Sleight of Hand

This article originally published on

What would you think if I told you that Medicare will require laboratories to disclose to CMS payment rates from private insurers? Or that they will identify physicians who order a high volume of CT tests and require them to pre-authorize those tests in 2020? How about that CMS will begin its own analysis of the time and cost of providing services in order to determine RVUs, a job currently done by the AMA RUC committee? Would you be surprised? Or, at least surprised you hadn’t heard about it? Both the House and Senate have passed HR 4302, which provides another temporary fix to the Sustainable Growth Rate (SGR) formula and a delay in the implementation of ICD-10.

In the furor over the manner in which the SGR fix bill was passed by the House and the accompanying howling about the delay of ICD-10, important policy changes included in the bill were left unmentioned. And some professional societies who had advocated for the ICD-10 delay weren’t happy with the bill, citing dismay at another temporary fix. Perhaps there were objections to the three huge policy changes in the bill.

 Section 216 is “improving Medicare policies for clinical diagnostic laboratory tests.” The first section title, however, tells a fuller tale. “Reporting of private-sector payment rates for establishment of Medicare payment rates.” And the policy is just that. It requires that beginning in January 2016 laboratories report to Medicare their payment rates from private insurance companies. Laboratories will be required to report both the payment and volume including discounts on all non-capitated business. If the lab has multiple rates with one payer all of those rates must be reported. A payer is defined as a health insurance company, a Medicare Advantage plan or Medicaid managed care plan. I don’t need to tell you why Medicare wants this information, do I? But, they aren’t being coy. It is in order to adjust their payment rates for lab services.

 Section 218 will dismay some physicians who order high volumes of CT tests. (Whoever develops the titles for these sections is pure genius. This section is entitled “quality incentives for computed tomography diagnostic imaging and promoting evidence-based care.”) CMS wants to recognize the appropriate use of these technologies and be sure they’re used only for developed or endorsed indications. Starting in 2017 they will identify no more than 5% of ordering physicians who are outliers in ordering these tests and who have low adherence to the evidence-based guidelines. Beginning in 2020, it will require prior authorization for these high users to order these tests. Exceptions are made for emergency care.

 Most of you reading this know how relative values for CPT codes are set. The American Medical Association’s relative value update committee, commonly known as the RUC, researches the time and costs for providing every CPT code. They pass these values on to CMS, which accepts most of them without changes. Section 220 of this bill gives CMS authority to develop its own values and use them, instead. The bill provides only $2 million each year for Medicare to collect information about the time expense and overhead of providing CPT services, so they can’t look at every CPT code, and will focus on codes they identify as mis-valued.   Since some primary care groups have long complained about the RUC process as dominated by and favoring specialists, I expected cheering from them about this section of the bill.

 This little bill is only 123 pages long. It provides a 0.0% change to the conversion factor, not a 24% decrease. It addresses ICD-10 in one sentence, stating that CMS may not implement the ICD-10 code set prior to October 1, 2015. It extends policies. But, perhaps, to paraphrase John Stewart you need a moment of Zen after the uproar about the bill.

 Here it is, a quote from the bill, your moment of Zen.

“Section 1898(b)(1) of the Social Security Act (42 U.S.C. 1395iii(b)(1) is amended by striking “$2,300,000,000” and inserting “$0.”

Tell me something I don’t know: confusion in reporting Psychiatry services

CMS recently released a MedLearn Matters article about coding for psychotherapy and evaluation and management (E/M) services on the same day. This article reported that the comprehensive error rate testing contractor (CERT) had found a high error rate when E/M services and psychotherapy are reported together. Tell me something I don’t know.

 In 2012 physicians, nurse practitioners, physician assistants and clinical nurse specialists working in psychiatry reported medication management with code 90862. That code was deleted in 2013. Medical practitioners working in psychiatry who performed medication management were instructed to report the service with E/M codes. If psychotherapy was provided there were new add-on codes for psychotherapy reported with medical evaluation services. The CPT book instructed clinicians not to use the time spent for the E/M service to determine the level of service for psychotherapy. While psychotherapy codes are time-based codes, E/M services may be reported either based on time (unless provided on the same day as psychotherapy) or based on the three key components of history, exam, and medical decision-making. It was all very confusing to medical clinicians working at psychiatry.

 The MedLearn Matters article tries to clarify this. “The main error that CERT has identified with the revised psychiatry and psychotherapy codes is not clearly documenting the amount of time spent only on psychotherapy services. The correct E&M code selection must be based on the elements of the history and exam and medical decision making required by the complexity/intensity of the patient’s condition. The psychotherapy code is chosen on the basis of the time spent providing psychotherapy.” That is, select the E/M service based on the history, exam, and medical decision-making documented and add a note “After the E/M service, I spent XX minutes in psychotherapy with the patient.” Describe the psychotherapy.   The article further stated that it needed to be clear that the time spent in psychotherapy did not include the time of the E/M service.“Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.”

Clinicians tell me that this is a false delineation, and that there is no easy way to mark when the E/M service stopped and the psychotherapy started. But, these are the coding rules that we have in 2014. What is a medical clinician working in psychiatry to do?

Providing medication management or medical evaluation only: if this is the only service provided a clinician may use time or the three key components to select the code. If psychotherapy is not done on the same day, and the visit is dominated by counseling, a clinician may use time to select the code. The CPT describes counseling as dominating the visit when over 50% of the time of the total visit time is composed of discussion of the diagnosis, prognosis, risks and benefits, importance of compliance, and patient or family education. In that case, document the total time and that more than 50% of the time was spent in counseling. “I spent 20 minutes with the patient over half of the discussing the side effects of medication and the other issues above.”

Only psychotherapy is provided: if only psychotherapy is provided and there is no medical E/M, use the psychotherapy standalone codes based on time. These codes are hurt 90832, 90834, and 90837. Document time in the record and describe the psychotherapy that was performed.

When both an E/M services (such as medication management) and psychotherapy are provided on the same calendar date: in this case report both an E/M service and an add on psychotherapy code. Select the level of service based on the history, exam and medical decision making. Then, document the time spent in psychotherapy not including in it the time it took to provide the E/M service.. I suggest documenting the patient’s subjective report, the mental status exam and the assessment in the plan. Then note “after the E/M service was performed I also provided XX minutes of psychotherapy.” Describe the nature of the psychotherapy. Do not document the total time of the visit because that includes both the E/M service and the psychotherapy.

Although most clinicians don’t want to read the CPT book, the section about psychiatry codes includes important editorial comments and instructions for use of the codes. Because there was such a major change in 2013, and Medicare has identified a high error rate for these services it is important for someone in the office to review this section of the book. It will only take 15 or 20 minutes to read through the editorial comments in the psychiatry section and the reward will be an increased understanding and higher coding accuracy.


SGR update bill delays ICD-10 implementation

On Monday, March 31, 2014 the Senate passed House bill H.R. 4302.  This bill gives physicians yet another temporary reprieve from a fee decrease and also delayed ICD-10 implementation.  The 120 page bill addresses it in one sentence “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for code sets….”  HR 4302 has other policies, that I’ll write about in the coming days.