CPT Coding Changes-Big Things Are Happening

Toto, dude! We're totally not in Kansas anymore.

On January 1st, 2013, CPT coding will change for psychiatry. Here's the scoop:

The codes we're used to, 90801, 90807, 90806, 90805, 90862, will no longer exist . The rationale is that they're trying to get MD's to code differently from psychologists or social workers. Something to do with parity (not parody).

An initial eval will be 90792 instead of 90801. Other types of sessions will need both a CPT or procedure code, and an Evaluation & Management (E/M) code. In other words, there's one code, the E/M, for how you figured out what needed to be done, and another code, the CPT, for what you actually did. I don't think the E/M requirement applies to group/couples/or family therapy, though. Also, I may be confused about the initial eval not requiring an additional E/M code

The CPT code is for psychotherapy, which is considered a procedure. There are 3 such codes:

90833- for 30 minute sessions
90836- for 45 minute sessions
90838- for 60 minute sessions

There are no longer time ranges for sessions (e.g. 90807 was 45-50 minutes)

These are face-to-face times, and there are minimum times to code for each:

At least 16 minutes of psychotherapy time for a 90833, 38 minutes for a 90836, and 53 minutes for a 90838. This is not as confusing as it looks. 16 is 1 more minute than half of 30, 38 is the first whole number greater than 37.5, the midway point between 30 and 45, and the same for 53 between 45 and 60. In other words, at least half.

But the implications are problematic. For example, if your patient arrives 20 minutes late for a 45 minute session, you can only bill for a 30 minute session. You can agree with your patient that he will need to pay the full fee for the amount of time you set aside, even if he's late, but if you accept assignment, you can't do that.

And if you want to charge your patient for missed sessions, you have to have an agreement in writing beforehand.

Which E/M code you add on to the CPT codes has to do with the level of complexity of the patient/session, and there are 4 such levels, numbered 99212 through 99215, although 99215 is complicated enough that you'll probably never be able to code for it. There are requirements for documentation at each level, with 99212 having the fewest requirements.

There are three components to what determines the E/M level: History, Examination, and Medical Decision Making. Naturally, the more complex the session, the greater the reimbursement, so it's important to document appropriately so you can bill for the highest possible level.

In my next post, I'll go into detail about how this works, and I'll include examples of notes that document different levels of care.

For Next Time

I'm posting this so I have a lasting reminder of everything that needs to get done when you move to a new office.

Not that I'm planning to move any time soon. Or ever. But I didn't plan on the last move, either. The people I was subleasing from just didn't realize they had a demolition clause in their lease.

These are the general categories:

Phone Change/Installation
Address Change
Hire Movers
Pack
Get New Stationary

Doesn't look that bad, right? Let's have a closer look, shall we?

These are all the address changes that need to be made:

Post Office
Office Insurance
Malpractice Insurance
License Registration
DEA
New Prescription Pads
Phone Carrier
Professional Organizations
Hospital Affiliations
Medical School Affiliations
Insurance Panels/Medicare/Medicaid.
Tax ID#
NPI
Department of Health

Now be sure to note that you can't get new prescription pads until you have your new DEA documentation, and you can't get that until you have your new license registration.

And I won't even get into what it takes to get your new phone installed. You try to keep your old number, because that's how your patients know to reach you. (Please disregard if you use a cell phone for your office. Ever since the big blackout in 2003, I just prefer a land line.) You wait around all day for them, and instead, they show up the next day when you're with a patient. And then they complain that it's a really complicated job. Or even better, they tell you they don't install in your building.

It feels so good to rant. Really, I just wanted to have all the info in one place.

Moving

I've had to move to a new office three times since I started my private practice. The last time, in particular, was really harrowing, because I found out I needed to move about three weeks before I actually did move.

No, I wasn't behind on my rent. My office was one of three in the suite, and I rented, or I guess, sublet, my office from the other two people, who jointly held the lease (completely legal, BTW). The suite was in a commercial building, and apparently, they had a "demolition clause" in the lease, which stated that the building could decide to demolish the suite, with very little notice, if it felt like it.

It did feel like it. It seems a lowly therapy office doesn't bring in the kind of money that a corporate client does. They basically knocked out the entire floor, on which there were a number of small businesses, including psychotherapists. I understand some of them may be suing. Not my problem.

Bottom line, I had to find a place and move in a hurry, so I thought it might be a good idea to record what was involved in that process, including searching for a new office, and all the changes of address involved.

To start off, I thought I'd list what I would want in my ideal office. I'll probably never have all my wishes come true, but I can dream. And I can even come close.

Ground floor of a residential building with a doorman.
Either no buzzer system, or a silent one.
Bathroom in the suite.
Even better, my own bathroom, in addition to the one in the suite.
Comfortable waiting room.
Air conditioner unit-a quiet one.
Heat I can shut off.
Good natural light.
Good sound insulation.
Nice sized office-not too big, not too small.
Reasonable rent, if I'm renting
I'd love to be the primary renter, or own the space.
Closet in the office.
Kitchen facilities in the suite-microwave, refrigerator, electric kettle.

I got some of the things I wanted. And I do love my new office, even though it's small, has lousy, make that no, natural light, has no closet, no private bathroom, there's no microwave, and there's central air. And I don't own it, and I'm not the primary renter. But maybe in a couple years I'll be able to have it all.

Or not. I really don't want to move again.

Tracking CME

I just bought an app to track my CME on my iphone. It's called, CMEasy, and it cost me $1.99. I know people complain about the cost of apps, but honestly, most of the apps I use are free, and if the occasional one costs a dollar or two, really, no biggee. It's less than a cappuccino.

