President's Blog

As the Chairman of ASAM's Board, I have the privilege of sitting on the Board of the National Council on Alcoholism and Drug Dependence. Founded by Marty Mann and with over 100 affiliates throughout the US, NCADD has played a key role in the development of the addiction treatment community. NCADD has a policy development group, a medical-scientific committee, and an annual meeting. Interestingly, though, other than my presence on the Board, there is no formal relationship between ASAM and NCADD, which act in parallel with very similar goals. I have taken the first step toward mending this breach by offering the NCADD Board a chance to assign a liaison to participate in our Board meetings. Since that offer was made, NCADD has already participated in a recent ASAM Board teleconference. I view this as a significant step forward, but I believe there is much more that we can accomplish.

This past week, I had the chance to meet with the Executive Director of NASADAD, the National Association of State Alcohol/Drug Abuse Directors. They too have an annual meeting, and their basic purpose is to "foster and support the development of effective alcohol and other drug abuse prevention and treatment programs throughout every State." NASADAD's bylaws specifically encourage a promotion of training within the field, a focus on translating research and knowledge into practice, and attention to shaping public policy positions that advance the state of addiction treatment. As I flew home from Washington after that meeting, I sat next to a group of people who had just attended the CADCA meeting. Thousands of attendees had been at the National Leadership Forum. But what is CADCA, I asked.

CADCA is the Community Anti-Drug Coalitions of America, a group that for 20 years has been representing the interests of more than 5000 community coalitions throughout the country, and which now terms itself the nation's leading drug abuse prevention organization. And although there is an MD on CADCA's Board of Directors, there is no formal relationship between CADCA and the addiction medicine community.

I could go on, noting the presence of Faces and Voices of Recovery, NAADAC, AATOD, AMERSA, AAAP, and the International Nurses Society on Addictions as further examples. The latter group is holding its 37th annual conference later this year. Missing in action, however, has been a true public face in the addiction world. Gary Mendell aims to correct that oversight, as he addressed the Clinton Foundation's 2013 Health Matters Conference recently with respect to his goals with www.Brianswish.org.

But at the end of the day we still have an illness that directly impacts well over 15% of our population and with the direction things are going with marijuana it is likely to have an even greater health and economic impact upon our society than ever before. And we have a dozen or two large organizations with overlapping missions and visions. While many of these groups cooperate informally and formally through coalitions on policy issues such as parity and ACA, there have been no regular meetings of Board Chairs. There have been no world congresses on addiction where we all get together at one time.

I'd like to see this oversight fixed. I want to reach out to my counterparts at the other groups and begin the discussions. But I'd prefer to do this with a major goal in mind. What I'm picturing, is putting the building blocks in place to hold a US Congress on Addiction sometime in the next four to five years.  This Congress would be, a single conference that would include and incorporate the annual meetings of major groups in the field, that would bring all the players together at one time to discuss policy, to hold educational sessions, to work on terminology, to address turf issues, and to respond to the growing problems with as much of a single voice as we can muster. We would include the scientific, medical, research, payer, recovery, and both public and private communities and related organizations. While there are many logistical, business and other details to sort out, we need to set our sights high.

ASAM has had some big goals over the past few years, among which have been parity and board certification. I raised another, a diagnostic manual, last time. And here is one more - the concept of bringing the entire field together to achieve a true working relationship, improved outreach, and a genuine network for the benefit of our patients with addiction.

Each medical specialty has its own language. The specialty itself generally defines the terms. It wouldn't do, for instance, if a surgeon asked for a "Richardson" and was handed a "Kelly." But that could happen if surgeons defined "Richardson" one way and nursing staff defined it as something else. Unfortunately, in the field of addiction, we have terms that are defined by various factions. This has led to the oft-heard discussion regarding the differences among use, overuse, misuse, abuse, dependence, addiction, not to mention recovery, sobriety, and abstinence. One might think that the variety of understandings result from the wide range of healthcare staff involved with addiction treatment. And yet as other specialties of medicine become multidisciplinary much as addiction treatment has been for many years, we don't see the same difficulties arising. Diabetes counselors don't define DKA any differently than the endocrinologists, and they don't call diabetes itself by some other name.

One of the major difficulties here is that our own national organization has not yet published a broad manual of definitions for the field. Psychiatry, for example, publishes their Diagnostic and Statistical Manual, now about to see its seventh edition (and naturally named DSM-5). And just to throw a monkey wrench into the works, DSM includes a section that defines various terms in the field of addiction. But isn't that our field of expertise? Why would one specialty of medicine follow another's definition of its own field? Why, particularly, when we have the start of our own approach that is at odds with the one in the psychiatric manual? (Our definition of addiction broadly does not recognize the various substance use categories as representative of differing disease states).

