Amy Heneghan, M.D. Palo Alto Medical Foundation

henegha@pamf.org

Coding for Mental Health Disorders in Primary Care

Learning Objectives

Participants will be able to…• Expand awareness of codes useful in describing

mental health and behavioral conditions commonly seen in primary care

• Learn how to bill insurers appropriately for the activities involved in caring for children with mental health and behavioral problems

• Understand how the medical home model applies to caring for children with mental health and behavioral problems

Diagnoses: What is it? • International Classification of Diseases, Ninth

Revision, Clinical Modification (ICD-9-CM)

– Arranges diseases and injuries into groups according to established criteria

– Revised approx. q 10 years by WHO, annual updates by Centers for Medicare and Medicaid Services (CMS)

– ICD-10-CM officially replaces ICD-9-CM on October 1, 2013, • Diagnostic and Statistical Manual of Mental Disorders-

Fourth Edition (DSM-IV): – Published by the American Psychiatric Association (APA)

– Aim: to develop an official nomenclature of mental disorders

– Subset of the ICD-9-CM: 290-319 series

Procedures: What did you do about it?

• Current Procedural Terminology (CPT)*:‒Listing of descriptive terms and 5-digit numeric identifying codes/modifiers for reporting medical services performed by physicians and other qualified medical providers‒Designated as the national procedural coding standard under the Health Care Portability and Accountability Act

* CPT copyright 2011 American Medical Association. All rights reserved.

Payments: What is its financial value?

• AMA/Specialty Society Relative Value Update Committee (RUC):

‒ Assigns appropriate relative value units for practice expense, physician work and malpractice expense

WHY CODING MATTERS• 21% of U.S. children and adolescents meet diagnostic

criteria for mental health disorder with impaired functioning

• 16% or more of U.S. children and adolescents have impaired mental health functioning and do not meet criteria for a disorder

• Despite “parity” legislation, ICD-9 and DSM-IV codes are often treated differently when they are used by primary care primary providers.

• Possible that 30% of your submitted claims rejected by private payers because they refuse to pay you for managing conditions in the ICD-9 290-319 series!

THE BASICS

• ICD-9 selected must be most specific• ICD-9 selected as primary diagnosis must

describe the condition necessitating the visit• ICD-9 code does not determine the level of

the service (i.e. CPT or E/M code)• V-codes can be used for diagnoses, but can be

problematic for some primary diagnosesexceptions: V20.2, V60-V69

ICD-9 codes for mental health

• Organic Psychotic Conditions 290-294• Other Psychoses 295-299• Neurotic Disorders, Personality Disorders, And

Other Non-psychotic Mental Disorders 300-316• Mental Retardation 317-319• Symptoms, Signs, And Ill-Defined Conditions 780-

799• Persons Encountering Health Services In Other

Circumstances V60-V69

2011 ICD-10-CM Diagnosis Codes Mental and behavioral disorders F01-F99

• F01-F09 Mental disorders due to known physiological conditions • F10-F19 Mental and behavioral disorders due to psychoactive substance use • F20-F29 Schizophrenia, schizotypal and delusional, and other non-mood psychotic

disorders • F30-F39 Mood [affective] disorders • F40-F48 Anxiety, dissociative, stress-related, somatoform and other nonpsychotic

mental disorders • F50-F59 Behavioral syndromes associated with physiological disturbances and

physical factors • F60-F69 Disorders of adult personality and behavior • F70-F79 Mental retardation • F80-F89 Pervasive and specific developmental disorders • F90-F98 Behavioral and emotional disorders with onset usually occurring in

childhood and adolescence • F99-F99 Unspecified mental disorder

Organic Psychotic Conditions 290-294

• 290 Dementias • 291 Alcohol-induced mental disorders • 292 Drug-induced mental disorders • 293 Transient mental disorders due to

conditions classified elsewhere • 294 Persistent mental disorders due to

conditions classified elsewhere

Other Psychoses 295-299

• 295 Schizophrenic disorders • 296 Episodic mood disorders • 297 Delusional disorders • 298 Other non-organic psychoses • 299 Pervasive developmental disorders

