Health inSite: Coding changes signal shift in healthcare thinking

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I was recently on a call with a partner of ours discussing the changes in coding established by the AMA known as Current Procedural Terminology (CPT) codes as of January 1 of this year.  These are the codes that allow claims to be submitted quickly and easily without needing heavy-to-lift, unstructured data such as clinical notes.  A very common code for psychotherapy previous to this change was CPT code 90806 (Individual Psychotherapy, 45-50 minutes).  The new code that most closely matches is code 90834 (psychotherapy, 45 minutes with patient and/or family).  The reason we were on the call was to deal with an issue that had come up where one group was asking for additional details to help resolve that this code was not being used for family therapy (an expressly excluded benefit under that particular plan).  It was following this call that, wanting clarification and to confirm my suspicions, I began looking into why the coding had changed at all.  I don’t work in claims, and these topics very rarely touch me, so I haven’t stayed 100% on this issue.

So, as I began searching for reasons why the change occurred, I found a couple of interesting things.  The first was the American Psychiatric Association’s crosswalk of CPT codes which confirmed our thinking that the 90834 was intended to replace code 90806.  The second, and more interesting thing I found was a PowerPoint presentation developed by the AMA which explains the coding usage through examples (slides 29-34) and an explanation for the change (slides 18-20).  It’s stated that the reasons for the change are:

  1. The site is no longer relevant to the CPT code to be used.
  2. To match the time-bounding of the codes for other areas of the CPT dictionary.
  3. Psychotherapy may include face-to-face time with family members as long as the patient is present for part of the session.

Slides 29 and 32 provide very instructive examples of a much larger issue that these new codes hope to achieve going forward – they are systems-oriented.  This is a big step!  Effectively, the AMA has recognized that the treatment plan as well as the acuity of a given Behavioral Health issue may either stem from, or may be treated in some way by, the system in which the patient operates.  Now it may only be the family unit so far, but I wonder if this may signal a slight shift in the fee for service (FFS) model that may help erode the need for classifying treatment for the purpose of reimbursement; it may even signal the eventual demise of a FFS model altogether.  In any case, it at least begins to push the reimbursement model toward considering systems-based psychotherapy which relies on support systems like the family to achieve treatment adherence.

Further, inclusion of the family unit in the psychotherapy model is a slight tip of the hat to shared health responsibility.  It doesn’t necessarily follow that we’re moving to a true “your friend’s friends make you fat” approach to health, but by bringing the family into the individual treatment setting means sharing in the health of the patient; some responsibility is shared with that family member to report on successes and failures, and help guide that patient down the path to greater health.  If that relationship were reciprocal, and as we know to some level that might be the case given link influence, then this step into the 90834 might start to have greater effects than was originally anticipated.

To our health,

Ryan Lucas
Supervisor, Marketing

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Health inSite: Transformations as the Future of Healthcare

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Have you read the book The Experience Economy?  To explain it very quickly (and not do true justice to the ideas proposed in the book), there are various levels of economic offering that warrant different valuations, and thereby ability to generate revenue.  The levels of development discussed in the book are elegantly displayed in the graph below by Pine and Gilmore (the authors of the book):

This progression has expanded over time with new levels being added as the market strives for differentiation.  Many of the examples brought up are clear and concise, such as Starbucks as a purveyor of coffee (a commodity) that really charges the market at the level of a Service.  Pine and Gilmore stop at the level of Service in their description of Starbucks, but I would readily argue that they reach towards the level of experience.  Starbucks actually refers to this in their training materials as creating “The Third Place;” it’s not your work, or your home, it’s that other place where you can unwind a little bit.  Even though the customer isn’t actually brewing their own coffee, as is a hallmark of many experiences, they are engaging with the sounds and smells of the coffee shop in a very intentional way.

The book spends a great deal of time discussing offerings that are on the level of Experience but certainly takes a moment to tip its hat toward Transformations, a burgeoning new market offering.  Transformations are marked by the engagement of the customer in a way that enables that person to learn or grow, exactly to Transform, themselves in a way that is truly valuable to the customer.  It includes giving the customer the skills and motivation to make changes that will both provide some immediate value but also cascade down into further value down the road.

In healthcare, this understanding of the market is significant and valuable.  As we, as an industry, discuss Accountable Care Organizations, capitated care models, and participatory medicine, it’s important for us to keep in mind where value is derived in the typical marketplace.  Healthcare, while arguably different in many ways from other industries by its virtual necessity in every citizen’s timeline, still must compete under the same rules as many other industries.  Many times, in healthcare, we present ourselves on the level of Service – that is that we are doing something for someone, for a fee.  As we look at these new systems, it is time for us to consider what the future of healthcare delivery will require under a population health model of delivery.

Eschewing the fee-for-service model opens up the possibility for the healthcare industry to reconsider offering the long-term value of teaching individuals how to keep themselves healthy, at least in terms of the 80% of healthcare costs that are mediated by behavior.   This decreases the time and services that must be provided creating new forms of cost savings.  As we move further up the economic offering ladder, it will become more necessary to move our industry into the Transformation realm.  In fact, there is no other industry more suited to it.

To our health,

Ryan
Marketing