Transcript Diagnostic and Procedural Coding

Diagnostic and Procedural
Coding
Objective
To improve diagnostic and
procedural coding for mental
health screening, assessment,
referral, and intervention
How do you document mental
health services?
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Who documents mental health
services?
 Where are mental health services
documented?
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– (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 cover…
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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???
“We can’t bill for mental health
services, so why code?”
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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?
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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
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Document necessity services
Illustrate complexity of services
General Coding Principles
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
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General Coding Principles
(cont.)
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Two Part Coding Process
– CPT – “What you do”
– ICD – “Why you do it”
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You must always
have both!
Diagnosis codes (ICD) must support
procedure codes (CPT)
General Coding Principles
(cont.)
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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
Where to document codes?
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Encounter Form
Database
BOTH (if separate):
 mental health chart AND
 medical record
Mental Health Diagnostic
Codes
Coding Systems
ICD-9-CM (International Classification of
Diseases, Ninth Revision, Clinical Modification)/
DSM-IV-TR (Diagnostic and Statistical Manual –
Fourth Edition – Text Revised)
* used by health care professionals to classify
patient illnesses, injuries, and risk factors.
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
300.3Obsessive-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
300.02Generalized Anxiety Disorder
300.00Anxiety Disorder NOS
Depressive Disorders
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296.xx Major Depressive Disorder
– .2x Single Episode
– .3x Recurrent
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300.4 Dysthymic Disorder
Specify if Early Onset/Late Onset
Specify With Atypical Features
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311 Depressive Disorder NOS
Disruptive Behavior Disorders
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314.xx Attention-Deficit/Hyperactivity Disorder
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314.9 Attention-Deficit/Hyperactivity Disorder NOS
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312.xx Conduct Disorder
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313.81 Oppositional Defiant Disorder
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312.9 Disruptive Behavior Disorder NOS
– .01 Combined Type
– .00 Predominantly Inattentive Type
– .01 Predominantly Hyperactive-Impulsive Type
– .81 Childhood-Onset Type
– .82 Adolescent-Onset Type
– .89 Unspecified Onset
Substance Abuse/Dependence
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303.90 Alcohol Dependence/305.00 Alcohol Abuse
304.00Amphetamine 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
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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.
Mental Health Procedural
Codes
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
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
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
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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
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
Who
can bill?
Fraud
and Abuse
Who can bill?
– What are the rules governing who can bill
for mental health diagnosis/treatment in
your state?
Who Can Bill?
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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
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A provider should
know what services
are covered.
Services must be
documented and
medically necessary
in order for payment
to be made.
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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?
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Reimbursement
– Reductions in reimbursement rates by
provider type
Physician
 Clinical Psychologist
 LCSW
 Other
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- not discounted
- discounted
- further discounted
- discounted if
covered
Reimbursement Issues
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E&M codes are limited to physicians, Pas,
NPs, nurses
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Same is true for 90805, 90807, 90809 codes
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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
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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”
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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
Actions Step:
Review Program Services
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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
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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?
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Do procedural codes represent all services
provided (including those not billed for)?
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Do diagnostic codes represent all diagnostic
categories (including those not billed for)?
Action Step:
Review and Modify Documentation Procedures
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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
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Research State Program Information
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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
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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
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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/preauthorizations, etc.
Assure you have a complete understanding
of program parameters re: Individual
Therapy, Case Management, Special
Behavioral Health Services, etc.