Toe-Tapping Tidbits from Behavioral Health

Transcription

1 Toe-Tapping Tidbits from Behavioral Health JoyLynn Waganer, Care Management Operations Integration Director Melissa Walker, Network Support Consultant Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden. 1

2 Agenda Overview of Wisconsin Autism Mandate and the Anthem UM Process Overview of New 2013 BH CPT Code Changes/Rationale 2

3 Overview of State Mandate & Wisconsin Specific Information 3

4 Autism Speaks: Autism Votes Government Relations Department State Autism Insurance Reform Initiative Map Source: Autism Speaks.org 4

5 Current Status of State Autism Insurance Reform Bills Autism Speaks: Autism Votes Source: Autism Speaks.org 5

6 Wisconsin Autism Mandate Specifics Mandate went into effect Nov 1, 2009 Covers both group and individual policies Covers Autism Spectrum Disorders ABA is covered (Applied Behavior Analysis) Intensive level services must be started between age 2 and 9. Non-intensive level services have no age limits. Individual products: $50,000 annual limit for Intensive level services, $25,000 annual limit for non-intensive level services Anthem has network of providers (BCBA s, Board Certified Behavioral Analysts) 6

7 Wisconsin Autism Mandate Specifics Continued Must have a prescription from a physician to receive treatment. All treatment must be provided by a qualified provider. Dollar limits apply only to Individual Policies 7

8 Wisconsin Autism Mandate Specifics Continued Intensive level services "Intensive-level services" means evidencebased behavioral therapy that is designed to help an individual with autism spectrum disorder overcome the cognitive, social, and behavioral deficits associated with that disorder. 20 or more hours weekly Billed with

9 Wisconsin Autism Mandate Specifics Continued Non-intensive level services "Nonintensive-level services" means evidencebased therapy that occurs after the completion of treatment with intensive-level services and that is designed to sustain and maximize gains made during treatment with intensive-level services or, for an individual who has not and will not receive intensive-level services, evidence-based therapy that will improve the individual's condition. Less than 20 hours weekly 9

10 Wisconsin Autism Mandate Specifics Continued "Practice of behavior analysis" means the design, implementation, and evaluation of systematic instructional and environmental modifications to "Practice produce of socially behavior significant analysis" improvements means in the human design, behavior, including the implementation, empirical identification and evaluation of functional of relations systematic between instructional behavior and environmental factors, known as functional assessment and analysis, and environmental modifications to produce socially including interventions based on scientific research and the direct significant observation improvements and measurement in human of behavior behavior, and environment. including the empirical identification of functional relations between behavior and environmental factors, known as functional assessment and analysis, including interventions based on scientific research and the direct observation and measurement of behavior and environment. "Practice of behavior analysis" does not include psychological testing, neuropsychology, psychotherapy, cognitive therapy, sex therapy, marriage counseling, psychoanalysis, hypnotherapy, and long-term counseling as treatment modalities. "Practice of behavior analysis" does not include psychological testing, neuropsychology, psychotherapy, cognitive therapy, sex therapy, marriage counseling, psychoanalysis, hypnotherapy, and long-term counseling as treatment modalities. 10

11 What providers are reimbursable? Coverage is available for the treatment for the mental health condition of autism spectrum disorder if the treatment is prescribed by a physician and provided by any of the following who are qualified to provide intensive-level services or non-intensive-level services: A psychiatrist A person who practices psychology A social worker, who is certified or licensed to practice psychotherapy A behavior analyst who is licensed under s (New) A paraprofessional working under the supervision of a provider listed A professional working under the supervision of an outpatient mental health clinic A speech-language pathologist An occupational therapist 11

12 WI Autism Mandate References and Questions The bill containing the autism mandate is available at: Claims Questions: Please contact Provider Service/Inquiry Electronic Claims EDI Solutions or Anthem.com Send paper claims to: Anthem P.O. Box Atlanta, GA Contract and/or Network Relations questions please call: Toll Free Line:

13 Example of Clean Claim 13

14 Overview of CPT Code Changes for Behavioral Health 14

15 CPT Code Changes Effective January 1, 2013, there were significant changes to Current Procedural Terminology (CPT) codes for psychiatry and psychotherapy services. The CPT code set is defined by the American Medical Association (AMA) and describes procedures and services by physicians and other health care professionals. 15

16 CPT Code Changes Changes to the CPT code sets are made on an annual basis, but the changes made for 2013 have had a much higher-thanusual impact on psychiatry and psychotherapy services. 16

17 Changes to CPT Codes Changes include: Removal of evaluation and management (E&M) plus psychotherapy codes from the psychiatry section (90805, 90807) Deletion of pharmacologic management (providers to use appropriate E&M code) Psychotherapy and E&M services are distinguished from each other (time spent on E&M services is not counted towards psychotherapeutic services, and separate codes can be used in combination with one another) 17

