Innerview Reimbursement in the Physician Office Setting * 2014

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1 OVERVIEW This Guide is intended to assist with the process of billing and coding for Innerview, a Mental Health Clinical Decision Support System used in the primary care setting. Billing, coding and payment options are reviewed below for private payers, Medicare and the Physician Quality Reporting System (PQRS). BILLING PRIVATE PAYERS FOR INNERVIEW The CPT s most appropriate for billing private payers for administration of Innerview in the physician s office setting include the following: 1 1. Evaluation and Management (E/M) s based on the level of service offered during the office visit, and 2. CPT which is used to administer and interpret health risk assessment. E/M Codes Perhaps the most commonly-used CPT s in a physician office setting are those that apply to new and established patient visits ( ; ). These are timed s the more time a physician spends with a patient, the higher the reimbursement. The use of Innerview in the clinic will provide organized patient reports requiring time and effort on behalf of physicians and other healthcare professionals to review these reports prior to the visit: The report includes: First person patient narrative Diagnostic & Statistical Manual of Mental Disorders (DSM)/ International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10; World Health Organization) driven diagnostic considerations Profile of symptoms and functioning and change in perceived severity or challenge with that symptom or function Table 1 below describes the relevant E/M s and shows how payment increases as the level of service and the time spent counseling and/or coordinating the care of the patient increases. Documentation Requirements: When incorporating Innerview, providers should select the appropriate level of E/M services based on the following criteria: For new or established patients, all the key components, i.e., history, examination, and medical decision making must meet or exceed the stated requirements to qualify for a particular level of service/cpt. 2 Be sure to document the increased time and workload necessary to administer, interpret and discuss the outputs of Innerview. Time can be the controlling factor for qualifying for a higher level of care (i.e., CPT reimbursed at a higher rate) if 50% or more of the physician/patient and/or family encounter is spent on counseling and/or coordination of care. 3

2 1 This list may not be all inclusive; providers should check benefit policy requirements of individual payers to determine what procedure s and coverage requirements apply. 2 Refer to CPT coding manual for more detailed description of coding requirements 3 AMA CPT Manual Introduction to E/M section, 2010 Table 1: List of CPT s and payments (based on 100% of 2014 Medicare allowable) that may be used to bill private payers for administration of Innerview in physician office (Providers should check individual payer benefit policies to determine actual coverage and payment amounts) New Patients CPT Codes Descriptions Payments-Physician s Office Established Patients Evaluation and Management-Office or Other Outpatient Services Office visits new patient- 10 minutes f-to-f w/patient or family $ Office visits new patient- 20 minutes f-to-f w/patient or family $ Office visits new patient- 30 minutes f-to-f w/patient or family $ Office visits new patient- 45 minutes f-to-f w/patient or family $ Office visits new patient- 60 minutes f-to-f w/patient or family $ Office visits established patient- 5 minutes (may not require phys) $ Office visits established patient- 10 minutes f-to-f w/patient or family $ Office visits established patient- 15 minutes f-to-f w/patient or family $ Office visits established patient- 25 minutes f-to-f w/patient or family $ Office visits established patient- 40 minutes f-to-f w/patient or family $142 Prevention Admn and interpretation of health risk assessment instrument $11 CPT CPT 99420, described as administration and interpretation of health risk assessment instrument is a preventive medicine listed in the chart above that is also appropriate to describe use of Innerview in the clinic. The AMA CPT Manuals states that the actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which CPT are available may be reported separately, in addition to the E/M. Use of modifier 25 CPT modifier -25 is used when, on the day a procedure or service was performed, the patient s condition required a significant, separately identifiable E/M service above and beyond the other service provided. When billing CPT together with the E/M s, providers should add modifier 25 to the appropriate level of E/M service. For example, for a 30 minute office visit with a new patient during which Innerview was administered and interpreted the physician would bill in addition to BILLING MEDICARE FOR INNVERVIEW The CPT/HCPCS s most appropriate for billing Medicare for administration of Innerview in the physician s office setting include the following: 4

3 1. CPT E/M office visit s described above ( ; ) based on the amount of time and level of service necessary. (Note: Medicare considers a non-covered benefit and it should not be used to bill for services to beneficiaries) 4 As is the case with private payers, providers should check with local their local Medicare contractor to determine whether these s are eligible for reimbursement. 2. Medicare- HCPCS office visit s (may be used in combination with E/M s above if the physician provides a significant separately identifiable medically necessary E/M service): GO402 Initial Preventive Physical Exam (once in a lifetime) GO438 Annual Wellness Visit (initial) G0439 Annual Wellness Visit (subsequent) 3. G0444, G0442 and G0443- see descriptions below ( may be used in conjunction with E/M s if modifier 25 is used appropriately as described above or with Medicare G0439) G0444: New Screening Code for Depression: In recognition of the need to provide preventive services and mental health screenings in the primary care setting, effective in 2011, Medicare added HCPCS GO444 to cover annual depression screenings up to 15 minutes for Medicare beneficiaries in primary care settings. Medicare does not identify depression screening tools that can be billed using G0444. Rather, the decision to use a tool is at the discretion of the clinician in the primary care setting. Since Innerview can be used to identify depression criteria, it should be covered by Medicare. G0442: New Screening Code for Alcohol Misuse: Effective in 2011, Medicare added HCPCS GO442 to cover annual screenings for alcohol misuse up to 15 minutes for Medicare beneficiaries in primary care settings. Medicare does not recommend screening tests for alcohol misuse but rather indicated clinicians can choose screening strategies that are appropriate for their clinical population and setting. Since Innerview can be used to identify alcohol misuse criteria, it should be covered by Medicare. G0443: New Screening Code- Behavioral Counseling Alcohol Misuse: Effective in 2011, Medicare added HCPCS GO443 to cover behavioral counseling for alcohol misuse. Medicare allows up to four brief counseling interventions per year for alcohol misuse up to 15 minutes. A primary care provider can bill for both G0443 and G0442 (screening for alcohol misuse) on the same day but cannot bill more than one G0443 per visit.

