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Mental Health Diagnostic and Procedural Coding

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Mental Health Diagnostic and Procedural Coding. Objective. To improve diagnostic and procedural coding for mental health screening, assessment, referral, and intervention. How Do Y ou D ocument M ental H ealth S ervices ?. Who documents mental health services?

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Mental Health

Diagnostic and Procedural Coding

objective
Objective

To improve diagnostic and procedural coding for mental health screening, assessment, referral, and intervention

how do y ou d ocument m ental h ealth s ervices
How Do You Document Mental Health Services?
  • Who documents mental health services?
  • Where are mental health services documented? (mental health chart, medical record, both charts, log sheet, database, encounter form)
  • How do mental health providers and primary care providers share information about mental health services?
what we ll c over
What We’ll Cover…
  • Why code?
  • General Coding Principles
  • Mental Health Diagnostic Codes
  • Mental Health Procedural Codes
  • Reimbursement
    • Who can bill?
    • Fraud and Abuse
  • Work plan suggestions
we can t bill for mental health services so why code
“We can’t bill for mental health services, so why code?”

You should still document in order to:

  • Justify your position
  • Assess mental health problems of school population
  • Track treatment
  • Track compliance
  • Assist in measuring outcomes
  • Demonstrate a need for mental health reimbursement
why code correctly
Why Code Correctly?
  • Reimbursement depends on services described by CPT codes--coding is the basis for reimbursement
  • Diagnosis codes support medical necessity for services delivered
  • Understanding coding assumptions and guidelines helps providers to optimize reimbursement
  • Providers must establish integrity in the health care system
      • Document necessity services
      • Illustrate complexity of services
general coding principles1
General Coding Principles
  • The purpose of codes is to document services provided
  • Documented services are likely to be paid
  • Services not documented “never happened”
  • Never “upcode” for the purpose of getting more money
  • Most likely, you are undercoding
general coding principles cont
General Coding Principles (cont)
  • Two Part Coding Process
    • CPT – “What you do”
    • ICD – “Why you do it”
  • Diagnosis codes (ICD) must support procedure codes (CPT)

You must always

have both!

general coding principles cont1
General Coding Principles (cont)
  • Primary Steps for Coding an Encounter:
    • Provider chooses procedure code (CPT) from encounter form or superbill
    • Provider notes diagnosis, which is matched to a diagnosis code (ICD)
documentation
Documentation

Where to document codes?

  • Encounter Form
  • Database

BOTH (if separate):

  • mental health chart AND
  • medical record
coding systems
Coding Systems

ICD-9-CM(International Classification of Diseases, Ninth Revision, Clinical Modification)

  • Used by health care professionals to classify patient illnesses, injuries, and risk factors

*ICD-10 coming out in 2012

DSM-IV-TR(Diagnostic and Statistical Manual – Fourth Edition – Text Revised)

  • Used by mental health clinicians to make a psychiatric diagnosis

*DSV-V coming out in 2013

anxiety disorders
Anxiety Disorders

300.01 Panic Disorder Without Agoraphobia

300.21 Panic Disorder With

Agoraphobia

300.22 Agoraphobia Without History of Panic Disorder

300.29 Specific Phobia

Specify type: Animal Type/Natural Environment Type/Blood- Injection-Injury Type/Situational Type/Other Type

300.23 Social Phobia

Specify if Generalized

300.3 Obsessive-Compulsive Disorder

Specify if With Poor insight

309.81 Posttraumatic Stress Disorder

Specify if Acute/Chronic

Specify if With Delayed Onset

308.3 Acute Stress Disorder

300.02 Generalized Anxiety Disorder

300.00 Anxiety Disorder NOS

depressive disorders
Depressive Disorders
  • 296.xx Major Depressive Disorder
    • .2x Single Episode
    • .3x Recurrent
  • 300.4 Dysthymic Disorder

Specify if Early Onset/Late Onset

Specify With Atypical Features

  • 311 Depressive Disorder NOS
disruptive behavior disorders
Disruptive Behavior Disorders
  • 314.xx Attention-Deficit/Hyperactivity Disorder
    • .01 Combined Type
    • .00 Predominantly Inattentive Type
    • .01 Predominantly Hyperactive-Impulsive Type
  • 314.9 Attention-Deficit/Hyperactivity Disorder NOS
  • 312.xx Conduct Disorder
    • .81 Childhood-Onset Type
    • .82 Adolescent-Onset Type
    • .89 Unspecified Onset
  • 313.81 Oppositional Defiant Disorder
  • 312.9 Disruptive Behavior Disorder NOS
substance abuse dependence
Substance Abuse/Dependence
  • 303.90 Alcohol Dependence/305.00 Alcohol Abuse
  • 304.00 Amphetamine Dependence/305.70 Amphetamine Abuse
  • 304.30 Cannabis Dependence/305.20 Cannabis Abuse
  • 304.20 Cocaine Dependence/305.60 Cocaine Abuse
  • 304.50 Hallucinogen Dependence/305.30 Hallucinogen Abuse
  • 304.60 Inhalant Dependence/305.90 Inhalant Abuse
  • 305.1 Nicotine Dependence
  • 304.00 Opioid Dependence/305.50 Opioid Abuse
  • 304.60 Phencyclidine Dependence/305.90 Phencyclidine Abuse
  • 304.10 Sedative, Hypnotic, or Anxiolytic Dependence/305.40 Sedative, Hypnotic, or Anxiolytic Abuse
  • 304.80 Polysubstance Dependence
  • 304.90 Other (or Unknown) Substance Dependence
  • 305.90 Other (or Unknown) Substance Abuse

