet in 2009, Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial, found that 38% of patients treated with online CBT recovered from depression (BDI<10), vs. only 24% of patients treated as usual by their GP. Since this study was done in the UK, I'm not sure what the usual function of a GP is there, and whether some do psychotherapy.
The China American Psychoanalytic Alliance (CAPA) has offered Skype or Oovoo training in psychoanalysis and psychotherapy to clinicians in China since 2006. It also offers low fee Skype psychoanalysis and Psychotherapy. There seems to be a lot of satisfaction with the program, with waiting lists for treatment, but there is no data that directly compares the results with face-to-face treatment.
So what do we know?
Please note, my DSM-V survey will close on the 28th, so if you haven't responded yet, you still have time. Just click HERE.
One study, The Effectiveness of Telemental Health Applications: A Review
Canadian Journal of Psychiatry | Nov 2008, reviewed 72 papers. There was evidence of success with "Telemental health" (TMH) in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive–compulsive disorder were less convincing.
Another study, Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010, Psychiatric Services, 2012, compared number of inpatient psychiatric admissions and days of psychiatric hospitalization among patients who participated in remote clinical videoconferencing during an average period of six months before and after their enrollment in the TMH services. Psychiatric admissions of TMH patients decreased by an average of 24.2%, and days of hospitalization decreased by an average of 26.6%.
Yet another study of 494 subjects, Is Telepsychiatry Equivalent to Face-to-Face Psychiatry? Results From a Randomized Controlled Equivalence Trial, Psychiatric Services, June 2007, compared interactive videoconferencing with face to face treatment in psychiatric consultation with brief follow-up (monthly, up to 4 months), and found equivalent improvements in function in both groups, with similar levels of satisfaction with service. And TMH cost 10% less than face-to-face treatment.
A study of 297 individuals, published in The Lancet in 2009, Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial, found that 38% of patients treated with online CBT recovered from depression (BDI<10), vs. only 24% of patients treated as usual by their GP. Since this study was done in the UK, I'm not sure what the usual function of a GP is there, and whether some do psychotherapy.
The China American Psychoanalytic Alliance (CAPA) has offered Skype or Oovoo training in psychoanalysis and psychotherapy to clinicians in China since 2006. It also offers low fee Skype psychoanalysis and Psychotherapy. There seems to be a lot of satisfaction with the program, with waiting lists for treatment, but there is no data that directly compares the results with face-to-face treatment.
So what do we know?
- TMH seems to be helpful in treating some conditions, such as depression and PTSD.
- In veterans, TMH has decreased admissions and length of stay by roughly 25%. 98,000 veterans-you can't ignore that number.
- TMH was equivalent to face-to-face treatment for consultation with brief follow-up, and cost less.
- Online CBT looked better than treatment by a GP in the UK.
- Many Chinese who otherwise wouldn't have access to psychotherapy or psychoanalysis are eager to have TMH treatment.
Based on this information I'd like to see a more formal study of face-to-face vs. Skype treatment for a more general population, and for, say, psychodynamic psychotherapy, before drawing any conclusions. But I certainly wouldn't dismiss the idea of TMH entirely.
Please note, my DSM-V survey will close on the 28th, so if you haven't responded yet, you still have time. Just click HERE.
Sunday, April 14, 2013
Dr. Tele-Love, or, How I learned to Stop Worrying and Love Skype
In the process of learning all about the new CPT coding, I also learned that phone and Skype sessions are not covered by insurance. The reasoning seems to be that they are considered substandard care. And apparently you can't cut a deal with your patient in which he will pay you for a phone or Skype session, regardless of his coverage, because a patient cannot legally agree to substandard care. Well, I guess you CAN make that agreement with your patient, but if he ever decides to sue you, you're buggered.
Furthermore, the point was made by the lawyer who gave the talk I attended that if you call your doctor to ask about something, say, at night, you don't get a bill for it. So, by extension, you can't bill for a full session that takes place on the phone.
True. Only lawyers can bill for phone exchanges. By the minute.
Personally, I don't like phone sessions. Maybe because I don't like talking on the phone, in general. I find it difficult to lose that sense you get of a patient who's in the room with you, not to mention the facial expressions and other visual cues (admittedly, these are lacking in analysis, as well).
That said, sometimes, it's necessary. A patient who needs to move suddenly, but hasn't transitioned to another psychiatrist yet. Or maybe doesn't want to. A patient who's laid up at home because of illness. Or maybe because of maternity or paternity leave. A patient who has to fly to a distant city due to a family emergency or a death.
It seems to me there are a lot of good reasons to rely on phone or Skype sessions, especially when the patient would suffer without any session at all. Are we, as psychiatrists, really supposed to spend 45 minutes on the phone with a patient, making the same comments and interpretations we would make in person, working just as hard as we would in person, and then not charge for the session?
This is a topic for another time, but why do people think it's immoral, or somehow distasteful, for doctors to want to make a living? Are we really supposed to work for free?
So what's the deal, here? Why is tele-medicine considered substandard? Is it just an excuse to limit coverage, or is it based on some factual data?
As it turns out, prison systems routinely use tele-psychiatry. I hope it isn't the case that prisoners are getting substandard care.
And you can use telepsychiatry in some states, but not others. Additionally, the use of telepsychiatry varies based on type of insurance.
For instance, medicaid covers telepsychiatry in NY.
Private insurance varies by insurer. My guess is, if there's any excuse not to cover, they won't cover.
Medicare covers telepsychiatry with some provisos. First, the consumer must be located in a "non-metropolitan statistical area", which may or may not be the same thing as a Health Professional Shortage Areas (HPSA) .
