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Diagnostic and Procedural Coding. Objective To improve diagnostic and procedural coding for mental health screening, assessment, referral, and intervention.

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Presentation on theme: "Diagnostic and Procedural Coding. Objective To improve diagnostic and procedural coding for mental health screening, assessment, referral, and intervention."— Presentation transcript:

1 Diagnostic and Procedural Coding

2 Objective To improve diagnostic and procedural coding for mental health screening, assessment, referral, and intervention

3 How do you document mental health services? Who documents mental health services? Where are mental health services documented? –(mental health chart, medical record, both charts, log sheet, database, encounter form) How do mental health providers and primary care providers share information about mental health services?

4 What we’ll cover… Why code? General Coding Principles Mental Health Diagnostic Codes Mental Health Procedural Codes Reimbursement –Who can bill? –Fraud and Abuse Work plan suggestions

5 Why Code???

6 “We can’t bill for mental health services, so why code?” You should still document in order to: –Justify your position –Assess mental health problems of school population –Track treatment –Track compliance –Assist in measuring outcomes –Demonstrate a need for mental health reimbursement

7 Why Code Correctly? Reimbursement depends on services described by CPT codes--coding is the basis for reimbursement Diagnosis codes support medical necessity for services delivered Understanding coding assumptions and guidelines helps providers to optimize reimbursement Providers must establish integrity in the health care system Document necessity services Illustrate complexity of services

8 General Coding Principles

9 The purpose of codes is to document services provided Documented services are likely to be paid Services not documented “never happened” Never “upcode” for the purpose of getting more money Most likely, you are undercoding

10 General Coding Principles (cont.) Two Part Coding Process –CPT – “What you do” –ICD – “Why you do it” Diagnosis codes (ICD) must support procedure codes (CPT) You must always have both!

11 General Coding Principles (cont.) Primary Steps for Coding an Encounter: –Provider chooses procedure code (CPT) from encounter form or superbill –Provider notes diagnosis, which is matched to a diagnosis code (ICD)

12 Documentation Where to document codes? Encounter Form Database BOTH (if separate): mental health chart AND medical record

13 Mental Health Diagnostic Codes

14 Coding Systems ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification)/ DSM-IV-TR (Diagnostic and Statistical Manual – Fourth Edition – Text Revised) * used by health care professionals to classify patient illnesses, injuries, and risk factors.

15 Anxiety Disorders Panic Disorder Without Agoraphobia Panic Disorder With Agoraphobia Agoraphobia Without History of Panic Disorder Specific Phobia Specify type: Animal Type/Natural Environment Type/Blood-Injection-Injury Type/Situational Type/Other Type Social Phobia Specify if Generalized 300.3Obsessive-Compulsive Disorder Specify if With Poor insight Posttraumatic Stress Disorder Specify if Acute/Chronic Specify if With Delayed Onset Acute Stress Disorder Generalized Anxiety Disorder Anxiety Disorder NOS

16 Depressive Disorders 296.xx Major Depressive Disorder –.2x Single Episode –.3x Recurrent Dysthymic Disorder Specify if Early Onset/Late Onset Specify With Atypical Features 311 Depressive Disorder NOS

17 Disruptive Behavior Disorders 314.xx Attention-Deficit/Hyperactivity Disorder –.01 Combined Type –.00 Predominantly Inattentive Type –.01 Predominantly Hyperactive-Impulsive Type Attention-Deficit/Hyperactivity Disorder NOS 312.xx Conduct Disorder –.81 Childhood-Onset Type –.82 Adolescent-Onset Type –.89 Unspecified Onset Oppositional Defiant Disorder Disruptive Behavior Disorder NOS

18 Substance Abuse/Dependence Alcohol Dependence/ Alcohol Abuse Amphetamine Dependence/ Amphetamine Abuse Cannabis Dependence/ Cannabis Abuse Cocaine Dependence/ Cocaine Abuse Hallucinogen Dependence/ Hallucinogen Abuse Inhalant Dependence/ Inhalant Abuse Nicotine Dependence Opioid Dependence/ Opioid Abuse Phencyclidine Dependence/ Phencyclidine Abuse Sedative, Hypnotic, or Anxiolytic Dependence/ Sedative, Hypnotic, or Anxiolytic Abuse Polysubstance Dependence Other (or Unknown) Substance Dependence Other (or Unknown) Substance Abuse The following specifiers apply to Substance Dependence as noted: With Psychological Dependence/Without Psychological Dependence Early Full Remission/Early Partial Remission/Sustained Full Remission/Sustained Partial Remission In a Contained Environment On Agonist Therapy

19 Documentation of Diagnostic Codes Report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services. Providers should report the diagnosis to their highest degree of certainty.

