AUDIT? NO PROBLEM! PROACTIVE DOCUMENTATION GUIDELINES, PART 2 MINNESOTA PSYCHOLOGICAL ASSOCIATION ANNUAL CONFERENCE, 2015 RICHARD SETHRE, PSY.D., L.P.

OVERVIEW  Overview – the importance/power of Medicare guidelines  CPT codes  Diagnostic Assessments  Treatment plan  Progress and psychotherapy notes  How to be proactive about audits

ANTONIO PUENTE, PH.D - ROCK STAR OF CODING GUIDELINES   content/uploads/2014/07/CPT- Webinar pdf content/uploads/2014/07/CPT- Webinar pdf  content/uploads/2015/02/CPT pdf (2-2-15) content/uploads/2015/02/CPT pdf

Puente  Medicare sets the standard  The Standard for Universal Health Care:  – Coding (what can be done)  – Value (how much it will be paid)  – Documentation (what needs to be said)  – Auditing (determination of whether it occurred)

Puente  Possible Codes for Psychology = Approximately 60  Sections = Five Primary Separate Sections  – Psychiatry (e.g., mental health)  – Biofeedback  – Central Nervous System Assessment (testing)  – Physical Medicine & Rehabilitation  – Health & Behavior Assessment & Management – Team Conference  – Evaluation and Management

Puente  Codes describe time- based face-to-face services with the family and/or patient, with times of 30, 45, and 60 minutes.  Time refers to “face-to-face” unless otherwise stated.  Unit of time = “when the midpoint has been passed”

Puente  Time: Defining 60 Minutes “The Rounding Rule” 1 unit > or equal to 31 minutes to or equal to 91 minutes to or equal to 151 minutes to or equal to 271 minutes to < 331 mns.  The choice of code is based on the one that is closest to the actual time. In the case of the 30 minute codes, the actual time must have at least crossed the midpoint (16 minutes). (never less than 16 minutes)

Puente  (30 minutes) for actual psychotherapy time of minutes  (45 minutes) for actual time of minutes  (60 minutes) for actual time of 53 minutes or more.  90 minutes = – to be determined for code and time – For now, use 60 minute code plus 22 modifier

Puente  60 Minutes – Pre-authorization required by some companies – Does not equal previous 45’ code  90 Minutes – In E & M section, hence CMS is not covering – Other carriers may  Use in Conjunction with the Appropriate Prolonged Service Code ( ) for face-to- face Psychotherapy Services with the Patient of 90 minutes or longer) (tip = current prolonged services codes are E & M and thus not typically reimbursable for non-physicians)  Interactive complexity, reported with add-on code 90785, refers to specific communication factors that complicate the delivery of certain psychiatric procedures (90791, 90792, , 90853).

Puente  Psychotherapy provided to a patient in a crisis state is reported using codes and  The presenting problem is typically life threatening or complex and requires immediate attention.  Codes and are used to report the total duration of time spent face-to-face with the patient and/ or family by the physician or other qualified healthcare professional providing psychotherapy related to crisis.  Code is reported only once for the first minutes of psychotherapy for crisis on a given date, even if the time spent by the physician or other health care professional is not continuous. Add-on code is used to report additional block(s) of time of up to 30 minutes each beyond the first 74 minutes reported by (i.e., total of minutes, minutes, etc.).

Puente  Each CPT Code Should Generate a Separate Report (or at least a separate section) If Separate Sections Within One Report, Clearly Label/Title Sections of the Report to Match Code Used (e.g., Interview)

Health and Behavioral Codes (H & B) - from APAPO  Typically, health and behavior assessemnt and intervention services address an assortment of physical health issues – including patient adherence to medical treatment, symptom management, health- promoting behaviors, health-related risk-taking behaviors and overall adjustment to physical illness.

APAPO, H & B Codes  Only an ICD-9 physical diagnosis may be used in connection with these services. The psychologist may not make a medical diagnosis, as our scope of practice does not include making medical diagnoses. Clinicians may not bill psychiatric and H & B codes on the same day. The clinician must bill for the principle service being provided. H & B codes are billed in 15 minute units, rounded up, face-to-face time only.

APAPO, H & B codes  96150, initial assessment  96151, reassessment  96152, interventoin service  96153, intervention provided to a group  – intervention provided to a family with patient presenting  – intervention provided to family w/o patient present

DIAGNOSTIC ASSESSMENT (D.A.) Puente, again  History obtained, includes:  - Past psychiatric history  – Chemical dependency history  – Family history  – Social history  – Treatment history  – Medical history

D.A., Puente  Additional Information Obtained – Review of systems – Safety – Lethality – Aggression – Competency

D.A., Puente Specialty Specific Examination – Mental status Diagnosi(e)s; – Psychiatric diagnosi(e)s – Personality considerations – Contributing medical factors – Psychosocial stressors – Current level of functioning

D.A., Puente Treatment Plan – Consideration of medications – Psychotherapy – Tests – Level of Care/Supervision Informed Consent for Treatment Plan Disposition of Patient (e.g., testing)

D.A., MN DHS  Brief Diagnostic Assessment  Standard Diagnostic Assessment  Extended Diagnostic Assessment  Adult Diagnostic Assessment Update

TREATMENT PLAN DOCUMENTATION Donald Wiger Ph.D., L.P Wiger, DE (2010). The clinical documentation sourcebook (4th ed.). New York: Wiley Wiger, DE (2007). The well-managed mental health practice your guide to building and managing a successful practice, group, or clinic. New York, Wiley.

