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APA is continuing to work to ensure that psychiatry's recommendations are incorporated by the federal government and the AMA when they refine or restructure Medicare coding standards and procedures.
Particularly gratifying, reported Donald Scherl, M.D., at a March 21 meeting of the Board of Trustees, is that APA was successful in getting the AMA/Relative Value Scale Update Committee (RUC) to accept all of its recommendations concerning the work value assigned to psychotherapy procedures. Work values reflect the time and complexity involved in performing a particular Medicare-reimbursable procedure. Scherl chairs APA's Work Group on the Resource-Based Relative Value Scale (RBRVS).
The work value assigned to a specific procedure, along with geographic and practice costs adjustments, is a critical component of the complex calculation that eventually determines the charge that Medicare will allow for a covered treatment or other reimbursable service. The federal government usually performs an annual update of these statistics, so the allowable charge for certain procedures may change slightly from year to year.
As part of the current update cycle, the AMA/RUC, whose recommendations are forwarded to the federal Health Care Financing Administration (HCFA), had insisted that professional organizations whose members routinely conduct psychotherapy reach consensus on their work value recommendations. Thus, APA worked along with the American Academy of Child and Adolescent Psychiatry, the American Psychological Association, the National Association of Social Workers, and the American Nurses Association on the psychotherapy codes that did not contain a medical evaluation and management (E&M) component-the "pure" psychotherapy codes. For psychotherapy procedures that did involve E&M, APA worked with the child psychiatry and nurses organizations only, Scherl reported (Psychiatric News, March 20).
In all, there are 24 psychotherapy-related codes that the groups assessed. (Over the last several years, HCFA has come to realize the complexity of psychotherapy. When the agency adopted the RBRVS system for determining Medicare reimbursements, it created only four psychotherapy codes.) The AMA/RUC recommends relative work values to HCFA for every procedure or service in the AMA's Current Procedural Terminology (CPT) manual.
This summer, HCFA, the federal agency that oversees Medicare and Medicaid, will review the AMA/RUC's recommendations as part of its annual update of the RBRVS system. If HCFA adheres to its traditional schedule, it will publish the revised work values in the fall and implement them on January 1, he noted.
The final work values assigned to psychotherapy and all other medical procedures are particularly crucial because, even though they have been developed for Medicare purposes, private insurers sometimes use them in determining their own reimbursement rates-a trend likely to accelerate in the next few years.
Scherl saluted psychiatrists Ronald Shellow, M.D., chair of the APA Joint Commission on Government Relations; Chester Schmidt, M.D., chair of the Work Group on Codes and Reimbursements; and Shelley Stewart and Gene Cassel of the APA Division of Government Relations for their successful efforts to get the RUC to accept the consensus work value recommendations from APA and the other organizations.
Scherl also called on Schmidt to update the Board of Trustees on the status of HCFA's revision of documentation guidelines for use with Medicare's E&M codes.
These new documentation guidelines for psychiatric evaluation and management were scheduled to go into effect on January 1, 1998, and were to serve as a standard that all the regional Medicare insurance carriers to evaluate claims.
Schmidt explained, however, that the AMA and its specialty society allies convinced the government's Medicare officials to postpone implementation until July 1 to allow additional time for modifying some sections and educating physicians about the guidelines (Psychiatric News, March 20).
A crucial element of the guideline modification that affects psychiatrists is the introduction of a single organ system-coding capability for E&M procedures. This will make coding E&M services more relevant to the way psychiatrists practice instead of wedging them into a coding scheme developed primarily with general practitioners and internists in mind, Schmidt noted. In contrast to their psychiatrist colleagues, these physicians often examine multiple systems as part of a routine evaluation, of which one may be psychiatric in nature.
A new five-level grid will assist psychiatrists in coding their E&M services with considerably more precision in terms of procedure complexity.