Psychology's visionary

Antonio Puente, PhD, never envisioned himself as an advocate for psychology. But in 1989, as president of the North Carolina Psychological Association and a neuropsychologist with a private practice, he decided he needed to push for better reimbursement for neuropsychological services.

At the time, he was providing neuropsychological exams and psychological testing services but not getting paid for much of his work since psychologists were only allowed to bill for a limited range of Current Procedural Terminology (CPT^®) codes.

"To put it simply, I just wanted to make a living," says Puente.

His goal was only to expand the American Medical Association's (AMA) understanding of psychological testing, through meetings and participation on the AMA's CPT advisory panel. But his advocacy was so successful, it led to a paradigm shift in AMA's perception of professional psychology — helping the medical establishment see psychologists as essential players in health care and helping to secure psychology's future in the process, says Sally Cameron, PhD, executive director of the North Carolina Psychological Association.

"CPT codes are the bedrock of making sure that independent professional practice continues as a viable option for psychologists," Cameron says. "Tony has had far more influence than most people realize, and he's been able to push the field forward to ensure we continue to gain ground."

In recognition of his expertise, in 2008, AMA elected Puente as the first psychologist ever to be a voting member of its CPT Editorial Panel.

"Dr. Puente's contributions and leadership in helping psychology to become established as a health profession have been truly stellar," says APA Chief Executive Officer Norman B. Anderson, PhD. "I shudder to think where we would be if not for his amazing work as the first and lone psychologist in AMA's CPT process."

Psychology as a health profession

CPT is the most widely recognized nomenclature system for health-care services and procedures. The CPT manual, published by the AMA and updated annually, contains thousands of codes used by third-party payers and government programs to identify health-care services. The CPT Editorial Panel reviews and votes on proposals for changes to CPT, including the addition of new codes.

Twenty years ago, when APA first invited Puente to represent the association as one of 10 nonphysician members of AMA's Health Care Professional Advisory Committee of the CPT Panel, psychologists could only bill to five CPT codes: an interview code, a psychological testing code and three psychotherapy codes.

"Now, there are about five dozen different codes that we have access to as psychologists that capture all kinds of services, including group psychotherapy, biofeedback, different forms of testing, and all the health and behavior codes [that were created by APA in 2001]," says Puente, who is also a professor of psychology at the University of North Carolina, Wilmington, and co-director of a bilingual mental health clinic for the poor and uninsured.

This change has allowed psychologists to be reimbursed for behavioral assessment and intervention work with people with all kinds of physical health problems.

Securing the codes wasn't easy. The medical community — and even some psychologists — resisted them, says Jim Georgoulakis, PhD, MBA, JD, APA's advisor to the Health Care Professionals Advisory Committee, who worked with Puente on the codes.

"People said, ‘Wait a minute, that's not what psychologists do,'" Georgoulakis recalls. "But Tony pushed back and said, ‘We're more than mental health professionals, we're health-care providers, and we work with the total patient.' This foresight has allowed psychologists now to be part of the greater health-care team rather than just being penciled into the mental health arena."

Linking health and lifestyle

As a member of the CPT advisory panel from 1994 to 2008, Puente educated his physician and nonphysician colleagues on psychology's intrinsic link to all health-related problems, particularly many chronic and costly illnesses, such as heart disease, respiratory problems and diabetes. He helped physicians understand how these disorders often correlate to a patient's lifestyle, through smoking, obesity, physical inactivity or high blood pressure.

He also helped them see that psychologists have the behavioral expertise and scientific evidence needed to guide the prevention and management of these conditions.

"Smoking alone results in close to half a million deaths per year, which are evenly distributed among cardiovascular, cancer and respiratory problems," Puente says. "But it's a lifestyle-based problem that responds well to behavioral interventions."

Puente's advocacy has also included ensuring psychologists are reimbursed at the same levels as their physician colleagues. Most recently, he has been working on a revision of the psychotherapy codes to help ensure they recognize the value psychologists add.

"The good news is that we're now driving the bus, together with our medical colleagues," says Puente.

But he does acknowledge that some psychologists may not be ready to embrace their newfound recognition.

"The bad news is that we have to follow the map," he says. "We can't just go into the wilderness and do our own thing anymore. Recognition and appropriate reimbursement require a level of standardization that maybe our field hasn't been accustomed to historically, but that's the evolution of the discipline."

Amy Novotney is a writer in Chicago.

Current Procedural Terminology (CPT®) copyright 2011 American Medical Association. All rights reserved.