Neurotic Disorders, Personality Disorders, And Other Nonpsychotic Mental Disorders 300-316

• 300 Anxiety, dissociative and somatoform disorders • 301 Personality disorders • 302 Sexual and gender identity disorders • 303 Alcohol dependence syndrome • 304 Drug dependence • 305 Nondependent abuse of drugs • 306 Physiological malfunction arising from mental factors • 307 Special symptoms or syndromes not elsewhere classified • 308 Acute reaction to stress • 309 Adjustment reaction • 310 Specific nonpsychotic mental disorders due to brain damage • 311 Depressive disorder not elsewhere classified • 312 Disturbance of conduct not elsewhere classified • 313 Disturbance of emotions specific to childhood and adolescence • 314 Hyperkinetic syndrome of childhood • 315 Specific delays in development • 316 Psychic factors associated with diseases classified elsewhere

Mental Retardation 317-319

• 317 Mild mental retardation • 318 Other specified mental retardation • 319 Unspecified mental retardation

Symptoms, Signs, And Ill-Defined Conditions 780-799

• 780-789 Symptoms • 790-796 Nonspecific Abnormal Findings • 797-799 Ill-Defined And Unknown Causes Of

Morbidity And Mortality

V60 Housing household and economic circumstances V61 Other family circumstances V62 Other psychosocial circumstances V63 Unavailability of other medical facilities for care V64 Persons encountering health services for specific procedures

not carried out V65 Other persons seeking consultation V66 Convalescence and palliative care V67 Follow-up examination V68 Encounters for administrative purposes V69 Problems related to lifestyle

Persons Encountering Health Services In Other Circumstances V60-V69

E/M Complexity and MH VisitsLevel of Visit

1 2 3 4 5

NewEstablishedConsult

99201 (10)

99241 (15)

99202 (20)99212 (10)99242 (30)

99203 (30)99213 (15) 99243 (40)

99204 (45)99214 (25)99244 (60)

99205 (60)99215 (40)99245 (80)

History 1 HPI 1 HPI1 ROS

4 HPI2 ROS1 PFSH

4 HPI10 ROS3 PFSH

4 HPI10 ROS3 PFSH

PhysicalExam

1 system or area (brief)

2 systems /areas(brief)

1 system detailed and 1

area (brief)

8 systems OR complete

exam of 1 system

8 systems OR complete

exam of 1 system

MDM Minimal Minimal Low Moderate High

• Meet level in all THREE components (History, Physical Exam, MDM) • Time: Total face to face time: “>50% of the visit spent in counseling and coordination of care”

Preventive, New 99381 – 99387 Preventive, Established 99391 – 99397

Documentation Requirements toBill Based on Time

• The 3 key components of history, PE, MDM may be ignored– Only time is used to select the level of care

• Use when the time spent in ‘counseling and coordination of care’ > 50% of the E&M visit

• May be used when the patient is present or when counseling a parent when the patient is not physically present

• The total length of time of the encounter must be documented and the record should describe the counseling and/or activities to coordinate care

• Time-based coding also may be used for follow-up appointments to discuss management of common medication side-effects such as appetite and/or sleep changes, behaviors requiring environmental changes rather than medication adjustment

• Resident/NP/PA face to face time can not be included (except under specialty specific Medicaid contracts)

Documentation Requirements toBill Based on Time

*** minutes spent, >50% in discussion and counseling with the family about *** above.

The more detail the better!

National Correct Coding Initiative (NCCI)Edits

• Developed by CMS to adjudicate Medicare claims• Informed by CPT code descriptors, instructions and

coding guidelines developed by national societies • Identify services that normally should not be billed

by the same physician for the same patient on the same date of service

• Used to determine payment policies for physician services

• Promote correct coding

Modifiers

• A means by which a physician can indicate a service or procedure has been altered by some specific circumstance but not changed in the basic code definition

• 2 digit suffix appended to a CPT code• The conditions of the modifier must be met• Medical record must support the change• Modifiers used for mental health care: -25; -59

Modifiers

• Modifier -25– Used for a significant, separately identifiable service that is

performed during the same patient encounter– Appended to the E/M code.– Both the E/M service and the other service or procedure

require individual documentation, although this documentation may be within the same written note

• Modifier -59– Signifies that a procedure or service was distinct or

independent from other non-E/M services performed on the same day.

