The CPT Coding Cliff: Thumbing My Nose at APA

As we approach the January 1 edge of the psychiatric CPT coding cliff it appears that physicians will proceed in either of two possible directions to secure payment for office follow up visits, depending on how much they value money relative to the physician-patient relationship. Scuttlebut on the Web convinces me that most will, unfortunately, take this direction (Plan A):

  1. The physician determines how much reimbursement she wants.
  2. The physician selects the E/M codes corresponding to that level.
  3. The physician documents activities to support the code.
  4. The physician  carries out those activities with the patient.
  5. The physician files a claim with a payer.
  6. The physician hopes for the best reimbursement.
  7. The uninsured patient pays an unpredictable and artificially inflated fee.

Physicians who follow the steps in this order will have complied with AMA and APA in their push to promote payers at the expense of private practice. Patient and physician, both at the mercy of payers, will have conflicting incentives: The cash patient will want to minimize the complexity of the encounter to minimize cost, possibly risking harm by withholding information from the physician. I plan to reverse the steps (Plan B):

  1. The patient will pay a standard fee, known to the patient before the encounter.
  2. The physician carries out those activities with the patient deemed medically necessary as determined by physician and patient.
  3. The physician documents those activities.
  4. The physician selects the code that corresponds to the described activities.
  5. The physician provides the patient with a claim to file with their payer.
  6. The patient with insurance hopes for the best reimbursement.

I will, starting next week replace old code 90862 with the E/M code that I believe adequately describes the level of service I have always provided, and my patients expect, 99212. I will continue to require payment of the same fee at the time of service and provide insured patients with a claim which they may file with their payer. I will remain blind to what happens between the patient and their payer.

If I provide a more complex set of services than 99212 I will still receive the same payment from the patient, regardless of whether the patient gets reimbursed. The payer may reimburse less than the encounter might have deserved, which may make the patient unhappy, but I will not worry that the payer will audit my notes and demand refund of overpayment due to (fraudulent?) “upcoding,” and I will not end up overcharging patients who, either because they have no insurance or because they have not satisfied their deductible, get no reimbursement.

AMA and APA, to the detriment of the physician-patient relationship, want physicians to deal directly with payers. Let’s thumb our noses at these organizations who have abandoned physicians in private practice in favor of corporate medicine. Patients will find physicians who follow plan A above increasingly responsive, not to them, but to payers.

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