Sandra Parker, M.D. Chief Medical Officer, AltaPointe Health Systems Vice-Chair, University of South Alabama Department of Psychiatry President-Elect, Alabama Psychiatric Physicians Association
No Disclosures This information is intended for educational and informational purposes only. It is based on my interpretation of the new CMS guidelines. Nothing presented is to be construed as an attempt to encourage following the legal CMS guidelines. For further questions about your practice consult with your Medicare Contractor or legal advisor. 2
Current Procedural Terminology This is how we get paid. CPT Codes Documentation and coding is part of our job. We do the clinical work, therefore we do the documentation and coding, not our staff We as psychiatrists can bill based on either the Evaluation and Management Codes (E/M codes) or the Psychiatric Evaluation and Therapeutic Procedure Codes (Psychiatric codes). 3
CPT Codes Continued For Example: E/M Codes will generally be used in/on/for: 1. Consumers on an inpatient psychiatric unit 2. Consumers seen on the consultation service 3. Consumers seen in nursing homes 4. Consumers seen in PHP Psychiatric Codes may be used in: 1. Outpatient settings 2. Assisted living facilities 4
What is CPT? Stands for Current Procedural Technology A listing of descriptive terms and identifying codes for reporting medical services and procedures by physicians and other qualified health professionals which provides a uniform language that will accurately describe medical, surgical and diagnostic services. CPT is a registered trademark of the AMA 5
History Employer-sponsored healthcare plans began during World War II Medicare enacted in mid-1960 s CPT codes were first published in 1966 designed for Medicare Health Care Financing Administration (HCFA), now Center for Medicare and Medicaid Services (CMS), developed the Resource Based Relative Value Scale (RBRVS) in 1991 6
Relative Value Units (RVU s) RBRVS ranked all procedures and professional services in standardized units called RVU s. RVU s are used to calculate physician payments for Medicare services. In the 1990 s private commercial insurance companies adopted the system. CPT provides standardized definitions and the numeric codes for all professional procedures and services performed by qualified healthcare professionals. 7
Make-Up of the RVU 1. Physician Work (RVW) 2. Practice Expense (PE) 3. Professional Liability Insurance (PLI) 8
Physician Work 1. Pre-time What you need to do before seeing the patient includes work done the preceding 24 hours 2. Intra-service Time What you do from the time the patient enters your room until they leave (face-to-face) 3. Post-time What you do after you see the patient and for the next 7 days 9
Physician Work (CPT) Definition Work describes the Intensity and Complexity of the procedure Mental effort and judgment required Stress to physician from potential risk to the patient from the procedure Not stress from a difficult, litigious family Time spent during the encounter 10
Calculating RVU RVW + PE + PLI = RVU RVW x Medicare Conversion Factor ($25.0008 2013) Medicare also adjusts by geographic practice cost indices 11
CPT Process Professional society determines the need for a code for a specific procedure or service that their members perform. 12
5-Year Review CMS was mandated by Congress in 1992 to comprehensively review all relative values every 5 years and make needed adjustments. The psychiatric codes were reviewed in 2010. The Relative Value Update Committee (RUC)* sent the psychiatric codes back to CPT Board for revision because they felt the codes did not accurately describe the work being done by the various professionals who rendered the services. Reworked, the codes and the new codes went into effect January 1, 2013 *consists of representatives from all the medical societies that qualify for representation at the AMA; there are 31 permanent voting members APA has a voting seat; the remainder of the representatives are advisors-aacap has an advisor. 13
Issues in the Review (Reasons to Seek Change) Do the diagnostic codes describe work that was beyond the scope of practice of the non-medical healthcare providers? i.e. the psychiatric codes were being lumped with non-m.d. codes Is the procedure of psychotherapy the exact same for all specialties? i.e. Under-valuation of E/M component of Psychotherapy with Evaluation and Management Does the evaluation and management component adequately describe the varying levels of medical management required for current psychiatric care? i.e. The lower level E/M codes were going down (90862) and the higher level ones were going up What code do prescribing psychologists use for medication management? 14
Results of the CPT Workgroup Diagnostic Services 90801 and 90802 Eliminated Interactive Codes Site of Service Codes Eliminated Eliminated Pharmacological Management 90862 Eliminated 15
Overview of Changes to Psychiatry Codes: Key codes have been deleted, e.g. 90862 Pharmacologic Management Key services have been assigned new numbers and/or are described differently, and all new codes can be used in all settings There are now two codes for an initial evaluation; one with medical services and one without Psychotherapy is no longer distinguished by site of service Psychotherapy with E/M is now an E/M as the base code with a Psychotherapy add-on There is a new crisis psychotherapy code Work previously described using the interactive codes is now done by using an add-on code 16
