Provider Training Series The Search for Compliance. Outpatient Psychiatric Services February 25, 2014 Melissa Hooks, Director of Program Integrity

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1 Provider Training Series The Search for Compliance Outpatient Psychiatric Services February 25, 2014 Melissa Hooks, Director of Program Integrity

2 Outpatient Psychiatric Services Psychotherapy: Individual, Family, & Group Medication Management: Evaluation and Management

3 Outpatient Psychotherapy 1. Overview of Regulations 2. Refresher on Documentation Requirements 3. Outpatient Psychotherapy Services Service Codes Definitions and Allowable Services 4. Common Audit Findings and Noncovered Services

4 Overview of Regulations State: Pennsylvania Code Chapter General Provisions (Medical Assistance Payment Regulations) Chapter Outpatient Psychiatric Services Definitions Chapter Mental Health Procedures Chapter Psychiatric Outpatient Clinics PA Medical Assistance Bulletin March 2002 Documentation Requirements

5 Overview of Regulations Federal: 42 CFR Program Integrity Requirements for Medicaid Centers for Medicare and Medicaid (CMS) Medicaid Documentation Requirements CPT Codes and Definitions American Psychological Association Crosswalk of 2012 CPT Codes to 2013 CPT Codes Evaluation and Management Codes Definitions of Psychotherapy

6 Overview of Regulations BH-MCO: VBH-PA Provider Manual Documentation Guide (All providers) Provider Information Section

7 Documentation Requirements All providers types (individual practitioners, clinics, and facilities) that provide psychiatric outpatient services are responsible to maintain records that a minimum have the following documentation requirements: 1. Treatment Plan 2. Progress Note 3. Encounter Forms

8 Documentation Requirements Treatment Plans There must be a treatment plan for payment, and the treatment plan must meet PA Code including the following: Initial plan Must be individualized per the initial assessment and diagnosis Must have measurable goals and objectives with specific timeframes Signed by the clinician/treatment team Signed by the member Periodic plan reviews depending on the level of care (outpatient is every 120 days or every 15 visits whichever is shorter) The progress notes must reflect the treatment plan goals

9 Documentation Requirements Progress Notes Claim Billing Documentation All progress notes must meet the following requirements for payment: Name or MA Id Date of service Start and stop times of service Units match the claims billing Place of service, including specific location in community Narrative that includes all clinical requirements (as stated above) Clinician signature, credentials, and signature date All requirements are legible All requirements are complete prior to claims billing date All encounters must have an encounter form All requirements must be completed and dated prior to claims submission date

10 Documentation Requirements Progress Notes Clinical Documentation All progress notes must meet the clinical documentation standards and the following requirements for payment: Reason for the session/encounter Treatment goals addressed Current symptoms and behaviors Interventions and response to treatment Next steps and progress in treatment Clinical justification to support utilization Supporting documentation, when applicable

11 Documentation Requirements Encounter Forms All encounter forms must meet the required CMS standards in accordance with 42 CFR and the following requirements for payment: Encounter details Member name including member identification number (as required in the PA Medicaid Bulletin) Type of service Date with start and stop times Total units billed Recipient s signature Clinician s signature

12 Outpatient Psychotherapy Services

13 Outpatient Psychotherapy Services All outpatient psychotherapy services must be medically necessary in order to be a billable service a. Clarification regarding the definition of medically necessary statement of policy. A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that: (1) Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability. (2) Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. (3) Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.

14 Outpatient Psychotherapy Services All outpatient psychotherapy services must be psychotherapy. According to the PA Code Definitions: Psychotherapy The treatment, by psychological means, of the problems of an emotional nature in which a trained person deliberately establishes a professional relationship with the patient with the object of removing, modifying or retarding existing symptoms, of mediating disturbed patterns of behavior, and of promoting positive personality growth and development. Outpatient A person who is not a resident of a treatment institution and who is receiving covered medical and psychiatric services at an approved or licensed outpatient psychiatric clinic or partial hospitalization facility which is not providing him with room and board and professional services on a continuous 24-hour-a-day basis.

15 Outpatient Psychotherapy Services All outpatient psychotherapy services must be psychotherapy. According to the American Psychological Association: Evidence-based practice in psychology is "the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences" (APA Task Force on Evidence Based Practice, 2006, p. 273); A working definition for Psychotherapy is as follows: "Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable" (Norcross, 1990, p ); A working definition for Treatment is as follows: Treatments when used in the context of health care, refer to any process in which a trained healthcare provider offers assistance based upon his or her professional expertise to a person who has a problem that is defined as related to "health" or 'illness." In the case of "mental" or "behavioral" health, the conditions for which one may seek "treatment" include problems in living, conditions with discrete symptoms that are identified as or as related to illness or disease, and problems of interpersonal adjustment. The treatment consists of any act or services provided by a bonafide health provider intended to correct, change or ameliorate these conditions or problems (Beutler, 1983; Frank, 1973);

16 Outpatient Psychotherapy Services 1. Individual Psychotherapy 2. Family Psychotherapy 3. Group Psychotherapy 4. Evaluation and Management (Medical Services)

17 Individual Psychotherapy CPT Codes (New 2013) psychotherapy, 30 minutes face to face psychotherapy, 45 minutes face to face psychotherapy, 60 minutes face to face Pennsylvania Medical Assistance does not permit rounding of the codes. The time required for each session must be the time spent face to face with the members.