From what I can tell the consumer also has to have the session in a qualified facility, which I guess means that he or she needs to show up at a clinic or hospital, and have a qualified staff person with him or her. During the actual session? I can't figure that out.
The clinician, on the other hand, can be anywhere, even at home, but has to be licensed in the appropriate state. I assume that's the state where the patient is located.
Now, back to that "substandard care" business. If it's good enough for prisoners and people in rural, underserved areas, it should be good enough for anyone. Alternatively, it's not really good enough for anyone, but it's the best anyone can do under certain circumstances.
The next question is, "What does the literature say about how telepsychiatry compares to in-person treatment?"
Stay tuned.
Furthermore, the point was made by the lawyer who gave the talk I attended that if you call your doctor to ask about something, say, at night, you don't get a bill for it. So, by extension, you can't bill for a full session that takes place on the phone.
True. Only lawyers can bill for phone exchanges. By the minute.
Personally, I don't like phone sessions. Maybe because I don't like talking on the phone, in general. I find it difficult to lose that sense you get of a patient who's in the room with you, not to mention the facial expressions and other visual cues (admittedly, these are lacking in analysis, as well).
That said, sometimes, it's necessary. A patient who needs to move suddenly, but hasn't transitioned to another psychiatrist yet. Or maybe doesn't want to. A patient who's laid up at home because of illness. Or maybe because of maternity or paternity leave. A patient who has to fly to a distant city due to a family emergency or a death.
It seems to me there are a lot of good reasons to rely on phone or Skype sessions, especially when the patient would suffer without any session at all. Are we, as psychiatrists, really supposed to spend 45 minutes on the phone with a patient, making the same comments and interpretations we would make in person, working just as hard as we would in person, and then not charge for the session?
This is a topic for another time, but why do people think it's immoral, or somehow distasteful, for doctors to want to make a living? Are we really supposed to work for free?
So what's the deal, here? Why is tele-medicine considered substandard? Is it just an excuse to limit coverage, or is it based on some factual data?
As it turns out, prison systems routinely use tele-psychiatry. I hope it isn't the case that prisoners are getting substandard care.
And you can use telepsychiatry in some states, but not others. Additionally, the use of telepsychiatry varies based on type of insurance.
For instance, medicaid covers telepsychiatry in NY.
Private insurance varies by insurer. My guess is, if there's any excuse not to cover, they won't cover.
Medicare covers telepsychiatry with some provisos. First, the consumer must be located in a "non-metropolitan statistical area", which may or may not be the same thing as a Health Professional Shortage Areas (HPSA) .
From what I can tell the consumer also has to have the session in a qualified facility, which I guess means that he or she needs to show up at a clinic or hospital, and have a qualified staff person with him or her. During the actual session? I can't figure that out.
The clinician, on the other hand, can be anywhere, even at home, but has to be licensed in the appropriate state. I assume that's the state where the patient is located.
Now, back to that "substandard care" business. If it's good enough for prisoners and people in rural, underserved areas, it should be good enough for anyone. Alternatively, it's not really good enough for anyone, but it's the best anyone can do under certain circumstances.
The next question is, "What does the literature say about how telepsychiatry compares to in-person treatment?"
Stay tuned.
Sunday, April 7, 2013
DSM-5: Take My Survey, Please
Yup, it'll be here soon. I was hesitant to write about it, and I can barely call it by its name. Maybe if I don't say it, it'll disappear.
What convinced me to write about it was the dumb, completely irrelevant fact that it's going to be published on my birthday. And you can preorder it on Amazon for only $133.22.
Here's a list of some of the changes:
1. Asperger's subsumed under the heading of Autism Spectrum Disorder.
2. Inclusion of Binge Eating Disorder.
3. Bereavement exception removed from the diagnosis of depression.
4. Gender Identity disorder changes its name to, "Gender Dysphoria".
5. Addition of Disruptive Mood Regulation Disorder for children who display “persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.”
6. Inclusion of Hoarding and addition of Excoriation as individual diagnoses.
7. Substance Abuse and substance Dependence combined under the heading, "Substance Use Disorder."
8. Dissolution of the Multiaxial System. Axes I, II, and III are now combined, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).
9. Chapters restructured based on disorders’ apparent relatedness to one another. These changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11).
I've been wondering about why I'm so wary of this new manual. Maybe because it's the "bible" of psychiatry, and reimbursement will be based on it, despite the sometimes nebulous scientific underpinnings of some of its content. Or maybe because it has the potential to pathologize normal elements of the human condition, such as grief following a loss, or temper tantrums during childhood.
And I wonder which of the changes will do the most harm. And which the most good.
What do you think? Please take the following 4 question survey. I'll post the results, and write in detail about whichever changes are the best and worst, in your opinion.
Thursday, March 28, 2013
SAFEty and The Cannibal Cop
For those who didn't follow it, the Cannibal Cop is the case of former NYPD officer Gilberto Valle, convicted on March 12th of conspiring to kidnap, rape, murder, and eat several women, including his wife, as well as illegally accessing a national crime database to research his potential victims.
The thing is, he never actually did the things he was convicted of conspiring to do. He fantasized. He plotted. He even went so far as to show up on the block of a woman he had agreed to kidnap in exchange for $5000. But he never did so. He only conspired to do so.
Am I glad he's behind bars? Yes I am. Do I believe he would have acted out his ghastly fantasies? Yes I do. Am I justified in feeling this way? Not sure.
This case begs the question: How do you differentiate between a fantasy to hurt someone, a wish to do so, the intention to do so, and the acting out of the fantasy?
