1. E/M coding for Mental Health Pamela Pully CPC, CPMA Professional Insurance Consultants.

2. Presenter  Pamela Pully  30+ years billing/coding/auditing all specialties.  CPC - Certified Professional Coder  CPMA – Certified Professional Medical Auditor  Member of American Academy of Professional Coders (AAPC), Past officer of local chapter. National Alliance of Medical Auditing Specialist (NAMAS) member, and current officer of Michigan Association of Reimbursement Officers (MARO)

3. Disclaimer  This information is accurate as of April 1, 2015 and is designed to offer basic information for coding and billing. All information is based on experience, training and has been researched, interpreted and carefully reviewed by this trainer. Medical compliance/coding and billing information changes quickly. This can become outdated quickly. This is intended to be an educational guide and should not be considered as legal or consulting opinion.

4. Disclaimer cont.  CPT, HCPCS and ICD-9 books were used for coding information.  Rules used come from AMA, ICD-9,CMS, final rule and others.  HIPAA and PPACA laws.  Any questions on information I am presenting, please ask. I will give you the source document I used.  It is important to me to give the best and most up to date information I can.

5. Goals for Training  Have a better understand of things you should and should not do when documenting for Evaluation and Management (E/M) codes.  Be aware of what is needed and/or required for each level of E/M.  Learn what is required for the new Diagnostic Evaluation.  Understand when to use add on codes

6. What we are going to talk about today. 1) Evaluation and Management (E/M) codes. The replacement for Medication Review 90862. 2) 7 Elements of E/M 3) 1997 Exam Rules 4) What are differences between New patient and established patients. 5) Diagnostic evaluation. 6) Add on code 90785 7) Documentation requirements. 8) This is an aggressive schedule, we can do it. 9) Ask questions as we go.

7. What we should not do  Cross Walk codes-90862 to any one E/M.  Use only time as factor for coding.  Use of unspecified diagnostic codes for services. Just minimal training in this area. Getting correct diagnosis especially ICD- 10 is a different training.  Treat all carriers the same.  Only use one carriers set of rules. This is especially important for Medicaid.

8. Different codes different rules  If you cross walk, the old medication review to one E/M code you run the risk for not meeting the documentation requirements.  Using the same code for easy and difficult cases can lead to rejections and flag for audit.  Documentation ( sometimes carrier utilization rules) decides the code.  Keep in mind 1% errors is100% wrong.

9. Review of documentation requirements 90862  Must include the condition for which the medication is needed, type of medication, dosage, directions for use, any frequent side effects and the effect the medication is having on the patients symptoms/condition 99213  2 of 3 for established patient  Expanded problem focus history  Expanded problem focus exam  Low Medical Decision Making (MDM)

10. Evaluation and Management  There are 7 components to E/M 3 key elements and 3 contributory factors and time. 1. History 2. Exam 3. Medical Decision Making 4. Counseling 5. Coordination of care 6. Nature of Presenting Problem 7. Time

11. E/M rules for time  Time factor: You can only use time if more than 50% of the visit is spent counseling and it is documented. More on this later.  You can have a higher level of E/M codes with less time.  Chief Complaint (CC) and Medical Decision Making (MDM) are the most important part of an E/M code.

12. Chief Complaint  The Chief Complaint also known as CC, is part of the medical history taking, and is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that are the reason for a medical encounter.medical historysymptomconditiondiagnosisphysician  The patient's initial comments to a physician, nurse, or other health care professional help form the differential diagnosis. nursehealth care professionaldifferential diagnosis

13. Understanding History Element of E/M CMS required history elements Type of history CCHPIROSPastPast, family, and/or socialfamilysocial Problem focused RequiredBriefN/A Expanded problem focused RequiredBrief Problem pertinent N/A DetailedRequiredExtended Pertinent Comprehensive RequiredExtendedComplete ]

14. 1995/1997 Exam rules  Best advise decide what works best for your practiced and use it.  You can use 1995 for one claim and 1997 for another.  Eliminate the potential risk from an audit. Make decision to use 1995 or 1997.  Write in policies and procedures. “We use 1997 exam rules for E/M” or “1995 rules”.

