2. Agenda. Evaluation and Management (E - PowerPoint PPT Presentation
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1. Billing for Mental Health Servicesin a Community Health Center
Jeanne M. Chapdelaine
2. 2 Agenda Evaluation and Management (E&M) Services
Psych Services (908xx codes)
Health and Behavior Assessment Services
3. 3 E&M Coding Evaluation and Management (E&M) codes are available to:
Physicians (including psychiatrists)
…but not to therapy staff (PhD, LPs, etc.).
4. 4 E&M Coding E&M codes will be the predominant service code when used by primary care providers.
The mental health series of codes (908xx) are typically expected (by payers) to be used by psychiatrists and therapists (though CPT does not state this).
5. 5 E&M Coding 99211 (lowest level established patient E&M) can be used by:
Nursing/medical assistant staff for miscellaneous services
RNs who provide medication management services, if they are supervised by a physician (but 99211 should not be billed if another provider is also billing that day).
6. 6 E&M Levels of Service Most E&M levels of service are selected using “Key Components:”
Medical decision making.
But, when counseling or coordination of care dominates the encounter (>50%), time can be the controlling factor in selecting the level.
This happens a lot in primary care, especially those providing behavioral health services.
7. 7 E&M Levels of Service “Counseling” is a discussion with the patient and/or family regarding:
Diagnosis, impressions, prognosis, or recommended diagnostic studies
Risk and benefits of treatment options
Instructions and/or importance of compliance, risk factor reduction
Emotional needs of patients
Patient and/or family education.
8. 8 E&M Levels of Service The provider must document the time spent counseling or coordinating care AND total encounter time.
In the clinic ? Face-to-face time
In the hospital ? Unit or floor time
(On unit/bedside rendering services for that patient:
Reviewing or adding to the record
Talking with patient/family or other providers.)
9. 9 E&M Levels of Service But the primary (and most confusing) method is to select the level of service based on:
Medical decision making.
Our discussion will focus on the Exam component because the History and Decision Making components do not vary by service type.
10. 10 E&M – Psychiatric Exam (1997)
11. 11 E&M – Exam (1995)
12. 12 E&M – Exam
13. 13 “Psych” Services (908xx codes) 90801 Psychiatric Diagnostic Interview
30 minute unit. Limited to one 2-hour session (4 units) per recipient per CY, unless extension requirements are met.
Prior to the completion of the diagnostic assessment, providers may bill for explanation of findings, psychological testing, and one psychotherapy session.
14. 14 “Psych” Services (908xx codes) Interactive services
Typically furnished to children.
CPT defines interactive services as involving:
15. 15 “Psych” Services (908xx codes) Interactive codes
90802 Initial psychiatric evaluation
90810-90815 Individual therapies
90857 Group therapy
16. 16 “Psych” Services (908xx codes) Group and Family Therapy codes
Length of session may be 1 hour or 1½ hours (family) and up to 2 hours (multiple family or group).
17. 17 “Psych” Services (908xx codes)
18. 18 “Psych” Services (908xx codes)
19. 19 “Psych” Services (908xx codes)
20. 20 “Psych” Services (908xx codes) 90882 Environmental Intervention
Adult benefit: 15-minute unit; children: no reference.
Authorization is required for more than 10 hours/month or 72 hours/CY.
21. 21 “Psych” Services (908xx codes) 90887 Interpretation of Test Results
Limited to 4 hours per CY.
No more than 1 hour may be billed for a date, unless special criteria are met.
Not covered … to share information at regularly scheduled coordination of care meetings.
23. 23 Psychological Testing Psych testing codes changed in 2006
96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorshach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report
24. 24 Psychological Testing 96102 Psychological testing (…e.g., MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face
96103 Psychological testing (…, e.g., MMPI), administered by a computer, with qualified health care professional interpretation and report
25. 25 Psychological Testing 96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour
26. 26 Psychological Testing Developmental testing, with interpretation and report
96110 limited (e.g., Developmental Screening Test II, Early Language Milestone Screen)
96111 extended (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments)
Health & Behavioral Assessments
28. 28 Health & Behavioral Assessments Health and behavior assessments identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.
The focus is not on mental health but on the biopsychosocial factors important to physical health problems and treatments.
