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Behavioral Health Coding that Works in Primary Care. Mary Jean Mork, LCSW April 16 & 17, 2009. Workshop Outline. Our program background Reimbursement big picture and problems Your questions about reimbursement Process for addressing problems Products to organize our thinking

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Behavioral health coding that works in primary care
Behavioral Health Coding that Works in Primary Care

Mary Jean Mork, LCSW

April 16 & 17, 2009

Workshop outline
Workshop Outline

  • Our program background

  • Reimbursement big picture and problems

  • Your questions about reimbursement

  • Process for addressing problems

  • Products to organize our thinking

  • Your challenges and successes

Learning objectives
Learning Objectives

Attendees will:

  • Be able to identify who to involve in order to better understand the regulatory and payment situation for integrated care in your own setting

  • Receive tools to help organize the facts around payment and licensing at home

Our mental health integration program primary care mental health teams
Our Mental Health Integration Program:Primary Care/Mental Health Teams

  • Primary Care sites

    • Rural Health Clinics (RHC)

    • Federally Qualified Health Centers (FQHC)

    • Hospital owned practices

    • Private practices

  • Local Mental Health Partners

    • Specialty Mental Health agencies

    • Hospital owned Behavioral Health organizations

    • Community Mental Health Centers

The goal creating a sustainable model of mental healthcare in primary care
The Goal: Creating a sustainable model of mental healthcare in primary care

The problems with integrated care
The Problems with Integrated Care

  • No one seems to know how to get paid

  • Mental Health regulations and licensing expectations don’t fit the primary care setting

  • Confidentiality vs. “shared records”

  • Lack of clarity and understanding about present practices

  • Complicated licensing and reimbursement rules without accessible experts

Examples from our program
Examples from our Program

  • A Psych NP working in a privately owned primary care practice is unable to bill for Psychiatric services for 3 years due to lack of Psychiatric Supervision “physically located on site.”

    Is this correct?

  • An LCSW is employed by a mental health center but working in a primary care practice.

    How should she bill?

  • An LCPC wants to work for a primary care practice, but is not employed by an agency.

    Will this work?

Some background information
Some Background Information

  • AMA determines E&M and CPT codes

  • CMS (Centers for Medicare & Medicaid Services) determines if and how they will reimburse the codes for Medicare

  • Medicaid determines what should be adopted on state level (as long as not in violation of CMS rule)

Various payers and various rules
Various Payers and Various Rules

  • Medicare

  • Medicaid

  • Commercial Insurers

  • Mental Health vs Medical codes

  • Licensing rules


  • Variation exists in the interpretation and application of the Federal program rules and guidelines

    • Fiscal Intermediaries often have a more narrow interpretation than Medicare law allows

    • Creates misunderstanding of policies and confusion at the practice level

    • Denies reimbursement for allowable procedures


  • Louisiana Regional Medicare Carrier – PBSI Medicare Services


  • Search site for Local Coverage Determinations (LCD’s) –

  • Look for H&B codes

  • Or – Find someone in your organization who does this all the time and make them your friend!


  • States have flexibility in defining covered mental health services

  • Can choose to contract with managed care

  • Billing requires both a diagnosis and a procedure code

    • Some states limit procedures, providers and/or practices that can use these codes

Commercial insurance
Commercial Insurance

  • Inconsistencies among various insurers

  • Lack of clarity around covered services

  • Difficulty finding “experts” to answer specific questions about reimbursement

  • Carve outs

  • Other problems?

Evaluation management e m
Evaluation & Management (E&M)

  • Use E&M codes 99201-99201 or 99211-99215 whenever possible

  • Services must be medically necessary

  • Practitioner must be practicing within their scope of practice

  • Used in conjunction with a medical or psychiatric diagnosis

Health and behavior codes

Health and Behavior Codes:

Consider Their Use

Using health behavior codes
Using Health & Behavior Codes

  • Patients with underlying physical illness or injury

  • Where biopsychosocial factor may be affecting medical treatment

  • Patients with cognitive capacity for the approach

  • Physician documents need

  • Assessment not duplicate of other assessment

Documentation assessment
Documentation - Assessment

  • Onset and History of physical illness

  • Clear rationale for H&B

  • Assessment outcome including:

    • Mental status and

    • Cognitive ability for treatment

  • Goals and expected duration of intervention

  • Length of time for assessment

Documentation intervention
Documentation - Intervention

  • Capacity

  • Intervention

    • Clearly defined

    • How this will improve compliance

    • Goals of intervention

    • Response to intervention

  • Rationale for frequency

  • Length of time for intervention

Billing for the h b
Billing for the H&B

  • Medical diagnosis

  • Medical bill – not mental health

  • Billed by practice with Mental Health Provider:

    • Hospital license

    • Primary care office

    • Rural Health Clinic

    • Federally Qualified Health Center

How can you figure this out for your setting
How can you figure this out for your setting?

  • Make friends with your billers and coders

  • Make connections at the state level for Medicaid. Talk to the Provider Relations folks

  • Find your Medicare site ( and see what is available for you

  • Talk with other providers doing this work

Consider a work group
Consider a Work Group

  • Representatives from all aspects of the reimbursement spectrum:

    • Billers and coders

    • Audit specialists

    • Clinicians

    • Primary Care Practice Manager

    • Mental Health Program Manager

    • Physician/Psychiatrist

  • Focus on all levels

  • Information and ongoing learning are key

  • Celebrate successes (and awareness) along the way

Work group strategies
Work Group Strategies

  • Understand the current rules

  • Identify opportunities and barriers that affect sustainability

  • Use understanding of current rules to:

    • recommend most effective way to organize services

    • maximize reimbursement for integrated care

  • Target barriers with highest priority and/or are most likely to be able to change

Organizing information

Organizing Information

“The Grid”

Components within the grid
Components within “the Grid”

  • Coding Category

  • Coding number for service

  • Discipline of Provider allowed to bill for service

  • Codes by insurer

  • Psychiatric Services by type of license

  • Practice site able to bill for code, funding source, provider and license

Where to begin
Where to begin

  • What is the discipline of your mental health practitioner?

  • What service will they deliver and what code will be used?

  • Under what license?

  • Where will the service be delivered?

  • Which insurance will be billed? What are the rules for that insurer?