18 Individual Psychotherapy PA Code Definitions. Individual psychotherapy Psychotherapy provided to one person with a diagnosed mental disorder for a minimum of 1/2 hour. These sessions shall be conducted by a clinical staff

19 Individual Psychotherapy CPT Code Definitions INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, APPROXIMATELY 30 MINUTES FACE-TO-FACE WITH THE PATIENT

20 Individual Psychotherapy CPT Code Definitions INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, APPROXIMATELY 45 MINUTES FACE-TO-FACE WITH THE PATIENT

21 Individual Psychotherapy CPT Code Definitions INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, APPROXIMATELY 60 MINUTES FACE-TO-FACE WITH THE PATIENT This should be documented as an extended session and should be an unusual codes, such as the previous

22 Family Psychotherapy PA Code Definitions. Family psychotherapy Psychotherapy provided to two or more members of a family. At least one family member shall have a diagnosed mental disorder. Sessions shall be at least 1/2 hour in duration and shall be conducted by a clinical staff person.

23 Family Psychotherapy CPT Code and Definitions Family psychotherapy, conjoint psychotherapy with the patient present 15 minute unit

24 Group Psychotherapy CPT Code and Definitions Group psychotherapy 15 minute unit

25 Group Psychotherapy PA Code Definitions. Group psychotherapy Psychotherapy provided to no less than two and no more than ten persons with diagnosed mental disorders for a period of at least 1 hour. These sessions shall be conducted by a clinical staff person.

26 Special Considerations Each service code must meet the face to face minimum requirements according to PA Medical Assistance All Psychotherapy sessions must meet the following = 30 minutes = 45 minutes = 60 minutes or more (extended session) All Group Therapy session units must be a minimum of 60 minutes and must be an additional 15 minutes to bill another unit. All Family Therapy session units must be a minimum of 30 minutes and must be an additional 15 minutes to bill another unit.

27 Evaluation and Management Medical Services CPT Codes New Patients Established Patients

28 Evaluation and Management Medical Services: New Patients Must meet all 3 requirements *PA Medical Assistance requires all psychiatric medication evaluation and management session to be at least 15 minutes History Exam Expanded problem-focused Expanded Problem-focused Problemfocused problemfocused Medical Decision Min PA Psych Medication E&M Minimum Straightforward Straightforward Detailed Detailed Low Comprehensive Comprehensive Moderate Comprehensive Comprehensive High 60 60

29 Evaluation and Management Medical Services: New Patients Must meet at least 2 requirements *PA Medical Assistance requires all psychiatric medication evaluation and management session to be at least 15 minutes History Exam Medical Decision Min PA Psych Medication E&M Minimum Not required Not required Not required Expanded problem-focused Expanded Problem-focused Problemfocused problemfocused Straightforward Low Detailed Detailed Moderate Comprehensive Comprehensive High 40 40

30 Special Considerations All Psychiatric Medication Evaluation and Management Codes must be at least a minimum of15 minutes according to PA Medical Assistance Service Code Grid Includes all codes through through require additional time and must meet higher medical complexity and examination standards. Includes all codes through through require additional time and must meet higher medical complexity and examination standards.

31 Evaluation and Management (Medical Services) Determining Evaluation and Management Codes for Level of History or Exam Problem Focused (99201 & 99212) = 1 to 5 Bullets Expanded Problem Focused (99202 & 99213) = 6 to 8 Bullets Detailed (99203 & 99214) = At least 9 Bullets Comprehensive (99204, 99205, & 99215) = All Bullets including an Assessment of the Musculoskeletal System/Body System

32 Evaluation and Management (Medical Services) Bullets for Determining Codes Measurement of any 3 of the following 7 vital signs: sitting or standing blood pressure, supine blood pressure, pulse rate and regularity, respiration, temperature, height, or weight General appearance of patient (eg development, nutrition, body habitus, deformities, attention to grooming) Description of speech including: rate, volume, articulation, coherence, and spontaneity with notation of abnormalities (eg preservation, paucity of language)

