Billing for Mental Health Services in a Community Health Center Jeanne M. Chapdelaine Director

2 Agenda  Evaluation and Management (E&M) Services  Psych Services (908xx codes)  Testing Services  Health and Behavior Assessment Services  Coding Scenarios  Diagnoses  Closing

3 E&M Coding  Evaluation and Management (E&M) codes are available to: Physicians (including psychiatrists) CNSs PAs NPs  …but not to therapy staff (PhD, LPs, etc.).

4 E&M Coding  E&M codes will be the predominant service code when used by primary care providers.  The mental health series of codes (908xx) are typically expected (by payers) to be used by psychiatrists and therapists (though CPT does not state this).

5 E&M Coding  (lowest level established patient E&M) can be used by: Nursing/medical assistant staff for miscellaneous services RNs who provide medication management services, if they are supervised by a physician (but should not be billed if another provider is also billing that day).

6 E&M Levels of Service  Most E&M levels of service are selected using “Key Components:” History Exam Medical decision making.  But, when counseling or coordination of care dominates the encounter (>50%), time can be the controlling factor in selecting the level.  This happens a lot in primary care, especially those providing behavioral health services.

7 E&M Levels of Service  “Counseling” is a discussion with the patient and/or family regarding: Diagnosis, impressions, prognosis, or recommended diagnostic studies Risk and benefits of treatment options Instructions and/or importance of compliance, risk factor reduction Emotional needs of patients Patient and/or family education.

8 E&M Levels of Service  The provider must document the time spent counseling or coordinating care AND total encounter time. In the clinic  Face-to-face time In the hospital  Unit or floor time (On unit/bedside rendering services for that patient: -Reviewing or adding to the record -Examining patient -Talking with patient/family or other providers.)

9 E&M Levels of Service  But the primary (and most confusing) method is to select the level of service based on: History Exam Medical decision making.  Our discussion will focus on the Exam component because the History and Decision Making components do not vary by service type.

10 E&M – Psychiatric Exam (1997)

11 E&M – Exam (1995)

12 E&M – Exam EXAM Problem Focused Expanded Problem Focused DetailedComprehensive 1997 (Psych) 1-5 bullets6-9 bullets9+ bullets All shaded elements; one from non-shaded areas 1995 Ltd exam problem area …plus add’l body areas/systems Extended exam problem area Complete single system (or general multi-system) exam Establ. Patient Codes Level of Service Breakdown - Psychiatry Exam

13 “Psych” Services (908xx codes)  Psychiatric Diagnostic Interview 30 minute unit. Limited to one 2-hour session (4 units) per recipient per CY, unless extension requirements are met. Prior to the completion of the diagnostic assessment, providers may bill for explanation of findings, psychological testing, and one psychotherapy session.

14 “Psych” Services (908xx codes)  Interactive services Typically furnished to children. CPT defines interactive services as involving: “The use of physical aids and non-verbal communication to overcome barriers to therapeutic interaction between the clinician and a patient who has not yet developed, or has lost, either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the clinician if he/she were to use ordinary adult language for communication.”

15 “Psych” Services (908xx codes)  Interactive codes Initial psychiatric evaluation Individual therapies Group therapy

16 “Psych” Services (908xx codes)  Group and Family Therapy codes Length of session may be 1 hour or 1½ hours (family) and up to 2 hours (multiple family or group). CodeDescription 90846Family therapy, without patient 90847Family therapy, with patient 90849Multiple family group therapy 90853Group therapy 90857Interactive group therapy

17 “Psych” Services (908xx codes)  Pharmacologic Management Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy M Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders

18 “Psych” Services (908xx codes)

19 “Psych” Services (908xx codes) Medicare guidelines state: “If the physician supplies other services in addition to pharmacologic management (PM) at the visit, then an E&M code may be used [instead]. The E&M service will include the PM [so should not also be billed]. If the patient receives psychotherapy and PM at the same visit, the psychotherapy codes that include E&M service should be used.”  In primary care, it is not unusual to provide both AND E&M services at the same encounter.  The MMA and MAFP are working with local payers to ensure we can report these services appropriately.

20 “Psych” Services (908xx codes)  Environmental Intervention Adult benefit: 15-minute unit; children: no reference. Authorization is required for more than 10 hours/month or 72 hours/CY.

21 “Psych” Services (908xx codes)  Interpretation of Test Results Limited to 4 hours per CY. No more than 1 hour may be billed for a date, unless special criteria are met. Not covered … to share information at regularly scheduled coordination of care meetings.

22 Psychological Testing

23 Psychological Testing  Psych testing codes changed in Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorshach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report

24 Psychological Testing Psychological testing (…e.g., MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face Psychological testing (…, e.g., MMPI), administered by a computer, with qualified health care professional interpretation and report

25 Psychological Testing  Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour

26 Psychological Testing  Developmental testing, with interpretation and report limited (e.g., Developmental Screening Test II, Early Language Milestone Screen) extended (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments)

27 Health & Behavioral Assessments

28 Health & Behavioral Assessments  Health and behavior assessments identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.  The focus is not on mental health but on the biopsychosocial factors important to physical health problems and treatments. Also, see Supplemental Information

29 Health & Behavioral Interventions  The focus of the intervention is to improve the patient's health and well being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems.