15. Understanding Exam Element of E/M  1995 rules are easy but usually for specialty physicians this is not the best rule to use.  1997 rules has bullet points within one area exam allowing you to get a better level.

16. 1995/1997  Lets look at the 1997 exam for psych  https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/eval_mgm t_serv_guide-ICN006764.pdf https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/eval_mgm t_serv_guide-ICN006764.pdf

17. Understanding MDM Element of E/M  A-number of diagnosis or treatment options  B-Risk of Complications and/or Morbidity or Mortality  C-amount and/or complexity of data reviewed  Remove the lowest next lowest rules.

18. A. number of diagnosis or treatment options A Number of Diagnoses or Treatment Options A B x C = D Problem(s) StatusNumberPointsResult Self-limited or minor (stable, improved, or worsening) Max = 2 1 Est. problem (to examiner); stable, improved 1 Est. problem (to examiner); worsening 2 New problem (to examiner); no additionalMax = 1 3 workup planned New problem (to examiner); add. Workup 4 planned

19. B. Risk of complications and/or morbidity or mortality  There is much information in this area.  It is found on the paper passed out with this power point.  Let review  Important factor in using the high level of toxic medicine.

20. Amount and/or complexity data reviewed C Amount and/or Complexity of Data Reviewed Reviewed DataPoints Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT1 Review and/or order of tests in the medicine section of CPT1 Discussion of test results with performing physician1 Decision to obtain old records and/or obtain history from someone other than patient Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider. 1 Independent visualization of image, tracing or specimen itself (not simply review of report) 2

21. AIMS test adds to E/M  Aims tests are not individually billable. Usually done by non-physician provider.  If you review test positive or negative and document you reviewed this is, an additional point is added to review of test data. This is in the MDM section of the E/M code. Test data reviewed, one point.

22. Time for counseling/coordination of care  You must spend more than 50% of the visit on counseling or coordinating care.  It must be documented: Total time and the amount of time spent on counseling or coordinating care.  You do not have to use start stop time of counseling. You can think of time spent as part of the entire visit. Just make sure you document.

23. N.A.M.A.S. 5/9/2014  Documentation of Time with Evaluation and Management Services:  Time is built into the E/M codes so physicians are told to base their E/M selection on the 3 components: History, Exam and Medical Decision Making. Times are listed in the CPT manual with each level of service as a guideline only.  If a provider spends more than 50% of a face-to-face visit counseling and/or coordinating patient's care, the provider can code the visit based on time spent even if the History, Exam and MDM elements are lacking.

24. N.A.M.A.S. 5/9/2014  Time must be documented as well as the detailed description of the circumstance (counseling patient or coordinating care). For example: 55 minutes spent with patient, 30 minutes was spent in discussion with patient and family regarding care.  Prolonged service codes can be reported in addition to an E/M code when the length of time a provider spends with a patient in an outpatient setting exceeds greater than 30 minutes beyond the typical for the level of service selected.

25. Difference in New patient and Established patient  A new patient for a group practice is one that has not been seen by anyone in the group with the same discipline in the last 3 years.  CMS and AMA have different rules for “new”  A new patient E/M code must meet 3 of 3 to be coded at that level.  An established patient only requires 2 of 3 to be coded at that level.

26. E/M codes for different place of service  AFC/Group home.  There are two groups of codes. New and Established.  New 99324-99328  Established 99334-99337  Residential home POS 12  New 99341-99345  Established 99347-99350

27. 90785 add on code for complicated cases 90785-This code can be used to add on to diagnostic evaluation and therapy codes not E/M when the follow is present. Factors typically present 1. Have other individuals legally responsible for their care, such as minors or adults with guardians, or

28. New 90785 add on code for complicated cases Factors typically present 2. Request others to be involved in their care during the visit, such as adults accompanied by one or more participating family member or interpreter or language translator or 3. Require the involvement of another third parties, such as child welfare agencies, parole or probation officers or schools.