This is the same question that lies at the heart of NY's SAFE act, which requires that certain mental health professionals, including psychiatrists, "Report to their local director of community services ("DCS") or his/her designees when, in their reasonable professional judgment, one of their patients is 'likely to engage in conduct that would result in serious harm to self or others.'" The information then gets forwarded to the Division of Criminal Justice Services (DCJS), who determine if the patient has a firearms license. If so, it's either suspended or revoked. If not, he gets put on a list so he can't get a firearms license.
There is so much wrong with this act, it's hard to know where to start.
The New York State Psychiatric Association (NYPSA) has taken issue with it because of its language. SAFE claims that the standard to use for determining danger is the same as for deciding whether to hospitalize a patient, or to call the police, or contact a potential victim, as in a Tarasoff situation. But this standard already exists in the law, and we know that if we think a patient is genuinely dangerous, we should do something about it. And that something shouldn't be contacting the local "DCS".
In other words, if the danger is immediate, I shouldn't be worrying about putting the patient on a no-firearms list, I should be hospitalizing him, or calling the police, or the potential victim. And if the danger is not immediate, how am I supposed to know if it's serious and real? It's like that Tom Cruise movie with the "precogs" who predict future crime.
I consider it my job to recognize patterns of thinking and behavior in my patients, and to point these out to them, so they can use that information to their benefit. But that doesn't mean I know what they're going to do down the line. And SAFE is asking me, no requiring me, to point out that information to a government agency, to be used to the patient's detriment.
Sure, there might be some clear cut cases. Shrink Rap mentioned the hypothetical case of a patient who tells her he's hanging around with his Al Qaeda buddies and taking flying lessons (sorry, I couldn't find the exact post). Okay. I can see that. But most of the time it's not gonna be that clear.
And what population are we talking about? Acutely hospitalized psych patients? Prisoners with co-morbid psychiatric diagnoses? Psychopaths? Neurotic outpatients? Dual diagnosis patients? These are very different groups.
I could understand if it were someone else's responsibility to report the patient. Say, the ER, after I've sent the patient there for evaluation, because I think he may hurt himself. Or the inpatient unit if he's admitted. Or the police, if I contact them because I think he's going to hurt someone besides himself. At that point, the immediate danger has been addressed, and then there's time to think about how dangerous this person is likely to be in the long run.
Okay, so let's assume, for the sake of argument, that I know for sure that my patient is going to do something dangerous down the line. And I report him the way I'm supposed to. And he loses his right to bear arms. He still hasn't lost his right to walk into Williams-Sonoma and buy himself a nice, big, sharp Santoku knife. Or to mosey into Costco and buy himself two giant bottles of tylenol.
Why create useless legislation? Oh, yeah, because they're politicians running for office.
Another BIG problem with SAFE is the issue of confidentiality and how it affects trust. Patients sometimes have thoughts about hurting themselves. If you've known your patient for a while, you can usually tell how serious a threat it is. If you don't know the patient, then you really can't tell, and you're now in the position of revealing something significant about her to the government, something that will affect her civil liberties for the rest of her life.
Will someone who needs psychiatric care hesitate to get it because of this possibility? I'm guessing yes. But then, of course, I can't predict the future.
The thing is, he never actually did the things he was convicted of conspiring to do. He fantasized. He plotted. He even went so far as to show up on the block of a woman he had agreed to kidnap in exchange for $5000. But he never did so. He only conspired to do so.
Am I glad he's behind bars? Yes I am. Do I believe he would have acted out his ghastly fantasies? Yes I do. Am I justified in feeling this way? Not sure.
This case begs the question: How do you differentiate between a fantasy to hurt someone, a wish to do so, the intention to do so, and the acting out of the fantasy?
This is the same question that lies at the heart of NY's SAFE act, which requires that certain mental health professionals, including psychiatrists, "Report to their local director of community services ("DCS") or his/her designees when, in their reasonable professional judgment, one of their patients is 'likely to engage in conduct that would result in serious harm to self or others.'" The information then gets forwarded to the Division of Criminal Justice Services (DCJS), who determine if the patient has a firearms license. If so, it's either suspended or revoked. If not, he gets put on a list so he can't get a firearms license.
The New York State Psychiatric Association (NYPSA) has taken issue with it because of its language. SAFE claims that the standard to use for determining danger is the same as for deciding whether to hospitalize a patient, or to call the police, or contact a potential victim, as in a Tarasoff situation. But this standard already exists in the law, and we know that if we think a patient is genuinely dangerous, we should do something about it. And that something shouldn't be contacting the local "DCS".
In other words, if the danger is immediate, I shouldn't be worrying about putting the patient on a no-firearms list, I should be hospitalizing him, or calling the police, or the potential victim. And if the danger is not immediate, how am I supposed to know if it's serious and real? It's like that Tom Cruise movie with the "precogs" who predict future crime.
I consider it my job to recognize patterns of thinking and behavior in my patients, and to point these out to them, so they can use that information to their benefit. But that doesn't mean I know what they're going to do down the line. And SAFE is asking me, no requiring me, to point out that information to a government agency, to be used to the patient's detriment.
Sure, there might be some clear cut cases. Shrink Rap mentioned the hypothetical case of a patient who tells her he's hanging around with his Al Qaeda buddies and taking flying lessons (sorry, I couldn't find the exact post). Okay. I can see that. But most of the time it's not gonna be that clear.
And what population are we talking about? Acutely hospitalized psych patients? Prisoners with co-morbid psychiatric diagnoses? Psychopaths? Neurotic outpatients? Dual diagnosis patients? These are very different groups.
I could understand if it were someone else's responsibility to report the patient. Say, the ER, after I've sent the patient there for evaluation, because I think he may hurt himself. Or the inpatient unit if he's admitted. Or the police, if I contact them because I think he's going to hurt someone besides himself. At that point, the immediate danger has been addressed, and then there's time to think about how dangerous this person is likely to be in the long run.
