1. Coding and Compliance Training Psychiatrists

2. Objectives  Remember the principles of compliance and their importance to your practice  Review teaching physician rules  Assure knowledge to appropriately document and bill in Psychiatry School of Medicine Compliance 843-8638

3. Compliance is important to reimbursement  Providing medically necessary services  Meeting documentation requirements  Understanding appropriate billing Understanding and applying coding and compliance conventions improves reimbursement and the quality of the medical record documentation. Providing good care while billing accurately and confidently requires: School of Medicine Compliance 843-8638

4. Good documentation and billing practices make for good patient care. Who’s Looking:  Recovery Audit Contractors (RACS)—Medicare, Medicaid and commercial insurers pay third party contractors to recoup inappropriately documented or billed services  Office of Inspector General (OIG), Health & Human Services— works with the Department of Justice to investigate suspected abuse or fraudulent claims  Routine error rate testing and auditing programs Compliance is important to reimbursement School of Medicine Compliance 843-8638

5. Types of Psychiatric Services  Psychiatric diagnostic evaluation  Evaluation and Management services (E&Ms)  Psychotherapy – Individual – For crisis – Group settings  Procedures/other School of Medicine Compliance 843-8638

6. Psychiatric Diagnostic Evaluation with Medical Services CPT Code 90792 Must include documentation of:  History  Mental status  Indicated physical exam elements  Recommendations Also includes, as appropriate:  Communicating with family or other sources  Ordering and/or reviewing of diagnostic studies School of Medicine Compliance 843-8638

7.  90792 is a comprehensive service used once per evaluation (even if two sessions are required)  If reported more than once per episode of illness, documentation is required to establish medical necessity.  May not be reported on the same day as an E&M service or psychotherapy  In certain, rare circumstances family members, guardians, or significant others may be seen in lieu of the patient. School of Medicine Compliance 843-8638 Psychiatric Diagnostic Evaluation-CPT Code 90792

8. For Interactive Complexity—add code 90785  Reports additional work due to specific communication factors that complicate the delivery of a psychiatric procedure  Interactive complexity factors are typically present with patients who:  have individuals legally responsible for their care such as minors or adults with guardians  request others to be involved in their care during the visit or  require the involvement of third parties such as child welfare agencies  At least one of the following must be present:  Need to manage maladaptive communication  Caregiver emotions or behavior that interfere with caregivers assistance in implementing the treatment plan  Evidence or disclosure of a sentinel event and mandated report to third party  Use of play equipment, other physical devices, interpreter or translator for a patient who — Is not fluent in the language of the physician — Hasn’t developed or has lost expressive language skills or receptive communication skills to understand the provider School of Medicine Compliance 843-8638

9. Psychotherapy – for billing purposes  Defined as the treatment for mental illness and behavioral disturbances in which the therapist, through definitive therapeutic communication, attempts to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development.  Includes ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement of family member(s) or others in the treatment process.  Maintenance psychotherapy is not usually covered. Well-documented sessions for helping a patient maintain his/her highest level of functioning, such as a patient with borderline personality disorder, may be covered on a case-by case basis. School of Medicine Compliance 843-8638

10. Documentation of Psychotherapy Services The note for each encounter must include:  The amount of time spent in psychotherapy,  The therapeutic maneuvers employed during the session such as behavior modification, supportive, or interpretive interactions and  The purpose of the psychotherapy Additionally, a periodic summary of goals, progress towards goals, and an updated treatment plan must be included in the medical record School of Medicine Compliance 843-8638

11.  Psychotherapy without medical evaluation and management services:  90832 (16-37 minutes)  90834 (38-52 minutes)  90837 (53 or more minutes)  Psychotherapy time may include face to face time with family members as long as the patient is present for part of the service.  Do not bill psychotherapy codes for sessions less than 16 minutes duration.  Interactive complexity is reported by also billing 90785 Psychotherapy Services School of Medicine Compliance 843-8638

