Mental Health in
Primary Care Settings
Assessing Mental Health in Primary Care
As far back as 1988, studies showed 25-30% of patients in the typical primary care practice had undiagnosed psychiatric disorders.* The PRIME-MD (Primary Care Evaluation of Mental Disorders) was designed by Dr. Spitzer** to assess for the five most common mental disorders in the primary care setting; depression, anxiety, alcohol use, eating disorders and somatoform disorder. Published in JAMA in 1994, it proved to be a valid method to detect mental disorders.
Dr. Spitzer’s noble goal was to develop a screening for the most common mental disorders that all PCPs could give to all Americans during their yearly exam. Everyone agreed until it was discovered in real world medical practice that the PRIME-MD:
1.) Takes 10+ minutes to give, but the typical appointment lasted only 7 minutes.
2.) Doctors needed special training to personally administer it.
3.) The PRIME-MD was NOT insurance reimbursable.
Well, “that dog won’t hunt” was my feeling in 1995 about the likelihood of the PRIME-MD being used in every doctor’s office after it was discovered to take more time to give than the average appointment was long and that it wasn’t billable. Sadly, this guaranteed a fast death to a good idea.
Still, we didn’t learn. We mental health experts persisted for years developing briefer and briefer tools for use in primary care settings. Since Medicare (and thus all insurances) will not pay for screenings we made them faster, cheaper and simpler–ideally under a minute, so doctors could do them for free, fitting them into ever shorter appointments. Of course, this degraded the results until no useful clinical data was yielded. So, of course no one used them. Thus, mental disorders still go undetected in doctors’ offices at the same rate as in the 1980s. It’s time for a different approach…
PQRS/MACRA
But wait, Medicare stepped in to help and of course made the situation worse. Medicare instituted the Physician Quality Reporting System (PQRS) requiring doctors to administer and report at least nine different screening measures on 50% or more of your patients or you face incremental reductions in their Medicare payments–up to 5% in penalties. Many health care businesses operate on a 2-5% profit margin or less, so this is a huge penalty on top of the 2% “budget sequestration” reduction in Medicare rates since 2013 due to Congress’s failure to conclude a “grand” deficit reducing budget. You could be earning 7% less in 2017 as compared to 2012.
The PQRS has proved to be stunningly complex, unwieldy and time consuming–as though it was designed by a huge committee, which it was. It was supposed to be quick and easy, and it is not. Of course there is no mechanism to bill for PQRS–in fact, it is so difficult to document compliance that private “registries” have evolved to charge doctors (who give the measures) to record the data to prove compliance to avoid the Medicare penalties. And, PQRS is here to stay having evolved into the current MACRA system. The PME incorporates many PQRS measures, meaning now you can get paid while administering and they are documented in the PME report.
A Better Idea: Get Paid To Do It!
HCPs can charge for using the PME to assess for addiction risk, mental disorders, pain and wellness. Consider, some of the best medications for pain are from the mental health arsenal; i.e., the SSRI antidepressants. Instead of doing unpaid screenings, you can bill for having a physician extender assist patients taking the Pain Management Evaluation on a tablet in your waiting room.
The PME qualifies as a computer-administered test billable by any HCP. These “testing” codes are recognized by all insurers. Most HCPs have never considered using the test codes, assuming they were only for psychologists. However, the codes allow for a computer, rather than a psychologist, to administer the tests. While the PME was designed by a neuropsychologist, it is administered by a computer under the supervision of a HCP. Thus, it meets criteria for CPT billing codes by medical professionals.
There are three testing codes based on whether the patient takes the computer-administered test: alone at home (for less reimbursement); or in your office with “assistance” by a staff member (higher reimbursement); or if you personally give it (highest reimbursement). The choice is yours as to how you administer and get paid to assess mental health, addiction risk, pain diagnoses, wellness and PQRS measures in your practice with the PME.
Still, we didn’t learn. We mental health experts persisted for years developing briefer and briefer tools for use in primary care settings. Since Medicare (and thus all insurances) will not pay for screenings we made them faster, cheaper and simpler–ideally under a minute, so doctors could do them for free, fitting them into ever shorter appointments. Of course, this degraded the results until no useful clinical data was yielded. So, of course no one used them. Thus, mental disorders still go undetected in doctors’ offices at the same rate as in the 1980s. It’s time for a different approach…
PQRS/MACRA
But wait, Medicare stepped in to help and of course made the situation worse. Medicare instituted the Physician Quality Reporting System (PQRS) requiring doctors to administer and report at least nine different screening measures on 50% or more of your patients or you face incremental reductions in their Medicare payments–up to 5% in penalties. Many health care businesses operate on a 2-5% profit margin or less, so this is a huge penalty on top of the 2% “budget sequestration” reduction in Medicare rates since 2013 due to Congress’s failure to conclude a “grand” deficit reducing budget. You could be earning 7% less in 2017 as compared to 2012.
The PQRS has proved to be stunningly complex, unwieldy and time consuming–as though it was designed by a huge committee, which it was. It was supposed to be quick and easy, and it is not. Of course there is no mechanism to bill for PQRS–in fact, it is so difficult to document compliance that private “registries” have evolved to charge doctors (who give the measures) to record the data to prove compliance to avoid the Medicare penalties. And, PQRS is here to stay having evolved into the current MACRA system. The PME incorporates many PQRS measures, meaning now you can get paid while administering and they are documented in the PME report.
A Better Idea: Get Paid To Do It!
HCPs can charge for using the PME to assess for addiction risk, mental disorders, pain and wellness. Consider, some of the best medications for pain are from the mental health arsenal; i.e., the SSRI antidepressants. Instead of doing unpaid screenings, you can bill for having a physician extender assist patients taking the Pain Management Evaluation on a tablet in your waiting room.
The PME qualifies as a computer-administered test billable by any HCP. These “testing” codes are recognized by all insurers. Most HCPs have never considered using the test codes, assuming they were only for psychologists. However, the codes allow for a computer, rather than a psychologist, to administer the tests. While the PME was designed by a neuropsychologist, it is administered by a computer under the supervision of a HCP. Thus, it meets criteria for CPT billing codes by medical professionals.
There are three testing codes based on whether the patient takes the computer-administered test: alone at home (for less reimbursement); or in your office with “assistance” by a staff member (higher reimbursement); or if you personally give it (highest reimbursement). The choice is yours as to how you administer and get paid to assess mental health, addiction risk, pain diagnoses, wellness and PQRS measures in your practice with the PME.
*Schubert HC, Burns BJ. Mental disorder in primary care: epidemiological, diagnostic, and treatment research directions. Get Hosp Psychiatry. 1988; 10(2):79-87).
**Chief architect of the DSM-III and author of the DSM-IV Casebook.