Transcript HRSA/TPR Webcast April 23, 2003

Billing
for
Behavioral
Health
Services
in
Effective Accounts Receivable Management
Primary Care Settings
Web-assisted Audio Conference for HRSA Grantees and Subgrantees
September 17, 2003
Facilitated by:
Charlotte Kohler and Phil Hurd
Navigant Consulting, Inc.
Speakers
• Charlotte Kohler, RN, CPA, CVA, CPAM
• Phil Hurd, MHA, CCP
2
Purpose
•
Purpose
– Provide focused technical assistance in
response to questions asked during
HRSA’s Third Party Reimbursement (TPR)
Training sessions.
3
Program Outline
I.
National Overview/Common Issues
II. State Structures and Variations
III. Documentation and Coding Issues
IV. Who Can Bill
V. Coding, What to Bill and How Much Are You Paid?
VI. Summary of Program Development Steps
4
Audience Profile
•
•
–
As of 9/12/2003, we had 401 people registered,
representing 278 organizations
206 organizations submitted information about BH
services
80% (164 organizations)are providing BH services, and
of those, 60% (100) are billing for these services
42
BH SVCS - NO
BH SVCS - YES
BILLING MH - YES
64
BILLING MH - NO
100
164
5
Audience Profile
• 38 states, plus the Puerto Rico and the District of
Columbia are represented:
Arizona, Arkansas, California, Colorado, Connecticut,
Delaware, Florida, Hawaii, Illinois, Indiana, Iowa,
Kentucky, Louisiana, Maine, Maryland, Massachusetts,
Michigan, Minnesota, Missouri, Montana, Nebraska,
Nevada, New Hampshire, New Jersey, New Mexico,
New York, North Carolina, Ohio, Oklahoma, Oregon,
Pennsylvania, South Dakota, Tennessee, Texas, Utah,
Vermont, Virginia, Wisconsin
6
Audience Profile
• All types of provider organizations, including:
- HIV/AIDS Bureau Ryan White and other HIV/AIDS programs
– Bureau of Health Professions National Health Service Private
Practices and Nurse Managed Centers
– Maternal and Child Health Bureau Healthy Start Programs, Title
V Grantees, Healthy Tomorrows and Providers to Children with
Special Health Care Needs
– Bureau of Primary Health Care Community Health Centers,
Homeless Grantees, Public Housing Grantees, Migrant Health
Centers and School Based Health Centers
– Office of Rural Health Policy Rural Outreach and Rural Network
Development Grantees
7
Effective Accounts Receivable Management
National Overview/Common Issues
Overview
•
Behavioral Health includes both Mental Health and
Substance Abuse services.
•
We will be discussing both the somatic – medical
services and psychosomatic – psychiatric services
Source: The Midwest Clinician’s Network Survey, 2000.
9
Overview
• The prevalence of Behavioral Health (BH) Issues is
large and growing.
• Primary Care Physicians (PCPs) spend 50% of average
work week directly treating mental health and substance
abuse.
• PCPs prescribe nearly 2/3
of medications and 80% of
anti-depressants.
10
Funding for Behavioral Health
• Most States obtained the waiver process to implement
Managed Care.
• Following the private sector, most states have “carvedout” Behavioral Health programs.
• The funding options for BH services and billing
requirements are numerous and varied.
11
Managed Care Prevalence
• 39 States operate 78 managed Behavioral Health
programs.
• 17.6 million enrollees were treated by Medicaid plans
with Behavioral Health services in 1999.
• Medicaid remains the largest funding source for public
managed Behavioral Health care.
12
Medicaid Managed Care
• Ten States account for 80% of the national enrollment
in Medicaid Managed Care programs; 3 for 50%
– California
– Michigan
– Tennessee
–
–
–
–
–
–
–
50%
Massachusetts
Pennsylvania
Maryland
Washington
New York
Texas
Oregon
13
Reimbursement/Provider Issues
• Payments are made to “preferred provider”.
• Reject application because “panel is full”.
• Some states and counties award BH services
exclusively to the local Community Mental
Health Center (CMHC)
– Are you one of them?
14
Coverage Requirements
• Meeting “medical necessity criteria”
– Can take 2 hours for evaluation
--If patient does not meet criteria, often the provider
does not get paid for the evaluation
15
Effective Accounts Receivable Management
State Structures and Variations
Program Structures - Examples
• California - Some capitation; contracts w/ county MH
Depts./LCSW must have Medicare PIN before MediCal;
FQHCs/RHCs can be reimbursed FFS.