New Psychiatric Code Structure 2 new diagnostic codes Diagnostic evaluation 90791 Diagnostic evaluation with medical services 90792 3 new individual stand-alone exact timed psychotherapy codes 30 minutes 90832 45 minutes 90834 60 minutes 90837 3 new Add-on exact time psychotherapy codes to be used with the E/M codes 30 minutes 90833 45 minutes 90836 60 minutes 90838 Interactive complexity add-on 90785 17
New Structure of Psychiatry Coding Psychiatry Coding Psychiatric Dx Evaluation (90791, 90792) Individual Psychotherapy w/pat or family (90832, 90834, 90837) Crisis Psychotherapy (90839, 90840) Interactive Complexity Add-on (90785) Add-on when used with Evaluation and Management Service Code, when applicable (90833, 90836, 90838) 18
Psychiatric Diagnostic Evaluation - Overview A distinction has been made between diagnostic evaluations without medical services and evaluations with medical services Interactive services are captured using an add-on code Add-on codes can be used in any setting can be used more than once in those instances where the patient and other informants are included in the evaluation Psychiatrists and other medical providers have the option of using the appropriate 99xxx series code in lieu of the 90792 19
What s the Difference? 90791- Psychiatric diagnostic evaluation is an integrated bio-psychosocial assessment, including history, mental status and recommendation The evaluation may include communication with family or other sources and review and ordering of diagnostic studies 90792 Psychiatric diagnostic evaluation is an integrated bio-psychosocial assessment, including history, mental status, other physical examination elements as indicated, and recommendations The evaluation may include communication with family or other sources, and review and ordering of diagnostic studies Prescriptions of medications, and review and ordering of laboratory and other diagnostic studies 20
What are Medical Services? 1. Medical activities: 1. Other physical examination elements, i.e. Ht, Wt, P, B/P, R, etc. 2. Prescription of Medications 3. Review and ordering of laboratory or other medical diagnostic studies 2. Medical thinking-consideration of: 1. Medical history and comorbidities, psychiatric and medical 2. Medications prescribed by others 3. Further medical work up 4. Medical treatments 5. Integration of signs and symptoms from a medical standpoint 21
What is Psychotherapy? The treatment of mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development The psychotherapy service codes include ongoing assessment and adjustment of psychotherapeutic interventions, and may include involvement of family member(s) or others in the treatment process 22
Psychotherapy - Overview Psychotherapy codes are no longer site specific Psychotherapy time includes face-to-face time spent with the patient and/or family member Time is chosen according to the CPT time rule Interactive psychotherapy is reported using the appropriate psychotherapy code along with the interactive complexity add-on code 23
Psychotherapy 3 stand-alone codes: 90832 30 minutes (range 16 37 minutes) 90834 45 minutes (range 38 52 minutes) 90837 60 minutes (range 53 67 minutes) Describe a pure psychotherapy service These codes will typically be used by non-medical providers 24
CPT Time Rule Applies to procedures in a series that are determined by exact time The initial time is reached after passing the half-way point of the specified time 30 minutes of psychotherapy is reached after 16 minutes In a series of timed codes, you reach the next time sequence when you have passed the mid-point of the differences in the time 45 minutes of psychotherapy is reached after 38 minutes 60 minutes of psychotherapy is reached after 53 minutes 25
E/M with psychotherapy - Overview Psychotherapy with E/M is now reported by selecting the appropriate E/M service code (99xxx series) and the appropriate psychotherapy add-on code The E/M code is selected on the basis of the site of service and the key elements performed The psychotherapy add-on code is selected on the basis of the time spent providing psychotherapy and does not include any of the time spent providing E/M services If no E/M services are provided, use the appropriate psychotherapy code (90832, 90834, 90837) 26
Psychotherapy add-on 3 add-on codes + 90833 + 90836 + 90838 Reported with the appropriate E/M service Describes the psychotherapy service which is ADDED- ON to the E/M service 27
What s an Add-on Code? An add-on code is a code that describes a separate, identifiable service or procedure that is done in addition to the primary service It is identified in the CPT manual with a + It cannot be used alone it must be used in conjunction with the primary service the E/M service in our case Examples include Psychotherapy, Interactive Complexity, and Crisis Services 28
