6/8/2015. Behavioral Health Coding, Contracting and Billing, Part 2 PRESENTER DISCLOSURES DISCLAIMER OBJECTIVES:

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1 PRESENTER DISCLOSURES Behavioral Health Coding, Contracting and Billing, Part 2 Presented By: Mimi Reed BHSA, CPC-A, MCP, MTA Consultant, APDM & Amy Valimont, MSSW, LCSW, LCAS Independent Contractor Mimi Reed BHSA, CPC-A, MCP, MTA & Amy Valimont, MSSW, LCSW, LCAS Consultant, APDM Independent Contractor No relationships to disclose DISCLAIMER Every effort has been made to ensure the accuracy of the information provided as of the date of this presentation. It is not intended to replace the information contained in the ICD and CPT manuals or specific coding, reporting, or reimbursement information that may be disseminated by third-party or government payers. We are not liable for any loss of profit. Every individual/organization is responsible for verifying coding, reporting or reimbursement information with his/her own payer sources as well as abiding by their specific state and federal guidelines. This presentation is based on our personal experiences and study of the topics presented. OBJECTIVES: Highlight differences between ICD-9-CM and ICD-10-CM Codes Discuss commonalities and differences between DSM-5 and ICD-10-CM Codes Highlight the importance of understanding and providing documentation in order to obtain reimbursement 1

2 International Classification of Diseases, 10 th Edition, Clinical Modification/Procedure Coding System ICD-10-CM/PCS The ICD family of codes is developed by the World Health Organization (WHO) October 1, 2015 all health care claims must utilize ICD-10 codes ICD-10 CM/PCS consists of two parts: o ICD-10-CM for diagnosis coding in all health care settings o ICD-10-PCS for inpatient procedure coding in hospital settings The number of codes will increase from 14,000 to approximately 70,000 International Classification of Diseases, 10 th Edition, Clinical Modification/Procedure Coding System ICD-10-CM/PCS ICD-10 will provide greater detail in describing diagnoses and procedures o Facilitate patient care coordination across settings o Improve public health reporting and tracking ICD-10 structure will allow for expansion - new codes to be added CPT (current procedural terminology) coding for outpatient and office procedures is not affected by the ICD-10 transition ICD-9-CM vs. ICD-10-CM ICD-10-CM CODE STRUCTURE CURRENT ICD-9-CM DIAGNOSIS CODES: NEW ICD-10-CM DIAGNOSIS CODES: 3-5 Characters 3-7 Characters First character is numeric or alpha (E or V) First character is alpha Characters 2-5 are numeric Character 2 is numeric Use of decimal after first 3 characters Characters 3-7 are alpha or numeric Use of decimal after 3 characters Alpha characters are not case-sensitive Category Etiology, anatomic site, severity, Extension First 3 4 th,5 th,6 th characters (if applicable) 7 th character (if applicable) Characters 2

3 ENCOUNTER EXTENTION _ A Initial encounter _ B Initial encounter for open fracture _ D Subsequent encounter _ G Subsequent encounter for fracture with delayed healing _ K Subsequent encounter for fracture with nonunion _ P Subsequent encounter for fracture with malunion _ S Sequelae For most ICD-10 diagnosis codes the 7th character indicates the following: A Initial encounter. The patient is receiving active treatment for the injury D Subsequent encounter. Used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase S Sequela. Used to indicate complications or conditions that arise as a direct result of an injury PLACEHOLDER CHARACTERS The dummy placeholder is always the letter X. This placeholders serve two uses: o Allows for future expansion o When a code has less than six characters and a 7 th character extension is required, the X is assigned for all characters less than six, so the code meets the requirement that all codes with an extension must have seven characters ICD-10 Guidelines EXAMPLES OF CODES FROM DSM-5: Child Neglect, Confirmed Initial Encounter T74.02XA Child Neglect, Confirmed Subsequent Encounter T74.02XD Antidepressant discontinuation syndrome T43.205A Initial Encounter T43.205D Subsequent Encounter T4.205S Sequelae Other adverse effect of medication T50.905A Initial Encounter T50.905D Subsequent Encounter T50.905S Sequelae 3

4 ICD-10 Categories ICD-10 Categories A00-B99 C00-D48 D50-D89 E00-E90 F00-F99 G00-G99 Certain Infectious and parasitic diseases Neoplasms Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Endocrine, nutritional and metabolic diseases Mental and Behavioral Disorders Diseases of the nervous system H00-H59 H60-H95 I00-I99 J00-J99 K00-K93 L00-L99 Diseases of the eye and adnexa Diseases of the ear and mastoid process Disease of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the skin and subcutaneous tissue ICD-10 Categories ICD-10 Categories M00-M99 N00-N99 O00-O99 P00-P96 Q00-Q99 R00-R99 Diseases of the musculoskeletal system and connective tissue Disease of the genitourinary system Pregnancy, childbirth and the puerperium Certain conditions originating in the perinatal period Congenital malformations, deformations and chromosomal abnormalities Symptoms, signs and abnormal clinical and laboratory findings, not S00-T98 V01-Y98 Z00-Z99 U00-U99 Injury, poisoning and certain other consequences of external causes (Note: were E codes under ICD-9) External causes of morbidity and mortality Factors influencing health status and contact with health services (Note: were V codes under ICD-9) Codes for special purposes elsewhere classified 4

