Behavioral Health Coding, Contracting and Billing, Part 1 Presented by

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1 Disclosures Behavioral Health Coding, Contracting and Billing, Part 1 Presented by Mimi Reed, BHSA, CPC A, MCP, MTA, Consultant, SCHA MI Mimi Reed, BHSA, CPC A, MCP, MTA, Consultant, SCHA MI Amy Valimont, MSSW, LCSW, LCAS, Independent Contractor No relationships to disclose Amy Valimont, MSSW, LCSW, LCAS, Independent Contractor 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. Overview CPT code changes Credentialing Contracting Strategies to optimize reimbursement 1

2 So, why change? Reasons for updating the code set Last update to psychotherapy codes was in? Current code set is inadequate to account for variances in psychotherapy and medical management A quick glance at some of the code changes Evaluation & Management [E/M] code series Documentation requirements Add On codes Identify procedures performed in addition to a primary procedure Apply only to services/procedures performed by the same health care professional Can never be reported alone as a stand alone code New Crisis Psychotherapy codes A quick glance at some of the code changes Diagnostic Evaluations now distinguish between: being provided by a non physician practitioner (90791) being provided with medical services by a physician (90792) Interactive Psychotherapy now uses the appropriate psychotherapy code in addition to the Interactive Complexity Add On code Pharmacologic Management code has been deleted incorporated into E/M code But first a review of the definition of three important terms: Solely for the purposes of distinguishing between new and established patients, professional services are those face to face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s). CPT Manual, Professional Edition,

3 New patient A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. Established patient An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. CPT Manual, Professional Edition, 2015 Determine what services were rendered and by whom Physician versus mental health provider Medical and/or psychotherapy versus psychotherapy only Select the appropriate CPT code for the service(s) rendered Documentation must support the CPT code(s) reported Psychotherapy only service code selection All mental health providers (psychiatrists, midlevel providers, psychologists, counselors and social workers) use the same new (as of 2013) codes for psychotherapy Be mindful to use the correct procedure code relative to time Procedure Code Time Allocation 90832, mins (16 37 minutes) 90834, mins (38 52 minutes) 90837, mins (53+ minutes) < 16 mins is not reported Diagnostic Evaluations distinction between provision of service by a non physician and provision of service with medical services by a physician Pharmacologic Management Pharmacologic Management code has been deleted now incorporated into the E/M level of service a word about Add On code used only by psychologists with prescribing authority, in conjunction with psychotherapy 3

4 Interactive Complexity Definition: refers to four specific communication factors during a visit that complicates delivery of the primary psychiatric procedure. American Academy of Child & Adolescent Psychiatry relates only to the increased work intensity of the psychotherapy service does not change the time for the psychotherapy service Evaluation and Management service code selection 3 Key Components History 4 Elements: Chief Complaint [CC]; History of Present Illness [HPI]; Past Family, Social History [PFSH] Examination 2 Elements: Number of system/body areas examined; Bullets or elements completed within specific systems Medical Decision Making 3 elements: Number of diagnoses or management options; Amount and/or complexity of data to be reviewed; Risk of Significant Complications, Morbidity and/or Mortality Select code from the correct category (ex. new vs established) Select the appropriate level of service Must be supported by documentation that reflects the work and medical necessity of the visit New Patients All 3 Key Components must be met/required Established Patients 2 of 3 Key Components must be met/required Evaluation and Management Table New Patient E/M Code History Physical Exam MDM Time Problem Focused Problem Focused Straightforward 10 mins Exp Prob Focused Exp Prob Focused Straightforward 20 mins Detailed Detailed Low 30 mins Comprehensive Comprehensive Moderate 40 mins Comprehensive Comprehensive High 60 mins 4

5 Evaluation and Management Table Established Patient E/M Code History Physical Exam MDM Time None None None Problem Focused Problem Focused Straightforward Exp Prob Focused Exp Prob Focused Low Detailed Detailed Moderate Comprehensive Comprehensive High 40 Evaluation and Management service with psychotherapy service select the appropriate E/M service level based on the Key Components of History, Exam and MDM Select the appropriate Psychotherapy Add On code (+90833, , ) based on the Time providing psychotherapy only Will only be used when medical and psychotherapy services are performed by the same physician during the same encounter Documentation 1997 Documentation Guidelines More definition and clarity in the Examination portion of the guidelines bullet points Documentation must be legible and support the medical necessity and level of service indicated always and every time Coding caveats Same day billing policies with regard to payors Some payors prohibit this practice Carrier policies can dictate some coding rules Rates and limitations are still decided by payors Be aware of how your group practice is defined Oftentimes a group is defined by the practice Federal Tax Identification Number (TIN) Effects the status of a patient 5

6 Credentialing Key to streamlining the contracting process with an increasing number of payors National provider database Council for Affordable Quality Healthcare (CAQH) Contracting Determine the Top 5 payors in your area Ascertain which provider types can be enrolled Require credentialing with plan got that covered! Be prepared to state your case Explain your purpose, the opportunities and services your center provides Discuss impact on current (and future) population(s) Partner with fiduciary or other centers within your area if need be Discuss your integrating role in care models (ex. ICO s, CCMH s, ACO s) Contracting Review your state s model contract with managed care organizations and/or other commercial payors Determine whether it suits your needs and if not, what modifications are necessary? Negotiate EOB suppression Identify any carve outs for specific services Behavioral Health is a popular one! Determine whether additional contracting/enrollment is required Negotiate fees for the services your center performs! Strategies to Optimize Reimbursement Know which payor(s) process your Behavioral Health Services Carve Outs Referral and/or Authorization process Variance among payors Utilize payor tools Website resources (ex. client portals) Defined process for working rejected claims Implement chart audits Monitor activity using reporting metrics 6

7 Resources 1997 Documentation Guidelines https://www.cms.gov/outreach and Education/Medicare Learning Network MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf National Correct Coding Initiative (NCCI) Tools and Education/Medicare Learning Network MLN/MLNProducts/Downloads/How To Use NCCI Tools.pdf Council for Affordable, Quality Healthcare National Council for Behavioral Health behavioral health services/ References Current Procedural Terminology, Professional Edition, 2015 (American Medical Association) The National Council for Behavioral Health, health services/, (retrieved, 05/26/2015) American Academy of Child & Adolescent Psychiatry, /EM_Coding_SUmmary_Guide_v2.pdf, (retrieved, 05/26/2015) American Academy of Child & Adolescent Psychiatry, https://www.aacap.org/app_themes/aacap/docs/clinical_practice_center/business_of_practice/cp t/interactive_complexity_guide_2012.pdf, (retrieved 05/26/2015) American Academy of Child & Adolescent Psychiatry, %20FINAL.pdf, (retrieved 05/26/2015) Centers for Medicare and Medicaid Services, https://www.cms.gov/outreach and Education/Medicare Learning Network MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf, (retrieved 05/26/2015) Contact Information Mimi Reed BHSA, CPC A, MCP, MTA Consultant, SCHA MI School Community Health Alliance of Michigan Phone: x223 mi.org Website: mi.org Amy Valimont, MSSW, LCSW, LCAS Independent Contractor 7

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