Transcript CPT Coding Changes for 2013

CPT Coding Changes for 2013
Getting Prepared
American Psychiatric Association
Welcome and Introductions
• Alison Lynch, MD
– Associate Professor,
Clinical
– Departments of
Psychiatry and Family
Medicine
– Carver College of
Medicine
– University of Iowa
• Robert Smith, MD
– Associate Professor,
Clinical – Emeritus
– Department of
Psychiatry
– Carver College of
Medicine
– University of Iowa
Who is here today?
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25 psychiatrists
9 mid-level providers
10 therapists
135 others (coders, administrators, billers,
directors, secretaries)
Workshop Goals
• All mental health providers utilizing the new
behavioral health codes correctly after
January 1, 2013
• All mental health prescribers are
knowledgeable about the E/M codes and
documentation guidelines and can correctly
utilize these codes for established patients
• Billers/coders are knowledgeable concerning
the CPT changes so as to assist their clinicians
Session I Overview
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Disclaimer
Legal Aspects of Coding
Why Change Now
Three Aspects of Time
Add – on Codes
Changes for Psychotherapy
Interactive Complexity
Crisis Therapy Code
E/M Codes with Psychotherapy
Disclaimer
• This information is for educational and
informational purposes only, and represents
the understanding of the presenters regarding
the material involved. The presenters
assumes no liability or responsibility for
behavior based on this presentation.
American Psychiatric Association
Disclaimer
• Although we are knowledgeable through our
own work and consultation with other experts
in the field, we are neither responsible for, nor
assume any liability for your work and coding.
You are ultimately responsible for your work,
coding, and the documentation
CPT Coding and Documentation –
Whose Job is it?
• Documentation and coding is part of
physician/provider work
• You are responsible for the clinical work and
equally responsible for the documentation
and coding
• This should not be the job of your staff!
American Psychiatric Association
Legal Issues
• Audits
• Sampling
CMS Expands Scope Of Medicare
Audits.
• American Medical News (10/1, Fiegl) reports, "A
Medicare auditor tasked with reviewing past
claims for physician and hospital services in 15
states will start scrutinizing the billing of office
visits, claims that previously had been off-limits
to recovery audit contractors." The audits will be
conducted by a contractor, Atlanta-based
Connolly Inc., and will "focus on upcoming and
cloned documentation." American Medical News
notes that many groups, including the AMA,
opposes CMS expanding audits to look at this
type of billing, known as E&M.
Legal Issues
• Overpayments
• Fines
Legal Issues
The OIG may impose civil monetary penalties if a
provider
• knows of an overpayment and does not report
and return the overpayment.
• $10,000 per claim
• Treble damages
• Additionally, the OIG may also exclude the
provider from participation in Federal health care
programs.
Why Seek Change Now?
• Psychiatric codes/Behavioral Health codes
suffered because of budget neutrality
• Evaluation and Management codes are
Increasing in Value
• Under-valuation of E/M component of
Psychotherapy with Evaluation and
Management Services
• Problem with “restricted contracts”
American Psychiatric Association
Medicare Payments
Follow-up Exams
• 90862
$58.54
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$19.74
$42.55
$70.46
$104.16
$139.89
99211
99212
99213
99214
99215
20% more
78% more
Medicare Payments
New Patient
• 90801
• 90802
$152.49
$166.10
• 90791
• 90792
$159.50
$131.40 ?
• 99204
• 99205
$160.66
$199.46
• 90791+90785 $164.50
• 90792+90785 $136.40
Timeline
• August 31, 2012
• November 2012
• January 1, 2013
• CPT electronic files released;
changes to CPT codes became
public
• CMS releases the Final Rule on the
2013 Physician Fee Schedule
(includes relative values)
• New code set goes in to effect –
must bill using new CPT codes
(This is non-negotiable)
American Psychiatric Association
Important Concepts
ISSUES of TIME AND THE NEW CODES
• CPT Time Rule for Psychotherapy
– “A unit of time is attained when the mid-point is
passed”
– “When codes are ranked in sequential typical
times and the actual time is between two typical
times, the code with the typical time closest to
the actual time is used.”
– As an example, codes of 30, 45, and 60 minutes
are billed at 16-37 mins, 38-52 mins, and 53-67
mins.