5 ICD-10 Chapter V: Mental and Behavioral Disorders F01-F09 Mental disorders due to physiological conditions F10-F19 Mental and behavioral disorder due to psychoactive substance use F20-29 Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders F30-F39 Mood (affective) disorders F40-F48 Anxiety, dissociative, stress-related, somatoform and other non-psychotic mental disorders ICD-10 Chapter V: Mental and Behavioral Disorders F50-59 Behavioral syndromes associated with physiological disturbances and physical factors F60-F69 Disorders of adult personality and behavior F70-F79 Intellectual disabilities F80-F89 Pervasive and specific developmental disorders F90-98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence F99 Unspecified mental disorder DSM-5 and ICD-10 DSM-5 is a diagnostic manual used as a guide for making a clinical diagnosis (criteria) DSM-5 applies to only mental disorders and includes both the recommended ICD-9-CM and ICD-10-CM codes for each condition ICD does not provide the detail that the DSM-5 provides regarding diagnostic criteria but does provide diagnostic categories, names and codes and is the set of HIPAA compliant codes utilized for billing and coding DSM-5 and ICD-10 ICD applies to both physical & mental disorders In DSM-5 o When only one ICD-10-CM is assigned to a disorder, it is at the top of the criteria box o If more than one code can be assigned to a disorder, the codes are at the bottom of the diagnostic criteria box or if there are specific notes they are located at the bottom of the criteria box DSM-5 Updates: 5

6 DOCUMENTATION CPT and ICD codes reported on the health insurance claim form or billing statement must be supported by the documentation in the medical record Proper coding is necessary to ensure appropriate reimbursement and avoid audit liability Correct coding implies the selection is the most accurate description of what services were provided and why they were provided ICD-10-CM does not include diagnostic criteria and the presence of documented DSM-5 diagnostic criteria in patient medical records is used by CMS and private insurance contractors for medical chart quality assessment, audit and fraud/abuse determinations DOCUMENTATION Documentation in the medical record must justify the services provided and demonstrate medical necessity. The focus of treatment or reason for visit is listed first o The exception is when a mental disorder is caused by a medical condition in which case the medical condition is listed first (ICD coding rule) Then others in descending order of clinical importance including V/Z codes The health record must be complete and legible DOCUMENTATION The documentation of each patient encounter typically includes: The date/time Reason for the encounter/presenting problem/chief complaint Relevant history Physical examination findings / diagnostic criteria to support the level of diagnosis given The acuity (level of severity) Etiology (cause) of the disease Any associated manifestations or complications Prior treatment / prior diagnostic test results assessment Level of care tools (if applicable) /screening tools Clinical impression / diagnosis Services delivered / interventions and how they related to treatment plan Including drugs and dosage prescribed or administered Client s response to treatment Plan for care / treatment plan / goals / outcomes / crisis plan / referrals Place of service, type of encounter (face to face etc.) / who participated Legible signature of the provider / credentials DOCUMENTATION Reporting guidelines and coverage vary greatly between Medicare, Medicaid, and other payers Variations impacted by: Provider type Reimbursement methodology Specific services provided Managed Care and other third-party payers will have their own guidelines depending on the payer and the patient s policy Other limitations by payer You are responsible for verifying with your specific state/federal guidelines/various payer sources/credentialing and licensing entities for required documentation guidelines 6