Okay, so let's assume, for the sake of argument, that I know for sure that my patient is going to do something dangerous down the line. And I report him the way I'm supposed to. And he loses his right to bear arms. He still hasn't lost his right to walk into Williams-Sonoma and buy himself a nice, big, sharp Santoku knife. Or to mosey into Costco and buy himself two giant bottles of tylenol.
Why create useless legislation? Oh, yeah, because they're politicians running for office.
Another BIG problem with SAFE is the issue of confidentiality and how it affects trust. Patients sometimes have thoughts about hurting themselves. If you've known your patient for a while, you can usually tell how serious a threat it is. If you don't know the patient, then you really can't tell, and you're now in the position of revealing something significant about her to the government, something that will affect her civil liberties for the rest of her life.
Will someone who needs psychiatric care hesitate to get it because of this possibility? I'm guessing yes. But then, of course, I can't predict the future.
Sunday, January 6, 2013
And How Does That Make You Feel?
We've been through a lot of E/M coding together. Figured out how to do some of it. Fumpfed other parts.
But tell me, how do you really feel about the new system?
I hate it, myself, but what I'm really having trouble with is why it exists. Saying that the only way Psychiatry can have parity with Medicine is by billing the same way is like saying the only way Psychiatry can have parity with Medicine is if psychiatrists listen to patients' hearts and lungs and bellies like internists.
It doesn't follow. It's different work.
I'm running on the assumption that someone, somewhere, is making money off this. But I don't know who or where. Or, for that matter, how. I guess the insurance companies will be reimbursing less, because not every session can be a 99215. But the insurance companies are always finding ways to reimburse less. I don't think they're the prime movers, in this case.
I'd be happy to hear people's thoughts about the topic.
And please link over to a poll on Shrink Wrap about the new coding system.
But tell me, how do you really feel about the new system?
I hate it, myself, but what I'm really having trouble with is why it exists. Saying that the only way Psychiatry can have parity with Medicine is by billing the same way is like saying the only way Psychiatry can have parity with Medicine is if psychiatrists listen to patients' hearts and lungs and bellies like internists.
It doesn't follow. It's different work.
I'm running on the assumption that someone, somewhere, is making money off this. But I don't know who or where. Or, for that matter, how. I guess the insurance companies will be reimbursing less, because not every session can be a 99215. But the insurance companies are always finding ways to reimburse less. I don't think they're the prime movers, in this case.
I'd be happy to hear people's thoughts about the topic.
And please link over to a poll on Shrink Wrap about the new coding system.
Sunday, December 9, 2012
Quick CPT Link
I just want to refer anyone who is interested to the blog, Shrink Rap, for 4 quick video tutorials on CPT and E&M coding.
And a shout out to Dinah for mentioning Psych Practice at the end of the last video.
The videos are clear, and Dinah claims they're boring, but they're not because of her fun style.
And a shout out to Dinah for mentioning Psych Practice at the end of the last video.
The videos are clear, and Dinah claims they're boring, but they're not because of her fun style.
Abilif-Eyeballs
What's up with the eyeballs in Abilify ads? Like this one:
Are they supposed to be cute?
A pair of eyeballs following around someone taking an antipsychotic. Seriously?
Oh yeah! This isn't an ad for Abilify the antipsychotic. It's an ad for Abilify the antidepressant augmentation med.
And if you watched through the ad, did you notice that 40 of the 90 seconds are spent describing side effects? Okay, you probably didn't bother to count like I did, but you get the idea.
I do not like drug ads on TV. But why?
Is it because they're a blatant manipulation of lay people by Big Pharma? Well, there is that.
Dammit, if pharmaceutical companies are going to manipulate people, then by golly let those people be doctors so we can get free pens and clipboards out of it.
Did you know that the amount of money pharmaceutical companies spend on advertising is 19 times what they spend on research? Huffington Post Link
One figure I found (click here) is 4.8 Billion dollars spent annually on direct to consumer marketing. That doesn't even include pens.
Now, don't get me wrong. I don't hate pharmaceutical companies the way I hate insurance companies. After all, the meds we prescribe have to come from somewhere. And some of them actually work. You can't blame a trillion-dollar conglomerate for tryin' to make a buck. They have products to offer that actually do some people some good. Unlike insurance companies, which offer a product designed to do as little as possible of the job it was purchased to do (i.e. reimburse).
Plus, drug companies will take you out to dinner every now and then. When was the last time United Healthcare bought you so much as a cookie?
I think it bothers me that the ads are misleading. Depression not improving? Here, this'll fix it.
In a recent study (2012), Fava, et al assessed the efficacy of low-dose aripiprazole added to antidepressant therapy (ADT) in 225 major depressive disorder (MDD) patients with inadequate response to prior ADT.They concluded that low-dose (2-5mg) aripiprazole was well-tolerated, but had only marginal efficacy in augmenting ADT.
The commercial never mentioned that. Nor did it state, or even imply, that abilify's original indication was for psychosis. It's as though, just when you thought antidepressants were inadequate to the task of treating depression, a magical pill appeared and saved everyone.
So they're lying. Or exaggerating. But is this really any worse than advertising candy bars, or laundry detergent, or tires?
I think there's a fine line between empowering people to be active participants in their health care, and convincing them they have greater expertise than they do, which is the real way drug ads mislead. You don't need to know much about candy bars to chose one. And maybe you should do a little research when you're purchasing new tires. But you don't need years of education and hands-on experience to make those decisions.
If I needed my car fixed, I wouldn't go to a mechanic and say, "I know what's wrong with my car and which components you need to fix it." And Google is not the great equalizer people would like it to be.