Up til now, I've been saving my certificates on my computer, and on Google Docs. It's a bit of a pain, uploading and moving things to the right place.

I looked around online for a tracker, but most are associated with sites to earn CME. The Epocrates CME app lets you track external credit, but it has all these drop down menus, and I know I won't bother.

The CMEasy app is nice. It lets you create templates for frequently used sources of CME. So, for example, I have a "Carlat" template, with a standard 1.0 CME credits. You can change the number of credits, if appropriate. It gives you a place to jot down notes, and it records the date.

It keeps a pie chart of all your CME by category type. You can create your own categories, including AMA Category 1 or 2, etc. The one real drawback is that it doesn't keep a copy of any certificates, just your word on what you've earned. But I figure as long as I have a list of where I earned the CME, I can always find the certificate. All-in-all, it's simple and intuitive, which means I'll probably use it.

CME-Where to Find It, Continued

Medpage Today

This is free CME in little bite sized pieces of news, worth 1/4 point each. It's quick, it's easy, it takes maybe 5 minutes, including the evaluation. It's jointly sponsored by The Perelman School of Medicine at the University of Pennsylvania, and by Medpage Today.

It has a nice little app that's very user friendly, but I have trouble finding the CME section on the webpage. So I recommend sticking with the app for the actual CME. The website has a good CME tracker, though.

Quantia

This is the real sell-out site. Not only do you get 1/4 point of CME, you can also earn "Q-Points". These are points you get for participating in some of their activities, and they can be redeemed as Amazon points.

Drawbacks include the obvious sell-out factor, and the fact that they don't specifically have a Psychiatry section. But there are Psychiatry-relevant pieces of CME in the Pain and General Medicine sections.

When I first found this site, I was a little hesitant to be that blatantly mercenary. But then I realized that I had paid the APA $300 for the answers to their CME questions, which basically amounts to paying for CME, without actually learning anything.

And then I did this activity on Quantia which was a power point given by a Fellow in Addiction Medicine. It was about the labs hospitals use to measure substances of abuse, and it was interesting, extremely well-presented, useful, and completely free of financial bias. When was the last time you saw an ad-free issue of The Green Journal?

Quantia has a nice iphone app, although the activities are easier to do online. Their site is pretty good, and the power points are interactive-a nice touch.

Epocrates

They have CME included in their app. There's not a lot of Psychiatry available, and what there is is case-based. But you can earn a couple points from them, and the app is worth having as a drug reference, in any case. This is another one where I couldn't find the CME on the web, but it's easily accessible from the app.

CME-Where to Find It

In my last post, I threw down the gauntlet with a bunch of questions about CME that I need answered. The first one I'm going to address is where to get CME. These are the resources I've found:

Psychiatrist.com

This is the site for The Journal of Clinical Psychiatry. I've always thought of this as a throwaway journal. I'm not even sure what list I'm on that allows me to receive copies of it. But the link takes you to a page that includes JCP, as well as The CME Institute, and some Neuro sites. The CME Institute is pay dirt. You need an account at psychiatrist.com, and then you can link to a plethora of material, all with free CME. And really not bad, if somewhat commercially biased. It even includes some self-assessment activities (more on what that means in a later post).

The one glitch I've found is that if you just click on the link that takes you directly to CMEinstitute.com, It's hard to find the extensive list of CME activities. It's much easier to get to the CME from the psychiatrist.com homepage, by clicking on the little "All CME Activities" link under CME Institute.

Or you can just use my link: All CME Activities. Also, a nice addition would be an iphone/ipad app.

The Carlat Report

This is a paid monthly newsletter that's worth paying for. First of all, they don't take money form Big Pharma, or any other commercial source. This means no ads, and little, if any commercial bias.

You get 12 CME category 1 credits per year, all taken online, although the questions are included in the hard copy. They also offer pretests, a relatively recent addition, in order to satisfy self assessment criteria. You take the pretest, which doesn't count, to see how much you know before you read the newsletter. Then you get your pretest score, along with the correct answers. Ostensibly, you go on at that point to read the report, and finally take the post-test, which is the same as the pretest, and for which you receive credit. In other words, you don't need to actually read the report to get all the answers right, which is annoying, but part of the deal with the genius of self-assessment.

That said, it's worth reading, anyway. The articles are well written, well-researched, and informative, and at the end of each-this is my favorite part-they give you the "TCPR take", their opinion of what the bottom line is. So you can cut through the nonsense and try to make good clinical decisions.

The Carlat Psychotherapy Report

New in 2012, this is a spin-off the the Carlat Report. It gives you 10 CME credits per year, all in topics involving psychotherapy. It costs $89 per year, with a $59 introductory rate. It employs the same format and standards as the original Report, and if therapy is a large percentage of your practice, as it is in mine, it's worth it.

CME-The Questions

First up on my agenda is to make it easy for myself to earn CME, preferably for free. As a member of the APA, I naively thought I could earn free CME from the Green Journal just because I have a subscription. Not so. You have to pay each month, if you want to earn the 1 point of CME they offer.

Last year, I subscribed to Focus, the APA's CME journal that allows you, POTENTIALLY, to earn your 50 points of CME. This cost me $300 and didn't prove that useful. So this year, I need a better way.

Here are some questions I need answered:

1. How many points of CME do I need each year, in order to meet requirements for Board recertification?

2. What kind of CME? Is it all category 1, or am I allowed some category 2? And what are these categories?

3.Where do I find the CME, if I don't want to attend grand rounds at the hospital I'm affiliated with?

4. What is the real educational value of the various CME I can get?

5. What qualifies as self-assessment and performance in practice, and how do I get these?

6. How can I keep track of my CME, if I get it from multiple places?

To be continued...