Addiction Billing Kimber Debelak, CMC, CMOM, CMIS Director, Recovery Pathways
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
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
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
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
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
Provider Types Medical Primary care Specialty and subspecialty Psychiatric Ψ Behavioral health Addiction medicine
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
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)
New Patient E&M Code 99201 99202 99203 99204 99205 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
Established Patient E&M Code 99211 99212 99213 99214 99215 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
Psychiatric Coding: 90801 90801 = Diagnostic Interview Key components History Mental status exam Disposition May include Family contact Ordering and reviewing of test results
Psychotherapy Coding Outpatient codes Individual session codes Insight Behavioral modification supportive Codes 23-30 min 45-50 min 75-80 min Therapy only 90804 90806 90808 Therapy + E&M 90805 90807 90809
Med Management coding: 90862 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
Behavioral Health vs. Primary Care Assessment 90801 Psychotherapy 90804, 90806, 90808 Psychotherapy + E&M 90805, 90807, 90809 Medication visits 90862 Group therapy 90853 New patient E&M 99201-99205 Established patient E&M 99211-99215 Counseling + Therapy 99211-99215 + >50% time Medication Visits 99211-99215 Group Therapy Not reimbursed
Buprenorphine vs. Primary Care Assessment 90801 Induction 90899, H0015 Psychotherapy + E&M 90805, 90807, 90809 Medication mgmt visit 90862 Group therapy 90853 Assessment 99205 Induction 99205-21, H0015 Counseling 99213-99215 Medication mgmt visit 99213-99215 Group therapy Self pay patient Hire behavioral health professional
Reimbursement Comparison Code Type Blue Cross Medicaid 99213 $77 $28 90805 $55 $38 Based on reimbursement rates in Michigan, retrieved August, 2012.
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
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
ICD 9 vs. ICD 10 3-5 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
ICD-10 for Mental Health Disorders Separate category (F17) for nicotine dependence Subcategories for specific tobacco product used ICD-9 currently only has 305.1 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
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
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
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
Timeline of Change May 2013 DSM-5 slated for publication October 2013 ICD 10 scheduled for implementation
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!
Code Change Sample ICD 9 304.0 Opioid type dependence 304.00 unspecified 304.01 continuous 304.02 episodic 304.03 in remission ICD 10 304.0 Opioid type dependence F11.20 uncomplicated F11.20 uncomplicated F11.20 uncomplicated F11.21 in remission
Code Change Sample ICD 9 Major depressive disorder single episode unspecified 296.20 Major depressive disorder, single episode without psychotic features 296.33 ICD 10 Major depressive disorder single episode unspecified F32.9 Major depressive disorder, single episode without psychotic features F32.2
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
Code Set Sample ICD-9 CODE DOCUMENTATION 331.0 Alzheimer s disease 294.11 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
Code Set Sample ICD-9 290-294 Organic Psychotic Conditions 295-299 Other Psychoses 300-316 Neurotic Disorders, Personality Disorders and Other Non-psychotic Mental Disorders 317-319 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
References & Resources American Medical Association (AMA) http://www.ama-assn.org/ama1/pub/upload/mm/399/icd10-icd9-differences-factsheet.pdf 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
Thank You For further questions Kimber Debelak, CMC, CMOM, CMIS debelakk@gmail.com Cell 517-505-6691