Specialty Training for Psychiatrists

1. Specialty Training for Psychiatrists Coding Compliance and Documentation Training for Re-appointment April 2019

2. Objectives • Review the principles of compliant billing and documentation and their importance to your practice • Review teaching physician rules • Assure knowledge of appropriate psychiatry documentation and billing • Documentation integrity in electronic medical records

3. General Compliance Overview

4. Basic Tenets Billing accurately and confidently requires only three essentials: • Doing only what is medically necessary • Documenting what is done • Billing what is documented Understanding and applying coding and documentation conventions allows for compliant billing, sometimes increased revenue and generally improved quality of the medical record documentation.

5. Compliance is important to reimbursement Good documentation and billing practices make for good patient care and maximized compensation. Who’s Looking: • Recovery Audit Contractors (RACS)—Medicare, Medicaid and commercial insurers pay third party contractors to recoup inappropriately documented or billed services • Office of Inspector General (OIG), Health & Human Services—works with the Department of Justice to investigate suspected abuse or fraudulent claims • Routine error rate testing and auditing programs

6. Psychiatric Services and Procedures

7. Types of Psychiatric Services

8. Psychiatric Diagnostic Evaluation with Medical Services Must include documentation of: • History • Mental status • Indicated physical exam elements • Recommendations Also includes, as appropriate: • Communicating with family or other sources • Ordering and/or reviewing of diagnostic studies CPT Code 90792

9. Psychiatric Diagnostic Evaluation with Medical Services • A comprehensive service used once per evaluation--even if two sessions are required to complete • If reported more than once per episode of illness, documentation is required to establish medical necessity. • May not be reported on the same day as an E&M service or psychotherapy • In certain, rare circumstances, family members, guardians, or significant others may be seen in lieu of the patient. CPT Code 90792

10. For Interactive Complexity—add code 90785 • The code reports additional work due to specific communication factors that complicate the delivery of a psychiatric procedure • Interactive complexity factors are typically present with patients who: • have individuals legally responsible for their care such as minors or adults with guardians • request others to be involved in their care during the visit or • require the involvement of third parties such as child welfare agencies

11. For Interactive Complexity—add code 90785 • At least one of the following must be present: • Need to manage maladaptive communication among participants that complicates delivery of care • Caregiver emotions or behavior that interfere with caregivers assistance in implementing the treatment plan • Evidence or disclosure of a sentinel event and mandated report to third party • Use of play equipment, other physical devices, interpreter or translator for a patient who • Is not fluent in the language of the physician • hasn’t developed or has lost expressive language skills or receptive communication skills to understand the provider

12. Psychotherapy–described for billing purposes • Defined as the treatment for mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development. • Includes ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement of family member(s) or others in the treatment process. • Maintenance psychotherapy is not usually covered. Well-documented sessions for helping a patient maintain his/her highest level of functioning, such as a patient with borderline personality disorder, may be covered on a case-by case basis.

13. Documentation of Psychotherapy Services The note for each encounter must include: • The amount of time spent in psychotherapy, • The therapeutic maneuvers employed during the session such as behavior modification, supportive, or interpretive interactions and • The purpose of the psychotherapy. Additionally, a periodic summary of goals, progress towards goals, and an updated treatment plan must be included in the medical record.

14. E&M with Additional Psychotherapy Services Psychotherapy withEvaluation and Management (E/M) services are reported with an E/M code and an “add-on” psychotherapy service code: • 90833 (16-37 minutes) • 90836 (38-52 minutes) • 90838 (53 or more minutes) If less than 16 minutes, no psychotherapy is billable.

15. E/M service with Psychotherapy • Requires differentiating E/M history gathering, physical exam and decision making from psychotherapy • The time spent in psychotherapy must be separately documented from the E/M service. • Example documentation: "The patient was seen for a total of 50 minutes of which 25 minutes was spent in psychotherapy. The psychotherapy was supportive in nature with the goal of continuing remission of the patient’s depressive symptoms and to help the patient in coping with his cognitive deficits."