• Massachusetts – Capitates four MCOs; MCOs
subcontract w/ Health Centers/others; some payment
arrangements are FFS
• Michigan – Capitated contracts w/ CMHSPs; FQHCs do
not participate in program but can contract w/ HMOs
17
Program Structures - Waivers
CALIFORNIA
Operates under 1915(b) waivers
MASSACHUSETTS
MICHIGAN
“MassHealth” is an 1115 demonstration
waiver
“Michigan Comprehensive Healthcare
Program (CHP)” is a 1915(b) waiver
Integrated MCO model
Medicaid Pre-paid Specialty Mental
Health and Substance Abuse Services
and Support for Persons with
Developmental Disabilities
Individuals join MCO
Department of Community Health
administers and has sole source
capitated contracts with 49 Community
Mental Health Service Programs
(CMHSPs)
18
Program Structures – Managed Care
CALIFORNIA
All 58 counties have Medicaid Managed
Care for Behavioral Health Services
3 Models:
- County Organized Health Systems
- Geographic Managed Care (GMC)
- Two-Plan Model
BH services are excluded from capitated
contracts for two-plan model and GMC
plans
MASSACHUSETTS
MICHIGAN
Division of Medical Assistance (DMA)
capitates two prepaid health plans and
two private non-for-profit MCOs
Serves 83 counties
Massachusetts Behavioral Health
Partnership (MBHP) is a carved out,
prepaid health plan
- Receives capitation from DMA
- Pays contracted providers FFS,
including safety net providers and health
centers
Full range of services to TANF and SSI
recipients
Statewide/integrated HMO program
Services can be provided:
- In-house
- Subcontract with managed BH
organizations
- Contract with community MH service
programs
HMOs provide up to 20 visits/year
Additional visits paid FFS under waivers
through CMHSP
19
Program Structures – Provider Issues
CALIFORNIA
Department of Mental Health contracts,
in most cases, with the County Mental
Health Departments
MASSACHUSETTS
MCOs subcontract with MBHOs and
Health Centers
RHCs and FQHCs can be reimbursed
on a FFS basis
Licensed Clinical Social Workers must
have a Medicare provider ID before
applying to MediCal
MICHIGAN
CMHSP contracts with
- Private managed behavioral health
organizations
- Non-profit human service organizations
- Coordinating substance abuse
agencies
FQHCs and other safety net providers
do not participate in this program
FQHCs contract with HMOs to provide
the 20 mental health visits
20
FQHCs - Examples
•
California – traditional psychotherapy referred to
Mental Community Health Center; visit limits can
vary w/in the state
•
Kansas – FQHCs not eligible as subcontractor for
BH services; program specifies the number of
hours by service per year.
•
Michigan – Integrated primary care delivery model
experiment for use of new codes – 9615x; model
does not limit visits but the Medicaid program has a
20 visit limit
21
FQHCs - General
CALIFORNIA
KANSAS
MICHIGAN
Mental Health services are carved out
Mental Health services are carved out
Mental Health services are carved out
County MH departments treat short crisis
psychiatric emergencies
Provision of services limited to
Community Mental Health Centers
CHCs can subcontract to the Managed
Behavioral Health Care Organization
(MBHCO)
Traditional on-going psychotherapy
services not offered by county – patients
referred to Mental Community Health
Center (MCHC)
FQHCs not eligible to participate as a
subcontractor for Mental Health services
Integrated Primary Care Delivery Model
experiment
- Expansion grant for BH services
- BH is one of the core services
- “Brief, Focused Intervention” Model
“Integrated” Model
- Two BH clinicians
- One certified social worker
- One limited license psychologist
22
FQHCs – Billable Services
CALIFORNIA
- Screening and assessment
-Psychotropic/psychiatric medication
prescription and management
-Individual/psychotherapy/counseling
within FQHC
KANSAS
Similar to California
-Assessments
- Individual
- Group
- Prescriptions and management
- Case management
-Group therapy within FQHC
-BH case management within FQHC
23
MICHIGAN
Patients needing traditional BH services
are referred to the local MH authority or
the MBHCO
Patients in need of “brief, integrated BH
interventions” are treated at the FQHC
FQHCs – Visit Restrictions
CALIFORNIA
No specific restrictions on number of
visits or length of visits for one FQHC,
but another FQHC reported a
requirement of 50 minutes for all visits
KANSAS
No time limits, but:
-32 hours/year non-EPSDT individual
therapy
- 40 hours/year EPSDT individual therapy
- 5 hours/year evaluation
- 6 hours/year non-EPSDT case
conference
- 12 hours/year EPSDT case conference
- 40 hours/year family and group therapy
24
MICHIGAN
Integrated model does not limit the
number of behavioral visits.
