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Pamela Ballou-Nelson, RN, MSPH, PhD Coding and Documenting Behavioral Health Pamela Ballou-Nelson, RN, MSPH, PhD Principal Consultant MGMA Health Care Consulting Group And Jill Atkinson, Ph.D. Community Reach Center Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 2

Objectives Coding Behavioral Health for Colorado Medicaid Coding Integrated Behavioral Health Documenting for Integrated Behavioral Health BH and Commercial Plans Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 3

Copyright 2017. Medical Group Management Association® (MGMA®) Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 4

Coding for integrated behavioral health and other psychotherapy services Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 5

Behavioral Health Integration Integrating behavioral healthcare 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. 6

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. 7

Integrated Mental Health Services Billing for Medicaid Jill Atkinson, Ph.D. Community Reach Center  

Behavioral Health billing for Integrated Care for Medicaid Patients Behavioral Health billing goes through a Behavioral Health Organization (BHO) You must have a contract with your BHO to bill behavioral health services You will get a fee for service contract Be sure the FFS contract includes H codes, as these are the most commonly used codes for screening and short interventions This will change once the RAE’s are in effect

Two strategies for billing behavioral health Level 1: CPT codes that are numeric and have 5 digits. Traditional mental health services – must have a mental health “covered” diagnosis and must meet minimum documentation requirements for the code. Service requires at least a Master’s Degree and a formal assessment that leads to the diagnosis. After 6 visits must do a CCAR, and must have a signed treatment plan. Level II: standardized coding system for services not included in the CPT codes. The codes are alpha numeric. For this presentation we will review the H codes. Integrated behavioral health approach: will rely on H codes. Most H codes either do not require a mental health diagnosis or exclude a mental health diagnosis.

H Codes Code Description Dx Required Example H0002 Behavioral health screening to determine eligibility for admission to program No Dx required. If no dx then use list as: Unspecified illness – R69 Encounter for observation for other unspecified diseases ruled out–Z03.89 PHQ-9 ASQ (for kids) H0023 Behavioral health outreach service No dx required Need to use R69, Z03.89 or unspecified F code Phone or in person contact designed to engage patient in services

Code Description Dx Required Example H0025 Behavioral health prevention education service (delivery of services to affect knowledge, attitude and/or behavior. It may include screenings to assist individuals in obtaining appropriate treatment. Prevention activities are delivered prior to the onset of a disorder and are intended to prevent or reduce the risk of developing a behavioral health problem. No dx required Need to use R69, Z03.89 or unspecified F code Parenting class, healthy living class

Code Description Dx Required Example H0004 Individual counseling/therapy outlined in the treatment/service plan. Problem(s) as identified by an assessment and listed in the treatment/service plan. The intended outcome is the management, reduction/resolution of the identified problem(s). Mental Health diagnosis is required H0004 offers flexibility in terms of time increments and POS. H0004 may include unplanned telephone contact and/or planned contact if medically necessary, clinically justified, and included in the treatment/service plan

Code Description Dx Required Example H2011 Unanticipated services rendered in the process of resolving a client crisis, requiring immediate attention, that without intervention, could result in the client requiring a higher LOC., Services include: immediate crisis intervention to de-escalate the individual or family in crisis, assess dangerousness of situation, No Dx required. If no dx then use list as: Unspecified illness – R69 Encounter for observation for other unspecified diseases ruled out–Z03.89 Face-to-face/telephone contact to provide immediate, short-term crisis-specific assessment and intervention/counseling with client and, as necessary, with client’s family members Referral to other applicable BH services, including pre-inpatient screening;

Code Description Dx Needed Example H2011 (cont’d) determine risk of suicide or danger to others, assess access to or ability to utilize support, triage, assess for and facilitate admission to higher level care or additional forms of treatment if needed to stabilize the immediate situation activities include telephone contacts/ meeting with receiving provider staff ● Face-to-face/telephone consultation with physician/ hospital staff, regarding need for psychiatric consultation or placement ● Face-to-face/telephone contact with another provider to help that provider deal with a specific client’s crisis ● Consultation with one’s own provider staff to address the crisis

Things to Remember Follow minimum documentation standards. Understand the unit for billing and the minimum amount of time needed to qualify for each one. Some codes are encounter based and some are 15 minute increments. There are many more H codes, look them over and see if you qualify to use any of them and have them added to your contract. Consider the implications of diagnosing and treating Substance Use Disorders. Develop clear protocols for use of BH services. Using H codes for any payer other than Medicaid will result in a denial and possibly a charge to the patient.

Resources Coding Manual: https://www.colorado.gov/pacific/sites/default/files/Uniform%20Service%20Coding%20Standards%20January%202017.pdf SBIRT/SUD Medicaid billing: https://www.colorado.gov/pacific/sites/default/files/SBIRT%20Billing%20Manual.pdf

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. 18

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. 19

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. 20

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. 21

2017 National Fee Schedule Non-facility rate G0502 $142.84 Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 22

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 Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 23

Psychotherapy with Evaluation & Management/Same Day +90833 Psychotherapy, 30 minutes with patient when performed with an E&M service +90836 Psychotherapy, 45 minutes with patient when performed with an E&M service +90838 Psychotherapy, 60 minutes with patient when performed with an E&M service List in addition to appropriate level of E&M service Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 24

Commercial Payers Know your contracts to see if BH is covered, in what manner, which product lines and which codes. The codes trigger any insurance company to act. They are covered or not covered; the plan dictates the coverage. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 25

Documentation Structured care plans. Clinicians create and maintain a care plan that outlines treatment, describes plans for follow-up, and ensures that the patient and all involved clinicians are on the same page. The plan provides access to patient information and identifies who’s responsible for addressing specific healthcare needs and goals. Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved.

Documentation Benefits of Using the EHR for Behavioral Health Providers: See what other providers see Participate more closely in care Ability to use note templates Allows use of Consult Tracking Allows for notes to be electronically signed Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved.

Resources PCPCI Tool Kit For BH Integration http://www.pcpci.org/sites/default/files/resources/P CBH%20Implementation%20Kit_FINAL.pdf AHRQ Tool Kit https://integrationacademy.ahrq.gov/research/literat ure-collection/literature/primary-care-behavioral- health-toolkit Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved.

Copyright 2017. Medical Group Management Association® (MGMA®) Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved. 29