16. E/M service with Psychotherapy • The E/M level is chosen before the amount of time spent in psychotherapy. • Psychotherapy inherently includes some ongoing assessment. • An E/M service with psychotherapy may not be billed based on time spent in counseling. • Prolonged services may not be reported with an E/M and psychotherapy. • The Office of Inspector General (OIG) is actively reviewing E/Ms with psychotherapy for appropriate documentation.

17. Psychotherapy for Crisis • Psychotherapy for crisis is 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. • Report the total duration of time face to face with the patient and/or with the family. The physician must be devote their full attention to the patient and therefore, cannot provide services to any other patient during the same time period. • The patient must be present for at least some portion of the service.

18. Billing Psychotherapy for Crisis • CPT code 90839 is billed for the first 60 minutes • Add 90840 for each additional 30 minutes after the initial hour • Psychotherapy for crisis of less than 30 minutes is reported with standard psychotherapy codes • Psychotherapy for crisis may not be billed on the same day as: • psychiatric diagnostic evaluation (90792) (or 90791—without medical services), • psychotherapy services (90832-90838) or • other psychiatric services (90785-90899)

19. Other Time-based Psychotherapy Services • Family psychotherapy occurs when the patient's family is part of the patient evaluation and treatment process. • 90846 without the patient present • 90847 patient and family Family dynamics as they relate to the patient's mental status and behavior are a main focus of the sessions. Attention is also given to the impact the patient's condition has on the family, with therapy aimed at improving the interaction between the patient and family members. Services less than 26 minutes cannot be reported.

20. Other Psychotherapy Services

21. Evaluation and Management Services

22. Choosing the Correct Outpatient Category Please use CPT 90792 for new patients

23. Use of Consultation Codes • Outpatient Consult Codes: 99241-99245 • Use when expert opinion or advice is requested by an appropriate source involved in patient’s care • Does not include patients referred for management of a condition or self-referred • Use outpatient consultation codes only one time per request, subsequent visits are established • Written or verbal request must be documented in the rendering providers note and the consultant's opinion communicated by written report to the requesting provider.

24. Documenting Consultations Documentation of a consultation request must be clearly stated in the note: WRONG: Mr. Patient is referred by Dr. Jones for management of major depressive disorder. RIGHT: “Mr. Patient is seen in consultation at the request of Dr. Jones for evaluation of major depressive disorder.”

25. Established Patient • Established Patient CPT codes: 99212-99215 • An established patient is defined as: • Having received an E/M service from the division within the past three years in any venue, including inpatient, outpatient, emergency room or consultations.

26. Documentation Components Consultations must include all three of the following components – established patient visits must include two of the three: • History • History of present illness • Review of systems • Past family and social history • Physical examination • Medical decision making* • Diagnosis and management options • Amount and complexity of data reviewed • Overall risk *Medical Decision Making helps to support the overall medical necessity of the service and is looked to as a key component for all services.

27. Teaching Physician Guidelines

28. Medicare Teaching Physician (TP) Requirements • The TP does not have to duplicate any resident documentation. • The TP must be present during performance of the resident’s key portions of the service or personally repeat the key portions of an E/M service for Medicare and TRICARE patients. • The TP must personally document his or her presence for E/M services and psychiatric diagnostic evaluations for TRICARE patients. • Documentation by a resident of the presence and participation of the TP in E/M services is sufficient for Medicare beneficiaries. • The resident note alone, the TP note alone or a combination of the two may be used to support the level of service billed.

29. Examples of Unacceptable TP notes • "Agree with above." followed by legible countersignature or identity; • "Rounded, Reviewed, Agree." followed by legible countersignature or identity; • "Discussed with resident. Agree." followed by legible countersignature or identity; • "Seen and agree." followed by legible countersignature or identity; • "Patient seen and evaluated." followed by legible countersignature or identity; and • A legible countersignature or identity alone. The preceding six and similar statements do not support whether the TP was present, evaluated the patient, and/or had any involvement with the plan of care.

