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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


Why code
Why Code?


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? code?”

  • 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 code?”

  • 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 code?”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 code?”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 code?”

Where to document codes?

  • Encounter Form

  • Database

    BOTH (if separate):

  • mental health chart AND

  • medical record



Coding systems
Coding Systems code?”

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 code?”

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 code?”

  • 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 code?”

  • 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 code?”

  • 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 code?”

  • 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 code?”

  • 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 code?”

  • 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 code?”

  • 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 code?”

  • 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 code?”

  • 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 code?”

  • Who can bill?

  • Fraud and Abuse


Who can bill
Who code?”Can Bill?

  • What are the rules governing who can bill for mental health diagnosis/treatment in your state?


Who can bill1
Who code?”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 code?”

  • 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 code?”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 code?”

  • 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: code?”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” code?”

  • 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


Work plan suggestions
Work code?”Plan Suggestions


Action step review program services
Action code?”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 code?”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 code?”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 code?”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 code?”

  • 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: code?”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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