– -59 is the “modifier of last resort”: only use -59 if it best explains the circumstances of the visit and no other

Example: Procedures and Modifiers• 96110: Developmental testing; limited

– Limited behavioral/emotional “testing”, with interpretation and report

• e.g., Vanderbilt, MCHAT, Pediatric Symptom Checklist– At this time, this is the only CPT code available for the non-

interactive screening and rating scales used in mental health care

• Use one unit for each individual rating scale administered, scored and interpreted

• Append modifier -25 to E/M to show the E/M is a separate and identifiable service by the same physician (on the same day of the procedure) from the procedure performed

• 96111 and 99420 also used in some circumstances

OTHER SERVICES

• Telephone Care (99441-99443)• Care Plan Oversight (99339-99340)• Medical Team Conferences (99367)• On-line services (99444) • Prolonged Services (99354-99359)

Telephone Care: MD

Telephone E/M service provided by a physician to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appt.99441: 5-10 min. medical discussion99442: 11-20 min. medical discussion99443: 21-30 min. medical discussion

Care Plan Oversight

• Recurrent physician supervision of a complex patient who requires multidisciplinary care and ongoing physician involvement

• Non-face-to-face• Reported separately from E/M services• Reported by the MD who has the supervisory role in the

pt’s. care or is the sole provider• Reported based on the amount of time spent/calendar

month• 99339: 15-29 minutes/month• 99340: greater than 30 minutes/month

Medical Team Conference: 99367

• At least 3 physicians from 3 different subspecialties • Participation by physician • Patient and/or family NOT present• If patient/family present, report attendance w/ appropriate E/M

service based on time • ≥ 30 minutes• Cannot be part of care plan oversight• Pre-service work: Review of chart• Post-meeting work: Clinician must document his/her

participation in the team– Information he/she contributed– Any treatment recommendations he/she made– Review of the patient’s care plan

ON LINE E/M SERVICE: 99444

• Using the Internet or similar electronic network• Non-face-to-face E/M service for established

patient• Provided by a physician to a patient, guardian,

or healthcare provider• Not originating from a related E/M service

provided within previous 7 days• In response to a patients’ online inquiry

PROLONGED SERVICES • Face to Face Prolonged Services

– 99354 30 – 74 minutes = 1 unit– 99355 74 + minutes (each 30 min additional = 1 unit;

multiple units allowed)– Must bill on same day as an E & M code, need not be continuous

time during that day

• Non Face to Face Prolonged Services

– 99358 30 – 74 minutes– 99359 74 + minutes (1 unit = 30 min of time;

multiple units allowed)– May be reported as stand alone encounter, need not be during

E/M encounter.

My Patient 1

• 24 month old girl at WCC• Happy, healthy, PE normal• MCHAT done to assess for autism

ICD-9-CM CPT

V20.2 Routine infant or 99392-25 Preventive medicine child health check service, established

patient, age 1-4 (attach modifier 25)

V20.2 96110 Developmental testing limited

My Patient 2• 7 year old girl for assessment of ADHD.• Mother/teacher both completed Vanderbilt rating scales,

mailed to her when she called about her daughter’s symptoms of distractedness, impulsivity, and poor school performance

• PE normal, forms scored by nurse show ADHD combined type• Placed on medication with phone follow up in 2 weeks

ICD-9-CM CPT

314.01 ADHD combined type 99215-25 established patient, 45 minutes spent

314.01 96110 Developmental testing limited

314.01 99442 telephone call 11-20 min

My Patient 3• 14 year old male for WCC• Tired, lack of focus, poor appetite, feels sad• Beck Depression Inventory, Parent CBCL, CRAFT

ICD-9-CM CPT

V20.2 Routine infant or 99397 Preventive medicine child health check service, established

patient, age 12-18799.29* Other signs and symptoms 99214-25 established patient, 25

involving an emotional state minutes799.29* 96110 Developmental testing

limited (Beck)799.29* 96110-59 Developmental testing

(parent CBCL)* Also consider: 780.79 tiredness and/or 296.2 major depressive affective disorder single episode unspecified degree

My Patient 3

• Call mental health professional to discuss case and initiate referral– could qualify as non face-to-face prolonged services (99358) if it exceeds

30 min and is documented.

