1. Billing, Coding and Documentation to Maximize Reimbursement
Mary Jean Mork, LCSW
April 12, 2018

2. Objectives Participants will be able to:
Identify necessary documentation for behavioral health billing
Describe when and how the Health and Behavior Codes can and should be used
Describe when and how the Crisis codes can and should be used
Get answers to questions they have about billing, coding and documentation

3. Official Disclaimer
Consultant makes no warranty regarding the manner in which any payor, governmental or private, will accept or deny any claim for reimbursement relating to integrated mental health services.
In publishing or otherwise disseminating any Work Product this author makes no representation or warranty regarding the manner in which any payor, governmental or private, will accept or deny any claim for reimbursement relating to integrated mental health services; that the provided is not intended to replace the information contained in the ICD-9- CM and CPT-4 manuals or specific coding, reporting, or reimbursement information that may be disseminated by third-party or government payers; and that providers should seek advice for their own consultants with respect to submission of particular claims or categories of claims for reimbursement by payors.

4. The Basics of Mental Health billing, coding and documentation
What’s in a record:
Initial Assessment
Treatment Plan
Progress Notes
What should you need to demonstrate:
Medical Necessity
Coordination with the provider
Progress and/or need for continued therapeutic intervention
A clear plan with measurable objectives
Exact time spent in sessions (where required)

5. Initial Assessment 90791
Must include: complete medical including past, family and social
Psychiatric history
Mental Status Exam
Establishment of initial diagnosis
Evaluation of patient’s ability and capacity to respond to treatment
Initial plan of treatment
Can be done:
At onset of illness
If a new episode of illness occurs
After a hiatus
Or on admission or readmission to an IP setting

6. The Treatment Plan Individualized Must state:
Type of treatment, e.g. CBT
Amount of treatment, e.g sessions
Frequency of treatment, e.g. every other week
Duration of services, 2 months
Diagnosis
Anticipated goals and specific objectives
“Not required if only a few brief services will be furnished”

7. Therapeutic interventions
90832 – – Individual Therapy - 30 to 60 minutes
Report actual time spent
90847 and – Family Therapy – when the primary purpose is the treatment of the patient’s condition
Can’t be reported for less than 26 minutes
90853 – Group treatment – involving no more than 12 patients. Actual time must be recorded.
Notes can be similar to Progress Notes, or
Notes can contain two portions:
Common language for all patients – key issues presented
That particular patient’s participation and any significant changes in status

8. Progress Notes Must be included Name of patient and date of service
Type of service, e.g. Individual, Family
Time element – exact time
Modalities and frequency of treatment furnished
A note for each encounter that includes: diagnosis, symptoms, functional status, focused MSA, treatment plan, prognosis and progress to date
Identity and credentials of person performing the service

9. Crisis Codes and 90840
Used for urgent assessment and history of crisis state, a mental status exam and disposition.
Includes psychotherapy, mobilization of resources to diffuse crisis and restore safety, and implementation of psychotherapeutic interventions to minimize risk
Typically life threatening, complex and requires immediate attention to a patient in high distress e.g. suicidality, homicidality
Can be coded by DO, MD, APRN, or PA or other qualified health care providers (LSW, LISW, psychology, counselors)
From: Coding and Documentation for Behavioral Health Providers (2016). Diane E. Zucker, M.Ed. CCS-P, Health Care Consultant.

10. Crisis Codes 90839 and 90840 - continued
Does not need to be continuous
Full attention of the provider (physician or other qualified health care provider) must be devoted to this patient/family
Patient must be present for some or all of the service
90839 – used for the first minutes and can only be coded once per date
used for each additional block of 30 minutes (not less than 15 minutes)
Do not report in conjunction with 90791, 90792, psychotherapy codes or other psychiatric services
From: Coding and Documentation for Behavioral Health Providers (2016). Diane E. Zucker, M.Ed. CCS-P, Health Care Consultant.

