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.

Template

There seems to be a frenzy of questions about CPT coding floating around cyberspace.

One issue that's been popping up is the split in billing. Some people are doing it, with a rough guideline of 60% CPT, and 40% E/M. Others are not. Some claims have already been rejected because of the absence of split billing.

There are all kinds of questions about what constitutes a 99212, or a 99215, arguments that confuse the value of our work with the question of which is the appropriate E/M code.

People, they're not related.  The E/M code is what you do to satisfy some sub-regulation of a regulation. The value of our work is infinitely more important, and correspondingly less understandable to anyone whose job it is to reimburse the work.

If you're still confused, read my E/M posts more carefully, because I couldn't possibly be anything but crystal clear in my exposition.

But enough about me. What do you think of my template?

Actually, it's not my template-it was developed by a colleague of mine, with some input and graphic design updating from yours truly. Also, you haven't seen it yet, so why am I asking?

First a disclaimer. Since the template was devised last December, I have made a lot of my own changes to this template, as has my colleague. I'll get to the ideas behind the changes, but I wanted to present it in an early version, so people can use and modify it as they see fit.

Another disclaimer: This template has not been endorsed by any agency involved in CPT and E/M coding, official or otherwise. It is not a guarantee of reimbursement. And I am not responsible for the fact that it may not be the right way to code. So you can't blame me, or my colleague, if you use it and something goes wrong.

I just find it convenient for my needs. And I'm presenting it with my colleague's permission. So here it is:

These are some of the changes I've made and why:

1. I've added a section entitled Plan/Discussed with Patient. I did this because otherwise, if I look back at the note a year after it was written, I won't be able to figure out what I did, or what my reasoning was.

2. I left the ROS section blank, to be filled in, because as it stands, it only deals with one organ system, and there are often others that need to be commented on.

3. I deleted the "severity" blurb under HPI, because severity is only 1 of the elements of history. I replaced it with: 

Location Quality Severity Duration Timing Context Modifying Factors Assoc. Signs/Sx

to remind myself of other HPI elements.

4. I removed anything that was there to remind me of what I need to satisfy that component of the note, e.g. "Problem Focused 99212".  I felt that should be in my head, not the note.

5. The template was originally designed to fit on one page, which my colleague prints out. I fill it out electronically, so I expanded it to two pages.

4. I added some additional elements to the CC and Psychotherapy sections. My colleague has since added others.

Bottom line: This is a work in progress, and it's helpful in some ways, and a royal pain in others.  You can use it, or elements of it, if you find it helpful. Please use appropriate attribution.

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.