7 DOCUMENTATION The NAME and the CODE number should always be recorded in the medical record to support BOTH DSM and ICD Review your coding procedures in DSM (i.e. specifying, etc.) DSM-5 states that the clinician is choosing to communicate the specific reason the client s presentation did not meet the criteria for any specific anxiety disorder ICD-9-CM ICD-10-CM EXAMPLE: Other Specified Anxiety Disorder (F41.8) Other Specific Anxiety Disorder, generalized anxiety not occurring more days than not (F41.8) DRUGS & ALCOHOL F10. Mental and behavioural disorders due to use of alcohol F11. Mental and behavioural disorders due to use of opioids F12. Mental and behavioural disorders due to use of cannabinoids F13. Mental and behavioural disorders due to use of sedative hypnotics F14. Mental and behavioural disorders due to use of cocaine F15. Mental and behavioural disorders due to use of other stimulants, including caffeine F16. Mental and behavioural disorders due to use of hallucinogens F17. Mental and behavioural disorders due to use of tobacco F18. Mental and behavioural disorders due to use of volatile solvents F19. Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances DRUGS & ALCOHOL The new arrangement of mental and behavioural disorders due to psychoactive substance use in the block F10-F19 has also been found more useful than the earlier system. The 3rd character indicates the substance used The 4 TH and 5 TH characters specify the clinical states o e.g. from acute intoxication and residual states 2015 ICD-10 Guidelines Themes In the Substance-Related and Addictive Disorders Chapter of DSM-5 F1x.1 Harmful Use F1x.2 Dependence F1x.9 Unspecified Alcohol Use Disorder: F10.10 Mild F10.20 Moderate F10.20 Severe Unspecified Alcohol-Related Disorder F10.99 Exceptions: Tobacco Use Disorder: Z72.0 Mild F Moderate F Severe 7

8 Themes In the Substance-Related and Addictive Disorders Chapter of DSM-5 Exceptions: DRUGS & ALCOHOL Misuse of other than psychoactive substances (i.e. laxatives etc.) should be coded by means of F55 (abuse of non-dependence producing substances): If intoxication, withdrawal or (alcohol etc.) substance induced mental disorder is also present you will need to look at the specific coding notes to indicate which ICD - 10 code to utilize The 4 TH and 5 TH characters specify the clinical states o e.g. from acute intoxication and residual states F55.0 Abuse of antacids F55.1 Abuse of herbal or folk remedies F55.2 Abuse of laxatives F55.3 Abuse of steroids or hormones F55.4 Abuse of vitamins The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines GEMS General Equivalence Mappings As a part of the conversion, two sets of diagnosis code General Equivalence Mappings (GEMS) have been developed. This mapping is a type of crosswalk to find corresponding diagnosis codes between the two code sets. The GEMs files are: o ICD-9 to ICD-10, which is forward mapping o ICD-10 to ICD-9 which is backward mapping CROSSWALKING TO ICD-10 No clear crosswalk between ICD-9 and DSM-5 to ICD-10 One to one crosswalks One to many crosswalks Many to one crosswalks No ICD-9 crosswalks to ICD-10 No ICD-10 crosswalks to ICD-9 8

9 CROSSWALKING TO ICD-10 One to One CROSSWALKING TO ICD-10 One to One ICD-9 and DSM-5 ICD-10 ICD-9 and DSM-5 ICD-10 Intellectual Disability, Mild 317 Intellectual Disability, Mild F70 Obsessive Compulsive Disorder Obsessive Compulsive Disorder F42 Intellectual Disability, Moderate Intellectual Disability, Moderate F71 Disruptive Mood Dysregulation Disorder Disruptive Mood Dysregulation Disorder F34.8 Intellectual Disability, Severe Intellectual Disability, Profound Intellectual Disability, Severe Intellectual Disability, Profound F72 F73 Generalized Anxiety Disorder Adjustment Disorder With Depressed Mood Generalized Anxiety Disorder F41.1 Adjustment Disorder With Depressed Mood F43.21 CROSSWALKING TO ICD-10 One to Many ICD-9 and DSM-5 Alcohol Induced Anxiety Disorder ICD-10 and DSM-5 Alcohol abuse with alcohol-induced anxiety disorder F Alcohol dependence with alcohol-induced anxiety disorder F Alcohol use, unspecified with alcohol-induced anxiety disorder F ICD-9 ONLY & ICD-10 ONLY ICD-9 only Poisoning by tranquilizers and other psychotropic agents, undetermined whether accidentally or purposely inflicted E98.03 ICD-10 only Type O blood, Rh Negative Z67.41 Anorexia Nervosa Anorexia nervosa, restricting type F50.01 Anorexia nervosa, binge eating/purging type F

10 RESOURCES American Health Information Management Association (AHIMA): American Medical Association (AMA): Centers for Medicare and Medicaid Services (CMS): (Provider Resources) (GEMs) CDC: Crosswalk: NC Tracks ICD-9/10 Crosswalk: REFERENCES Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5 (American Psychiatric Association) The ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines World Health Organization (Retrieved 05/21/2015) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines Retrieved 05/23/2015) (Retrieved 05/23/2015) ICD-10-CM Official Guidelines for Coding and Reporting FY (Retrieved 05/20/2015) (Retrieved 05/20/2015) (Provider Resources) (Retrieved 05/20/2015) (Retrieved 05/26/2015) Contact Information: Mimi Reed BHSA, CPC-A, MCP, MTA Consultant, APDM School Community Health Alliance of Michigan Phone: x223 Fax: (Confidential) Website: Amy Valimont, MSSW, LCSW, LCAS Independent Contractor 10