30. Supervision of Psychotherapy for Medicare Billing • The TP presence requirement is met by concurrent observation of the service by video or one-way mirror. • For Medicare and TRICARE psychotherapy services, the TP must be present for entire time spent in psychotherapy. UNC HCS has not traditionally supervised in this manner and therefore does not bill Medicare or TRICARE for resident psychotherapy. • For any time-based service involving a resident, the amount of time billed to Medicare must be the teaching physician’s time. • If E/M with psychotherapy is performed with a resident, the E/M portion may be billed if the teaching physician documents that he was present for the key portions and agrees with or amends the resident’s assessment and plan.

31. Medicaid Requirements • For Medicaid E/M services, the teaching physician must be "immediately available" to the resident by telephone and for other procedures, "direct supervision" is required. • Direct supervision does not necessarily mean that the TP must be present in the room when the service is performed, but must be on site “in the office suite.” • The degree of supervision is the responsibility of the TP and is based on the skill, level of training, and experience of the resident as well as the complexity and severity of the patient's condition. • Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician.

32. Documentation Integrity in Electronic Health Records

33. Data Replication in Electronic Documentation • Altering notes improperly may undermine the integrity of the electronic health record (EHR) and jeopardize reimbursement and patient safety. • Medicare does allow documentation changes within limits, including amendments, corrections, addenda, and delayed entries if they are clearly identified and there is no tampering with original content. • The billing provider is responsible for the entire content of the documentation including its accuracy and any copied information. • Clinical documentation must demonstrate clearly distinct variation between notes. • The HPI, ROS, exam, and impression and plan must demonstrate documentation relevant to EACH clinical encounter and be reviewed and edited appropriately. • When possible, the use of copying and pasting of laboratory, pathology or radiology results in its entirety should be minimized in order to reduce “note bloat”. Summarizing findings and medical judgment is encouraged. See PolicyStat ID: 5153534 Copying and Pasting and Data Replication in Electronic Documentation.

34. Software Features and Capabilities • Templates • Auto-populating tools and drop down menus may multiply the effect of an incorrect piece of data and may also contribute to the inappropriate up coding of an encounter. • Cloning • Cloning occurs when an entry in the EHR is worded the exact same way or is very similar to previous entries. • When entries are copied and pasted without being edited, medical necessity is not established because the documentation isn’t specific to the current patient encounter. • Patient care could be compromised if old treatment plans are copied and pasted.

35. What are auditors looking for? • Inaccurate or outdated information • Redundant information, which makes it difficult to identify the current information • Inability to identify the author or intent of documentation • Inability to identify when the documentation was first created • Propagation of false information • Internally inconsistent progress notes • Unnecessarily lengthy progress notes

36. “Make Me the Author” Function in Epic • Allows a provider to substitute their signature for that of another person who entered notes in the EHR. • This function does not replace the attestation requirement for a Teaching Physician working with a Resident physician as it does not support the documentation by the Teaching Physician of their face-to-face involvement with the patient during the patient encounter.

37. Tips to Avoid Re-entering Documentation • For physical exams performed that were identical in scope and findings, make a statement in the current note. • “Same exam performed as on 11/15/17 with same findings as below.” • You may refer to material reviewed in EPIC instead of entering specific detail into the note. • “Medication list and medical history reviewed.” • “Patient intake form dated November 15, 2017 reviewed; all systems other than those in HPI are negative.”

38. Use of Scribes • Scribes MAY NOT: • Provide any clinical care to patients • Interject their own observations, impressions or recommendations of care for care into the EMR • Scribe Documentation: If the encounter note was written by a scribe, the scribe must sign the note and indicate that they were acting as a scribe. • For example: “Entered by xx, (name of scribe), acting as scribe for Dr./PA/APP. Signature (of scribe)” • Provider Documentation: The provider should include a statement that they reviewed the documentation, and attest to the accuracy of the note. The provider may add to the note if additional information is needed. The provider then co-signs the note. • For example: “The documentation recorded by the scribe accurately reflects the service I personally performed and the decisions made by me. Signature (of provider)” • See PolicyStat ID: 5153539 Documentation of Care Health Related Data by Scribes.

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