CPT Coding Update And Other Issues

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1 CPT Coding Update And Other Issues Robert E. Smith, M.D. Alison Lynch, M.D. November 13, Disclaimer This information is for educational and informational purposes only, and represents the understanding of the presenters regarding the material involved. The presenters assumes no liability or responsibility for behavior based on this presentation. Reminder for Medicare Documentation E/M codes (99xxx) documentation requirements determined by CMS Behavior Health codes (90791, & 908xx) documentation determined by the carrier:wps 1

2 Individual Psychotherapy - Documentation Reminder WPS Medicare has noted recent Comprehensive Error Rate Testing (CERT) denials for individual psychotherapy services because the documentation requirements for the services were not met. In these cases, the CERT reviewer found the clinical record submitted was missing one or more of these required elements: Target symptoms Goals of therapy Methods of monitoring outcomes Frequency of treatments Clinical records to support beneficiary's relevant medical history Results of diagnostic tests or procedures Prognosis and progress to date Estimated duration of treatment It is important for providers who bill these services to be aware of the documentation requirements. Upon a Medicare request for a review, all documentation to support the billed service(s) must be submitted or services may be denied. Behavioral Health CPT RVUs Values for 2013 were interim values Crisis Code values set by the third party payer (carrier pricing) Values for 2014 have been submitted to CMS 2014 RVU Values 2

3 Changes with DSM-5 Multi-axial System GONE! WHY: GAF Questionable psychometrics in routine practice Axis IV ICD-9-CM and ICD-10-CM have their own V and Z codes for psychosocial and environmental problems Changes with DSM-5 Axis I, II and III now are combined to reflect the relationships between physical and mental illness Meaningful use now comes in play with the requirement for a problem list How can this be good? Loss of Axis I - III 25 minute visit with a schizophrenic patient on olanzepine and doing fairly well. Pt has history of increased BP, 20 lbs weight gain. Smokes a pack per day of cigarettes. Visit diagnoses represents the conditions addressed at this appointment. 3

4 Loss of Axis I - III Diagnoses becomes: Schizophrenia (Principle Dx), Metabolic Syndrome, Hypertension, Tobacco Use Disorder Medical Decision Making clearly more complex ICD-10-CM Coming ICD-9-CM diagnostic codes are the ones we are currently using ICD-10-CM codes are referenced in DSM-5 (i.e.) Major Depressive D/O, single episode-moderate (F32.1) ICD-9-CM ICD-10-CM Experts say physicians who have not begun preparations for ICD-10 should begin now. Among the many changes that may be required are such comprehensive measures as: : Upgrading billing, claims processing and electronic health record software Revising forms and coding support tools Training staff Updating payer contracts and fee schedules Identifying coverage changes Testing updated systems Stockpiling cash reserves to preserve cash flow 4

5 CMS Quality Improvement and Incentive Programs Medicaid EHR Incentive Program Medicare EHR Incentive Program Physician Quality Reporting System (PQRS) Medicare Improvements for Patients and Providers Act (MIPPA) e-prescribing Incentive Program MEDICARE S PHYSICIAN QUALITY REPORTING SYSTEM (PQRS) A CMS incentive program to improve quality of care for individuals covered under Medicare Part B. But has a potential for penalties Details for fulfilling Changes annually Eligible and Able to Participate in PQRS Medicare physicians Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic Practitioners Physician Assistant Nurse Practitioner* Clinical Nurse Specialist* Certified Registered Nurse Anesthetist* Clinical SocialWorker Clinical Psychologist Registered Dietician Audiologists *Includes Advanced Practice Registered Nurse (APRN) 5

6 MEDICARE S PHYSICIAN QUALITY REPORTING SYSTEM (PQRS) WHAT YOU NEED TO KNOW RIGHT NOW To avoid the 2015 penalty an eligible provider has only to report on one appropriate measure for one Medicare patient by the end of 2013 Penalty for those Participating in Medicare PQRS in 2015 providers who failed to participate in the PQRS as of this year, 2013, will be hit with a 1.5% penalty for all their Medicare reimbursements beginning on January 1, This penalty increases to 2% on all Medicare payments in PQRS In measures measures pertinent to mental health providers, including five measures on depressive disorder, four measures on screening for unhealthy substance use, and one measure on medication reconciliation 6

7 EXAMPLE OF HOW INFORMATION WOULD BE ENTERED ON THE 1500 Measure #9--Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD Description: Patients aged 18 years and older diagnosed with new episode of major depressive disorder (MDD) and documented as treated with antidepressant medication during the entire 84-day (12 week) acute treatment phase. * Applicable Procedure Codes 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90849, 90853, 99078, 99201, , , , Action Taken Acute treatment with antidepressant medication G-Code G8126 Patient w/ new episode of MDD documented as being treated w/ antidepressant medication during entire 12-wk acute treatment phase Measure #107 (NQF 0104): Adult Major Depressive Disorder (MDD): Suicide Risk Assessment This measure is to be reported a minimum of once per reporting period for all patients with an active diagnosis of major depressive disorder seen individually during the reporting period, including episodes of MDD that began prior to the reporting period. This measure may be reported by clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding 7

8 Measure #107 (NQF 0104): Adult Major Depressive Disorder (MDD): Suicide Risk Assessment When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes, and the appropriate CPT Category II code OR G-code. All measure-specific coding should be reported on the claim(s) representing the eligible encounter Numerator Quality-Data Coding Options for Reporting Satisfactorily: Suicide Risk Assessed G8932: Suicide risk assessed at the initial evaluation MEDICARE S PHYSICIAN QUALITY REPORTING SYSTEM (PQRS) Link for list of 2013 measures: Initiatives-Patient-Assessment- Instruments/PQRS/MeasuresCodes.html. CMS Quality Improvement and Incentive Programs Medicaid EHR Incentive Program Medicare EHR Incentive Program Physician Quality Reporting System (PQRS) Medicare Improvements for Patients and Providers Act: (MIPPA) e- Prescribing Incentive Program 8

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