Psychiatric diagnoses in primary care
April 10th, 2009 - Codapedia Editor
Anyone who has tried to get an appointment with a psychiatrist can tell you how difficult it is to find the right mental health professional, and get an appointment. In fact, much of the frontline of psychiatric diagnosis and treatment happens in primary care offices. The problem is, how can they be paid?
Medicare pays 80% of medical services in a physician office, unless the diagnosis code is a psychiatric one. Then, Medicare pays 62.5%, giving the patient a higher deductible amount. The MIPPA legislation, passed in July 2009, gradually phases out the difference in payment.
Commercial insurances may deny the claim altogether if a code in the 300 or 311 is used in the first position of the claima form. Why? The PCP is not part of their "behavioral health network" and the service wasn't pre-authorized. Typically, however, the PCP is not eligible to become part of that network, and the patient doesn't want to be seen by the behavioral health network.
It is incorrect to unbundle a diagnosis. That is, if the diagnosis is known (depression) but the patient complains of a symptom that the physician feels is a
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