TX PLAN, Wiger OFAID system Onset Frequency Antecedents (triggers) Intensity (rating scales) Duration

TX PLAN, Wiger, OFAID example Child with tantrums - Onset one year ago - Frequency 3 times per week - Antecedents – when not permitted to get her way - Intensity- 7 on a scale of 10 -Duration – minutes Goal: specific and measurable treatment goals

PROGRESS NOTES Wiger SOAP  Subjective  Objective  Assessments  Plan DAP  Data  Assessment  Plan

PROGRESS NOTES, MH DHS Progress notes include:  Type of service  Date of service  Session start and stop times  Scope of service (nature of interventions or contacts including treatment modalities, phone contacts, etc.)  Recipient’s progress (or lack of) to overall treatment plan goals and objectives  Recipient’s response or reaction to treatment intervention(s)  Formal or informal assessment of the recipient’s mental health status  Name and title of person who gave the service  Date documentation was made in the client record

PROGRESS NOTES, MH DHS Other elements that may(emphasis added) be included:  current risk factors the recipient may be experiencing  emergency interventions consultations with or referrals to other professionals summary of effectiveness of treatment, prognosis, discharge planning, etc. test results and medications symptoms

“Psychotherapy notes” vs. “Progress notes”, MN Law Acknowledgments include “special advisers” - includes Trisha Stark, MPA

PSYCHOTHERAPY NOTES, MN LAW Psychotherapy Notes Defined. Notes recorded by a health care provider who is a mental health professional that: 1) Document or analyze the contents of conversations during a counseling session; and 2) Are separated from the rest of the patient’s medical records. (45 C.F.R. § )

PSYCHOTHERAPY NOTES, MN LAW Federal law (HIPAA Privacy Rule) allows a mental health professional to share psychotherapy notes, at the provider’s discretion, with patient consent. In recognition of the sensitivity of this information, HIPAA requires that this consent be captured on a form only documenting the consent to release psychotherapy notes.

PSYCHOTHERAPY NOTES, MN LAW Minnesota law is more stringent than HIPAA with respect to the rights of individuals.2 In Minnesota, patients have the right to view or release all parts of their medical record and psychotherapy notes are part of that medical record that can be viewed or released. The added protection of the notes inclusion in the medical record is to assure greater access for patients to all of their protected health information.

PSYCHOTHERAPY NOTES, MN LAW What’s in a medical record? Much of the confusion stems from the differences in definition of what constitutes a medical record. Even if psychotherapy notes are kept in a separate file, in Minnesota, they are considered to be part of the medical record. This is to ensure that patients have full access to complete information about their health.

PSYCHOTHERAPY NOTES, MN LAW HIPAA standard. Psychotherapy notes are specifically excluded from a patient’s general right to access or inspect their own medical records under HIPAA’s Privacy Rule. If mental health professionals wish to disclose the psychotherapy notes, they are generally permitted to do so, but must receive the patient’s authorization.

PSYCHOTHERAPY NOTES, MN LAW Minnesota standard. Minnesota’s Health Records Act gives patients access to “complete and current information possessed by that provider concerning any diagnosis, treatment, and prognosis” and does not distinguish psychotherapy notes from other medical records.

PSYCHOTHERAPY NOTES, MN LAW Minnesota law requires that a provider give a patient “complete and current” information concerning any diagnosis, treatment or prognosis that relates to the patient upon request. (Minn. Stat. § , subd. 2). A client also has the right to access and consent to release records related to psychological services under administrative rules governing psychologists (Minn. R ).

PSYCHOTHERAPY NOTES, MN LAW Minnesota has created an exception, however, that gives providers the discretion to withhold health records (including psychotherapy notes) if the provider believes that “the information is detrimental to the physical or mental health of the patient, or is likely to cause the patient to inflict self harm, or to harm another.” (Minn. Stat. § , subd. 7).

AUDITS, PROACTIVE DOCUMENTATION, Wiger  “The best preparation for an audit is to be prepared, with or without notice.”  “Charts should be up to date as a matter of standard procedure.”  “Charts should be written in a standardized format.”  Do not modify charts when preparing for an audit.  Be courteous and professional when interacting with the auditor.

AUDITS, PROACTIVE PREPARATIONS, Wills and Sethre Be knowledgeable about the policies and procedures for all MCO's with which you are contracted. You, or someone on your behalf, signed a contract with each MCO that includes a clause stating that you will read and comply with the MCO's policies and procedures guidelines.

ONLINE RESOURCES APAPO Billing and Coding page: rg/reimbursement/billing/ For a text copy of this presentation, including long urls:

QUESTIONS, DISCUSSION, COMMENTS