1. CPT Coding Changes for 2013 Getting Prepared American Psychiatric Association

2. Welcome and Introductions Alison Lynch, MD – Associate Professor, Clinical – Departments of Psychiatry and Family Medicine – Carver College of Medicine – University of Iowa Robert Smith, MD – Associate Professor, Clinical – Emeritus – Department of Psychiatry – Carver College of Medicine – University of Iowa

3. Who is here today? 25 psychiatrists 9 mid-level providers 10 therapists 135 others (coders, administrators, billers, directors, secretaries)

4. Workshop Goals All mental health providers utilizing the new behavioral health codes correctly after January 1, 2013 All mental health prescribers are knowledgeable about the E/M codes and documentation guidelines and can correctly utilize these codes for established patients Billers/coders are knowledgeable concerning the CPT changes so as to assist their clinicians

5. Session I Overview Disclaimer Legal Aspects of Coding Why Change Now Three Aspects of Time Add – on Codes Changes for Psychotherapy Interactive Complexity Crisis Therapy Code E/M Codes with Psychotherapy

6. Disclaimer This information is for educational and informational purposes only, and represents the understanding of the presenters regarding the material involved. The presenters assumes no liability or responsibility for behavior based on this presentation. American Psychiatric Association

7. Disclaimer Although we are knowledgeable through our own work and consultation with other experts in the field, we are neither responsible for, nor assume any liability for your work and coding. You are ultimately responsible for your work, coding, and the documentation

8. CPT Coding and Documentation – Whose Job is it? Documentation and coding is part of physician/provider work You are responsible for the clinical work and equally responsible for the documentation and coding This should not be the job of your staff! American Psychiatric Association

9. Legal Issues Audits Sampling

10. CMS Expands Scope Of Medicare Audits. American Medical News (10/1, Fiegl) reports, "A Medicare auditor tasked with reviewing past claims for physician and hospital services in 15 states will start scrutinizing the billing of office visits, claims that previously had been off-limits to recovery audit contractors." The audits will be conducted by a contractor, Atlanta-based Connolly Inc., and will "focus on upcoming and cloned documentation." American Medical News notes that many groups, including the AMA, opposes CMS expanding audits to look at this type of billing, known as E&M. American Medical News

11. Legal Issues Overpayments Fines

12. Legal Issues The OIG may impose civil monetary penalties if a provider knows of an overpayment and does not report and return the overpayment. $10,000 per claim Treble damages Additionally, the OIG may also exclude the provider from participation in Federal health care programs.

13. Why Seek Change Now? Psychiatric codes/Behavioral Health codes suffered because of budget neutrality Evaluation and Management codes are Increasing in Value Under-valuation of E/M component of Psychotherapy with Evaluation and Management Services Problem with “restricted contracts” American Psychiatric Association

14. Medicare Payments Follow-up Exams 90862 $58.54 99211 $19.74 99212 $42.55 99213 $70.46 20% more 99214 $104.16 78% more 99215 $139.89

15. Medicare Payments New Patient 90801 $152.49 90802 $166.10 90791 $159.50 90792 $131.40 ? 99204 $160.66 99205 $199.46 90791+90785 $164.50 90792+90785 $136.40

16. Timeline August 31, 2012 November 2012 January 1, 2013 CPT electronic files released; changes to CPT codes became public CMS releases the Final Rule on the 2013 Physician Fee Schedule (includes relative values) New code set goes in to effect – must bill using new CPT codes (This is non-negotiable) American Psychiatric Association

17. Important Concepts ISSUES of TIME AND THE NEW CODES CPT Time Rule for Psychotherapy – “A unit of time is attained when the mid-point is passed” – “When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used.” – As an example, codes of 30, 45, and 60 minutes are billed at 16-37 mins, 38-52 mins, and 53-67 mins. American Psychiatric Association

18. ISSUES of TIME AND THE NEW CODES CMS has “typical times” for the new patient E/M codes and for the established E/M codes When greater than 50% of the time of the visit is counseling and/or coordination of care, time becomes the controlling factor for a level of E/M service

19. Counseling & E/M Codes and Psychotherapy Counseling with the patient and/or family is a discussion of the following: 1.Prognosis 2.Test Results 3.Instructions 4.Risk Reduction 5.Education 6.Compliance/Adherence

20. Important Concepts Add-on Codes – It is a code(s) that describes work that is performed in addition to the primary service – It is never reported alone – Examples include Psychotherapy, Interactive Complexity and Crisis Services

21. Overview of Changes Implemented in the Behavioral Health codes for 2013 Key services have been assigned new numbers and/or are described differently, and all new codes can be used in all settings There are now two codes for an initial evaluation; one with medical services and one without Psychotherapy is no longer distinguished by site of service Work previously described using the interactive codes is now done by using an add-on code There is a new crisis psychotherapy code Key codes have been deleted, e.g. 90862 Pharmacologic Management and replaced with E/M codes Psychotherapy with E/M is now an E/M code with a Psychotherapy add-on American Psychiatric Association

22. Psychiatry Coding Psychiatric Dx Evaluation (90791, 90792) Individual Psychotherapy w/pat &/or family (90832-90838) Crisis Psychotherapy (90839, 90840) Interactive Complexity Add-On (90785) Add–On when used with Evaluation and Management Service Code, when applicable New Structure of Psychiatry Coding

23. Psychiatric Diagnostic Evaluation - Overview A distinction has been made between diagnostic evaluations without medical services and evaluations with medical services Interactive services are captured using an add-on code – These codes can be used in any setting – These codes can be used more than once in those instances where the patient and other informants are included in the evaluation – These codes can be used for reassessments Psychiatrists and other medical providers have the option of using the appropriate 99xxx series code in lieu of the 90792 American Psychiatric Association

