CPT Coding Changes for 2013

Transcription

1 CPT Coding Changes for 2013 Getting Prepared Welcome and Introductions Alison Lynch, MD Associate Professor, Clinical Departments of Psychiatry and Family Medicine Carver College of Medicine University of Iowa Robert Smith, MD Associate Professor, Clinical Emeritus Department of Psychiatry Carver College of Medicine University of Iowa Session I Overview Disclaimer Legal Aspects of Coding Why Change Now Three Aspects of Time Add on Codes Changes for Psychotherapy Interactive Complexity Crisis Therapy Code E/M Codes with Psychotherpy 1

2 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. Disclaimer Although we are knowledgeable through our own work and consultation with other experts in the field, we are neither responsible for, nor assume any liability for your work and coding. You are ultimately responsible for your work, coding, and the documentation CPT Coding and Documentation Whose Job is it? Documentation and coding is part of physician/provider work You are responsible for the clinical work and equally responsible for the documentation and coding This should not be the job of your staff! 2

3 Audits Legal Issues Sampling CMS Expands Scope Of Medicare Audits. American Medical News (10/1, Fiegl) reports, "A Medicare auditor tasked with reviewing past claims for physician and hospital services in 15 states will start scrutinizing the billing of office visits, claims that previously had been off-limits to recovery audit contractors." The audits will be conducted by a contractor, Atlanta-based Connolly Inc., and will "focus on upcoding and cloned documentation." American Medical News notes that many groups, including the AMA, opposes CMS expanding audits to look at this type of billing, known as E&M. Legal Issues Overpayments Fines 3

4 Legal Issues The OIG may impose civil monetary penalties if a provider knows of an overpayment and does not report and return the overpayment. $10,000 per claim Treble damages Additionally, the OIG may also exclude the provider from participation in Federal health care programs. Why Seek Change Now? Psychiatric codes/mental Health codes suffered because of budget neutrality Evaluation and Management codes are Increasing in Value Under-valuation of E/M component of Psychotherapy with Evaluation and Management Services Problem with restricted contracts Medicare Payments New Patient $ $ $ $131.40? $ $ $ $

5 90862 $58.54 Medicare Payments Follow-up Exams $ $ $ % more $ % more $ Timeline August 31, 2012 November 2012 January 1, 2013 CPT electronic files released; changes to CPT codes became public CMS releases the Final Rule on the 2013 Physician Fee Schedule (includes relative values) New code set goes in to effect must bill using new CPT codes (This is non-negotiable) Important Concepts ISSUES of TIME AND THE NEW CODES CPT Time Rule for Psychotherapy A unit of time is attained when the mid-point is passed When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used. As an example, codes of 30, 45, and 60 minutes are billed at mins, mins, and mins. 5

6 ISSUES of TIME AND THE NEW CODES CMS has typical times for the new patient E/M codes and for the established E/M codes When greater than 50% of the time of the visit is counseling and/or coordination of care, time becomes the controlling factor for a level of E/M service Important Concepts Add-on Codes It is a code(s) that describes work that is performed in addition to the primary service It is never reported alone Examples include Psychotherapy, Interactive Complexity and Crisis Services Overview of Changes Implemented in 2013 Key services have been assigned new numbers and/or are described differently, and all new codes can be used in all settings There are now two codes for an initial evaluation; one with medical services and one without Psychotherapy is no longer distinguished by site of service Work previously described using the interactive codes is now done by using an add-on code There is a new crisis psychotherapy code Key codes have been deleted, e.g Pharmacologic Management and replaced with E/M codes Psychotherapy with E/M is now an E/M code with a Psychotherapy add-on 6

7 New Structure of Psychiatry Coding Psychiatry Coding Psychiatric Dx Evaluation (90791, 90792) Interactive Complexity Add-On (90785) Individual Psychotherapy w/pat &/or family ( ) Crisis Psychotherapy (90839, 90840) Add On when used with Evaluation and Management Service Code, when applicable Psychiatric Diagnostic Evaluation - Overview A distinction has been made between diagnostic evaluations without medical services and evaluations with medical services Interactive services are captured using an add-on code These codes can be used in any setting These codes can be used more than once in those instances where the patient and other informants are included in the evaluation These codes can be used for reassessments Psychiatrists and other medical providers have the option of using the appropriate 99xxx series code in lieu of the Psychiatric Diagnostic Evaluation , Psychiatric diagnostic evaluation 90792, Psychiatric diagnostic evaluation with medical services plus 90785, Psychiatric diagnostic evaluation with interactive complexity plus 90785, Psychiatric diagnostic evaluation with medical services and with interactive complexity 7