30 Health & Behavioral Assessments and Interventions  These codes describe services for patients who present with primary physical illnesses, diagnoses, or symptoms, and may benefit from assessments and interventions that focus on the biopsychosocial factors related to the patient's health status.  E&M codes should not be reported on the same day.

31 Health & Behavioral Assessments  Health and behavior assessment (e.g., health- focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires) each 15 minutes face-to-face with the patient; initial assessment each 15 minutes face-to-face with the patient; re-assessment

32 Health & Behavioral Interventions  Health and behavior intervention, each 15 minutes face-to-face; individual face-to-face; group (2 or more patients) face-to-face; family (with the patient present) face-to-face; family (without the patient present)

33 Coding Scenarios

34 Mental Health Coding Scenarios  Issue: (psychotherapy, office, min.) coded on the same day as an E&M service.  Response: If another provider provides an E&M service on the same day, append the 59 modifier (distinct procedural service) to If the same physician is providing both services, bill (psychotherapy, office, min., w/ E&M) instead.

35 Mental Health Coding Scenarios  Issue: Conjoint sessions where the focus of the therapy session is helping family members learn how to respond beneficially to the primary mental health issue of the identified client.  Response: Bill as family therapy services, under the name of the identified client.

36 Mental Health Coding Scenarios  Issue: Reporting collateral contacts or meetings. Collateral therapy is offered to assist the people in the client's life so they may better support the client's emotional healing. Collateral therapy may involve family members, school personnel, clergy, law enforcement officers, DCF staff, neighbors, etc.

37 Mental Health Coding Scenarios  Response: If the service is provided by a physician, the E&M codes can be used for meeting with others on behalf of the identified client. (Medicare will not pay for this type of service when the patient is not present, however). If the service is provided to the family by a therapist, use code (family therapy without the patient).

38 Mental Health Coding Scenarios For meetings with outside agencies or professionals (Social Workers, schools, etc.), use (environmental intervention). (Although many managed care plans do not pay for it, DHS and some commercial insurers do.) Finally, exists to report any mental health service that does not have a specific CPT code that describes it.

39 Mental Health Coding Scenarios  Issue: Two professionals from the same practice both attend a client meeting. Is there a way that each can bill for the meeting?  Response: If both providers contribute to the session and add value (and documentation supports this), we advocate both providers billing for their services recognizing that both may not be reimbursed.

40 Mental Health Coding Scenarios Nonetheless, we encourage clinics to report these services to ensure that: -Production data is correct -Clinics have the ability to truly assess collection rates from each of its payers. Supporting documentation must be sent with the claim, indicating the medical necessity for two providers.

41 Mental Health Coding Scenarios  Issue: Two hour diagnostic scheduled (lasts much longer due to records review and outside interviews) Many progressive tests over a period of weeks Report takes a long time, given the complexity and timing of tests.

42 Mental Health Coding Scenarios  Response: Consider whether this service is a consultation Consider prolonged service codes Apply for an extension for diagnostic assessment (beyond 2 hours) Bill tests according to total time (see code descriptions). Document ALL time.

43 ICD-9 Coding  ICD-9 coding is often assigned at (or close to) the first encounter – the initial psychiatric evaluation (code 90801) – and rarely changes after that point.

44 ICD-9 Coding  Providers should add/alter ICD-9s on charge tickets when circumstances change so it can be reported on claims. For example, the therapist might write “same” on a ticket for a visit in which the originally identified codes remain true. If there are changes, (s)he might write “same plus anxiety concerning unemployment (V62.0),” which can then be added to that claim.

45 ICD-9 Coding  Reporting a change in a patient’s status is important because it can affect the number of visits authorized, support more extensive visits, etc.

46 Next Steps

47 Next Steps  Assess E&M utilization patterns

48 Next Steps  Monitor CPT and ICD-9 frequency reports  Provide COMPLETE list of CPT and HCPCS codes to providers  Develop third-party payer matrix to manage the various reimbursement rules and idiosyncrasies

49 Next Steps – Third-Party Payer Matrix See Supplemental Information

50 Closing  Coding should be logical, clinically appropriate, and must be supported by documentation.  Accurate coding creates a useful internal database for: Compliance analysis Payer negotiations Compensation considerations Optimum reimbursement Service and best practice analysis Reporting uncompensated care.

51 Supplemental Information

52

53 For More Information This presentation was prepared by: Jeanne M. Chapdelaine, Director Direct Phone: (952) Partners Healthcare Consulting A Service of Wipfli LLP 7601 France Avenue South, Suite 400 Edina, MN

54 Disclaimer The information presented and responses to questions posed are not intended to serve as coding or legal advice. Many variables affect coding decisions and our response to the limited information provided in a presentation session is intended only to provide general information that might be considered in resolving coding issues. All coding must be considered on a case-by-case basis and must be supported by medical necessity and appropriate documentation. Therefore, we recommend considering a variety of sources to determine appropriate coding and claim submission. CPT codes are produced and copyrighted by the American Medical Association (AMA). Specific questions regarding the use of CPT codes may be directed to the AMA.