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2. 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
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3. 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 for “health risk screen of a caregiver for the benefit of the patient.”
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4. Poll Are you currently coding for chronic care management? Yes No
Inconsistently
Not sure
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5. Chronic care management coding ccm
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6. Chronic Care Overview Click to edit Master text styles First level
Second level
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7. 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.
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8. 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, )
Advance Consent (verbal now allowed)
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9. 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
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10. 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 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.
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11. 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
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12. 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 (Complex CCM, $94)
CPT (Complex CCM Add-On, $47)
CPT 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
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13. What is New for CY 2017
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14. 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)
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15. Summary
RHCs and FQHCs can receive payment for CCM when CPT code 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
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16. 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
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17. Summary
New Complex CCM Codes (CPT 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
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18. Coding for integrated behavioral health and other psychotherapy services
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19. 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
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20. 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:
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21. Poll Are you currently coding for BH visits? Yes No Inconsistently
Not sure
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22. 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
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23. 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.
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24. 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.
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25. 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.
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26. 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
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27. 2017 National Fee Schedule Non-facility rate G0502 $142.84
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28. 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
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29. Screening brief intervention and referral for treatment
SBIRT Coding
Screening brief intervention and referral for treatment
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30. 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.
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31. Poll Are you currently coding for SBIRT? Yes No Inconsistently
Not sure
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32. 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
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33. 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.
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34. 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).
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35. 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.
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36. 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 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).
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37. 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.
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38. “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.”
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39. 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 for maternal depression screening 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 or (alcohol and/or substance abuse structured screening and brief intervention services).
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40. Poll I now have a better understanding of coding opportunities for:
Chronic care management
Behavioral health
SBIRT
All of the above
Yes No
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41. Copyright 2017. Medical Group Management Association® (MGMA®)
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