Transcript Presentation on How to Code Clinical BH Encounters in Primary Care
Coding Clinical Encounters
Definition of Terms: CPT E/M and Procedure Codes
The CPT E/M section is divided into broad categories such as office visits, hospital visits, and consultations CPT Procedure Codes are based upon the specific procedure being performed.
National Correct Coding Policy
Applies to services billed by a single provider for a patient on the same day Some CPT Procedure codes have been developed that are considered “comprehensive” These CPT Procedure codes incorporate the E/M service; therefore the E/M Code should not be coded The RVU assigned to these CPT Codes are based on the comprehensiveness of the procedure (i.e., incorporate the “value” of the E/M service) However, ADM 3.0 software requires an E/M to be coded CCI EDITS Audit checks to ensure (and deleted if found) additional codes are not billed with comprehensive or exclusive codes
RVUs
Relative Value Units (RVUs) Since 1992, reimbursement (payment) to providers has been based on a fee schedule using RVUs RVUs are a nationally recognized measurement of the resources (the amount of time, effort and intensity) required to provide a particular service or procedure Every CPT E/M and Procedure Code has an RVU assigned, but some are ZERO RVU is multiplied by the standard conversion factor to get the “payment amount” RVUs are tracked as an indication of provider workload
ICD 9 CM Diagnosis
What’s the Same?
Same method for deciding the diagnostic code Refer to flow sheet and superbills Can code up to four diagnoses V71.09 and 799.9 are not recommended for use; Code presenting symptom or chief complaint What’s Different?
New Codes for Consultative BH Care in medical clinic New method for deciding the CPT E/M and procedure Codes
ICD 9 CM Diagnosis
The type of diagnosis (psychiatric or physical) now guides the type of CPT E/M and Procedures Codes to use PSYCHIATRIC Diagnosis (YELLOW on Superbill in Appendix 11) Use 99499 (E/M) along with 90801 (new patient) or 90804 (follow-up patient) for CPT Procedure PHYSICAL Diagnosis (PEACH on Superbill in Appendix 11) Use 99499 (E/M) along with 96150 (new patient) or 96152 (follow-up patient) for CPT Procedure OR Use 99242 (consultative E/M code) for any “new patient”, regardless of diagnosis, with NO CPT Procedure Code
E & M Codes If using a CPT Procedure code, then use 99499 (unlisted E/M Code) because the CPT Procedure Codes used for BH in primary care are Comprehensive Codes Telephone contacts are types of CPT E/M codes – 3 types
DO CODE these DO NOT code a CPT Procedure code with telecons
Consultation E/M Codes
Consultation E/M Codes (99241, 99242) Consultations are provided at the request of another provider, to render an opinion or advice regarding the evaluation and management of a specific problem.
You must document the need in the patient’s record You may initiate diagnostic and/or therapeutic services, such as writing prescriptions or initiating treatment plans.
You must document the opinion you render and services you order or perform in the patient’s medical record. Report this information to the requesting provider.
Report separately any identifiable procedure or service performed on, or subsequent to, the date of the initial consultation.
When you assume responsibility for the management of any or all of the patient’s care subsequent to the consultation encounter, consult codes are no longer appropriate.
BH CPT Procedure Codes
Two Categories of BH CPT Procedure Codes Health Behavior Assessment and Intervention (96150-96155) – Use “quantities” for these Psychiatric (90801; 90804, etc) Both sets of CPT procedure codes are ‘comprehensive’ and have CCI edits Use 99499 E/M code (unlisted E/M code) with these Use diagnosis to determine which category to use Can code multiple CPT Procedure codes for one visit (but not same CPT; if same CPT use quantities) For example, using a CPT procedure code for health risk assessment (99420), but there are no RVUs for this service If you choose to use a consultation E/M code, do not also use a CPT Procedure code. Use only for initial BHC consultation visits. (there is no ‘right’ answer)
Coding Logic
CPT CODES Non-Consultative Codes
(99499 E/M Code plus CPT Procedure Code determined from logic below)
Consultation E/M Codes
(99241, 99242, 99243)
Psychiatric ICD-9 CM Diagnosis
(Use CPT Procedure Codes 90801, 90804)
Physical ICD-9 CM Condition/Diagnosis
(Use CPT Procedure Codes 96150-96155)
Examples
PATIENT TYPE REFERRAL QUESTION / PRESENTING PROBLEM ICD-9 CM CODE E/M CODE CPT CODE
New Patient Headache
RVUs
784.0
99499 96150
.72 x 2 = 1.44
x constant ($36.20) = Dollar Value Equivalent $52.13
Examples
PATIENT TYPE
New Patient New Patient Follow-Up Patient
REFERRAL QUESTION / PRESENTING PROBLEM
R/O Anxiety Disorder Headache Headache
ICD-9 CM CODE
300.01
99242
784.0 784.0
E/M CODE CPT CODE 99242 99242 ------- ------- ------- RVUs
1.88
x constant ($36.20) = Dollar Value Equivalent $68.06
1.88 1.88
$68.06 $68.06
Examples
PATIENT TYPE
New Patient New Patient
REFERRAL QUESTION / PRESENTING PROBLEM
Depression
ICD-9 CM CODE E/M CODE CPT CODE
296.30
99499 90801
Sleep Disturbance, Unspecified 780.50
99499 96150 RVUs
3.79 .72 x 2 = 1.44
x constant ($36.20) = Dollar Value Equivalent $137.20 $52.13
Examples
PATIENT TYPE REFERRAL QUESTION / PRESENTING PROBLEM ICD-9 CM CODE E/M CODE CPT CODE
Follow-Up Patient Follow-Up Patient Follow-Up Patient Insomnia Diabetes Management Depression 307.42 250.02 296.30
99499 99499 99499 90804 96152 90804 RVUs
1.64
x constant ($36.20) = Dollar Value Equivalent $59.37
.66 x 2 = 1.32 1.64
$47.78 $59.37