So watch out for those eyeballs.
Are they supposed to be cute?
A pair of eyeballs following around someone taking an antipsychotic. Seriously?
Oh yeah! This isn't an ad for Abilify the antipsychotic. It's an ad for Abilify the antidepressant augmentation med.
And if you watched through the ad, did you notice that 40 of the 90 seconds are spent describing side effects? Okay, you probably didn't bother to count like I did, but you get the idea.
I do not like drug ads on TV. But why?
Is it because they're a blatant manipulation of lay people by Big Pharma? Well, there is that.
Dammit, if pharmaceutical companies are going to manipulate people, then by golly let those people be doctors so we can get free pens and clipboards out of it.
Did you know that the amount of money pharmaceutical companies spend on advertising is 19 times what they spend on research? Huffington Post Link
One figure I found (click here) is 4.8 Billion dollars spent annually on direct to consumer marketing. That doesn't even include pens.
Now, don't get me wrong. I don't hate pharmaceutical companies the way I hate insurance companies. After all, the meds we prescribe have to come from somewhere. And some of them actually work. You can't blame a trillion-dollar conglomerate for tryin' to make a buck. They have products to offer that actually do some people some good. Unlike insurance companies, which offer a product designed to do as little as possible of the job it was purchased to do (i.e. reimburse).
Plus, drug companies will take you out to dinner every now and then. When was the last time United Healthcare bought you so much as a cookie?
I think it bothers me that the ads are misleading. Depression not improving? Here, this'll fix it.
In a recent study (2012), Fava, et al assessed the efficacy of low-dose aripiprazole added to antidepressant therapy (ADT) in 225 major depressive disorder (MDD) patients with inadequate response to prior ADT.They concluded that low-dose (2-5mg) aripiprazole was well-tolerated, but had only marginal efficacy in augmenting ADT.
The commercial never mentioned that. Nor did it state, or even imply, that abilify's original indication was for psychosis. It's as though, just when you thought antidepressants were inadequate to the task of treating depression, a magical pill appeared and saved everyone.
So they're lying. Or exaggerating. But is this really any worse than advertising candy bars, or laundry detergent, or tires?
I think there's a fine line between empowering people to be active participants in their health care, and convincing them they have greater expertise than they do, which is the real way drug ads mislead. You don't need to know much about candy bars to chose one. And maybe you should do a little research when you're purchasing new tires. But you don't need years of education and hands-on experience to make those decisions.
If I needed my car fixed, I wouldn't go to a mechanic and say, "I know what's wrong with my car and which components you need to fix it." And Google is not the great equalizer people would like it to be.
So watch out for those eyeballs.
Sunday, December 2, 2012
Artwork for the Office
Enough already with the E&M coding. It's time for some pretty pictures.
What artwork do psychiatrists have in their offices?
I always wonder what the impact of the artwork is, which has made me very particular about what I choose to put on my walls.
In my first office, which was in the hospital I was working for, I had a painting that I bought from a man in the park across from the hospital. His name is Alan Streets, and here's a link to his site.
This is a painting he did of the Brooklyn Bridge, in the same style:
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But when I moved to my own office, it seemed a bit too personal (and a little too creepy), to put on my wall. I wanted something brighter, and maybe thought provoking. But not too thought provoking.
Well, I couldn't find anything like that, so then I just bought some nice paper that I happened to like and framed it.
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It seemed fairly innocuous, and I still think it looks like balanced stones. My patients commented on it occasionally.
In my current office, I really wanted something special, that I liked looking at. But it couldn't be too personal or showcase my tastes too much. It could be thought provoking for my patients, but not too controversial or "out there". I wanted it to be colorful. I wanted it to be a real "work", but not too valuable, especially since I can't afford anything like that. And I wanted it to not scare anyone.
I had purchased another painting on the street about a year before the Alan Streets one. It was by a man named Ivan Jenson. It's very similar to this one:
I really like it, and I had intended it for my office, but on looking at it, there's something disturbing. Maybe that's what I like about it. But I couldn't see subjecting paranoid patients to it, or even regressed analytic patients on the couch.
I also bought a poster from him, that looks a lot like this, except with bolder strokes and more brown than blue:
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This one's called "Bearded Man", and I suspect mine is, too, and that they're not intended to be anyone in particular. A little Van Gogh, a little Stalin when he still had hair. But it was a little too "Freud" for me to be comfortable putting it in my office with my analytic couch. I already feel like something out of a Woody Allen movie.
I thought about going the standard New Yorker route. You know:
Or:
They were just too predictable. And I didn't want anything silly.
I liked the idea of having something New Yorky, though. Ikea has this one:
I did buy a little 10x8 painting from a young man who was selling his work on Union Square. The poor guy was trying to make rent, and I didn't have much cash on me, so he sold it to me for whatever I had, I think $30. I offered to bring him more money the next day-he was just a kid-but I never saw him again. It's a great painting of the Bushwick Subway Station, slightly impressionistic, in muted blues and purples, like it was raining the day he painted it. But it's tiny, and it sits on my desk. I doubt most of my patients can even see it well. I don't remember his name or I'd list it, because the kid has talent.
Then what?
I love Charlie Harper
but I thought that would be too specialized.
I think Banksy is great
But he's a little sarcastic.
I'm a huge animation fan
But in my office?
For quite a while, I just left the walls completely blank, other than my diplomas and license registration. Admittedly, there was something soothing about the plain white walls.
Then one day, I was in a store that sells used house stuff, and I saw this up on the wall:
The walls were very high, so I couldn't see it well, and I almost walked away. But I couldn't stop looking at it, and I finally asked the guy to take it down. He wanted $10 for it, and it was already framed, so I figured the frame alone was worth 10 bucks.
