DOUBLE CLICK TO ADD TITLE

Pamela Ballou-Nelson, RN, MSPH, PhD Coding for Success: A look at four coding opportunities Pamela Ballou-Nelson, RN, MSPH, PhD Senior Consultant MGMA Health Care Consulting Group Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 2

Objectives Understand the changes in Chronic Care Management, codes and billing requirements. Behavioral health coding: can you bill behavioral health and EM code on the same day? If so, how and what codes? Discover SBIRT coding and requirements for billing Commercial, Medicare and Medicaid. Discover code 96161 for “health risk screen of a caregiver for the benefit of the patient.” Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 3

Poll Are you currently coding for chronic care management? Yes No Inconsistently Not sure Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 4

Chronic care management coding ccm Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 5

Chronic Care Overview Click to edit Master text styles First level Second level Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 6

What is Chronic Care Management? Chronic Care Management (CCM) services by a physician or non- physician practitioner (Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist and/or Certified Nurse Midwife) and their clinical staff, per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until death, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Timed services – the threshold amount of clinical staff and billing practitioner time, performing qualifying activities, and ongoing oversight that is required per month. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 7

Chronic Care Management Services Include: Use of a Certified Electronic Health Record (EHR) Continuity of Care with Designated Care Team Member Comprehensive Care Management and Care Planning Transitional Care Management Coordination with Home- and Community-Based Clinical Service Providers 24/7 Access to Address Urgent Needs Enhanced Communication (for example, email) Advance Consent (verbal now allowed) Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 8

What is Chronic Care Management? CCM is a critical component of care that contributes to better health outcomes and higher patient satisfaction CCM is person-centered CCM requires more centralized management of patient needs and extensive care coordination among practitioners and providers Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 9

What is Chronic Care Management? Ongoing CMS effort to pay more accurately for CCM in “traditional” Medicare by identifying gaps in Medicare Part B coding and payment (especially the Medicare Physician Fee Schedule or PFS) Initially adopted CPT code 99490 beginning January 1, 2015, to separately identify and value clinical staff time and other resources used in providing CCM Beginning January 1, 2017, CMS adopted 3 additional billing codes (G0506, CPT 99487, CPT 99489) Detailed guidance on CCM and related care management services for physicians is available on the PFS web page. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 10

Eligible Patients and Providers Eligible beneficiaries have: Two or more chronic conditions expected to last at least 12 months or until death, that place them at significant risk of death, acute exacerbation, or functional decline No other diagnostic limitations A given beneficiary receives either non-complex CCM (CPT 99490) or complex CCM (CPT 99487,9) for a given month Eligible reporting practitioners, providers and suppliers: Physicians, Physician Assistants, Clinical Nurse Specialists, Nurse Practitioners, and Certified Nurse Midwives RHCs and FQHCs Hospitals (including critical access hospitals) Only 1 practitioner or 1 hospital can report CCM per month Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 11

What is New for CY 2017 Significant changes starting in 2017 based on feedback from stakeholders: Increased payment amount through 3 new billing codes (PFS)G0506 (Add-On Code to CCM Initiating Visit, $64) CPT 99487 (Complex CCM, $94) CPT 99489 (Complex CCM Add-On, $47) CPT 99490 still effective for Non-Complex CCM ($43) For all CCM codes – Simplified and reduced billing and documentation rules, especially around patient consent and use of electronic technology Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 12

What is New for CY 2017 Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 13

Summary of Changes Complex CCM service codes provide higher payment for complex patients - Those for whom the billing practitioner is addressing problems of moderate or high complexity during the month, who also require 60 or more minutes of clinical staff time and substantial care plan revision (or care plan establishment) Facilitated patient consent – Verbal rather than written consent allowed (must still be documented in the medical record) Reduced technology requirements – Retained requirement for certified EHR (limited data set), but change focus to timely exchange of health information (the care plan and transitional care document(s)) rather than specific electronic technology for these pieces. Care plan no longer has to be available electronically to individuals providing CCM after hours, as long as they have timely information Fax is discouraged but can count for electronic exchange, if timely Improved alignment with CPT language and simplified documentation Initiating visit only required for new patients or those not seen within a year prior (rather than for all patients) Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 14

Summary RHCs and FQHCs can receive payment for CCM when CPT code 99490 is billed alone or with other payable services on a RHC or FQHC claim The RHC and FQHC face-to-face requirements are waived when CCM services are furnished to a RHC or FQHC patient Payment is based on the Medicare PFS national non-facility payment rate The rate is updated annually and has no geographic adjustment Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 15