• 6 weeks later you call mental health professional to discuss increasing dose of Prozac. – Any additional time spent in discussion with the mental health

professional after the referral has been make could count towards care plan oversight 99339 (for 15 – 29 minutes) or 99340 (for 30 minutes or more) PER MONTH

– Log of care plan oversightDates, service provided, action, amount of time

My Patient 3

• Initial Follow-up at 2 weeks– 90 minute discussion of treatment plan (Discuss

risks and benefits of SSRI’s, other therapies)ICD-9 296.2 or 799.29CPT 99215 and 99354

• On-going follow-up monthly– to assess progress with screening tool

ICD-9 296.2 or 799.29CPT 99213-25 established patient, 15 minutes

96110 standardized screening forms

My Patient 3

• M.P. 3 improves steadily,– follow-up visit intervals lengthen to every 3 months – 99213-25, 96110; 296.5 or 799.29 to monitor progress via

standardized screening forms– Send progress notes to Mental Health Professional (CPO log)

• M.P. recovers completely– Longer visit to discuss wean and discontinuation of medication– 99214, ICD-9 296.92 or 799.29– Send progress notes to Mental Health Professional (CPO log)

Pediatric Councils• Pediatricians and medical directors of insurance

companies meet regularly to discuss quality of care issues for children

• Most states now have Pediatric Councils – Chapter President has information

• If insurance companies not paying PCP’s for mental health code, discuss value of doing this at a Pediatric Council meeting (cost-effective, insufficient supply of Mental Health Professsionals

• Psychologists and social workers in community should work with pediatricians to discuss their issues at Pediatric Council meetings

SUMMARY • Coding properly matters.• Documenting properly matters more!!• If in doubt, ASK! • Both screening tools and collaborating with mental

health professionals are good for patients and if properly performed, can be good for your practice.

• Coding is a moving target with changes that require and deserve your attention. (e.g., ICD-10)

• Advocate for your patients AND your practice regarding identifying and treating mental health and behavioral problems in primary care.

AAP Pediatric Coding• AAP Coding Hotline:

aapcodinghotline@aap.org• AAP Coding Fact Sheets for

Primary Care Clinicians– Developmental Screening and

Testing– Anxiety– Bereavement – Depression – Inattention, Impulsivity, Disruptive

Behavior, and Aggression – Post-traumatic Stress Disorder – Substance Use/Abuse– coding.aap.org

TeenScreen Website: www.teenscreen.orgTS Email: teenscreeninfo@childpsych.columbia.eduAAP Website: www.aap.org/mentalhealthAAP Email: mentalhealth@aap.orgAmerican Academy of Child/Adolescent Psychiatry: www.aacap.org AAP Section on Developmental and Behavioral Pediatrics (SODBP): www.dbpeds.org

RESOURCES

RESOURCES

• http://www.cdc.gov/nchs/icd/icd10cm.htm#10update

• http://www.icd9coding.com/• http://www.icd9data.com/2011/Volume1/

default.htm• http://www.medicalhomeinfo.org/

downloads/pdfs/MedicalHomeCodingFactSheet.pdf

REFERENCES

• American Academy of Pediatrics. Coding for Pediatrics-2011:A Manual for Pediatric Documentation and Payment. Elk Grove Village, IL: American Academy of Pediatrics, 2010.

• American Academy of Pediatrics. Pediatric Coding Newsletter. Elk Grove Village, IL: American Academy of Pediatrics.

• American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics. “Coding Conundrums”. Semi-annual Newsletter. Elk Grove Village, IL: American Academy of Pediatrics.

• AAP: Addressing Mental Health Issues in Primary Care: A Clinician’s Toolkit http://www.aap.org/commpeds/dochs/mentalhealth/KeyResources.html