12. Psychotherapy with evaluation and management services are reported with an E&M service and a psychotherapy add-on code:  90833 (16-37 minutes)  90836 (38-52 minutes)  90838 (53 or more minutes) If less than 16 minutes, no psychotherapy is billable. E&M with Additional Psychotherapy Services School of Medicine Compliance 843-8638

13. E&M service with Psychotherapy  Requires differentiating E&M history gathering, physical exam and decision making from psychotherapy  The time spent in psychotherapy must be documented separately from the E&M service.  Example documentation: “The patient was seen for a total of 50 minutes. 25 Minutes was spent in psychotherapy. The psychotherapy was supportive in nature with the goal of continuing remission of the patient’s depressive symptoms and to help the patient in coping with his cognitive deficits.“ School of Medicine Compliance 843-8638

14.  The E&M level is chosen before the amount of time spent in psychotherapy.  Psychotherapy inherently includes some ongoing assessment  An E&M service with psychotherapy may not be billed based on time counseling.  Prolonged services may not be reported with an E&M and psychotherapy.  The OIG is actively reviewing E&Ms with psychotherapy for appropriate documentation School of Medicine Compliance 843-8638 E&M service with Psychotherapy

15.  In most cases, the level of E&M service when billed with a psychotherapy add-on is expected to be a lower level than an E&M service without psychotherapy because  the frequency of evaluation of the patient when psychotherapy is part of the treatment plan  psychotherapy includes ongoing assessment that may not be also billed as E&M services  Benchmark data from academic psychiatrists compiled by the Association of American Medical Colleges shows over 50% are billed at 99213 when psychotherapy is also performed: School of Medicine Compliance 843-8638 9921199212992139921499215 2.1%17.6%54.4%24.9%0.9% E&M service with Psychotherapy

16. Billing Psychotherapy with an E&M service School of Medicine Compliance 843-8638

17. Choosing the Correct Outpatient Category Outpatient E&M Categories Consultation New Established School of Medicine Compliance 843-8638

18. Use of Consultation Codes  Outpatient Consult Codes: 99241-99245  Use when expert opinion or advice is requested by an appropriate source involved in patient’s care  Does not include patients “referred for management of a condition” or self referred  Use outpatient consultation codes only one time per request, subsequent visits are established  Written or verbal request must be documented in the rendering providers note and the consultant's opinion communicated by written report to the requesting provider. School of Medicine Compliance 843-8638

19. Documenting Consultations Documentation of a consultation request must be clearly stated in the note: WRONG: Mr. Patient referred by Dr. Jones for management of GERD symptoms. RIGHT: “Mr. Patient is seen in consultation at the request of Dr. Jones for evaluation of abdominal pain.” School of Medicine Compliance 843-8638

20. New Patient  New Patient CPT codes: 99201-99205  Has not received any professional evaluation and management (E&M) services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years, including inpatient, outpatient or emergency room.  A patient would still be considered “new” if a diagnostic procedure was billed without an E&M visit charge. School of Medicine Compliance 843-8638

21. Established Patient  Established Patient CPT codes: 99212-99215  Has received an E&M service from the division within the past three years—any venue inpatient, emergency room or consultations School of Medicine Compliance 843-8638

22. Visit Components Consults and new patient visits must include all three of the following components – established patient visits must include any two of the three:  History – History of present illness Documenting History Documenting History – Review of systems History example History example – Past family and social history  Physical examination 1995 Physical Exam 1995 Physical Exam 1997 Single Organ Exams  Medical decision Making – Diagnosis and management options Documenting MDM Documenting MDM – Amount and complexity of data reviewed – Overall risk Risk Table Risk Table Click these links for more information School of Medicine Compliance 843-8638

23. Psychotherapy for crisis  Psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status exam and a disposition.  The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma.  The presenting problem is typically life threatening or complex and requires immediate attention to a patient in high distress.  Report the total duration of time face to face with the patient and/or with the family.  The patient must be present for at least some portion of the service. School of Medicine Compliance 843-8638