11. Health and Behavioral Assessment Codes

12. Health & Behavior (H&B) Codes 96150 – 96155
Underlying physical illness or injury
Biopsychosocial factor may be affecting medical treatment
Cognitive capacity for the approach
Patient
Documents need
Physician
Does not duplicate other assessment
Assessment

13. Health and Behavior Codes
96150
Assessment
Initial assessment to determine the biological psychological and social factors affecting the physical health and any treatment problems, e.g. health-focused interview
96151
Re-assessment
Re-assessment to evaluate the condition and determine the need for further treatment. Can be performed by clinician other than the one who did the initial assessment
96152
Ind Intervention
Service to modify the psychological, behavioral, cognitive and social factors affecting the pt's physical health and well-being, e.g. using CBT
96153
Grp Intervention
Group sessions typically last 90 minutes and involve 8-10 pts, e.g. Smoking cessation
96154
Fam Intervention
Service to family with pt. present, e.g. relaxation techniques with diabetic child with parent present

14. Billing for H&B Medical diagnosis Medical bill – not mental health
Billed by practice with Behavioral Health Clinician:
Hospital license
Primary care office
Rural Health Clinic
Federally Qualified Health Center

15. Examples

16. Adult H&B examples
55 year-old: Hx of AMI, HTN, cholesterol, family history of CVD. High risk - cardiac complications.
35 year-old: diagnosis chronic asthma, HTN, panic attacks. Seen for assessment and follow-up Original assessment - emotional, social and medical history, including ability to manage problems r/t chronic asthma, hospitalizations & treatments.

17. Adolescent H&B examples
16-year-old: fibromyalgia, hx numerous pain episodes, poor school attendance, isolation from peers Prior to disease: school attendance normal, difficulties with peers not reported Previous attempts by rheumatology service & pain team: manage pain and facilitate positive school adjustment not successful.
15-year-old: acute lymphoblastic leukemia recently began maintenance phase of treatment. Monthly blood cell counts suggest chemotherapy was not being taken, physician spent considerable time with patient discussing potential consequences. Referral for suspected non-adherence.

18. Options Referral: improve diabetes management Referral: reduce anxiety
Health and Behavior Assessment
Medical referral and diagnosis
Brief, focused assessment and intervention
Referral: reduce anxiety
Mental Health Assessment
Medical referral needed?
Mental Health diagnosis
“Comprehensive” assessment and treatment

19. The Codes H&B codes Mental Health Codes 96150: Assessment
96151: Reassessment
96152:
Individual intervention
96153:
Group intervention
96154:
Family intervention
Mental Health Codes
90791:
Initial Assessment
90832, 90834, 90837:
Individual Therapy
90846, 90847:
Family Therapy
90853:
Group Therapy
E/M codes

20. Insurance Ramifications
H&B codes:
Covered by some insurers, not all
Discipline reimbursable for some, not all
Medical benefit: No pre-auth, no carve-out, no different co-pay
Medical practice bills
Mental Health codes:
Covered by most insurers
Generally reimbursable
Contract & credentialing with behavioral health carve-out needed
May eventually need pre-auth
May require larger co-pay

21. Documentation Patient has underlying physical illness or injury
Biopsychosocial factors affect the treatment of the medical problem
Patient has capacity to benefit from the treatment
Need for psychological evaluation or intervention is necessary
Not duplicative of other providers

22. Documentation – Reassessment 96151
Detailed progress notes must include the following elements:
Date of change in mental or physical status
Clear rationale for why re-assessment is required, and
Clear indication of the precipitating event that necessitates re-assessment

23. Documentation – Initial Assessment 96150
Must include, at a minimum, the following elements:
Date of initial diagnosis of physical illness
Clear rationale for why assessment is required, and
Assessment outcome including mental status and ability to understand or respond meaningfully, and
Goals and expected duration of specific psychological intervention(s), if recommended.

24. Documentation – Intervention 96152-96154
Must include, at a minimum, the following elements:
Evidence that the patient has the capacity to understand or to respond meaningfully, and
Clearly defined psychological intervention planned, and
Goals of the psychological intervention
Expectation that psychological intervention will improve compliance with the medical treatment plan, and
The response to the intervention and
Rationale for frequency and duration of services

25. Time and Billing Limitations (Unclear)
Initial assessment limited to a maximum of one hour (4 units)
Reassessment limited to maximum of one hour (4 units)
Intervention is limited to maximum of twelve hours (48 units)
Each regardless of number of sessions

26. Getting Started and Increasing the H&B Services
Pick a population
Use your established screening process
Start with Anthem patients ….

27. Resources Medicare Links http://www.cms.gov/Manuals/IOM/list.asp
Medicare Documentation Guidelines for Evaluation and Managements Services 95 & 97
NHIC
Other
– the National Council for Community Behavioral Healthcare
– Integrated Behavioral Health Project
AHRQ Playbook

28. Contact Mary Jean Mork, LCSW
MaineHealth and Maine Behavioral Healthcare
Presentation delivered through:
The Collaborative Family Healthcare Association