I've been asked to comment on the new section in DSM-5 dealing with addiction. I have not done so since I haven't seen the new section. I've heard that it creates definitions for mild, moderate, and severe substance use disorders, something we've not had before and something I've never heard any of our members request. I can't see myself telling a patient that he has a "moderate alcohol use disorder." And I worry that an individual defined as having a "mild" substance use disorder would not be able to gain access to treatments that would be available if he simply had a substance use disorder. What I've learned from patients is that addiction is something you either do or do not have. There's little middle ground. I've also heard that DSM-5 fails to correct the oversight of earlier editions that separate alcohol use disorders from other sedative use disorders. This means that by definition, individuals' alcohol use disorders are gone once they've switched from Bud to Xanax. They now have another disease state. And that is simply wrong.

But we've never said that formally. Isn't it time to do so? Isn't it time, now that we have our own Board and our own residencies and our very well established specialty of more than 50 years, to have our own set of terms and definitions? 

15 years is a long time – psychiatric and behavioral health services are now being changed by the AMA CPT committee. Brand new codes were created and old frequently used codes were eliminated.  These coding revisions were announced in the fall and the changes are supposed to activate for January 1, 2013.  Expect that most insurers will implement the codes and not accept the old ones, and so prepare for possible suspensions or denials.

I will briefly review the coding changes and then address the implications and challenges that present to our members.  For those of you (the majority of our members) who are not psychiatrists and do not have a behavioral health provider number and profile, these changes will not affect you.  For those who employ substance abuse counselors or other mental health professionals in your office, you will be affected as the new codes apply to all behavioral health providers and not just psychiatrists.

The old coding schema was based upon time based psychotherapy services with and without pharmacotherapy.  Pharmacotherapy could be billed as a distinct med visit or combined with psychotherapy.  The new codes continue time based psychotherapy services with a three time based tiers, but changed the durations from 30, 60 and 90 minutes to 30, 45 and 60 minutes.  They maintained the definition of a unit of service as when the mid-point is passed, so that the 30 minute code may range from 16-37 minutes, 45 minute code can be 38-52, and the 60 minute code, anything over 53.  Services longer than 60 minutes may add modifier 22, but be aware that modifier codes may result in manual processing, procedural delays and medical record requests for documentation justification. 

The major change for 2013 transfers pharmacological services from psychiatric specialty services into the general medical category of evaluation and management codes (E/M codes).  The very commonly used “med visit” code (90862) has been eliminated and replaced with use of medical E/M codes [99211-99215. Medical management services combined with psychotherapy will require two codes – the E/M for the med management and an “add on” code for the psychotherapy (90833, 90836 or 90838 for 30, 45 or 60 minutes)].  It is unclear at this time how insurers will process two codes on the same date of services, so it is imperative that each provider check request clarification of coding rules. 

A major challenge will be that the new coding schema will require mixing time based and severity based documentation requirements.  Time based services require documentation of treatment issues, treatment service duration and modality of treatment provided.   E/M codes are much more medically oriented and choice of coding visits depends upon the extent of four domains: comprehensiveness of history and examination, extent of review of system involvement and complexity of medical decision making and risk of complications. Gone are the days of a brief med visit as a standalone code.  Gone are the days of making twice as much per hour for multiple med visits with minimal documentation.  Documentation for E/M services should be organized in this manner  – a major change that could create potential problems in organizing psychotherapy notes into a medical format.  

One component that I suspect will be confusing for both providers and insurers is the definition and documentation of  time spent for talking therapy.   Not all talking services are considered the same – counseling during E/M services involves discussion of such issues as explanation of illness, monitoring of progress, pharmacotherapy and issue of treatment planning and prognosis, etc.  Psychotherapy services require documentation of therapy provided to alter course of illness, such as cognitive behavioral, insight oriented therapy, etc.  Patient discussion will now need to be split into two documentation formats. 

This alone will be challenging, but will be even more complicated by the fact that severity based E/M codes can be converted into time based codes by application of the 50% rule. For example, if less than 50% of the E/M visit was spent counseling the patient, then the documentation of the four domains of severity of problems and complexity of visit are not needed.  The E/M codes switches to a time based code ranging from 5 minutes for a limited 99211-99212 codes, to 45 minutes for a 99215.  The 50% rule requires documentation in the medical record of the percentage of time spent for counseling and must only include direct face to face time spent.

I have not been able to find any references on the web or on coding sites that has yet given a definitive answer for these overlapping talking therapy issues.  Until guidance is provided in more detail, we have to rely upon a few examples within the 2013 AMA coding manual.  I recommend that each psychiatric provider call each of their participating insurers and go on their websites for additional information, rather than making assumptions that later are overruled during a retrospective payment audit.

Other changes include new evaluation codes, crisis intervention codes and two categories of add-on codes – for psychotherapy included with the E/M visit as described previously and for interactive complexity (90785).  Add-on codes need to be combined with another services including initial evaluation codes, psychotherapy codes, non-family group psychotherapy codes and E/M codes.   The psychiatric diagnostic interview (90801) has been replaced by 90791 for new patients without medical evaluation and 90792 with medical evaluation.  

