behavioral health coding changes 2013 effective january 1 st, 2013
TRANSCRIPT
THE MOST BASIC FUNDAMENTALS
A. Codes are assigned as a method of recording:
• The reason for a visit (diagnosis codes)
• The work performed during a visit (CPT & HCPCS codes)
• Any consideration for third‐party reimbursement
B. Assignment of codes can be complicated and many variables may apply to code selection.
C. Ultimately, it is the responsibility of the clinician to assure that proper codes are assigned for their services.
D. Codes assigned must be a mirror‐image match between code and information documented in the medical record.
WHO PAYS WHAT?
Remember – the diagnosis code must represent diagnoses evaluated today and CPT codes represents work performed today.
Sometimes services are provided for which there will be no payment.
The presence of a code is not a payment guarantee.
Third‐party payers may decide what they will and what they will not reimburse Decision based on:
a. what services, [codes]
b. which professionals [credentials]
MEDICARE /MEDICAID FQHC ENCOUNTER
Billable FQHC encounters (visit) are:
- Medically necessary and between a core provider and a patient
FQHC core services – Physician services, including costs for contracted physician services, to the extent covered in Washington
statute and administrative code. Contracted physicians must be identified in the FQHC’s Core Provider Agreement. The contracted physician must be a preferred provider and receive an identification number from the Provider Enrollment Section at the Agency.
Mid-Level Practitioner (PAs, ARNPs and CNMs) services – To the extent covered in Washington statute and administrative code, including costs for contracted mid-level practitioner services.
Clinical Psychologist services – Per the medical mental health benefit for individuals not eligible for the RSN Access to Care Standards OR the mental health benefit for services provided through an RSN contract for individuals meeting the RSN Access to Care Standards.
Licensed Clinical Social Worker services (LCSWs) – Per the medical mental health benefit for individuals not eligible for the RSN (Regional Support Network) Access to Care Standards OR the mental health benefit for services provided through an RSN contract for individuals meeting the RSN Access to Care Standards.
Visiting Nurse Home Health services (in designated areas where there is a shortage of home health agencies) – To the extent covered in Washington statute and administrative code.
Non-Billable FQHC encounters (visit) are:
• Medically necessary
• Provided by a non-core FQHC provider
• Follow documentation guidelines for provider services
• Billed out as a BH001 zero charge code for all psych services
Common misconception:
- “If we aren’t billing for it, I don’t need to document”.
False! – Any patient encounter requires proper charting regardless of reimbursement. If documentation is missing the billing department will send a worklog task requesting completion.
MEDICARE /MEDICAID FQHC ENCOUNTER
PSYCHOTHERAPY TIPS ON TIME
Document actual time in all records
• Face‐to‐face time is actual time
• No extra for pre‐ or post‐service work
Consider modifiers:
• 52 if time less than code specifies
• 22 if time greater than code specifies
BIG CHANGES IN PSYCHIATRY CODING
C P T C O D E S F R O M
P A S T Y E A R S
90801
&
90802Old Psychiatric
Diagnostic Interview
Examinations
C O M M O N N E W C P T C O D E S
90792 Psychiatric Dx. Evaluation medical
Psychiatric Diagnostic Evaluation
with medical service by MD, DO, NP, or PA
May add 90785 Interactive Complexity
90791
Psychiatric Dx. Evaluation non-medical
May add 90785 Interactive Complexity
BIG CHANGES IN PSYCHIATRY CODINGC P T C O D E S F R O M
P A S T Y E A R S
90862Old "Medication
management"
C O M M O N N E W C P T C O D E S
99201-99215 E/M Codes
Medical clinicians may assign CPT E/M visit codes
based on history, exam and MDM or qualifying time.
Note: E/Ms coded with a Psychotherapy code today may not be coded based on time.
BIG CHANGES IN PSYCHIATRY CODING
90805 90807 90809
Old Psychotherapy with
medical evaluation and
management
90833 - 30 min90836 - 45 min90838 - 60 min
May add E/M based on Hx/Ex/MDM
Psychotherapy provided
by MD, DO, NP or PA
C P T C O D E S F R O M
P A S T Y E A R S
C O M M O N N E W C P T C O D E S
BIG CHANGES IN PSYCHIATRY CODING
90804 90806 90808
Old Psychotherapy without
medical evaluation and
management
90832 - 30 min90834 - 45 min90837 - 60 min
May add E/M based on Hx/Ex/MDM
Psychotherapy provided
by MD, DO, NP or PA
C P T C O D E S F R O M
P A S T Y E A R S
C O M M O N N E W C P T C O D E S
• INTERACTIVE COMPLEXITY +90785ADD ON CODEREFERS TO SPECIFIC COMMUNICATION FACTORS THATCOMPLICATE THE DELIVERY OF A PSYCHIATRIC SERVICE.
COMMON FACTORS INCLUDE MORE DIFFICULT COMMUNICATIONWITH DISCORDANT OR EMOTIONAL FAMILY MEMBERS ANDENGAGEMENT OF YOUNG AND VERBALLY UNDEVELOPED ORIMPAIRED PATIENTS.
TYPICAL PATIENTS HAVE THIRD PARTIES SUCH AS PARENTS,GUARDIANS, OTHER FAMILY MEMBERS, INTERPRETERS,LANGUAGE TRANSLATORS, COURT OFFICERS…SCHOOLS INVOLVEDIN THEIR PSYCHIATRIC CARE.
BIG CHANGES IN PSYCHIATRY CODING