33 Evaluation and Management (Medical Services) Bullets for Determining Codes (cont.) Description of thought processes including: rate of thoughts, content of thoughts (eg logical vs. illogical, tangential), abstract reasoning, and computation Description of associations (eg loose, tangential, circumstantial, intact) Description of abnormal psychotic thoughts including: hallucinations, delusions, preoccupation, with violence, homicidal or suicidal ideation, and obsessions

34 Evaluation and Management (Medical Services) Bullets for Determining Codes (cont.) Completion of Mental Status Examination including the following: Orientation to time, place and person Recent and remote memory Attention span and concentration Language (eg naming objects, repeating phrases) Fund of Knowledge (eg awareness of current events, past history, vocabulary) Mood and affect (eg depression, anxiety, agitation, hypomania, lability)

35 Audit Findings and Non- Covered Services

36 Individual Psychotherapy Common Audit Findings No treatment plans Length of service, must meet the time OMHSAS has not approved rounding Multiple units for event code Progress notes do not support the utilization Progress notes do not meet minimum standards

37 Family Psychotherapy Common Audit Findings No treatment plans Billing family member individually Billing individual codes instead of family psychotherapy codes Billing family therapy codes to discuss child s treatment and results with guardian or parent

38 Group Psychotherapy Common Audit Findings No treatment plans Group topics are not related to treatment plan Billing individual codes instead of group psychotherapy codes Group sizes are over 10 participants (Unable to verify group size) Repetitive progress notes Progress notes are not individualized Progress notes do not meet minimum standards

39 Evaluation and Management (Medical Services) Common Audit Findings No treatment plans Up-coding Consistently billing same codes for all members Progress notes do not meet 2 of 3 components or medical necessity requirements VBH-PA still requires 15-minutes until CPT guidance is provided later in 2013 from DPW/OMHSAS High ratios of High ratios of 99204, 99205, 99215, & 99215

40 Noncovered Services Noncovered services (in accordance with ) VBH-PA will not pay for the following types of services regardless of where or to whom they are provided and applies to clinics and individual practitioners: A covered clinic, psychotherapy, or partial hospitalization service conducted over the telephone. Cancelled appointments. Covered services that have not been rendered.

41 Noncovered Services (cont.) A MA covered service, including psychiatric clinic and partial hospitalization services, provided to inmates of State or county correctional institutions or committed residents of public institutions. Psychiatric outpatient clinic or partial hospitalization services to residents of treatment institutions, such as, persons who are also being provided with room or board or both, and services, on a 24-hour-a-day basis by the same facility or distinct part of a facility or program. Services delivered at locations other than approved practitioners approved office locations, psychiatric outpatient clinics, or partial hospitalization facilities with the exception of home visits under specific conditions. Vocational rehabilitation, occupational or recreational therapy, referral, information or education services, case management, central intake or records, training, administration, program evaluation, research or social services provided in psychiatric outpatient clinics

42 Noncovered Services (cont.) Case management, central intake or records, training, administration, social rehabilitation, program evaluation or research provided in psychiatric outpatient partial hospitalization facilities. Psychiatric outpatient clinic services and psychiatric partial hospitalization provided on the same day to the same patient. Covered psychiatric outpatient clinic services and psychiatric partial hospitalization services, with the exception of family psychotherapy, provided to persons without a mental disorder or mental retardation diagnosis rendered by a psychiatrist in accordance with the International Classification of Diseases ICD-9-CM, Chapter V, Mental Disorders. Psychiatric outpatient clinic and psychiatric partial hospitalization services provided to patients with drug/alcohol abuse or dependence problems, such as alcohol dependence and nondependent abuse of drugs, alcohol psychoses, and drug psychoses, unless the patient has a primary diagnosis of a nondrug/alcohol abuse/dependence related mental disorder.

43 Noncovered Services Drugs and biologicals and supplies furnished to psychiatric clinic or psychiatric partial hospitalization patients during a visit to the practitioner, clinic or facility. These are included in the medication visit fee or partial hospitalization session payment. Separate billings from any source for items and services provided in the clinic are noncompensable. Services not specifically included in the MA Program Fee Schedule are noncompensable. Services provided beyond the 15th calendar day following intake, without the psychiatrist s review and approval of the initial assessment and treatment plan.

44 Noncovered Services The hours that the client participates in an education program delivered in the same setting as a children and youth partial hospitalization program unless, in addition to the teacher, a clinical staff person works with the child in the classroom. The Department will reimburse for only that time during which the client is in direct contact with a clinical staff person. Group psychotherapy provided in the patient s home. Psychiatric clinic and partial hospitalization services provided to nursing home residents on the grounds of the nursing home or under the corporate umbrella of the nursing home.

45 Q&A Session Please feel free to ask questions related to compliance

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