So, what advice do I have for our members and myself.  First – buy a 2013 AMA CPT book and read the sections yourself, rather than delegating the issue to your billing staff.  Next - ask, ask, ask.  Then – prepare for the reimbursement schedule.  Contact your insurer prior to January 1st, as they are required to make fee schedule changes by this date.
I hope that this overview has been helpful and provides enough information to get going a lively discussion with your staff, your patients and your insurers.  Feel free to post comments on the website and contact me directly.

The September issue of our Journal of Addiction Medicine features an article by JW Boyd and JR Knight discussing ethical dilemmas confronting state physician health programs (PHP's). Within the article, the authors show concern regarding the coercive nature of the system, specifically indicating that "physicians have little choice but to cooperate with any and all recommendations if they wish to continue practicing medicine." There is also concern that when such treatment is recommended, cost may be prohibitive for the standard 90 day length of rehabilitation, notably longer than the 20-28 day stay typical for other patients undergoing substance abuse treatment, despite what they describe as a lack of evidence that healthcare professionals require longer treatment.

The Federal Aviation Administration has similar rules applying to aircraft pilots identified as having addictive illness. These pilots have little choice but to cooperate with FAA standards and regulations if they wish to obtain a special issuance medical certificate, under which they may continue to fly either privately or commercially. They too have to pay sometimes prohibitive amounts for their treatment, which as it happens is also a 90 day length of rehabilitation as a starting point. The questions which Boyd and Knight pose for physicians could therefore also be posed for pilots. A quick literature search reveals there to be no evidence that pilots require longer treatment.

But there's a problem with this line of thinking. Both pilots and physicians have been demonstrated to do well with these treatment programs. Recovery rates over 80% appear to be rather consistently identified both by PHPs and by studies of pilots conducted by the FAA and by independent airlines. These long term recovery rates appear dramatically superior to the recovery rates obtained within the general population, which, depending on what literature you believe, seems to lie somewhere in the 40-50% area. Further, one could easily argue that many of our patients have little choice but to cooperate with recovery programs if they are to regain their physical health, their financial status, custody of their children and their legal freedom. It would seem that these measures of coercion would often be at least equal to one's desire to simply regain access to one's chosen occupation or avocation.

Given that recovery rates are demonstrably higher with pilots and physicians going through these well-defined recovery programs, I would flip the question as posed by Boyd and Knight: is there any evidence that the general public requires less treatment than do healthcare professionals and pilots? I would further ask, given the excellent outcomes generally obtained by PHPs and pilot recovery programs, why there have been no studies in which members of the lay public go through identical programs to determine what their long term outcome would be. Indeed, what happens when a non-healthcare professional or non-pilot goes through 90 days of rehab, and is then followed regularly by an addiction specialist physician while simultaneously attending twelve-step or similar self-help groups and being subject to random urine drug testing, all as the FAA requires of pilots requesting a special issuance medical, and as state medical boards generally require of physicians wanting to return to practice? Would they too have an 80-90% recovery rate?

Before we go after a successful set of programs, perhaps we should first ask the question as to whether we should direct our attention toward less successful approaches. This is not meant in any way to undermine the ethical dilemmas addressed by Boyd and Knight; such dilemmas are legitimate and deserving of focus and attention so as to ameliorate the inherent conflicts of interest as best we can. The authors have done an expert job at pointing out the major issues to be considered. But as with all ethical dilemmas, there are valid arguments on both sides that need to be considered closely, and each argument needs to be considered from an opposing direction to determine if the stage is set properly for any investigation to follow.

Over the past few years since the National Institute of Health has brought us proof that addiction is a “Brain Disease,” and since effective counseling strategies and effective medications have been developed, we find that payers are quickly creating “new” barriers and hurdles that our patients must overcome to access the benefits from years of research and development. Addiction is recognized as a chronic medical illness like diabetes, hypertension and asthma. Yet, patients are not always able to access the treatment that is required as determined by the physician. There are road blocks concerning the level of care a patient can access not in keeping with ASAM PPC-2R. There are hurdles regarding prior authorizations before medication can be prescribed, and then there is the burden of “hurry up and get off” the efficacious lifesaving medications, as though chronic medical illness are curable!

No one cajoles diabetics off insulin. No one tells hypertensive patients that they only are on medication for six months to one year before their prescription benefits are terminated. Certainly, no insurer tells an asthma patient that their daily dosage of medication is limited to a pre-selected amount, even if they continue to be symptomatic. No insurer does that to any other patient except people that suffer from addiction. In fact, the treatment that patients with addiction receive in terms of their insurance benefit for addiction treatment is like punishment for willful misconduct rather than compassion for a chronic disease.

The paper “The Impact of Managed Care on Addiction Treatment: An Analysis” reviews these and other issues and offers some recommendations that would improve this situation. Please read it and tell me what you think.