Collaborative Care Tips for Sustainability Virna Little, PsyD, LCSW r, SAP The Institute for Family Health NYS Collaborative Care Initiative
Teamwork Applies to Billing Too!!! Combine with other initiatives where there may be dollars helpful for staff NCQA Gain Sharing Agreements PCMH ACO Health Homes DSRIP
Speaking of Teams Collaborative Care adds two new members to the primary care team Psychiatric Consultant Depression Care Manager
License Matters Article 28 FQHC Article 28 non FQHC Article 31 FQHC Article 31 non FQHC Dually licensed Physician Group
FQHC Providers Article 28 licensed PPS rate Can utilize social workers to bill for behavioral health services clinical services Up to 10,000 visits per location Ancillary to primary care ( referral) Short term treatment
Article 28 Non FQHC June 2011 Medicaid Update has details Bill for behavioral heath for designated populations Guidance may be to apply for Article 31 with waivers for shared space, records, DCM Same guidance for visits up to 10,000 short term and ancillary
Article 31 9 Dually licensed FQHC providers in New York Specialized mental health services Able to bill all codes for behavioral health APG rates except for FQHC providers who opted out of APG rates
Integrated License Currently a pilot project Potential ability for increased revenue for integrated licensure status Expected continuation in 2015 but unclear as to parameters or regulatory requirements Now must be already dually licensed Health, Mental Health and Substance Abuse
Depression Care Managers Social Worker LMSW or LCSW Licensed Counselors Nurse Practitioner RN Psychologist PhD or PsyD Who to hire for maximum revenue?
Depends on Setting and Payer Mix Review your payer mix Checks codes vs provider vs payer Develop a spreadsheet to determine where you might have reimbursement gaps DO THIS FIRST!!! (even if you are grant funded )
LCSW, LCSW r Recognized by Medicare Reimbursable by more plans More likely to be able to supervise students Higher salary than LMSW
LMSW Not recognized by Medicare however can Incident too bill Some plans will not recognize Requires some oversight Lesser salary
Nurse Practitioner Reimbursable with plans Medicare reimbursement Not good use of prescriber time to provide care management services that are not reimbursable Higher salary PST longer sessions vs. medication management sessions
RN Not reimbursable for most part Higher salary than social workers often Could be combined with provider visit for higher coding
Psychologists Masters level not reimbursable PhD and PsyD recognized by Medicare and most payers Higher salary Able to supervise interns /trainees
Counselors Not recognized by Medicare Not recognized by all payers Diagnosing Salary equal to Social Workers LMSW range Only able to bill in Article 31 centers
Psychiatric Consultants Reimbursable for direct care Review payer mix and reimbursement to determine number of patients for viability Consultation not reimbursable unless joint visit and can by higher code ( 99214)
Behavioral Health Billing First time for many organizations Codes in contracts Process for authorizations Professional appointment Credentialing Codes in system Trained providers for billable notes
Psychosocial Assessment 90801 90791 Same definition: History (social, psychiatric, medical, substance, etc.) Mental status Assessment of symptoms Same documentation Does not include psychotherapy! Face to face Article 31 45 minute minimum
Psychotherapy PST Visits 90832 Article 31 minimum 30 min Article 28 16 to 37 minutes Few Visits 90834 Article 31 minimum 45 minutes Article 28 38 to 52 minutes Groups 90853 Article 31 minimum 60 minutes Min 2 max 12 Article 28 53+ minutes
Not all DCM Services Billable Care management for the most part unless done under some agreement Same day services often not reimbursable Warm hand off many times not billable because of duration, content and being same day however may work in favor for show rates for next visit
Viability of Depression Care Managers Diversity of visits is a good thing but often makes business plans a struggle Productivity does not paint a full picture and often limits access Capacity is better measure counting actual time in patient care
HBAI Codes CPT codes adopted in 2002 to address primary-carebased BH services delivered in coordination with PCP services. DEPRESSION CARVED OUT Adopted by Medicare Not opened by PA Medicaid and private sector adoption is spotty; check contract Mauer, National Council Community Behavioral Healthcare, 2006
Telephone Consultation Not traditionally covered by payers Can be completed by physicians and qualified non physician providers Must be established patient or collateral Can t be within 7 days following an appointment or prior to next appointment 98967: 11 20 minutes of medical discussion 98968: 21 30 minutes of medical discussion 98966: 5 10 minutes of medical discussion
CPT Codes for Medical Case Conferences 99366 Medical team conference with interdisciplinary team of health care professionals, face to face with patient and/or family, 30 minutes or more, participation by non physician qualified health care professional. 99367 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more participation by physician. 99368 Participation by non physician qualified health care professional.
Documentation for Case Conferences Each participant should document participation in team conference Documentation should include contributed treatment recommendations Documentation should include role of individual in patient s care Documentation should include subsequent treatment recommendations
Who Reimburses for Depression Screening in Primary Care?
Medicare G0444 Healthcare Common Procedure Coding System Code (HCPCSC) Code to report screening for depression in adults Effective October 14, 2011 Reimburses for depression screening up to 15 minutes
The Affordable Care Act includes incentive payments through 2014 & requires a penalty beginning in 2015,for eligible professionals who do not satisfactorily report PQRS assessments. G0444
Medicare G0444 Appropriate for patients entitled to benefits under Part A and Part B Medicare coinsurance and Part B Deductible waived Needed for reporting claim, but Medicare does not require an ICD 9 CM diagnosis code for depression screening in adults
Medicare G0444: What is not covered Treatment options for depression Chronic conditions resulting from depression Therapeutic interventions: pharmacotherapy, combination therapy or other interventions for depression Depression screening more than once in a 12 month period
Depression in Primary Care Program Seeks to promote depression screening and monitoring within primary care Provides PHQ 9 for screening and monitoring depressed patients Offers reimbursement for depression screening and follow up
How to Trigger Reimbursement Claims must have the following billing combination: CPT code 99420 (administration and interpretation of a health risk assessment) Diagnosis code V79.0 (screening for depression)
Other Relevant Information Patients must have Aetna medical insurance; Aetna behavioral health coverage not required Providers need to be credentialed by Aetna Codes need to be included in organization s contract with Aetna Allowed up to three (3) initial visits in PCP office, a maximum of 30 minutes each
ITPC in Medicare Advantage Hierarchical Condition Category (HCC) Payment Methodology: HCC Code 55 (Depression) adds ~ $ 300 to monthly payment for Medicare Advantage patient Move from 311 coding to alternate code like Major Depressive Disorder
Questions Email Questions to Tjames@institute2000.org