Combined Service Psychotherapy with E/M services is not doing psychotherapy and then the E/M service it is an integrated, combined procedure, but the components must be separately indentified for CPT coding purposes. 29
How do I choose the combined code? 1. Choose the appropriate E/M code (not based on time). 2. Then choose the psychotherapy add-on code based on time. 30
Documentation of E/M with Psychotherapy E/M Key Components Medically necessary history or Medically necessary exam Medical decision-making Psychotherapy Time spent Who Participated? What psychotherapy issues were addressed? What techniques were used? 31
E/M codes The psychotherapy add-on code can be billed with the following E/M codes: Outpatient, established patient: 99212 99215 Subsequent hospital care 99231 99233 Subsequent nursing facility 99307-99310 32
Interactive Complexity The new name/code It is an add-on code: +90785 The old interactive codes have all been deleted Never reported alone May not be reported with an E/M stand alone code (can be reported with the psychiatry codes, or an E/M with psychotherapy code) 33
Important concepts Interactive Complexity 90785 Interactive in previous codes was limited in use to times when physical aids, translators*, interpreters*, and play therapy was used. Interactive Complexity extends the use to include other factors that complicate the delivery of a service to a patient. These include: Arguing or emotional family members in a session that interfere with providing the service Third party involvement with the patient, including parents, guardians, courts, schools Need for mandatory reporting of a sentinel event *as of 2013 Medicare does not recognize the use of translators or interpreters as a qualifying event 34
The Typical Patient Others legally responsible for patient s care Minors or adults with guardians Adults accompanied during the visit by Participating family members Interpreter or language translator Required involvement of other third parties Child welfare agencies Parole or probation officers Schools 35
The Communication Factors At least one of the following communication factors must be present during the visit Use of play equipment, physical devises, interpreter or translator The need to manage maladaptive communication (related to high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care Caregiver emotions or behavior that interfere with implementation of the treatment plan Evidence or disclosure of a sentinel event and mandated report to a third party (i.e. abuse or neglect report to a state agency) 36
The Primary Procedures Interactive Complexity may be reported in conjunction with Psychiatric Diagnostic Evaluation (90791, 90792) Psychotherapy (90832, 90834, 90837) E/M with psychotherapy add-on (90833, 90836, 90838)* Group Psychotherapy (90853) *in this case you will have two add-on codes 37
Psychiatric Diagnostic Evaluation Crosswalk 2012 2013 90801 90802 90791, Psychiatric diagnostic evaluation 90792, Psychiatric diagnostic evaluation with medical services 90792 plus 90785, Psychiatric diagnostic evaluation with medical services and with interactive complexity 38
Psychotherapy Crosswalk 2012 2013 90804, 90806 90832, Psychotherapy, 30 minutes 90806, 90818 90834, Psychotherapy, 45 minutes 90808, 90821 90837, Psychotherapy, 60 minutes 39
Psychotherapy with E/M vs E/M with Psychotherapy 2012 2013 Appropriate 99xxx series code plus one of the following: 90805, 90817 90807, 90819 90809, 90821 90833, Psychotherapy, 30 minutes when performed with an E/M 90836, Psychotherapy 45 minutes when performed with an E/M 90838, Psychotherapy 60 minutes when performed with an E/M 40
E/M with Psychotherapy and Interactive Complexity 2012 2013 90811, 90824 90813, 90827 90815, 90829 99xxx plus 90833 and 90785, E/M with psychotherapy, 30 minutes with interactive complexity add-on 99xxx plus 90836 and 90785, E/M with psychotherapy, 45 minutes with interactive complexity add-on 99xxx plus 90838 and 90785, E/M with psychotherapy, 60 minutes with interactive complexity add-on 41
Psychotherapy for Crisis A new code and an add-on code have been added to describe crisis psychotherapy (90839) 90839, Psychotherapy for crisis, first 60 minutes (CPT Rule applies: 30-74 minutes) +90840, Psychotherapy for crisis each additional 30 minutes Crisis Psychotherapy: an urgent assessment and history of a crisis state, a mental status exam, and a disposition. The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma. The presenting problem is typically life threatening or complex and requires immediate attention to a patient in high distress 42
Pharmacologic Management 90862 has been DELETED Psychiatrists should use the appropriate E/M series code (99xxx) to report this service A new add-on code 90863 has been added to describe pharmacologic management when performed by a prescribing psychologist; Physicians should never use 90863 43
Where to learn more APA has developed educational materials and opportunities that can be found on the APA website at www.psych.org/practice Things such as: A CPT coding crosswalk On-line course on E/M coding and documentation Live and recorded Webinars on E/M coding Live Q&A conference calls Face-to-face courses on CPT coding and documentation APA CPT Coding Network (for questions by email) 44