Behavioral Health Update for Kentucky Providers Kelly Jacobs, LISW-S, Business Change Manager, Central Region Melissa Walker, Network Support

Transcription

1 Behavioral Health Update for Kentucky Providers Kelly Jacobs, LISW-S, Business Change Manager, Central Region Melissa Walker, Network Support Consultant, Central Region

2 Agenda Overview of Kentucky Autism Mandate and the Anthem UM Process Overview of New 2013 BH CPT Code Changes/Rationale Precertification Processes and Forms Partial Hospitalization (PHP) Coding

3 Overview of State Mandate & Kentucky Specific Information 3

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

5 Current Status of State Autism Insurance Reform Bills Autism Speaks : Autism Votes States with Endorsed Autism States with Autism Insurance Reform Insurance Reform Laws (32) Bills States Pursuing Autism Insurance Reform Alaska Missouri Georgia Mississippi Alabama Arizona Montana Hawaii Ohio Idaho Arkansas Nevada Minnesota Utah Maryland Colorado New Hampshire Nebraska Oklahoma States not Currently Pursuing Autism Insurance Reform Connecticut New Jersey North Carolina South Dakota Delaware New Mexico Oregon Washington Florida New York Tennessee Washington, DC Iowa Pennsylvania Wyoming Illinois Indiana Kentucky Louisiana Massachusetts Michigan California Kansas Rhode Island South Carolina Vermont Virginia West Virginia Wisconsin Expansion Bills Maine Texas 5

6 Kentucky Autism Mandate Specifics Mandate went into effect in 1996, but covered only respite services Updated Mandate went into effect 1/1/2011 Covers both group and individual policies Covers PDD (including Autism and Asperger s) Age and dollar limits apply ABA is covered (Applied Behavior Analysis) Mandate does not affect limits on PT/OT/ST Anthem has network of providers (BCBA s, Board Certified Behavioral Analysts) 6

7 Kentucky Autism Mandate Specifics Continued Treatment plans must be signed by physician or psychologist Medical necessity can only be determined by a specialist in autism spectrum disorders Treatment plans can be requested at 12 month intervals Anthem Kentucky uses CPT code to represent ABA therapy. BCBA time is differentiated from the paraprofessional time by utilizing modifiers. This breakout of hours is requested at the time of precert. We are not allowing BCBA time to be billed under as the BCBA is typically not licensed as a psychologist or physician 7

8 Coding for ABA Services Based on CPT Code 1. BCBA 2. Paraprofessional 3. Group CPT Code BCBA Services ABA services performed by a paraprofessional ABA delivered in a group setting by a BCBA ABA delivered in a group setting by a paraprofessional 8

9 PDD Treatment Plan Form 9

10 Behavior Therapies Assessment Request Form 10 10

11 Example of Clean Claim 11 11

12 Current Procedural Terminology (CPT) Code Changes for 2013 Overview

13 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

14 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 higherthan-usual impact on psychiatry and psychotherapy services

15 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) Inclusion of add-on codes for psychiatry, which are services performed in addition to a primary service or procedure (and never as a stand-alone service) Addition of code for interactive complexity New code for psychotherapy for a patient in crisis 15 15

16 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

17 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 17 17

18 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 18 18

19 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 19 19

20 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 20 20

21 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 21 21

22 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)

23 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 23 23

24 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 24 24

25 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)

26 American Psychiatric Association CPT Coding Resources for APA Members Crosswalk of 2012 CPT Codes to 2013 CPT 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)

27 American Psychiatric Association CPT Coding Resources for APA Members Crosswalk of 2012 CPT Codes to 2013 CPT Codes (cont.) 27 27

28 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) 28 28

29 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 29 29

30 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

31 Flow Chart of New CPT Coding From the American Academy of Child and Adolescent Psychiatry 31 31

32 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

33 Certification and/or Recertification Processes Most plans require precertification for higher levels of care (i.e., Inpatient, Partial Hospitalization, Intensive Outpatient) Most plans do NOT require precertification for Outpatient Office visits (with the exception of some psychological testing, ECT, and TMS services). Please call the number on the back of the member s card to verify eligibility, benefits, and precert requirements. Specialty services may require precertification depending on number of hours and type of procedure requested 33 33

34 Outpatient Treatment Request Form 34 34

35 Psychological Testing Request Form 35 35

36 Transcranial Magnetic Stimulation (TMS) Per Anthem Medical Policy: Transcranial magnetic stimulation (TMS) involves placement of a small coil over the scalp through which a rapidly alternating current is passed. This produces a magnetic field which affects electrical activity in the brain. This document addresses TMS as a treatment of behavioral health indications including depression and other neuropsychiatric disorders. This service is a covered benefit in some plans. It MUST be precertified and meet medical policy requirements to be authorized

37 Transcranial Magnetic Stimulation (TMS) Request 37 37

38 Partial Hospitalization Billing Highlights Successfully billed claims are generally: Billed on a UB-04 form or CMS 1500 Revenue codes used are 0912 or 0913 PHP services are billed by day Physician services may be billed separately Most higher level of care services such as PHP need to be precertified. Please call the number on the back of the member s card for benefits and eligibility

39 Partial Hospitalization Billing Highlights Successfully billed Physician claims are generally: Billed on a CMS 1500 form Place of Service (POS) code should be 52 (Psychiatric Facility- Partial Hospitalization Program) CPT Code should match the POS code used (i.e., for new patients; for established patients Facility services are billed separately Trying to bill an inpatient code with an outpatient POS or an outpatient code with an inpatient POS, causes the claims system to "pend" the claim due to error

40 Example of a Clean PHP Claim 40 40

41 Wrap Up Questions & Answers Thank you for having us!! 41 41