4 Table 2: Guidelines for billing Medicare- s for Innerview and payments (based on 100% of 2014 Medicare allowable) Medicare Preventive Services Coding Guidelines Services HCPCS/CPT Codes/ Payment ICD-9 Codes Who is covered Frequency Beneficiary Pays Initial Preventive Physical Examination (IPPE) For services on or after 1/1/05 G0402- IPPE $163 No Medicare beneficiaries enrolled under Part B and who obtain IPPE no later than 12 months after date of first Part B coverage Once in a lifetime Annual Wellness Visit (AWV) For services on or after 1/1/11 G0438- Initial G0439- Subsequent $168 $113 No Medicare beneficiaries who are no longer within 12 months of IPPE Medicare beneficiaries with no AWV within last 12 months Once for G0438 Annually for G0439 Screening for Depression For service on or after 10/14/11 G0444 Annual depression screening. 15 minutes $18 No Medicare beneficiaries in a primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, treatment and follow up Annually Screening for Alcohol Misuse For service on or after 10/17/11 GO442- Annual alcohol misuse screening, 15 minutes $18 No Medicare beneficiaries enrolled under Part B Annually Behavioral Counseling for Alcohol Misuse For service on or after 10/17/11 GO443 brief face-to-face behavioral counseling for alcohol misuse, 15 minutes $25 No Medicare beneficiaries enrolled under Part B who screen positive for alcohol misuse Up to 4 brief faceto-face behavioral counseling interventions per year deductible waived CODING SCENARIOS Billing and coding for mental health services can be confusing for primary care providers. While it is not possible to provide coding guidelines for every patient encounter, the following case scenarios are examples of situations that may be appropriate for billing Innerview. Scenario #1 Private pay patient, initial office visit A 43 year patient with private health insurance making initial office visit presents with sleep problems that may be related to anxiety. A detailed history and examination is conducted involving medical decision making of low complexity. Innerview is administered. Approximately 30 minutes spent in face to face meeting with patient and/or family.

5 Coding/Payment CPT/HCPCS Code(s) Modifier Medicare allowable (private payments vary) ICD-9 Code/description (other examples may apply) $ Generalized anxiety disorder $11 V79.0-Screening exam, depression Scenario #2 Private pay patient, established office visit A 29 year patient with private health insurance making follow-up office visit, presents with stomach aches, chronic generalized pain and mood swings. A comprehensive history and examination is conducted involving medical decision making of high intensity, and Innerview is administered. Approximately 40 minutes spent in face to face meeting with patient and/or family. Coding/Payment CPT/HCPCS Code(s) Modifier Medicare allowable (private payments vary) ICD-9 Code/description (other examples may apply) $ Episodic mood disorder $11 V79.0-Screening exam, depression Scenario #3 Medicare patient, subsequent annual wellness visit A 68 year Medicare beneficiary patient making follow up visit, showing weight loss, demonstrating less interest in daily activities and less ability to concentrate. A comprehensive history and examination is conducted and Innerview is administered. Practitioner reviews Innerview results with patient/family and decides on follow up plan. Coding/Payment CPT/HCPCS Code(s) Modifier 2013 Medicare allowable ICD-9 Code/description (other examples may apply) G0439 $ Depression disorder, not otherwise specified G0444 $18 V79.0-Screening exam, depression

6 PHYISICIAN QUALITY REPORTING SYSTEM (PQRS) PQRS is a program where an incentive payment is made to professionals including primary care physicians who report data on various measures. Innerview may be used to meet data collection requirements in the following scenarios: CPT Code(s) PQRS # Measure Title Reporting Options Anti-depressant Medication Management Registry, EHR Adult Major Depressive Disorder (MDD): Comprehensive Claim, Registry Depression Evaluation: Diagnosis and Severity Adult MDD: Suicide Risk Assessment Claim, Registry, EHR Preventive Care and Screening: Screening for Clinical Depression Claim, Registry, EHR, and Follow-Up Plan GPRO l Community/Preventive Care and Screening: Unhealthy Alcohol Use-Screening Registry, Group 247 Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence Claim, Registry 248 Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence Claim, Registry 325 Adult MDD: Coordination of Care of Patients with Specific Comorbid Conditions Registry G0402 G0438 G Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Claim, Registry, EHR, GPRO l G Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan 173 Community/Preventive Care and Screening: Unhealthy Alcohol Use-Screening Claim, Registry, EHR, GPRO l Registry, Group *Disclaimer: The information contained in this Guide is for educational purposes only and should not be construed as written policy for any private payer or federal agency. It is not intended to take the place of written laws or regulations. Providers should exercise independent clinical judgment in determining that reimbursement information for governmental and private payers is both current and accurate.

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