My original post on the problems with the 90862 CPT code has turned out to be one of the most popular posts on this blog. I decided to revisit that post in the context of the impending code changes the first of the year. The headline in this weeks Clinical Psychiatry News says it all: "New E&M Coding Set to Go Into Effect Jan. 1". The article encourages psychiatrists to learn the new system in the hope that they will be able to get more fair reimbursement in the future. The explicit downside is that more documentation will be required. In my own practice more complex E&M codes can require anywhere from two to four times as much time and effort to document with additional time to managed the case apart from additional telephone calls, lab review, and consultation. The implicit downside is that despite the promise of more reasonable reimbursement that will actually take political action as stated: "Values might rise in 2014, after the professional societies have a chance to survey psychiatrists on the new codes and the RUC (Relative Value Update Committee) looks at revaluing those codes..."
For anyone reading this who does not have a knowledge of this coding system this template from the American Academy of Family Practice provides a good summary. To give a general idea of the subjectivity of this entire system, I have been documenting and billing 15 and 30 minute 90862s at my current employer for over two years. Our coding expert told me that all of these notes would meet criteria for 99214. Actual time with the patient is roughly 20-30 minutes with 10-20 minutes added onto that for associated tasks (lab ordering, call to other doctor, associated paperwork, etc). I have been billing like this for most of my career, except in a previous specialty clinic where I used E & M codes.
The interesting aspect of this coding system that I always come back to (and can't emphasize enough) is the near total subjectivity of it. I have described my 90862 procedure and that usually results in a note of about 300 to 500 words. When I review the notes of other psychiatrists, I often see the note condensed to 4 brief sentences. The entire note can be less than 75 words. It is often difficult to tell if an actual conversation occurred between a doctor and a patient. I describe this to point out the huge variation in the documentation of clinical practice and there is good reason for it. Compulsive documentation takes an incredible amount of time. It is usually not possible for me to complete the documentation that I think is necessary during the regular work day and I know I am not alone. I have called primary care physicians at 7 or 8 PM to find many of them still there trying to catch up on all of the paperwork and documentation from that day. That is a lot of time investment because of a vague guideline.
The most interesting aspect of coding is how it has been used to intimidate physicians by both the government and the insurance industry. Apart from satisfying billing requirements most physicians engaged in compulsive documentation are doing it because of the threat of a coding audit. In that situation the actual notes are reviewed and somebody makes a decision about whether the documentation meets certain coding requirements for a particular bill. If the decision is no - the physician involved could face massive financial repercussions. Some insurance companies will look at 10 notes and on that basis calculate a rate of overcoding and multiply that rate by the total patient they cover in that practice and demand repayment. Although this physician has apparently not been told why the FBI decided to close down her practice, the tactics described on her blog are the similar to those described in cases of alleged billing "fraud". Keep in mind the only scientific study of this process showed that professional coders could agree that a document reflected a particular billing code at a rate no greater than chance.
Anyone who has read along to this point have probably picked up on the fact that I am not very hopeful that this is a major reform in psychiatric reimbursement. This whole system was invented to control physician reimbursement and not improve it. It is a system that looks like it may have some objectivity on the surface but beyond the surface it is pure politics. The best example I can think of is that any insurance company can decide to reimburse physicians at any rate they want. They may decide for example that "Dr. Dawson has been billing 90862s for decades, why would we want to suddenly reimburse him for 99214s? We will just pay him the same regardless of what his coding expert or billing document says." Just another inefficiency that physicians need to tolerate that detracts from the provision of medical care.
George Dawson, MD, DFAPA
King MS, Lipsky MS, Sharp L. Expert agreement in Current Procedural Terminology evaluation and management coding. Arch Intern Med. 2002 Feb 11;162(3):316-20.
Showing posts with label CPT code. Show all posts
Showing posts with label CPT code. Show all posts
Saturday, December 22, 2012
Sunday, October 7, 2012
Confusion about Capitation versus Fee-For-Service versus National Health Care
This is from the Shrink Rap blog this morning the consensus is that capitated care is better than fee-for-service care. What is wrong with that picture?
Starting out with the much maligned fee-for-service (FFS) - most medical and psychiatric services are not delivered in that context. You can safely say that FFS, disappeared a long time ago. According to a 2012 Medscape survey of 24,216 physicians across 25 specialties only 4% worked in cash only or concierge style practices. That means that everyone else is subject to varying degrees of insurance company discounting. From my years of providing inpatient care for example, there is a standard DRG payment based on a global discharge or admission diagnosis. For the most common psychosis DRGs the standard payment is $4,500 no matter how long a person is stays in the hospital.