24.  90839 is billed for the first 60 minutes  Add 90840 for each additional 30 minutes after the initial hour  Psychotherapy for crisis of less than 30 minutes is reported with standard psychotherapy codes School of Medicine Compliance 843-8638 Psychotherapy for crisis

25. The following services are not time-based:  Family psychotherapy - medically necessary treatment of the family unit when maladaptive behaviors of family members are exacerbating the patient’s illness in the treatment process.  90846 without the patient present  90847 patient and family  90849 multiple family group psychotherapy  90853 Group psychotherapy - personal and group dynamics are discussed, allowing emotional catharsis, instruction, insight and support  90845 Psychoanalysis (not reimbursed by most insurers) School of Medicine Compliance 843-8638 Other Psychotherapy Services

26. Psychotherapy is not covered if:  Documentation indicates that dementia has caused significant cognitive deficiency to prohibit establishing a therapeutic relationship.  Patient suffers from profound mental retardation. School of Medicine Compliance 843-8638 Psychotherapy services

27. Clinical Psychologists may bill:  96101 – Psychological testing (includes assessment of emotionality, intellectual abilities, personality and psychopathology, eg MMPI, Rorschach, WAIS)  96116 – Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg acquired knowledge, attention, language, memory, planning and problem solving and visual spatial abilities.  96118 – Neuropsychological testing (eg Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test)  96125 – Standardized cognitive performance testing (eg Ross Information Processing Assessment) School of Medicine Compliance 843-8638 Central Nervous System Assessments

28.  It is expected that the administration of these tests will generate material that will be formulated into a report.  A minimum of 31 minutes must be provided to report any of the testing “per hour” codes (psychologist’s or physician’s time)  Bill both time spent face-to-face with the patient and interpreting and preparing the report  Bill the quantity of hours spent School of Medicine Compliance 843-8638 Central Nervous System Assessments

29. Medicare’s Teaching Physician (TP) Attestation Requirement  The teaching physician (TP) does not have to duplicate any resident documentation.  The TP must be present during performance of the resident’s key portions of the service or personally repeat the key portions  The TP must personally document his or her presence for E&M services.  Documentation by a resident of the presence and participation of the TP is not sufficient.  The resident note alone, the TP note alone or a combination of the two may be used to support the level of service billed.  Documentation may be dictated and typed, or a computer-inserted statement if it is initiated by the TP. School of Medicine Compliance 843-8638

30. Medicare’s Examples of Unacceptable TP notes 1."Agree with above." followed by legible countersignature or identity; 2."Rounded, Reviewed, Agree." followed by legible countersignature or identity; 3."Discussed with resident. Agree." followed by legible countersignature or identity; 4."Seen and agree." followed by legible countersignature or identity; 5."Patient seen and evaluated." followed by legible countersignature or identity; and 6.A legible countersignature or identity alone. The preceding six and similar statements don’t make it possible to determine whether the TP was present, evaluated the patient, and/or had any involvement with the plan of care. School of Medicine Compliance 843-8638

31. Medicare Guidelines for Supervision of Psychotherapy The TP presence requirement met by concurrent observation of the service by video or one-way mirror. Must be present for entire period of time billed if psychotherapy code is used. School of Medicine Compliance 843-8638

32. Medicaid Requirements Medicaid requires that the TP be "immediately available" to the resident and patient and use "direct supervision". Direct supervision does not necessarily mean that the TP must be present in the room when the service is performed. The degree of supervision is the responsibility of the TP and is based on the skill, level of training and experience of the resident as well as the complexity and severity of the patient's condition. Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician. School of Medicine Compliance 843-8638

33. Where To Get Help http://www.med.unc.edu/compliance School of Medicine Compliance Office 919-843-8638  Heather Scott, CPC, SOM Compliance Officer  Dana Petty, CPC, SOM Compliance Review Analyst  Nirmal Gulati, MS, CPC, SOM Compliance Auditor  Tracy Riggs, FNP, SOM Compliance Consultant School of Medicine Compliance 843-8638