The Medicaid program, with the mental
health carve out does, have a 20 visit
limit.
FQHCs – Reimbursement Issues
CALIFORNIA
KANSAS
Most serious issue is inability to
bill a medical visit and
behavioral health visit on the
same day and receive
reimbursement for both
Do receive payment form
private insurers for a medical
visit and mental health visit on
the same day, but do not from
Medicare and Medicaid. This
can be a very significant issue.
25
MICHIGAN
- Program
currently funded by a
grant
-Wanted to bill 96xxx codes (to
be reviewed later)
-CPT definition and
requirements different from
State instructions
State severely limits use of
96xxx codes to a small set of
services, e.g., smoking
cessation, weight management
Program Structures – Summary
• Most BH benefits are carved-out.
• Contractual arrangements and eligible providers
vary widely by state and by county within the
state.
• Must work closely with your state structure to
clearly define requirements for your program.
26
Effective Accounts Receivable Management
Documentation and Coding Issues
Documentation and Coding:
Fraud and Abuse
• Behavioral Health Services have been subject to fraud
as have many other services.
• Services that have been billed inappropriately in the
past include:
• Routine screening and periodic testing
• Testing for other than diagnosing a suspected mental illness or to
evaluate a change in mental illness
• Generic psychotherapy (group) not specific to patient’s condition.
28
Documentation and Coding:
Fraud and Abuse
• The biggest problem in Behavioral Health relates to
medical necessity (determination by payers based on a review of
services billed)
– Services performed by a non-licensed provider
particularly as “incident to” using the PIN of the
licensed provider.
– Music, game, instrument, pet interaction therapies,
sing-alongs, arts and crafts, and other similar
activities should not be billed as group or individual
activities.
29
Elements of “Incident To”
1. An integral part of the physician’s professional service
2. Commonly rendered without charge or generally not
itemized separately in the physician’s bill
3. Of a type that are commonly furnished in physician’s
office or clinic
4. Furnished under the physician’s direct personal
supervision
30
Medical Record Documentation
• Complete records contain all pertinent and essential
information related to the patient’s current encounter.
• Each entry must be able to “stand-alone”.
• Medical records must indicate that the patient has a
psychiatric illness or emotional behavioral symptoms.
31
Who Can Bill?
Who Can Bill?
Who can bill for behavioral health services?
• Most States Accept physicians, Clinical
Psychologists (CP), Licensed Clinical Social
Workers (LCSW), (Certified, Independent, Licensed
– State defines)
• However, each State has its own rules and many will
pay for other professionals.
33
Who Can Bill?
• Physicians
• Clinical Psychologists
• Licensed Social Workers (Certified, Independent
or Clinical – different by State)
• Certified Marriage and Family Therapists (CMFT)
• Pastoral Counselors
34
Who Can Bill? (Cont.)
•
•
•
•
Registered Nurses
Nurse Practitioners
Alcohol and Drug Abuse Counselors
Clinical Nurse Specialist
BUT - Every State is different and requirements
are different
35
Who Can Bill?
Clinical Psychologist - Medicare Criteria
• Physician supervision not required
• Considered to be an “allied health professional”
• Services generally covered in independent
practice or as employee of a physician or
physician-directed clinic.
36
Who Can Bill?
Clinical Psychologist - Medicare Criteria
• Agree to consult with patient’s attending
physician, unless the patient does not agree to
the consult.
• Can not bill for monitoring or prescribing
medication.
37
Who Can Bill?
State Comparisons
– Arkansas - Providers are licensed with the state
AND certified by the Division of Mental Health
– Indiana - More restrictive; providers must be
certified as Health Service Provider in Psychology
– Nebraska – Less restrictive
38
Billable Providers - Examples
Arkansas
• Clinical Psychologist (CP)
• Licensed Clinical Social Worker
(LCSW)*
• Licensed Professional Counselor
(LPC)*
*Must be Licensed with the state AND
certified by the Division of Mental Health
Indiana
• Clinical Psychologist (CP)-Must be
Licensed and certified as a Health
Service provider in Psychology
(HSPP) by the Health Professionals
Bureau
Providers who cannot receive a
Medicaid number and bill
Independently
• Non-HSPP Psychologist
• Master of Social Work
• Clinical Social Worker
• Psychiatric Nurse
These providers can be issued
provider numbers but must be billed
with appropriate modifier and the
supervising practitioner’s PIN.
