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.

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.

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.

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:

The one I have is this awesome painting of the buildings on the park across from the hospital, except that everything is just a little crooked, like the one above, and I watched him paint it.

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.

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:

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:

But it's a bit too Ikea.


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.

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.

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.

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: 

• 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?