8 Documentation Guidelines and Date Chief complaint History of present illness Past history Family Social Medical Psychiatric (Note: no ROS required) Comprehensive mental status examination Diagnosis Formulation/prognosis Assessment of patient s willingness to comply with treatment program Legible signature Psychotherapy - Overview Psychotherapy codes are no longer site specific Psychotherapy time includes face-to-face time spent with the patient and/or family member Time is chosen according to the CPT time rule Interactive psychotherapy is reported using the appropriate psychotherapy code along with the interactive complexity add-on code Psychotherapy , , , , Psychotherapy, 30 minutes 90834, Psychotherapy, 45 minutes 90837, Psychotherapy, 60 minutes 8

9 Documentation Guidelines for Psychotherapy Time (CPT Time Rule Applies) Modality of Therapy Goals and Progress Treatment Plans and Periodic Updates Old Interactive CPT Codes All deleted: Interactive diagnostic interview examination Interactive individual psychotherapy Interactive group psychotherapy Meant to capture language difficulties Typically for children Use of physical aids and non-verbal communication 26 Interactive Complexity CPT add-on code Add-on code background Listed with + prefix in the CPT Manual However, the billing form should list the 5-digit number WITHOUT the + May only be reported in conjunction with specified other codes ( primary procedure ) Never reported alone Describes 4 types of communication factors These factors complicate the primary procedure Describes types of patients and situations most commonly associated with interactive complexity Commonly present during visits by children and adolescents but may apply to visits by adults, as well 27 9

10 The Primary Procedures for Interactive Complexity May be reported in conjunction with Psychiatric diagnostic evaluation (90791, 90792) Psychotherapy (90832, 90834, 90837) Psychotherapy add-on (90833, 90836, 90838) when reported with E/M Group psychotherapy (90853) May not be reported in conjunction with E/M alone Family psychotherapy (90846, 90847, 90849) Psychotherapy for new crisis codes (90839, 90840) 28 The Communication Factors Interactive complexity may be reported when at least one of the following communication factors is present: 1. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care 2. Caregiver emotions or behavior that interfere with implementation of the treatment plan 3. Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants 4. Use of play equipment, physical devices, interpreter or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not developed or lost expressive or receptive language skills to use or understand typicallanguage 29 Exception? CMS does not recommend billing for interactive complexity when using a translator/ translation services. The Americans with Disabilities Act prevents use of these services to justify billing. 10

11 Reporting Psychotherapy Time with When performed with psychotherapy Interactive complexity component (90785) relates ONLY to the increased work intensity of the psychotherapy service does NOT change the time for the psychotherapy service 31 Psychotherapy for Crisis A new code with an add-on code have been added to describe crisis psychotherapy (90839) 90839, Psychotherapy for crisis, first 60 minutes (CPT Rule applies: minutes) , Psychotherapy for crisis each additional 30 minutes: ( minutes) Crisis Psychotherapy ( 90839, ) Rationale: New concept and an addition to the psychotherapy section When psychotherapy services are provided to a patient who presents in high distress with complex or life threatening circumstances that require urgent and immediate attention Musher Group, LLC

12 Crisis Psychotherapy is a stand-alone code not to be reported with psychotherapy or psychiatric diagnostic evaluation codes, the interactive complexity code, or any other psychiatry section code is an add-on code that should be reported for each additional 30 minutes of service. Musher Group, LLC Psychotherapy for Crisis Crisis Psychotherapy: an Example an urgent assessment and history of a crisis state, a mental status exam, and a disposition. The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma. The presenting problem is typically life threatening or complex and requires immediate attention to a patient in high distress. E/M with Psychotherapy Overview Psychotherapy with E/M is now reported by selecting the appropriate E/M service code (99xxx series) and the appropriate psychotherapy add-on code The E/M code is selected on the basis of the site of service and the key elements performed The psychotherapy add-on code is selected on the basis of the time spent providing psychotherapy and does not include any of the time spent providing E/M services If no E/M services are provided, use the appropriate psychotherapy code (90832, 90834, 90837) 12

13 Psychotherapy with E/M vs E/M with Psychotherapy , , , Appropriate 99xxx series E/M code plus one of the following: 90833, Psychotherapy, 30 minutes when performed with an E/M 90836, Psychotherapy 45 minutes when performed with an E/M 90838, Psychotherapy 60 minutes when performed with an E/M (CPT Time Rule Applies) E/M codes The psychotherapy add-on code are most often billed with the following E/M codes: Outpatient, established patient: Subsequent hospital care Subsequent nursing facility care Pharmacologic Management has been DELETED Psychiatrists/mid-levels should use the appropriate E/M series code (99xxx) to report this service A new add-on code has been added to describe pharmacologic management when performed by a prescribing psychologist; Physicians/mid-levels should NEVER use