As a psychiatrist and psychotherapist who accepts some insurance, I am concerned about the impact of current mental health procedural terminology (CPT) codes on psychotherapy—especially their effect on quality of care, payment, access, and privacy.
The January 2013 coding changes are as follows:
Most prior mental health evaluation and therapy codes were eliminated.
Individual therapy, when concurrent with evaluation and management (E&M) is not billed as the primary service. Treatment is billed with an E&M code plus an add-on psychotherapy code.
New individual psychotherapy codes, with and without E&M, cover a range of time instead of a specific time. For example, a 45-minute session is coded for 37–52 minutes, determined by the “CPT time rule.”
The E&M codes, with add-on therapy, are based on complexity, not time. We are required to use data points based on a medical model to document care. For example, the documentation template suggested by the American Psychiatric Association includes such sections on Chief Complaint, History of Present Illness, Mental Status Exam, each consisting of “data elements” (i.e., severity, triggers and associated symptoms) that are added together to determine complexity and coding.
Psychiatrists and nurse practitioners can bill for just E&M. Time can be used to choose the procedure code for E&M without psychotherapy, if more than half the time is spent in counseling and/or coordinating care.
There is a new code for crisis psychotherapy and a new add-on code for interactive complexity, in lieu of a prior “interactive therapy” billing code. Interactive complexity is defined by having to use more complex communication techniques, i.e., an interpreter, third-party informant or manipulatives such as play therapy.
These codes devalue psychotherapy, making therapy an add-on procedure, if it takes place with E&M. Billing integrated treatment (therapy with E&M) as two services falsely dichotomizes what would be otherwise seamless, concurrent treatment. Comparably low fees for individual therapy without E&M, crisis psychotherapy and therapy with interactive complexity emphasize psychotherapy's second-class status in this new reimbursement scheme.
The coding changes will no doubt impact therapeutic process. The new psychotherapy time frames distort the notion of the traditional 50- or 60-minute session, and fit poorly with how we actually practice.
The associated documentation guidelines potentially distract us from attending to patients' thoughts, feelings, and reactions, as well as our own, because of the necessity to elicit required data. Transference and countertransference, core psychodynamic principles, are pushed to the periphery in this new health care model that detracts from spontaneity and quality.
Though total insurance fees for therapy with E&M have increased, the allowable reimbursement for the therapy component has decreased for psychiatrists and advanced practice nurses. Because E&M is more lucrative, psychiatrists and nurses may prefer to code sessions as time-based E&M, provided the work consists of “counseling/coordination of care.” Billing records could spuriously underrepresent integrated psychotherapy and can be expected to endanger insurance coverage for psychotherapy by psychiatrists and advanced practice nurses.
Most insurers, without prior authorization, disallow 60-minute sessions; some pay the same amount for 45- and 60-minute sessions, making longer sessions less economically desirable. Furthermore, because “average times” determine fees, payment will not accurately reflect the actual time spent. The requirement that psychotherapists document the type of psychotherapy may herald decreased reimbursement or reduced insurance coverage for long-term psychoanalytic psychotherapy, in favor of short-term, “cost-effective” treatment modalities. This could endanger the future of psychodynamic psychotherapy.
Margo P. Goldman, M.D., a psychiatrist in Andover, Massachusetts, is an advocate for patient confidentiality. She is a Distinguished Life Fellow of the American Psychiatric Association, Psychotherapist Associate Member of APsaA, and an active member of the Psychotherapist Associates Committee.
Therapists will increasingly practice “off the grid,” treating patients who can pay out of pocket. Paradoxically, the expanded mental health provision of the Affordable Care Act will be associated with decreased availability of psychotherapy. In the aftermath of atrocities like Newtown, as well as other massacres involving untreated mental illnesses, it is disgraceful that those most in need of treatment will have less access.
Patients' records are now created to justify payment, rather than chronicle treatment. The expectation is for records to be audited. Such audits starkly conflict with our professional ethics regarding patient confidentiality and the “minimum necessary” policy, which strictly limits the scope of information that can be disclosed to insurers.
Documenting with “data points” creates an incentive to use computerized templates, because the electronic health record's “checklist” format saves time. But aside from convenience, using the electronic health record increases the risk of privacy breaches, thereby further eroding the bedrock of trust in the therapist-patient relationship.
The new codes' impact on quality of care, payment, access and confidentiality could make psychodynamic psychotherapy scarce for patients using their insurance. Psychotherapists should advocate for patients by raising such concerns to professional organizations and patient advocate groups. As professionals, we should demand a clinically sound, fiscally manageable billing infrastructure that will safeguard and sustain the practice of psychodynamic psychotherapy.