American Psychiatric Association
ISSUES of TIME AND THE NEW CODES
• CMS has “typical times” for the new patient
E/M codes and for the established E/M codes
• When greater than 50% of the time of the visit
is counseling and/or coordination of care,
time becomes the controlling factor for a level
of E/M service
Counseling & E/M Codes and
Psychotherapy
Counseling with the patient and/or family is a
discussion of the following:
1. Prognosis
2. Test Results
3. Instructions
4. Risk Reduction
5. Education
6. Compliance/Adherence
Important Concepts
• Add-on Codes
– It is a code(s) that describes work that is
performed in addition to the primary service
– It is never reported alone
– Examples include Psychotherapy, Interactive
Complexity and Crisis Services
Overview of Changes Implemented in the
Behavioral Health codes for 2013
• Key services have been assigned new numbers and/or are
described differently, and all new codes can be used in all
settings
• There are now two codes for an initial evaluation; one with
medical services and one without
• Psychotherapy is no longer distinguished by site of service
• Work previously described using the interactive codes is
now done by using an add-on code
• There is a new crisis psychotherapy code
• Key codes have been deleted, e.g. 90862 Pharmacologic
Management and replaced with E/M codes
• Psychotherapy with E/M is now an E/M code with a
Psychotherapy add-on
American Psychiatric Association
New Structure of
Psychiatry Coding
Psychiatry
Coding
Psychiatric
Dx Evaluation
(90791, 90792)
Individual
Psychotherapy
w/pat &/or
family
(90832-90838)
Interactive
Complexity
Add-On (90785)
Crisis
Psychotherapy
(90839, 90840)
Add–On when
used with
Evaluation and
Management
Service Code,
when applicable
Psychiatric Diagnostic Evaluation Overview
• A distinction has been made between diagnostic
evaluations without medical services and evaluations
with medical services
• Interactive services are captured using an add-on code
– These codes can be used in any setting
– These codes can be used more than once in those
instances where the patient and other informants are
included in the evaluation
– These codes can be used for reassessments
• Psychiatrists and other medical providers have the
option of using the appropriate 99xxx series code in
lieu of the 90792
American Psychiatric Association
Psychiatric Diagnostic
Evaluation
2012
2013
• 90801
• 90791, Psychiatric diagnostic evaluation
• 90792, Psychiatric diagnostic evaluation
with medical services
• 90802
• 90791 plus 90785, Psychiatric diagnostic
evaluation with interactive complexity
• 90792 plus 90785, Psychiatric diagnostic
evaluation with medical services and with
interactive complexity
American Psychiatric Association
Documentation Guidelines
90791 and 90792
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Date
Chief complaint
History of present illness
Past history
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Family
Social
Medical
Psychiatric
• (Note: no ROS required)
• Comprehensive mental
status examination
• Diagnosis
• Formulation/prognosis
– Assessment of patient’s
willingness to comply with
treatment program
• Legible signature
Psychotherapy - Overview
• Psychotherapy codes are no longer site
specific
• Psychotherapy time includes face-to-face time
spent with the patient and/or family member
• Time is chosen according to the CPT time rule
• Interactive psychotherapy is reported using
the appropriate psychotherapy code along
with the interactive complexity add-on code
American Psychiatric Association
Psychotherapy
2012
2013
• 90804, 90816
• 90832, Psychotherapy, 30 minutes
• 90806, 90818
• 90834, Psychotherapy, 45 minutes
• 90808, 90821
• 90837, Psychotherapy, 60 minutes
American Psychiatric Association
Documentation Guidelines for
Psychotherapy
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Time (CPT Time Rule Applies)
Modality of Therapy
Goals and Progress
Treatment Plans and Periodic Updates
“Old” Interactive CPT Codes
• All deleted:
– Interactive diagnostic
interview examination
– Interactive individual
psychotherapy
– Interactive group
psychotherapy
• Meant to capture
language difficulties
– Typically for children
– Use of physical aids and
non-verbal
communication
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Interactive Complexity
• CPT add-on code 90785
• Add-on code background
– Listed with “+” prefix in the
CPT Manual
• However, the billing form
should list the 5-digit
number WITHOUT the “+”
– May only be reported in
conjunction with specified
other codes (“primary
procedure”)
– Never reported alone
• 90785
– Describes 4 types of
communication factors
• These factors complicate
the primary procedure
– Describes types of patients
and situations most
commonly associated with
interactive complexity
– Commonly present during
visits by children and
adolescents but may apply
to visits by adults, as well
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The Primary Procedures
for Interactive Complexity
• May be reported in
conjunction with
– Psychiatric diagnostic
evaluation (90791,
90792)
– Psychotherapy (90832,
90834, 90837)
– Psychotherapy add-on
(90833, 90836, 90838)
when reported with E/M
– Group psychotherapy
(90853)
• May not be reported in
conjunction with
– E/M alone
– Family psychotherapy
(90846, 90847, 90849)
– Psychotherapy for new
crisis codes (90839,
90840)
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The Communication Factors
• Interactive complexity may be
reported when at least one of the
following communication factors
is present:
1. The need to manage maladaptive
communication (related to, e.g., high
anxiety, high reactivity, repeated
questions, or disagreement) among
participants that complicates
delivery of care
2. Caregiver emotions or behavior that
interfere with implementation of the
treatment plan
3. Evidence or disclosure of a
sentinel event and mandated
report to a third party (e.g., abuse
or neglect with report to state
agency) with initiation of
discussion of the sentinel event
and/or report with patient and
other visit participants
4. Use of play equipment, physical
devices, interpreter or translator
to overcome barriers to diagnostic
or therapeutic interaction with a
patient who is not fluent in the
same language or who has not
developed or lost expressive or
receptive language skills to use or
understand typical language
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Exception?
