Transcript Document

Mental Health
Diagnostic and
Procedural Coding
Objective
To improve diagnostic and procedural coding for
mental health screening, assessment, referral, and
intervention
2
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 Cover…
Why code?
General Coding Principles
Mental Health Diagnostic Codes
Mental Health Procedural Codes
Reimbursement
– Who can bill?
– Fraud and Abuse
• Work plan suggestions
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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?
• 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 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
General Coding Principles (cont)
• Two Part Coding Process
– CPT – “What you do”
– ICD – “Why you do it”
You must always
have both!
• Diagnosis codes (ICD) must support procedure
codes (CPT)
General Coding 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
Where to document codes?
• 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)
• 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
300.01
Panic Disorder Without
Agoraphobia
300.3 Obsessive-Compulsive Disorder
Specify if With Poor insight
300.21
Panic Disorder With
Agoraphobia
300.22
Agoraphobia Without History of
Panic Disorder
309.81 Posttraumatic Stress Disorder
Specify if Acute/Chronic
Specify if With Delayed Onset
300.29
Specific Phobia
Specify type: Animal Type/Natural
Environment Type/BloodInjection-Injury Type/Situational
Type/Other Type
300.23
Social Phobia
Specify if Generalized
308.3 Acute Stress Disorder
300.02 Generalized Anxiety Disorder
300.00 Anxiety Disorder NOS
Depressive Disorders
• 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
• 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
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303.90
304.00
304.30
304.20
304.50
304.60
305.1
304.00
304.60
304.10
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304.80
304.90
305.90
Alcohol Dependence/305.00 Alcohol Abuse
Amphetamine Dependence/305.70 Amphetamine Abuse
Cannabis Dependence/305.20 Cannabis Abuse
Cocaine Dependence/305.60 Cocaine Abuse
Hallucinogen Dependence/305.30 Hallucinogen Abuse
Inhalant Dependence/305.90 Inhalant Abuse
Nicotine Dependence
Opioid Dependence/305.50 Opioid Abuse
Phencyclidine Dependence/305.90 Phencyclidine Abuse
Sedative, Hypnotic, or Anxiolytic Dependence/305.40 Sedative, Hypnotic, or Anxiolytic
Abuse
Polysubstance Dependence
Other (or Unknown) Substance Dependence
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
• 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
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90804 - 90829
90804 - 90815
90810 - 90815
90816 - 90829
• 90845 - 90857
• 90862 - 90889
Psychiatric Diagnostic or Evaluative
Interview Procedures
Psychotherapy
Office or Other Outpatient Facility
Interactive Psychotherapy
Inpatient Hospital, Partial Hospital
or Residential Care Facility
Other Psychotherapy
Other Psychiatric Services or
Procedures
Psychiatric Therapeutic Procedures
• 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?
• 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
• 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?
Reimbursement
• Reductions in reimbursement rates by provider type
– Physician
- not discounted
– Clinical Psychologist
- discounted
– LCSW
- further discounted
– Other
- discounted if covered
Reimbursement Issues
• 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
• 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”
• 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
Action 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
• 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
• 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
• 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
• 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
• 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.