I took it home, dusted it off, and looked it up online. It's a poster Frank Stella did for the, obviously, Lincoln Center Festival '67. I don't know if mine's one of the originals, but they sell for $400-$800 online.
This is the one I put on my wall. It's colorful and interesting. It has an intricate graphic pattern and cool lettering (you can't see it in this image, but the background is graph paper). It's cheerful but not silly, and certainly not scary. It's New Yorky, but not in an in-your-face way. And I like it.
Writing this got me thinking about why what decorates the walls of ones office matters. And to whom.
Am I concerned about influencing my patients too much with my tastes? With my self? Am I worried about criticism or ridicule of the things that are important to me? By hiding my aesthetic preferences, do I want to limit my patients' intrusion into my world? Am I trying to get my patients to comment? Or not to comment?
I was thinking that if I really wanted to be non-comital about it, I'd put up a Rothko poster, which doesn't tell you much about what I like. But which one?
And wouldn't my patients just wonder why I picked the pink one rather than the purple?
So what do other shrinks have on their walls? And why? I'd love to hear about it.
Friday, November 30, 2012
I Was Inspired
In my last post, I simplified the leap from 99212 to 99213:
99213 = 6 exam elements and 1 ROS
So I started to wonder if I could have an equally simple mantra for 99214.
Well...not really.
But let me see what I can do.
The problem is that for a 99214 exam, you need 12 elements from 2 or more organ systems. Not gonna happen. So the Exam is not going to help here, which leaves History and MDM.
History:
You need a Detailed History, which includes 4 elements of HPI, 2 ROS systems, and 1 PFSH.
Can I make that easy for myself?
Hx x 4, Psych + 1, and Allergies.
Not so easy.
The good news is that MDM is not that hard. Either 1 worsening condition or 2 stable conditions counts.
So for MDM: 1 worse or 2 same.
And here's the 99214 Montra:
99214 = Hx x 4, Psych + 1, Allergies, 1 worse or 2 same
Not really jingle-worthy, but could be worse. Could be raining.
99213 = 6 exam elements and 1 ROS
So I started to wonder if I could have an equally simple mantra for 99214.
Well...not really.
But let me see what I can do.
The problem is that for a 99214 exam, you need 12 elements from 2 or more organ systems. Not gonna happen. So the Exam is not going to help here, which leaves History and MDM.
History:
You need a Detailed History, which includes 4 elements of HPI, 2 ROS systems, and 1 PFSH.
Can I make that easy for myself?
Hx x 4, Psych + 1, and Allergies.
Not so easy.
The good news is that MDM is not that hard. Either 1 worsening condition or 2 stable conditions counts.
So for MDM: 1 worse or 2 same.
And here's the 99214 Montra:
99214 = Hx x 4, Psych + 1, Allergies, 1 worse or 2 same
Not really jingle-worthy, but could be worse. Could be raining.
Wednesday, November 28, 2012
A Simplified 99213
Okay. I've plowed through figuring out how to E/M code three different notes. And in case you were wondering, I can't remember what to do from one note to the next. I have to keep referring back to my own posts. I imagine after I've done it 100 or so times, I will remember. But the whole process is so meaningless, so devoid of context and content, that I can't retain it.
(I've decided there should be a new way of swearing at people: "Oh yeh!? Well E/M code you!")
I can't do this for every single note I write. I NEED a shortcut.
So here it is:
With few exceptions, all my notes will be either a 99212 or a 99213. On the rare occasion when I think I've spent a lot of time on complicated issues, especially psychopharm, I'll code formally and see if it's worth a 99214.
How to differentiate 99212 from 99213?
Well, since you only need two out of the three key components to meet any level, I'm going to ignore the most convoluted one, MDM, and just focus on History and Exam.
And I absolutely refuse to include another E/M@!3#&%# Table.
Exam is the easiest. You need at least 6 elements for a 99213. So my note template should look like this:
General Appearance:
Speech:
Thought Process:
Thought Content:
Associations:
Judgment:
Insight:
Mood/Affect:
Other:
Even in the most Freudian session, I should be able to come up with 6 of these.
Exam? Check!
Now History. You may recall, or not, that a 99212 History is Problem Focussed, and a 99213 History is Extended Problem Focussed.
So what's the difference between a Problem Focussed History and an Extended Problem Focussed History?
1 ROS!
That's it!
Both require a brief HPI, including 1-3 elements, and no PFSH. So just 1 ROS.
Now I'm really disgusted.
And now that I've uber-simplified things, these are some questions I have:
1. Does insight count as its own exam element?
2. Does writing, "ROS negative for anxiety or depressed mood," constitute a valid ROS?
3. What am I missing?
4. Can I list defenses as "Other" on the exam?
5. Do dreams count as one element of the history?
And once again, to summarize:
99213=6 exam elements and 1 ROS.
Now I need a template I can use. Maybe next post.
(I've decided there should be a new way of swearing at people: "Oh yeh!? Well E/M code you!")
I can't do this for every single note I write. I NEED a shortcut.
So here it is:
With few exceptions, all my notes will be either a 99212 or a 99213. On the rare occasion when I think I've spent a lot of time on complicated issues, especially psychopharm, I'll code formally and see if it's worth a 99214.
How to differentiate 99212 from 99213?
Well, since you only need two out of the three key components to meet any level, I'm going to ignore the most convoluted one, MDM, and just focus on History and Exam.
And I absolutely refuse to include another E/M@!3#&%# Table.