• CMS does not recommend billing for
interactive complexity when using a
translator/ translation services. The
Americans with Disabilities Act prevents use of
these services to justify billing.
Reporting Psychotherapy Time
with 90785
• When performed with
psychotherapy
– Interactive complexity
component (90785)
relates ONLY to the
increased work intensity
of the psychotherapy
service
– 90785 does NOT change
the time for the
psychotherapy service
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Psychotherapy for Crisis
A new code with an add-on code have been
added to describe crisis psychotherapy (90839)
• 90839, Psychotherapy for crisis, first 60
minutes
– (CPT Rule applies: 30-74 minutes)
• +90840, Psychotherapy for crisis each
additional 30 minutes: (75 – 104 minutes)
American Psychiatric Association
Crisis Psychotherapy (90839, +90840)
Rationale:
• New concept and an addition to the
psychotherapy section
• When psychotherapy services are provided to
a patient who presents in high distress with
complex or life threatening circumstances that
require urgent and immediate attention
Musher Group, LLC © 2012
Crisis Psychotherapy
• 90839 is a stand-alone code not to be
reported with psychotherapy or psychiatric
diagnostic evaluation codes, the
interactive complexity code, or any other
psychiatry section code.
• +90840 is an add-on code that should be
reported for each additional 30 minutes of
service.
Musher Group, LLC © 2012
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Psychotherapy for Crisis
• Crisis Psychotherapy: an Example
– “an urgent assessment and history of a crisis state, a
mental status exam, and a disposition. The treatment
includes psychotherapy, mobilization of resources to
defuse the crisis and restore safety, and implementation of
psychotherapeutic interventions to minimize the potential
for psychological trauma. The presenting problem is
typically life threatening or complex and requires
immediate attention to a patient in high distress.”
E/M with Psychotherapy
Overview
• Psychotherapy with E/M is now reported by selecting
the appropriate E/M service code (99xxx series) and
the appropriate psychotherapy add-on code
• The E/M code is selected on the basis of the site of
service and the key elements performed
• The psychotherapy add-on code is selected on the
basis of the time spent providing psychotherapy and
does not include any of the time spent providing E/M
services
• If no E/M services are provided, use the appropriate
psychotherapy code (90832, 90834, 90837)
American Psychiatric Association
Psychotherapy with E/M vs. E/M with
Psychotherapy
2012
• 90805, 90817
• 90807, 90819
• 90809, 90821
2013
Appropriate 99xxx series E/M code plus
one of the following:
• 90833, Psychotherapy, 30 minutes
when performed with an E/M
• 90836, Psychotherapy 45 minutes
when performed with an E/M
• 90838, Psychotherapy 60 minutes
when performed with an E/M
(CPT Time Rule Applies)
American Psychiatric Association
E/M codes
The psychotherapy add-on code are most often billed
with the following E/M codes:
Outpatient, established patient:
• 99212 – 99215
Subsequent hospital care
• 99231 – 99233
Subsequent nursing facility care
• 99307 – 99310
American Psychiatric Association
Pharmacologic Management
• 90862 has been DELETED
• Psychiatrists/mid-levels should use the
appropriate E/M series code (99xxx) to report
this service
• A new add-on code – 90863 – has been added to
describe pharmacologic management when
performed by a prescribing psychologist;
Physicians/mid-levels should NEVER use 90863
American Psychiatric Association
Thank You For Your Attention