The following specifiers apply to Substance Dependence as noted:

With Psychological Dependence/Without Psychological Dependence

Early Full Remission/Early Partial Remission/Sustained Full Remission/Sustained Partial Remission In a Contained Environment On Agonist Therapy

documentation of diagnostic codes
Documentation of Diagnostic Codes
  • Report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services.
  • Providers should report the diagnosis to their highest degree of certainty.
coding systems1
Coding Systems
  • CPT (Current Procedural Terminology) - codes that predominantly describe services & procedures.
  • They provide a common billing language that providers and payers can use for payment purposes
evaluation management e m codes
Evaluation & Management (E&M) Codes
  • 99201 – 99215 New and Established Patient Office Visits
  • 99241 - 99245 Consultations
  • 99361 - 99362 Case Management Services, Team Conferences
  • 99371 - 99373 Case Management Services, Telephonic
mental health procedure codes
Mental Health Procedure Codes
  • 90801 - 90802 Psychiatric Diagnostic or Evaluative Interview Procedures
  • 90804 - 90829 Psychotherapy
  • 90804 - 90815 Office or Other Outpatient Facility
  • 90810 - 90815 Interactive Psychotherapy
  • 90816 - 90829 Inpatient Hospital, Partial Hospital or Residential Care Facility
  • 90845 - 90857 Other Psychotherapy
  • 90862 - 90889 Other Psychiatric Services or Procedures
psychiatric therapeutic procedures
Psychiatric Therapeutic Procedures
  • CPT Codes 90804 – 90889
  • Psychotherapy is the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the patient and, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.
e m codes and mh codes
E&M Codes and MH Codes
  • The Evaluation and Management services should not be reported separately, when reporting codes: 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, 90829
reimbursement
Reimbursement
  • Who can bill?
  • Fraud and Abuse
who can bill
Who Can Bill?
  • What are the rules governing who can bill for mental health diagnosis/treatment in your state?
who can bill1
Who Can Bill?
  • Who can bill for behavioral health services?
    • Most states accept physicians, Clinician Psychologists (CP), Licensed Clinical Social Workers (LCSW)
    • However, each State has its own rules and many will pay for other professionals
coverage issues
Coverage Issues
  • A provider should know what services are covered.
  • Services must be documented and medically necessary in order for payment to be made.
  • Do you, as a provider, know if all services provided are covered?
  • Are you documenting properly, and what about this “medically necessary” bit?
how much are you paid
How Much Are You Paid?

Reimbursement

  • Reductions in reimbursement rates by provider type
    • Physician - not discounted
    • Clinical Psychologist - discounted
    • LCSW - further discounted
    • Other - discounted if covered
reimbursement issues
Reimbursement Issues
  • E&M codes are limited to physicians, Pas, NPs, nurses
  • Same is true for 90805, 90807, 90809 codes
  • An E&M (992XX) and a therapy (908XX) cannot be billed on the same date of service to most Medicaid programs
documentation and coding fraud and abuse
Documentation and Coding:Fraud and Abuse
  • Services MUST be medically necessary (determined by payers based on a review of services billed)
  • Music, game, instrument, pet interaction therapies, sing-alongs, arts and crafts, and other similar activities should not be billed as group or individual activities.
  • Services performed by a non-licensed provider particularly as “incident to” using the PIN of the licensed provider
elements of incident to
Elements of “Incident To”
  • An integral part of the physician’s professional service
  • Commonly rendered without charge or generally not itemized separately in the physician’s bill
  • Of a type that are commonly furnished in physician’s office or clinic
  • Furnished under the physician’s direct personal supervision
action step review program services
Action Step:Review Program Services
  • Define the Behavioral/Mental Health Services your students are receiving
  • Determine if there are additional Behavioral/Mental Health Services you want to provide
action step review and modify encounter form
Action Step:Review and Modify Encounter Form
  • Does encounter form include both diagnostic and procedural codes that would be used for behavioral health when delivered by primary care providers? Mental health providers?
  • Do procedural codes represent all services provided (including those not billed for)?
  • Do diagnostic codes represent all diagnostic categories (including those not billed for)?
action step review and modify documentation procedures
Action Step:Review and Modify Documentation Procedures
  • Are diagnostic and procedure codes documented for in each progress note?
  • Are codes for each encounter documented in both the SBHC medical record and mental health chart (if separate)?
  • Are codes entered into database regardless of reimbursement?
action step understand state program and provider coverage issues
Action Step:Understand State Program and Provider Coverage Issues
  • Research State Program Information
    • www.cms.gov (Medicare Regulations)
    • Search by state by Department of Health or Department of Mental Health to find state specific information
  • Contact State Medicaid Assistance Program and determine specific Behavioral Health Service requirements
  • Invite Medicaid Representatives to your facility or visit them to present Behavioral Health Program and clearly understand the requirements
questions to answer
Questions to Answer
  • What criteria must programs (SBHC) meet in order to provide behavioral health services?
  • What providers are eligible to provide behavioral health services?
  • What are your state’s credentialing and licensing requirements for providers of behavioral health services?
  • What credentialing and licensing requirements are necessary for billing in your state?
  • What are the guidelines for billing services as “incident to?”
action step determine reimbursement estimates
Action Step:Determine Reimbursement Estimates
  • Obtain reimbursement rates by provider type for state and other programs
  • Understand billing rules by payer, e.g. billing E&M visit same day as Behavioral Health visit, number of visits limits, auth/pre-authorizations, etc.
  • Assure you have a complete understanding of program parameters re: Individual Therapy, Case Management, Special Behavioral Health Services, etc.
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