Exam is the easiest. You need at least 6 elements for a 99213. So my note template should look like this:
General Appearance:
Speech:
Thought Process:
Thought Content:
Associations:
Judgment:
Insight:
Mood/Affect:
Other:
Even in the most Freudian session, I should be able to come up with 6 of these.
Exam? Check!
Now History. You may recall, or not, that a 99212 History is Problem Focussed, and a 99213 History is Extended Problem Focussed.
So what's the difference between a Problem Focussed History and an Extended Problem Focussed History?
1 ROS!
That's it!
Both require a brief HPI, including 1-3 elements, and no PFSH. So just 1 ROS.
Now I'm really disgusted.
And now that I've uber-simplified things, these are some questions I have:
1. Does insight count as its own exam element?
2. Does writing, "ROS negative for anxiety or depressed mood," constitute a valid ROS?
3. What am I missing?
4. Can I list defenses as "Other" on the exam?
5. Do dreams count as one element of the history?
And once again, to summarize:
99213=6 exam elements and 1 ROS.
Now I need a template I can use. Maybe next post.
Tuesday, November 27, 2012
E/M Psychoanalysis Note-Tuesday
Here's the second note of the week:
Name: Socrates DOB: 469 BCE Date of Service: 11.27.12
Start time: 2:30pm Stop Time: 3:15pm. Total Face Time: 45 minutes
CPT: 90836, E/M ?????
CC: F/U for "Self Knowledge"
Interval History: Patient's checking behavior has not worsened. He met with one of his students yesterday, about whom he has had some homosexual fantasies, and had a dream last night in which he was trapped in a cave where he could only see shadows.
ROS: none
PFSH: The patient works closely with his students.
PME:
Dx: Anxiety NOS, consider OCD
Current Meds: none
Labs: Ordered-none; reviewed-none
Allergies: Hemlock
Psychotherapy Note: Interpreted dream in the context of the patient's concerns regarding his homoerotic fantasies.
Plan:
Continue psychoanalysis 4x/week
And here we go again with the coding:
The interval history has, maybe 1 or 2 elements, say associated symptoms (checking), and timing (an implicit "overnight"). In any case, it certainly doesn't have 4 elements, so it's a brief history.
There is no ROS.
And there is one element in PFSH.
So for the level of history,
we end up with "problem focussed".
Once again, the Exam has 6 elements.
And for the MDM:
You get 1 problem point for checking, an established, stable problem.
There are 0 data points.
And the risk is low, for one stable, chronic illness.
Making the MDM straightforward.
In summary, then:
This gives us a 99212 E&M code.
Now, this was interesting as an exercise, but I don't really want to do this kind of careful review for every note I write. It would be easier to keep the note to a minimum and bill as a 99212, which most notes will probably turn out to be, anyway. But then, sometimes, it's possible to eke out a 99213, or even a 99214, and this makes a very real financial difference.
So is it worth it to comb through every note? I don't know. Thoughts?
Name: Socrates DOB: 469 BCE Date of Service: 11.27.12
Start time: 2:30pm Stop Time: 3:15pm. Total Face Time: 45 minutes
CPT: 90836, E/M ?????
CC: F/U for "Self Knowledge"
Interval History: Patient's checking behavior has not worsened. He met with one of his students yesterday, about whom he has had some homosexual fantasies, and had a dream last night in which he was trapped in a cave where he could only see shadows.
ROS: none
PFSH: The patient works closely with his students.
PME:
- Speech-Greek
- Thought processes-logical
- Thought Content: Focussed on dream
- Affect: Mildly Anxious
- General Appearance: Wearing toga
- Other: Uses intellectualization and reaction formation as defenses
Dx: Anxiety NOS, consider OCD
Current Meds: none
Labs: Ordered-none; reviewed-none
Allergies: Hemlock
Psychotherapy Note: Interpreted dream in the context of the patient's concerns regarding his homoerotic fantasies.
Plan:
Continue psychoanalysis 4x/week
And here we go again with the coding:
The interval history has, maybe 1 or 2 elements, say associated symptoms (checking), and timing (an implicit "overnight"). In any case, it certainly doesn't have 4 elements, so it's a brief history.
There is no ROS.
And there is one element in PFSH.
So for the level of history,
Level of Hx
|
HPI
|
ROS
|
PFSH
|
Problem Focussed
|
Brief
|
None
|
None
|
Extended Problem Focussed
|
Brief
|
1 System
|
None
|
Detailed
|
Extended
|
2 Systems
|
1
|
we end up with "problem focussed".
Once again, the Exam has 6 elements.
And for the MDM:
You get 1 problem point for checking, an established, stable problem.
There are 0 data points.
And the risk is low, for one stable, chronic illness.
Making the MDM straightforward.
In summary, then:
Level of Care
|
Hx
|
Exam
|
MDM
|
99212
|
Problem Focussed
|
1-5
|
Straightforward
|
99213
|
Extended Problem Focussed
|
>6
|
Low Complexity
|
99214
|
Detailed
|
12 from 2 or more organ systems
|
Moderate Complexity
|
99215
|
Comprehensive
|
2 from each of 9 organ systems
|
High Complexity
|
This gives us a 99212 E&M code.
Now, this was interesting as an exercise, but I don't really want to do this kind of careful review for every note I write. It would be easier to keep the note to a minimum and bill as a 99212, which most notes will probably turn out to be, anyway. But then, sometimes, it's possible to eke out a 99213, or even a 99214, and this makes a very real financial difference.
So is it worth it to comb through every note? I don't know. Thoughts?
Monday, November 26, 2012
E/M Psychoanalysis Note-Monday
In my last post, I included an example of what I think would be a reasonable 99213 note.
But that example is most suitable for psychopharm or psychotherapy of low frequency. I've been trying to figure out what to do for my psychoanalysis patients, who I see 4 times per week.