39
Nebraska
• State recognizes a broader array
of Health Professionals but
providing Mental Health Services:
– Certified SW must be
supervised
– Certified Master SW must be
supervised
No supervision required for:
– Licensed Clinical SW (LCSW)
– Psychologist
– Certified Marriage and Family
Therapist (CMFT)
– Certified Professional Counselor
(CPC)
Targeted Case Management (TCM) - Examples
Arkansas
Indiana
Only the following can bill for TCM:
• MSWs
• RNs
• LPNs
• LCSWs
• Licensed Psychiatric Technical Nurse
• Masters Level School Guidance
Counselors, School Psychology
Specialist, and special Education
Supervisors who are also certified with
the Board of Education
40
•
Psychologist, MD, OD, SW, OT,
Speech Pathologist or Audiologist, RN,
PT who are qualified Mental
Retardation Professionals.
•
Services are provided by or under the
supervision of qualified Mental Health
Professionals.
Arkansas
Other
• If Medicare covers the service, provider must be
a credentialed Medicare provider before
Medicaid.
• RHCs must be certified by CMS and participate
with Medicare
41
State Comparison - Summary
• State requirements vary widely
• Different providers have different supervision
requirements
• Make sure BH Professionals are licensed by the
right agency and certified, as required.
42
State Comparison - Summary
• Make sure you understand practice location
requirements
• Reimbursement methodology and amounts
vary by practice setting-know the
differences.
43
Coding, What to Bill and How
Much are You Paid?
What To Bill?
E&M
New
99201
99205
Est’d
99211
Psychotherapy
90804
20 90805
90806
90807
90808
90809
80 Min.
Health and Behavioral
Assessment/ Intervention
90801 - Psychiatric
Diagnostic Interview
Examination includes
history, mental status and a
disposition. Psychosomatic
90804,-06,-08
Treatment for mental
illness in which the
clinician establishes a
professional contract
New codes effective 1/1/02
Used to identify the
psychological, behavioral,
emotional cognitive and
social factors important to
physical health.
90802 – Interactive Psych.
Dx. Interview. Involves use
of physical aids and nonverbal communication.
90805,-07,-09
psychotherapy w/
medical evaluation and
mgmt. Services.
Initial
Assessment
90801
Insight
90802
Interactive
99215
Evaluation and Management
(E/M) Codes
Physician Services for
somatic care
45
96150 – 96155
Patients are not diagnosed
with mental illness.
What To Bill?
E&M
Codes?
Where?
What?
New
99201
Est’d
99211
99205
99215
Service Emphasis
90801
Insight
90802
Interactive
Psychotherapy
90804
20
90805
90806
90807
90808
90809
80 Min.
Behavioral Assessment
96150 - 96155
Medical Office or other O/P
Service
Behavior Health Office or
other O/P Facility
Behavior Health Office or
other O/P Facility
Behavior Health Office or
other O/P Facility
Medical Visit that can
include Counseling
10
10
Psychiatric
Diagnostic
Interview
Examination
Individual
Individual
Psychoth.
Psychoth.
Insight
w/ medical
Oriented
mgmt.
Face-to-Face
W/patient
Health and Behavior
Assessment, re-assessment,
Individual and group
60
Min.
Who?
Initial Assessment
Interactive
Dx.Interv.
Using play
Equip.,etc.
40
Min.
Physician, NP, Other
Medical Clinicians
Psychiatrist, LCSW, CP, NP,
Other. Payer criteria
Medical
Behavioral Health Initial
Assessment
46
All
On-going Individual
Psychotherapy
Clinical Psychologist, NP,
Other for Medicare
Biopsychosocial factors
important to Physical Health
problems and treatments
How Much Are You Paid?
Reimbursement
– Reductions in reimbursement rates by provider type
•
•
•
•
Physician
Clinical Psychologist
LCSW
Other
47
- not discounted
- discounted
- further discounted
- discounted if covered
State Reimbursement Example
Ranges by Provider Type
CODE
STATE
90801
90802
MD, PA, ADV
PRACT NURSE
LICENSED
PSYCHOLOGIST
PROVISIONALLY
LICENSED
PSYCHOLOGIST
LICENSED MH
PRACTITIONER
CERTIFIED
ALCOHOL &
DRUG ABUSE
COUNSELOR
Nebraska
$144.82
$98.48
$73.86
N/A
N/A
Maryland
$95.00
$63.00
$47.00
N/A
N/A
Nebraska
$87.16
$87.16
$65.37
$65.37
$60.14
Maryland
$79.00
$52.00
$40.00
N/A
N/A
48
How Much Are You Paid?
• Reimbursement Ranges
99201
99202
Medicare
$ 36.85
65.94
99203
99204
99205
97.74
139.24
177.64
1
Maryland
$ 25.00
33.00
Nebraska
$ 24.64
36.01
37.00
48.00
50.00
53.06
75.80
98.54
1) Unadjusted
49
How Much Are You Paid?