Summary RHCs and FQHCs can furnish CCM services under general supervision requirements instead of direct supervision requirements Revised Scope of Service Requirements (initiating visit, electronic care plan, beneficiary consent, etc.) consistent with PFS scope of services changes Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 16

Summary New Complex CCM Codes (CPT 99487 and 99489) and Initiating Visit Add-on (G0506) Payments for RHC and FQHC services are not adjusted for length or complexity of the visit RHCs and FQHCs are not authorized to bill these three new codes These codes should not be billed by RHCs/FQHCs, and would be subject to recoupment if they are paid Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 17

Coding for integrated behavioral health and other psychotherapy services Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 18

Behavioral Health Integration Integrating behavioral health care with primary care is now widely considered an effective strategy for improving outcomes for the many millions of Americans with mental or behavioral health conditions. New England Journal of Medicine, Perspective February 2, 2017 Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 19

Breaking the Barriers Previously, not separately reimbursable, leaving practices without a clear business model for incorporating these services into their practice. Schwenk TL. Integrated behavioral and primary care: what is the real cost? JAMA2016; 316: 822-3. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 20

Poll Are you currently coding for BH visits? Yes No Inconsistently Not sure Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 21

Sumo CMS Final Rule for 2017 Medicare Payments for Integrated Behavioral Health Services For patients participating in a Collaborative Care Model (CoCM) Medicare has established three new codes to report integrated behavioral services G0502 G0503 G0504 Other BHI models G0507 Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 22

G0502 ~ Initial psychiatric collaborative care mgmt G0502 ~ Initial psychiatric collaborative care mgmt., first 70 minutes in the first calendar month of behavioral healthcare manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other QHCP with the following required elements: Outreach to and engagement in treatment of a patient directed by the treating physician or other qualified healthcare professional; Initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan; Review by the psychiatric consultant with modifications of the plan if recommended; Entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 23

G0503 ~ Subsequent psychiatric collaborative care mgmt G0503 ~ Subsequent psychiatric collaborative care mgmt., first 60 minutes in a subsequent month of behavioral healthcare manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other QHCP with the following required elements: Tracking patient follow-up and progress using the registry, with appropriate documentation; Participation in weekly caseload consultation with the psychiatric consultant; Ongoing collaboration with and coordination of the patient’s mental healthcare with the treating physician or other qualified healthcare professional and any other treating mental health providers; Additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant; Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies; Monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 24

G0504 ~ Initial or Subsequent psychiatric collaborative care mgmt G0504 ~ Initial or Subsequent psychiatric collaborative care mgmt., each additional 30 minutes in a calendar month of behavioral healthcare manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other QHCP. List separately in addition to code for primary procedure. (Use G0504 in conjunction with G0502 & G0503) G0507 ~ Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified healthcare professional time, per calendar month. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 25

Cognition-focused evaluation including history and examination G0505 ~ Assessment and Care Planning for patients with Cognitive Impairment New code G0505 will cover assessment and care planning for patients with cognitive impairment, such as Alzheimer’s disease or dementia, if the following elements are satisfied: Cognition-focused evaluation including history and examination Moderate or high complexity medical decision-making Functional assessment, including decision-making capacity Use of standardized instruments to stage dementia Medication reconciliation and review for high-risk medications (if applicable) Evaluation for neuropsychiatric and behavioral symptoms, including depression Evaluation of safety, including motor vehicle operation Identification of caregiver(s), caregiver’s knowledge, caregiver’s needs, social support, and caregiver’s willingness to give care Advance care planning and palliative care needs Creation and sharing of a care plan with the patient and/or caregiver with initial education and support Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 26

2017 National Fee Schedule Non-facility rate G0502 $142.84 Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 27

n engl j med 376;5 nejm.org February 2, 2017 Widespread implementation of CoCM and other effective BHI services could substantially improve outcomes for millions of Medicare beneficiaries and produce savings for the Medicare program. n engl j med 376;5 nejm.org February 2, 2017 Quick Start Guide to Behavioral Health Integration Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 28

Screening brief intervention and referral for treatment SBIRT Coding Screening brief intervention and referral for treatment Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 29

What is SBIRT? Screening: Routine alcohol screening to identify patients who drink above low-risk limits Brief Intervention: Intervention(s) for patients who screen positive may include: A statement of concern by the health professional A suggestion to cut-back or quit Educating about low-risk limits and impact on patient-specific health conditions (hypertension, diabetes, obesity/BMI etc.) Short-term follow-up sessions with a health professional The development of a plan for reducing drinking given health, legal, social concerns (with patient support) Patient follow-up (face to face/telephone) Referral to Treatment: For patients who endorse use behavior that may be consistent with a substance use disorder, a referral to a Primary Care-based integrated behavioral health consultant and/or a follow-up visit with care provider, or a referral to Chemical Dependency Treatment Services (Specialty Behavioral Health) for full assessment and treatment is recommended. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 30