20 Mental Health Procedural Codes

21 Coding Systems CPT (Current Procedural Terminology) - codes that predominantly describe services & procedures. They provide a common billing language that providers and payers can use for payment purposes.

22 Evaluation & Management (E&M) Codes – New and Established Patient Office Visits Consultations Case Management Services, Team Conferences Case Management Services, Telephonic

23 Mental Health Procedure Codes Psychiatric Diagnostic or Evaluative Interview Procedures Psychotherapy Office or Other Outpatient Facility Interactive Psychotherapy Inpatient Hospital, Partial Hospital or Residential Care Facility Other Psychotherapy Other Psychiatric Services or Procedures

24 Psychiatric Therapeutic Procedures CPT Codes – Psychotherapy is the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the patient and, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.

25 E&M Codes and MH Codes The Evaluation and Management services should not be reported separately, when reporting codes: 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827,

26 Reimbursement  Who can bill?  Fraud and Abuse

27 Who can bill? –What are the rules governing who can bill for mental health diagnosis/treatment in your state?

28 Who Can Bill? Who can bill for behavioral health services? –Most states accept physicians, Clinician Psychologists (CP), Licensed Clinical Social Workers (LCSW) –However, each State has its own rules and many will pay for other professionals

29 Coverage Issues A provider should know what services are covered. Services must be documented and medically necessary in order for payment to be made. Do you, as a provider, know if all services provided are covered? Are you documenting properly, and what about this “medically necessary” bit?

30 How Much are you Paid? Reimbursement –Reductions in reimbursement rates by provider type Physician- not discounted Clinical Psychologist- discounted LCSW- further discounted Other- discounted if covered

31 Reimbursement Issues E&M codes are limited to physicians, Pas, NPs, nurses Same is true for 90805, 90807, codes An E&M (992XX) and a therapy (908XX) cannot be billed on the same date of service to most Medicaid programs

32 Documentation and Coding: Fraud and Abuse Services MUST be medically necessary (determined by payers based on a review of services billed) Music, game, instrument, pet interaction therapies, sing-alongs, arts and crafts, and other similar activities should not be billed as group or individual activities. Services performed by a non-licensed provider particularly as “incident to” using the PIN of the licensed provider

33 Elements of “Incident To” An integral part of the physician’s professional service Commonly rendered without charge or generally not itemized separately in the physician’s bill Of a type that are commonly furnished in physician’s office or clinic Furnished under the physician’s direct personal supervision

34 Work plan Suggestions

35 Actions Step: Review Program Services Define the Behavioral/Mental Health Services your students are receiving Determine if there are additional Behavioral/Mental Health Services you want to provide

36 Action Step: Review and Modify Encounter Form Does encounter form include both diagnostic and procedural codes that would be used for behavioral health when delivered by primary care providers? Mental health providers? Do procedural codes represent all services provided (including those not billed for)? Do diagnostic codes represent all diagnostic categories (including those not billed for)?

37 Action Step: Review and Modify Documentation Procedures Are diagnostic and procedure codes documented for in each progress note? Are codes for each encounter documented in both the SBHC medical record and mental health chart (if separate)? Are codes entered into database regardless of reimbursement?

38 Action Step: Understand State Program and Provider Coverage Issues Research State Program Information (Medicare Regulations) Search by state by Department of Health or Department of Mental Health to find state specific information Contact State Medicaid Assistance Program and determine specific Behavioral Health Service requirements Invite Medicaid Representatives to your facility or visit them to present Behavioral Health Program and clearly understand the requirements

39 Questions to Answer What criteria must programs (SBHC) meet in order to provide behavioral health services? What providers are eligible to provide behavioral health services? What are your state’s credentialing and licensing requirements for providers of behavioral health services? What credentialing and licensing requirements are necessary for billing in your state? What are the guidelines for billing services as “incident to?”

40 Action Step: Determine Reimbursement Estimates Obtain reimbursement rates by provider type for state and other programs Understand billing rules by payer, e.g. billing E&M visit same day as Behavioral Health visit, number of visits limits, auth/pre- authorizations, etc. Assure you have a complete understanding of program parameters re: Individual Therapy, Case Management, Special Behavioral Health Services, etc.


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