This is my attempt at 2 such notes for the same patient. I'll include the Monday note in this post, and the Tuesday note in my next post:
Name: Socrates DOB: 469 BCE Date of Service: 11.26.12
Start time: 2:30pm Stop Time: 3:15pm. Total Face Time: 45 minutes
CPT: 90836, E/M ?????
CC: F/U for "Self Knowledge"
Interval History: The patient expressed conflict over homosexual impulses. He also c/o increasing obsessional thoughts over the weekend, in which he worries about being poisoned, and checks his food and drink 4-5 times before partaking of them. He is increasingly argumentative, particularly with authority figures.
ROS: Patient reports increased checking behavior, as well as insomnia.
PFSH: Patient has difficult relationship with his wife.
PME:
Dx: Anxiety NOS, consider OCD
Current Meds: none
Labs: Ordered-none; reviewed-none
Allergies: Hemlock
Psychotherapy Note: Interpreted patient's defenses, encouraged less intellectualization, and further exploration of his emotional life.
Plan:
Continue psychoanalysis 4x/week
Now to determie the E/M code:
The Interval History includes 4 elements:
Since 3 out of 3 elements are needed for History, this note would have an
Extended Problem Focussed History.
Next is the Psychiatric Exam, which includes 6 elements.
And finally, the MDM.
Since obsessional thoughts are an established problem that is worsening, this would earn 2 problem points.
In addition, since the patient is increasingly argumentative, that is another established problem that is worsening, worth another 2 points. So there are a total of 4 problem points.
There are 0 data points, since I didn't review labs or call anyone etc.
And the Level of Risk is moderate, since there are one or more established conditions that are worsening. I don't think I can call this a "severe exacerbation", but if I could, then the level of risk would be high.
Looking at the Table for MDM, we have:
Since only 2 out of 3 elements are needed for MDM, this would qualify as Moderate Complexity.
Finally, summing it all up :
Ladies and Gentlemen, this is a 99213 note. Ta Da!
But that example is most suitable for psychopharm or psychotherapy of low frequency. I've been trying to figure out what to do for my psychoanalysis patients, who I see 4 times per week.
This is my attempt at 2 such notes for the same patient. I'll include the Monday note in this post, and the Tuesday note in my next post:
Name: Socrates DOB: 469 BCE Date of Service: 11.26.12
Start time: 2:30pm Stop Time: 3:15pm. Total Face Time: 45 minutes
CPT: 90836, E/M ?????
CC: F/U for "Self Knowledge"
Interval History: The patient expressed conflict over homosexual impulses. He also c/o increasing obsessional thoughts over the weekend, in which he worries about being poisoned, and checks his food and drink 4-5 times before partaking of them. He is increasingly argumentative, particularly with authority figures.
ROS: Patient reports increased checking behavior, as well as insomnia.
PFSH: Patient has difficult relationship with his wife.
PME:
- Speech-Greek
- Thought processes-logical
- Thought Content: Obsessional thinking and compulsive checking
- Affect: Anxious
- General Appearance: Wearing toga
- Other: Uses intellectualization and reaction formation as defenses
Dx: Anxiety NOS, consider OCD
Current Meds: none
Labs: Ordered-none; reviewed-none
Allergies: Hemlock
Psychotherapy Note: Interpreted patient's defenses, encouraged less intellectualization, and further exploration of his emotional life.
Plan:
Continue psychoanalysis 4x/week
Now to determie the E/M code:
The Interval History includes 4 elements:
- Severity- "Increasing" and checking 4-5 times
- Timing-"Over the weekend"
- Context-"With authority figures"
- Associated Syptoms-Checking
So this is an extended Interval History.
The ROS includes 1 system-Psychiatric.
And the PFSH includes 1 element of Social History.
Looking at Table 2, History, from my last post:
Level of Hx
|
HPI
|
ROS
|
PFSH
|
Problem Focussed
|
Brief
|
None
|
None
|
Extended Problem Focussed
|
Brief
|
1 System
|
None
|
Detailed
|
Extended
|
2 Systems
|
1
|
Since 3 out of 3 elements are needed for History, this note would have an
Extended Problem Focussed History.
Next is the Psychiatric Exam, which includes 6 elements.
And finally, the MDM.
Since obsessional thoughts are an established problem that is worsening, this would earn 2 problem points.
In addition, since the patient is increasingly argumentative, that is another established problem that is worsening, worth another 2 points. So there are a total of 4 problem points.
There are 0 data points, since I didn't review labs or call anyone etc.
And the Level of Risk is moderate, since there are one or more established conditions that are worsening. I don't think I can call this a "severe exacerbation", but if I could, then the level of risk would be high.
Looking at the Table for MDM, we have:
Overall MDM
|
Problem Points
|
Data Points
|
Risk
|
Straightforward
|
1
|
1
|
Minimal
|
Low Complexity
|
2
|
2
|
Low
|
Moderate Complexity
|
3
|
3
|
Moderate
|
High Complexity
|
4
|
4
|
High
|
Since only 2 out of 3 elements are needed for MDM, this would qualify as Moderate Complexity.
Finally, summing it all up :
Level Of Care Requirements (2 out of 3 needed)
Level of Care
|
Hx
|
Exam
|
MDM
|
99212
|
Problem Focussed
|
1-5
|
Straightforward
|
99213
|
Extended Problem Focussed
|
>6
|
Low Complexity
|
99214
|
Detailed
|
12 from 2 or more organ systems
|
Moderate Complexity
|
99215
|
Comprehensive
|
2 from each of 9 organ systems
|
High Complexity
|
Ladies and Gentlemen, this is a 99213 note. Ta Da!
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