24. Psychiatric Diagnostic Evaluation 2012 90801 90802 2013 90791, Psychiatric diagnostic evaluation 90792, Psychiatric diagnostic evaluation with medical services 90791 plus 90785, Psychiatric diagnostic evaluation with interactive complexity 90792 plus 90785, Psychiatric diagnostic evaluation with medical services and with interactive complexity American Psychiatric Association

25. Documentation Guidelines 90791 and 90792 Date Chief complaint History of present illness Past history – Family – Social – Medical – Psychiatric (Note: no ROS required) Comprehensive mental status examination Diagnosis Formulation/prognosis – Assessment of patient’s willingness to comply with treatment program Legible signature

26. Psychotherapy - Overview Psychotherapy codes are no longer site specific Psychotherapy time includes face-to-face time spent with the patient and/or family member Time is chosen according to the CPT time rule Interactive psychotherapy is reported using the appropriate psychotherapy code along with the interactive complexity add-on code American Psychiatric Association

27. Psychotherapy 2012 90804, 90816 90806, 90818 90808, 90821 2013 90832, Psychotherapy, 30 minutes 90834, Psychotherapy, 45 minutes 90837, Psychotherapy, 60 minutes American Psychiatric Association

28. Documentation Guidelines for Psychotherapy Time (CPT Time Rule Applies) Modality of Therapy Goals and Progress Treatment Plans and Periodic Updates

29. “Old” Interactive CPT Codes All deleted: – Interactive diagnostic interview examination – Interactive individual psychotherapy – Interactive group psychotherapy Meant to capture language difficulties – Typically for children – Use of physical aids and non-verbal communication 29

30. Interactive Complexity CPT add-on code 90785 Add-on code background – Listed with “+” prefix in the CPT Manual However, the billing form should list the 5-digit number WITHOUT the “+” – May only be reported in conjunction with specified other codes (“primary procedure”) – Never reported alone 90785 – Describes 4 types of communication factors These factors complicate the primary procedure – Describes types of patients and situations most commonly associated with interactive complexity – Commonly present during visits by children and adolescents but may apply to visits by adults, as well 30

31. The Primary Procedures for Interactive Complexity May be reported in conjunction with – Psychiatric diagnostic evaluation (90791, 90792) – Psychotherapy (90832, 90834, 90837) – Psychotherapy add-on (90833, 90836, 90838) when reported with E/M – Group psychotherapy (90853) May not be reported in conjunction with – E/M alone – Family psychotherapy (90846, 90847, 90849) – Psychotherapy for new crisis codes (90839, 90840) 31

32. The Communication Factors Interactive complexity may be reported when at least one of the following communication factors is present: 1.The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care 2.Caregiver emotions or behavior that interfere with implementation of the treatment plan 3.Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants 4.Use of play equipment, physical devices, interpreter or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not developed or lost expressive or receptive language skills to use or understand typical language 32

33. Exception? CMS does not recommend billing for interactive complexity when using a translator/ translation services. The Americans with Disabilities Act prevents use of these services to justify billing.

34. Reporting Psychotherapy Time with 90785 When performed with psychotherapy – Interactive complexity component (90785) relates ONLY to the increased work intensity of the psychotherapy service – 90785 does NOT change the time for the psychotherapy service 34

35. Psychotherapy for Crisis A new code with an add-on code have been added to describe crisis psychotherapy (90839) 90839, Psychotherapy for crisis, first 60 minutes – (CPT Rule applies: 30-74 minutes) +90840, Psychotherapy for crisis each additional 30 minutes: (75 – 104 minutes) American Psychiatric Association

36. Crisis Psychotherapy ( 90839, + 90840) Rationale: New concept and an addition to the psychotherapy section When psychotherapy services are provided to a patient who presents in high distress with complex or life threatening circumstances that require urgent and immediate attention Musher Group, LLC © 2012

37. 37 Crisis Psychotherapy 90839 is a stand-alone code not to be reported with psychotherapy or psychiatric diagnostic evaluation codes, the interactive complexity code, or any other psychiatry section code. +90840 is an add-on code that should be reported for each additional 30 minutes of service. Musher Group, LLC © 2012

38. Psychotherapy for Crisis Crisis Psychotherapy: an Example – “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.”

39. E/M with Psychotherapy Overview Psychotherapy with E/M is now reported by selecting the appropriate E/M service code (99xxx series) and the appropriate psychotherapy add-on code The E/M code is selected on the basis of the site of service and the key elements performed The psychotherapy add-on code is selected on the basis of the time spent providing psychotherapy and does not include any of the time spent providing E/M services If no E/M services are provided, use the appropriate psychotherapy code (90832, 90834, 90837) American Psychiatric Association

40. Psychotherapy with E/M vs. E/M with Psychotherapy 2012 90805, 90817 90807, 90819 90809, 90821 2013 Appropriate 99xxx series E/M code plus one of the following: 90833, Psychotherapy, 30 minutes when performed with an E/M 90836, Psychotherapy 45 minutes when performed with an E/M 90838, Psychotherapy 60 minutes when performed with an E/M (CPT Time Rule Applies) American Psychiatric Association

41. E/M codes The psychotherapy add-on code are most often billed with the following E/M codes: Outpatient, established patient: 99212 – 99215 Subsequent hospital care 99231 – 99233 Subsequent nursing facility care 99307 – 99310 American Psychiatric Association

42. Pharmacologic Management 90862 has been DELETED Psychiatrists/mid-levels should use the appropriate E/M series code (99xxx) to report this service A new add-on code – 90863 – has been added to describe pharmacologic management when performed by a prescribing psychologist; Physicians/mid-levels should NEVER use 90863 American Psychiatric Association

43. Thank You For Your Attention