29. 90785 maybe reported when at least one is present: 1. The need to manage maladaptive communication (related to, e.g.; high anxiety, high reactivity, repeated questions or disagreements ) among participants that complicates delivery of care. 2. Caregiver emotions or behavior that interferes with the caregivers understand and ability to assist in the implementation of the treatment plan.

30. 90785 maybe reported when at least one is present: 3. Evidence or disclosure of a sentinel event and mandated report to third party (e.g., abuse neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.

31. 90785 maybe reported when at least one is present: 4. Use of play equipment, other physical devices, interpreter, or translator to communicate with the patient to overcome barriers to therapeutic or diagnostic interaction between the physician or other qualified health care professional and a patient who…….next slide

32. 90785 maybe reported when at least one is present: a) Is not fluent in the same language as the physician or healthcare professional. b) Has not developed or has lost, either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the physician or healthcare professional.

33. 99211  This is the most basic service done in the office.  Usually done by nurse when patients is not being seen by doctor.  You must document 2 elements, Example vitals and what you did. This must be billed under the provider.

34. 99211  This code is for the office setting only.  If there is a nurse visit done in the home you have to follow the rule: CPT code first HCPCS codes second.  There is no CPT code for nurse visit in the home so you look to HCPCS.  The best HCPCS code for a nurse visit in the home is T1002.  Do not use T1002 for in office visits.

35. Documentation Documentation Guidelines a) They are in place and you need to familiarize yourself with them. b) Medical necessity is the most weighted elements in a E/M. There needs to be a reason for the visit. Chief Complaint. c) There are different guidelines for different carriers when it come to billing.

36. Documentation rules for E/M  We now know the parts of E/M. We need to be reminded that documentation must be complete in these areas.  You can lose money or increase revenue with your documentation.  You must put down what you are doing and the calculations in your head must be documented.  One doctor I worked with put it like this. “Document what you did do and why did you do it. Explain your thought process.”

37. Timeliness requirement  3.3.2.5 - Late Entries in Medical Documentation  (Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11)  The MACs, CERT, Recovery Auditors, and ZPICs shall give less weight when making review determinations to documentation, including a provider’s internal query responses, created more than 30 calendar days following the date of service. If the MACs, CERT, or Recovery Auditors identify providers with patterns of making late (more than 30 calendar days past the date of service) entries in the medical documentation, including the query responses, the reviewers shall refer the cases to ZPIC and may consider referring to the RO(regional office) and State Agency.

38. Diagnostic Evaluation CPT 90791 and 90792  Local Coverage Determination (LCD): Psychiatry and Psychology Services (L30489)  90791 : A psychiatric diagnostic evaluation (90791 is an integrated assessment that includes history, mental status and recommendations. It may include communicating with the family and ordering further diagnostic studies. Use add-on code 90785 in conjunction with 90791 when the diagnostic evaluation includes interactive complexity services.  90792 : A psychiatric diagnostic evaluation with medical services (90792) includes 90791 and a medical assessment. It may require a physical exam, communication with the family, prescription medications and ordering laboratory or other diagnostic studies. Use add-on code 90785 in conjunction with 90792 when the diagnostic evaluation includes Interactive Complexity services

39. Diagnoses  The rule is to code to the highest specificity.  Should not use unspecified codes.  Make sure to include all diagnoses that you considered before setting the plan or prescribing medication.  ICD-9 has ordering rules.  Final rule ICD-10 effective 10-01-2015

40. Medicaid provider qualifications requirements  90791--ok for N.P. or psychiatrist  90792 require a psychiatrist.  There was much discussion in Lansing with the state and changing this requirement. I finally happened 1/1/2015  The current mental health qualification chart has been changed.

41. Any questions?

42. Thank you  Pamela Pully CPC, CPMA  P.I.C. 810-964-1987  PamelaPully@yahoo.com