Also, see Supplemental Information
29. 29 Health & Behavioral Interventions The focus of the intervention is to improve the patient's health and well being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems.
30. 30 Health & Behavioral Assessments and Interventions These codes describe services for patients who present with primary physical illnesses, diagnoses, or symptoms, and may benefit from assessments and interventions that focus on the biopsychosocial factors related to the patient's health status.
E&M codes should not be reported on the same day.
31. 31 Health & Behavioral Assessments Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires)
96150 each 15 minutes face-to-face with the patient; initial assessment
96151 each 15 minutes face-to-face with the patient; re-assessment
32. 32 Health & Behavioral Interventions Health and behavior intervention, each 15 minutes
96152 face-to-face; individual
96153 face-to-face; group (2 or more patients)
96154 face-to-face; family (with the patient present)
96155 face-to-face; family (without the patient present)
34. 34 Mental Health Coding Scenarios
35. 35 Mental Health Coding Scenarios
36. 36 Mental Health Coding Scenarios Issue: Reporting collateral contacts or meetings.
Collateral therapy is offered to assist the people in the client's life so they may better support the client's emotional healing. Collateral therapy may involve family members, school personnel, clergy, law enforcement officers, DCF staff, neighbors, etc.
37. 37 Mental Health Coding Scenarios Response:
If the service is provided by a physician, the E&M codes can be used for meeting with others on behalf of the identified client. (Medicare will not pay for this type of service when the patient is not present, however).
If the service is provided to the family by a therapist, use code 90846 (family therapy without the patient).
38. 38 Mental Health Coding Scenarios For meetings with outside agencies or professionals (Social Workers, schools, etc.), use 90882 (environmental intervention). (Although many managed care plans do not pay for it, DHS and some commercial insurers do.)
Finally, 90899 exists to report any mental health service that does not have a specific CPT code that describes it.
39. 39 Mental Health Coding Scenarios Issue: Two professionals from the same practice both attend a client meeting. Is there a way that each can bill for the meeting?
Response: If both providers contribute to the session and add value (and documentation supports this), we advocate both providers billing for their services recognizing that both may not be reimbursed.
40. 40 Mental Health Coding Scenarios Nonetheless, we encourage clinics to report these services to ensure that:
Production data is correct
Clinics have the ability to truly assess collection rates from each of its payers.
Supporting documentation must be sent with the claim, indicating the medical necessity for two providers.
41. 41 Mental Health Coding Scenarios Issue:
Two hour diagnostic scheduled (lasts much longer due to records review and outside interviews)
Many progressive tests over a period of weeks
Report takes a long time, given the complexity and timing of tests.
42. 42 Mental Health Coding Scenarios Response:
Consider whether this service is a consultation
Consider prolonged service codes
Apply for an extension for diagnostic assessment (beyond 2 hours)
Bill tests according to total time (see code descriptions). Document ALL time.
43. 43 ICD-9 Coding ICD-9 coding is often assigned at (or close to) the first encounter – the initial psychiatric evaluation (code 90801) – and rarely changes after that point.
44. 44 ICD-9 Coding Providers should add/alter ICD-9s on charge tickets when circumstances change so it can be reported on claims.
For example, the therapist might write “same” on a ticket for a visit in which the originally identified codes remain true.
If there are changes, (s)he might write “same plus anxiety concerning unemployment (V62.0),” which can then be added to that claim.
45. 45 ICD-9 Coding Reporting a change in a patient’s status is important because it can affect the number of visits authorized, support more extensive visits, etc.
47. 47 Next Steps Assess E&M utilization patterns
48. 48 Next Steps Monitor CPT and ICD-9 frequency reports
Provide COMPLETE list of CPT and HCPCS codes to providers
Develop third-party payer matrix to manage the various reimbursement rules and idiosyncrasies
49. 49 Next Steps – Third-Party Payer Matrix
50. 50 Closing Coding should be logical, clinically appropriate, and must be supported by documentation.
Accurate coding creates a useful internal database for:
Service and best practice analysis
Reporting uncompensated care.
53. 53 For More Information This presentation was prepared by:
Jeanne M. Chapdelaine, Director
Direct Phone: (952) 548-3374
Partners Healthcare Consulting
A Service of Wipfli LLP
7601 France Avenue South, Suite 400
Edina, MN 55435
54. 54 Disclaimer