• Reimbursement Ranges
Medicare
90801
$ 157.08
90802
$ 167.17
1
Maryland
Nebraska
$ 95.00
$ 144.82
N/A
1) Unadjusted
50
N/A
How Much Are You Paid?
• Reimbursement Ranges- Physicians
Medicare
90804 (20 minutes)
90806 (45 minutes)
90808 (60 minutes)
1)
$ 67.87
101.62
151.65
Unadjusted
51
1
Maryland Nebraska
$ 44.00 $ 43.45
79.00
87.16
105.00 112.89
How Much Are You Paid?
• Reimbursement Ranges
Medicare
$28.31
96150
(15 minutes)
1) Unadjusted
96151
96152
96153
96154
96155
$27.15
$25.99
$ 5.82
$25.60
$24.82
52
1
Medicaid
The state of
Alaska is the
only state
currently
reimbursing
for these
new codes
Reimbursement Issues
• Reimbursement Issues/Problems
– E&M codes are limited to physicians, NP, Nurses
– The same is true for the 90805, 90807, 90809 codes
– The new codes as of Jan. 1, 2002, 96150-96155, are
for use by clinical psychologists, only.
53
Coding and What to Bill
•
Reimbursement Issues/Problems
– Two big problems:
1. An E&M (992XX) and a therapy (908XX) cannot be
billed on the same date of service to most
Medicaid programs.
2. Alaska is the only state, to date, that approves
payment for Medicaid recipients for the 9615096155 health and behavioral assessment codes.
54
Summary
• Coding and reimbursement can be tricky
• Understand the reimbursement rates by provider
BEFORE moving forward – the program may not
be financially viable
55
Effective Accounts Receivable Management
Summary of Program Development Steps
So What Does All This Mean?
• Behavioral Health Services may be a service option for
you and your patients.
• Program location and mix of providers will dictate
reimbursement opportunities.
• Behavioral Health is very large and demand likely to
increase.
• Reimbursement challenges are difficult.
57
So How Do You Get Started?
A.
B.
C.
D.
E.
F.
G.
H.
Program Design
State Program Coverage Issues
Providers
Reimbursement Estimates
HIPAA
Marketing
Medication Management
Regulatory Changes
58
So How Do You Get Started?
A. Program Design
1) Define the Behavioral Health Services your
patients are receiving.
2) Determine what Behavioral Health Services
you want to provide.
59
So How Do You Get Started?
B. State Program Coverage Issues
1) Research State Program Information.
2) Contact State Medical Assistance Program and
determine specific Behavioral Health Service
requirements.
3) Invite Medicaid Representatives to your facility or
visit them to present Behavioral Health Program
and clearly understand the requirements.
60
So How Do You Get Started?
C. Providers
1) Determine eligible providers.
2) Determine provider credentialing and Licensing
requirements.
3) Determine managed care panel and
credentialing issues.
4) Identify supervision “Incident to”. Independent
criteria for billing by provider.
61
So How Do You Get Started?
D. Reimbursement Estimates
1)
Obtain reimbursement rates by provider type for state and other
programs.
2)
Understand billing rules by payer, e.g. billing E & M visit same
day as Behavioral Health visit, number of visits limits, auth/preauthorizations, etc.
3)
Assure you have a complete understanding of program
parameters re: Individual Therapy, Case Management, Special
Behavioral Health Services, etc.
4)
Use the HRSA TPR Business model to estimate potential
revenue.
5)
Consider supervision issues and how to best handle.
62
So How Do You Get Started?
E. HIPAA
1) Assure patient confidentiality.
2) Review space requirements.
3) Assure electronic files are compliant.
63
So How Do You Get Started?
F. Marketing
1) Consider referral source of patients.
2) How do your physicians refer to your
Behavioral Health Professionals?
64
So How Do You Get Started?
G. Medication Management
1) Incorporate appropriate medication
management supervision into
program procedures as required.
2) What physician, internal/external will be
managing medications?
65
So How Do You Get Started?
H. Regulatory Charges
1) Stay abreast of State policy changes regarding
Behavioral Health Carve out services, eligible
providers, etc.
66
Helpful Websites
1) www.cms.gov
Medicare Regulations
2) www.medicarenhic.com
Part B Billing Resource
3) www.aswb.org
Social Worker Requirements by State
4) Search by state by Department of Health or
Department of Mental Health to find state Specific
Information.
67
Thank you for participating in HRSA’s web-assisted
audioconference!
Additional questions can be directed to:
[email protected]
or
1-866-877-8439
68
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69