Addiction Billing. Kimber Debelak, CMC, CMOM, CMIS Director, Recovery Pathways

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1 Addiction Billing Kimber Debelak, CMC, CMOM, CMIS Director, Recovery Pathways

2 Objectives Provide overview of addiction billing contrasting E&M vs. behavioral health codes Present system changes in ICD-9 to ICD-10 codes and sample sets Consider changes to ICD-10 coding with incorporation of DMS-5 Review sample code set changes

3 Coding Overview CPT codes the common procedure codes for the services you provide Evaluation and Management (E&M) Behavioral Health codes ICD-9 codes the codes used for the diagnoses of the patient ICD-9 codes for all pathologies DSM codes must be translated into ICD-9 codes

4 CPT codes Procedure codes for evaluation and management contain 3 components History Physical exam Medical decision making Behavioral health codes Based on time Inclusions of counseling

5 Practice Decisions Treat addiction within scope of primary care Combined with treatment of the co-morbid medical diagnoses Treat addiction outside the scope of primary care Detox centers Behavioral health facilities Outpatient clinics

6 Insurance Difficulties Even with parity, navigating the insurance labyrinth in order to be reimbursed for services provided is difficult Know if SA or MH is covered under your NPI Know if the insurances you participate with covers SA or MH treatment for your discipline May need to renegotiate your managed care contracts May need to redefine insurances you par with

7 Provider Types Medical Primary care Specialty and subspecialty Psychiatric Ψ Behavioral health Addiction medicine

8 Provider Types Behavioral health provider Psychiatric CPT Psychotherapy Med management DSM for psychiatric disease classification Substance Abuse services usually reimbursed Contract dependent Medical provider Use E&M codes New vs. established visits Uses ICD-9 for medical diagnosis Substance Abuse services may not be reimbursed Contract dependent

9 E&M Codes Mandatory key components History Physical exam Medical decision making Other contributing factors Counseling Coordination of care Time (must be face to face)

10 New Patient E&M Code History Problem focused Expanded problem focused Detailed Comprehensive Comprehensive Exam Problem focused Expanded problem focused detailed Comprehensive Comprehensive Decision making straightforward Straightforward Low complexity Moderate complexity High complexity Presenting problem Self limited or minor Low to moderate severity Moderate severity Moderate to high severity Moderate to high severity Time 10 min 20 min 30 min 45 min 60 min

11 Established Patient E&M Code History NA Problem focused Expanded problem focused Exam NA Problem focused Expanded problem focused Decision making NA Straightforward Low complexity Detailed Detailed Moderate complexity Comprehensive Comprehensive High complexity Presenting problem Minimal Self limited or minor Low to moderate severity Moderate to high severity Time 5 min 10 min 15 min 25 min 40 min Moderate to high severity

12 Psychiatric Coding: = Diagnostic Interview Key components History Mental status exam Disposition May include Family contact Ordering and reviewing of test results

13 Psychotherapy Coding Outpatient codes Individual session codes Insight Behavioral modification supportive Codes min min min Therapy only Therapy + E&M

14 Med Management coding: Patient requires med management only as they are receiving psychotherapy from different provider Management of detox, maintenance, mood stabilizing medications Usually no E&M service provided No time limits No quantity limits May not require treatment plan

15 Behavioral Health vs. Primary Care Assessment Psychotherapy 90804, 90806, Psychotherapy + E&M 90805, 90807, Medication visits Group therapy New patient E&M Established patient E&M Counseling + Therapy >50% time Medication Visits Group Therapy Not reimbursed

16 Buprenorphine vs. Primary Care Assessment Induction 90899, H0015 Psychotherapy + E&M 90805, 90807, Medication mgmt visit Group therapy Assessment Induction , H0015 Counseling Medication mgmt visit Group therapy Self pay patient Hire behavioral health professional

17 Reimbursement Comparison Code Type Blue Cross Medicaid $77 $ $55 $38 Based on reimbursement rates in Michigan, retrieved August, 2012.