18 Changes to CPT Codes Changes include: Inclusion of add-on codes for psychiatry, which are services performed in addition to a primary service or procedure (and never as a standalone service) Addition of code for interactive complexity New code for psychotherapy for a patient in crisis 18

19 Who Is Impacted by these Changes? All provider disciplines are impacted. This includes psychiatrists, psychologists, social workers, licensed professional counselors, licensed marriage and family counselors and all other behavioral health providers that use CPT codes. 19

20 Diagnostic Evaluation Psychiatric diagnostic evaluation (used by Psychologists and Independently Licensed Masters Level Practitioners) Psychiatric diagnostic evaluation with medical services (used by Physicians, Nurse Practitioners, Physician Assistants, Clinical Nurse Practitioners) Neither is defined for new or established patients or by location Removes interactive distinction in 2012 CPT initial evaluation codes Distinguishes with medical evaluation 20

21 Psychotherapy Codes New time instructions for psychotherapy Separated into psychotherapy performed with or without an E/M service Psychotherapy with an E/M service: an add-on code Use in all locations 21

22 Psychotherapy: No E/M For use by Psychologists, Independently Licensed Masters Level Therapists May be used by Physicians and Non-Physician Practitioners for psychotherapy without E/M 90832: Psychotherapy, 30 minutes with patient and/or family 90834: Psychotherapy, 45 minutes with patient and/or family 90837: Psychotherapy, 60 minutes with patient and/or family 22

23 Psychotherapy: With E/M May be used by Physicians and Non-Physician Practitioners (Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists) : Psychotherapy, 30 minutes with patient and/or family when performed with E/M service : Psychotherapy, 45 minutes with patient and/or family when performed with E/M service : Psychotherapy, 60 minutes with patient and/or family when performed with E/M service 23

24 Time Thresholds Now Conform to CPT Rules Use and (30 minutes) for therapy time from minutes Use and (45 minutes) for therapy time from minutes Use and (60 minutes) for therapy time 53 minutes or more 24

25 CPT Code Changes What are E/M Codes? E and M stands for Evaluation and Management Services Codes. These are codes specific to medical management services used by Medical Providers such as MD/DO, APN and PAs (providers licensed to prescribe medication). 25

26 Use E/M Codes When performing medical evaluation and treatment, including medication management, use Evaluation and Management codes Add-on psychotherapy codes if performed E/M codes are only to be used by Physicians, Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists If performing E/M and psychotherapy, may not use time to select E/M code 26

27 Use E/M Codes New ( ) or established patient visits ( ) for office and outpatient department services Initial hospital services ( ) for inpatients, if visit is not psychiatric diagnostic interview Use subsequent hospital visits ( ) for rounds See chart on next slide to reference frequently used E/M codes 27

28 American Psychiatric Association CPT Coding Resources for APA Members Most Frequently Used Evaluation and Management (E/M) Codes CPT five-digit codes, descriptions, and other data only are copyright 2011 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. CPT is a registered trademark of the American Medical Association (AMA). 28

29 American Psychiatric Association CPT Coding Resources for APA Members Most Frequently Used Evaluation and Management (E/M) Codes CPT five-digit codes, descriptions, and other data only are copyright 2011 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. CPT is a registered trademark of the American Medical Association (AMA). 29

30 American Psychiatric Association CPT Coding Resources for APA Members Most Frequently Used Evaluation and Management (E/M) Codes CPT five-digit codes, descriptions, and other data only are copyright 2011 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. CPT is a registered trademark of the American Medical Association (AMA). 30

31 Crisis Management Codes 90839: Psychotherapy for crisis; first 60 minutes : Each additional 30 minutes of psychotherapy for crisis Not described as new or established Location not a factor in description May be performed by Physician or other health care professional (psychologists, licensed independent masters level therapists) 31

32 Interactive Complexity Code This is an add-on code to: 90791, Psychiatric diagnostic evaluation 90832, 90834, Psychotherapy 90833, 90836, Psychotherapy when performed with an E/M service Group therapy 32

33 When to use Interactive Complexity Add-on: Per CPT, refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients. Typical patients are those who have third parties, such as parents, guardians, other family members, interpreters, language translators, agencies, court officers, or schools involved in their psychiatric care. 33

34 Flow Chart of New CPT Coding Source: The American Academy of Child and Adolescent Psychiatry 34

35 2013 CPT Code Changes for Behavioral Health Please visit the American Medical Association (AMA) website and/or the American Psychiatric Association (APA) website for further details of the 2013 CPT Code changes for Behavioral Health providers. 35

36 Toe-Tapping Tidbits from Behavioral Health Questions? 36