Presentation on theme: "Amy Heneghan, M.D. Palo Alto Medical Foundation Coding for Mental Health Disorders in Primary Care."— Presentation transcript:
Amy Heneghan, M.D. Palo Alto Medical Foundation 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: 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 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 diagnoses exceptions: V20.2, V60-V69
ICD-9 codes for mental health Organic Psychotic Conditions Other Psychoses Neurotic Disorders, Personality Disorders, And Other Non-psychotic Mental Disorders Mental Retardation Symptoms, Signs, And Ill-Defined Conditions 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 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 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 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
Symptoms, Signs, And Ill-Defined Conditions Symptoms Nonspecific Abnormal Findings 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 Visits Level of Visit New Established Consult (10) (15) (20) (10) (30) (30) (15) (40) (45) (25) (60) (60) (40) (80) History1 HPI 1 ROS 4 HPI 2 ROS 1 PFSH 4 HPI 10 ROS 3 PFSH 4 HPI 10 ROS 3 PFSH Physical Exam 1 system or area (brief) 2 systems /areas(brief) 1 system detailed and 1 area (brief) 8 systems OR complete exam of 1 system MDMMinimal LowModerateHigh 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 – Preventive, Established – 99397
Documentation Requirements to Bill 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 to Bill 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 and also used in some circumstances
OTHER SERVICES Telephone Care ( ) Care Plan Oversight ( ) Medical Team Conferences (99367) On-line services (99444) Prolonged Services ( )
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 : 5-10 min. medical discussion 99442: min. medical discussion 99443: 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: minutes/month 99340: greater than 30 minutes/month
Medical Team Conference: 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: 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 – – 74 minutes = 1 unit – 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 – – 74 minutes – 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-CMCPT V20.2 Routine infant or Preventive medicine child health check service, established patient, age 1-4 (attach modifier 25) V 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-CMCPT ADHD combined type established patient, 45 minutes spent Developmental testing limited telephone call 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-CMCPT V20.2 Routine infant or Preventive medicine child health check service, established patient, age * Other signs and symptoms established patient, 25 involving an emotional state minutes *96110 Developmental testing limited (Beck) * Developmental testing (parent CBCL) * Also consider: tiredness and/or 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 (for 15 – 29 minutes) or (for 30 minutes or more) PER MONTH – Log of care plan oversight Dates, 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 or CPT and On-going follow-up monthly – to assess progress with screening tool ICD or CPT established patient, 15 minutes standardized screening forms
My Patient 3 M.P. 3 improves steadily, – follow-up visit intervals lengthen to every 3 months – , 96110; or 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 or – 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.
REFERENCES American Academy of Pediatrics. Coding for Pediatrics-2011:A Manual for Pediatric Documentation and Payment. Elk Grove Village, IL: American Academy of Pediatrics, 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 s.html