The same thing happens on the outpatient side. I have discussed this more extensively is a previous post. Looking at the commonest outpatient billing code - actual reimbursement for providing services can be as little as $22.45 per visit. In the case where bills are submitted with CPT codes (common to all of medicine) Medicare pays 50% of the usual and customary charge for psychiatry compared with 80% for the rest of Medicine. A lot depends on contracting arrangements since a contract can limit a psychiatrist to billing only a 90862 code and the company can also decide that they disagree that services were provided and either deny payment or demand repayment of a significant amount of money based on a review of the documentation.
The business adaptation to this on the hospital and managed care side (if they own the hospital) is to hire case managers to get patients out of the hospital within 3 or 4 days. Some of these systems have confabulated their own "guidelines" that allow them to do this that are totally independent of any professional standards. So if you are a managed care business and you own the hospital you are winning at two levels - you already shift the risk to the providers and hospitals by the Medicare style DRG payment and you do it a second time by insisting that they go along with the business decision to discharge the patient from the hospital.
Strictly speaking, the examples of discounted fees are technically not capitation. Discounted fees still allow for some elasticity within the system because there is still a fee paid per service event. Capitated systems of care like behavioral health carve outs can be set up to pay a set fee for managing a specific population. For example, a system of care is under contract for providing all services to a specific group of employees for a rate that is negotiated irrespective of actual patient visits.
The best way to understand capitated care is that it is designed to provide insurance companies a significant financial incentive for rationing care. That incentive comes directly out of the total amount of money available for health care spending Psychiatry, mental health, and addiction services were the easiest targets due to insitutionalized stigma, lack of a vocal constituency, and the political ineptness of psychiatrists. It is anybody's guess about how much a managed care company can make for denying or rationing care but some estimates of the margins have been as high as 20-40%.
One thing is for certain. Capitated care is not a comprehensive national health system. It takes hundreds of billions of dollars out of the health care system and diverts it to CEOs and stockholders. Contrary to the political opinion it does not contain the cost of health care inflation. One of the readers of the Shrink Rap blog pointed out that in a national system of health care you might be able to get an expensive medication like aripiprazole but you would have to wait longer. In our current system of capitated care if your managed care company decides - you will not be able to get it at all.
That is probably the best example of the difference.
George Dawson, MD, DFAPA
Starting out with the much maligned fee-for-service (FFS) - most medical and psychiatric services are not delivered in that context. You can safely say that FFS, disappeared a long time ago. According to a 2012 Medscape survey of 24,216 physicians across 25 specialties only 4% worked in cash only or concierge style practices. That means that everyone else is subject to varying degrees of insurance company discounting. From my years of providing inpatient care for example, there is a standard DRG payment based on a global discharge or admission diagnosis. For the most common psychosis DRGs the standard payment is $4,500 no matter how long a person is stays in the hospital.
The same thing happens on the outpatient side. I have discussed this more extensively is a previous post. Looking at the commonest outpatient billing code - actual reimbursement for providing services can be as little as $22.45 per visit. In the case where bills are submitted with CPT codes (common to all of medicine) Medicare pays 50% of the usual and customary charge for psychiatry compared with 80% for the rest of Medicine. A lot depends on contracting arrangements since a contract can limit a psychiatrist to billing only a 90862 code and the company can also decide that they disagree that services were provided and either deny payment or demand repayment of a significant amount of money based on a review of the documentation.
The business adaptation to this on the hospital and managed care side (if they own the hospital) is to hire case managers to get patients out of the hospital within 3 or 4 days. Some of these systems have confabulated their own "guidelines" that allow them to do this that are totally independent of any professional standards. So if you are a managed care business and you own the hospital you are winning at two levels - you already shift the risk to the providers and hospitals by the Medicare style DRG payment and you do it a second time by insisting that they go along with the business decision to discharge the patient from the hospital.
Strictly speaking, the examples of discounted fees are technically not capitation. Discounted fees still allow for some elasticity within the system because there is still a fee paid per service event. Capitated systems of care like behavioral health carve outs can be set up to pay a set fee for managing a specific population. For example, a system of care is under contract for providing all services to a specific group of employees for a rate that is negotiated irrespective of actual patient visits.
The best way to understand capitated care is that it is designed to provide insurance companies a significant financial incentive for rationing care. That incentive comes directly out of the total amount of money available for health care spending Psychiatry, mental health, and addiction services were the easiest targets due to insitutionalized stigma, lack of a vocal constituency, and the political ineptness of psychiatrists. It is anybody's guess about how much a managed care company can make for denying or rationing care but some estimates of the margins have been as high as 20-40%.
One thing is for certain. Capitated care is not a comprehensive national health system. It takes hundreds of billions of dollars out of the health care system and diverts it to CEOs and stockholders. Contrary to the political opinion it does not contain the cost of health care inflation. One of the readers of the Shrink Rap blog pointed out that in a national system of health care you might be able to get an expensive medication like aripiprazole but you would have to wait longer. In our current system of capitated care if your managed care company decides - you will not be able to get it at all.
That is probably the best example of the difference.
George Dawson, MD, DFAPA
Subscribe to:
Posts (Atom)