18 What is happening to ICD? International Classification of Disease (ICD) Means of classifying diagnoses Must be used when billing insurance companies Only diagnostic code set that meets HIPAA and insurer mandated coding requirements Current version is ICD 9 ICD 10 Mandated by US Department of Health and Human Services Implementation date October 1, 2014

19 ICD 10 Code set maintained by WHO Version updated Increased specificity Exponential increase in number of codes Used by the majority of the world Will allow greater epidemiology with common worldwide diagnostic language Mandatory change

20 ICD 9 vs. ICD characters in length 13,000 codes 1 st digit may be alpha or numeric 5 digits long Limited space for new codes Lacks detail Lacks laterality 3-7 characters in length 68,000 codes 1 st digit is alpha & 2 nd and 3 rd numeric 7 digits long Potential space for new codes Very specific Has laterality

21 ICD-10 for Mental Health Disorders Separate category (F17) for nicotine dependence Subcategories for specific tobacco product used ICD-9 currently only has for tobacco use disorder or dependence Removes stage of substance use No distinction for continuous or episodic Unique codes for substance use that separate from abuse or dependence

22 ICD-10 for Mental Health Disorders Combination codes for drug and alcohol use and associated conditions such as withdrawal, sleep disorders or psychosis Specific codes related to blood alcohol level (Y90-) More specific codes regarding state of withdrawal, associated symptoms, and pathophysiology

23 How will this affect practice? Physicians Must increase the specificity of documentation as related to laterality, stage of healing, episodes of care, etc. Clinical: ABN forms, superbills, patient education Managers: budgets, training, contract, policies Lab: increased specificity of coding and ordering Coding and billing: will completely change their world Nursing: order form changes, increased documentation Front desk: HIPAA forms

24 DSM-5 Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) Scheduled for publication in May 2013 Undergoing analysis of field trials Will bring change to the diagnosis coding of mental health disorders Will need to translate DSM-5 codes to ICD10 codes for billing in 2013

25 Timeline of Change May 2013 DSM-5 slated for publication October 2013 ICD 10 scheduled for implementation

26 How can we adapt? Must be prepared Must accept change Must allow for physician and staff training Must consider potential delays in billing claim submission and reimbursement Must reformat all current patient forms, contracts, ordering and billing forms Must start NOW!

27 Code Change Sample ICD Opioid type dependence unspecified continuous episodic in remission ICD Opioid type dependence F11.20 uncomplicated F11.20 uncomplicated F11.20 uncomplicated F11.21 in remission

28 Code Change Sample ICD 9 Major depressive disorder single episode unspecified Major depressive disorder, single episode without psychotic features ICD 10 Major depressive disorder single episode unspecified F32.9 Major depressive disorder, single episode without psychotic features F32.2

29 Code Set Sample ICD-10 CODE CATEGORY CODE DESCRIPTIONS F31.1 -Bipolar disorder, current episode manic without psychotic features -F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified -F31.11 Bipolar disorder, current episode manic without psychotic features, mild -F31.12 Bipolar disorder, current episode manic without psychotic features, moderate -F31.13 Bipolar disorder, current episode manic without psychotic features, severe

30 Code Set Sample ICD-9 CODE DOCUMENTATION Alzheimer s disease Dementia in conditions classified elsewhere with behavioral disturbance V40.31 Wandering in conditions classified elsewhere ICD-10 CODE DOCUMENTATION G30.9 Alzheimer s disease, unspecified F02.81 Dementia in diseases classified elsewhere, with behavioral disturbance Z91.83 Wandering in diseases classified elsewhere

31 Code Set Sample ICD Organic Psychotic Conditions Other Psychoses Neurotic Disorders, Personality Disorders and Other Non-psychotic Mental Disorders Intellectual Disabilities ICD-10 F01-F09 Mental Disorders due to known Physiological condition F10-F19 Substance Abuse F20-F29 Schizophrenia & nonmood disorders F30-F39 Mood/Affective disorders F40-F49 Anxiety, etc F50-F59 Behavioral syndromes due to physical factors F60-F69 Adult personality disorders F70-F79 Intellectual disabilities F80-F89 Developmental disorders F90-F98 Behavioral/Emotional disorders, childhood onset F99Unspecified mental disorder

32 References & Resources American Medical Association (AMA) American Society of Addiction Medicine (ASAM) Overview of billing for psych vs. primary care American Academy of Professional Coders (AAPC) How to prepare for ICD-10 American Psychiatric Association (APC) DSM-5 revisions and updates

33 Thank You For further questions Kimber Debelak, CMC, CMOM, CMIS Cell

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