Poll Are you currently coding for SBIRT? Yes No Inconsistently Not sure Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 31

Substance Use Disorder Those who abstain or do not drink Alcohol Misuse vs. Alcohol Use Disorders Severe Alcohol Use Disorder Diagnosed Substance Use Disorder Moderate Alcohol Use Disorder Mild Alcohol Use Disorder Problem Drinkers A Continuum of Use Heavy Drinkers Moderate Drinkers Light Drinkers Those who abstain or do not drink Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 32

Medicare Medicare defines SBIRT as an early intervention approach that targets those with nondependent substance use to provide effective strategies for intervention prior to the need for more extensive or specialized treatment. The service can be performed by physicians, non-physician practitioners, and other providers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/or A/B Medicare Administrative Contractors (A/B MACs) for certain mental health services provided to Medicare beneficiaries. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 33

Medicare Medicare created two Healthcare Common Procedure Coding System (HCPCS) G-codes to allow for the appropriate Medicare reporting and payment for alcohol and substance abuse assessment and intervention services. These two HCPCS G-codes are: G0396 (Alcohol and/or substance (other than tobacco) abuse structured assessment (for example, AUDIT, DAST) and brief intervention, 15 to 30 minutes), and G0397 (Alcohol and/or substance (other than tobacco) abuse structured assessment (for example, AUDIT, DAST) and intervention greater than 30 minutes). Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 34

Colorado Medicaid SBIRT Payment (updated May 2016) The SBIRT benefit is available to members ages 12 and older. Brief Screen or Pre-Screen: one to several short questions relating to drinking, tobacco and drug use. Payers consider this to be an integral part of routine preventive care and is therefore not separately reimbursable. It can be administered by providers or any other staff member, in writing, orally, or through other technologies. Full Screen or Brief Assessment: this more definitively categorizes a patient’s substance use and is indicated for patients with positive brief or pre-screens. Providers are required to use an evidence-based screening tool for this step such as the AUDIT, DAST, ASSIST, CRAFFT, or POSIT. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 35

Colorado Medicaid SBIRT Payment (updated May 2016) Brief Intervention: brief motivational conversation with a patient intended to induce a change in health-related behavior. Payment for up to two (2) full screens per state fiscal year. Payment for up to two (2) sessions of brief intervention referral per year. When applicable, attach bypass modifiers (typically 25 or 59) to H0049, 99408, and 99409 line items to indicate that a separate amount of time was spent conducting the SBIRT process from other office procedures (see manual for additional details). Negative full screens may be billed using H0049. SBIRT and other services, EM codes can be paid on same visit, except when billing under the Mental Health and Substance Use disorder using procedure codes H0002 and H0004 or with any code that represents the same or similar service (usually true for all payers). Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 36

Commercial Payers Know your contracts to see if SBIRT is covered, in what manner and which codes. The codes trigger any insurance company to act. They are covered or not covered; the plan dictates the coverage. 99408: Alcohol and/or substance (other than tobacco) abuse structured screening (for example, AUDIT, drug abuse screening test [DAST]) and brief intervention (SBI) services of 15 to 30 minutes. 99409: Alcohol and/or substance (other than tobacco) abuse structured screening (for example, AUDIT, DAST) and SBI services greater than 30 minutes. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 37

“Health risk screen of a caregiver for the benefit of the patient.” Code 96161 “Health risk screen of a caregiver for the benefit of the patient.” Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 38

96160 will be the code for patient-focused health risk screen. 96161 for “health risk screen of a caregiver for the benefit of the patient.” 96161 will replace 99420 for maternal depression screening. 99420 will be discontinued in CPT - Oct 2, 2016. 96160 will be the code for patient-focused health risk screen. Code 96161, similar to 96160, is used for the administration of caregiver- focused health risk assessment instrument (e.g., depression inventory) and must contain scoring and documentation. It also cannot be reported with 99408 or 99409 (alcohol and/or substance abuse structured screening and brief intervention services). Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 39

Poll I now have a better understanding of coding opportunities for: Chronic care management Behavioral health SBIRT All of the above Yes No Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 40

Copyright 2017. Medical Group Management Association® (MGMA®) Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 41