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Behavioral Health Coding that Works in Primary Care Mary Jean Mork, LCSW April 16 & 17, 2009.

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Presentation on theme: "Behavioral Health Coding that Works in Primary Care Mary Jean Mork, LCSW April 16 & 17, 2009."— Presentation transcript:

1 Behavioral Health Coding that Works in Primary Care Mary Jean Mork, LCSW April 16 & 17, 2009

2 Workshop Outline Our program background Reimbursement big picture and problems Your questions about reimbursement Process for addressing problems Products to organize our thinking Your challenges and successes

3 Learning Objectives Attendees will: Be able to identify who to involve in order to better understand the regulatory and payment situation for integrated care in your own setting Receive tools to help organize the facts around payment and licensing at home

4 Mental Health Integration in Maine

5 Our Mental Health Integration Program: Primary Care/Mental Health Teams Primary Care sites –Rural Health Clinics (RHC) –Federally Qualified Health Centers (FQHC) –Hospital owned practices – Private practices Local Mental Health Partners –Specialty Mental Health agencies –Hospital owned Behavioral Health organizations –Community Mental Health Centers

6 The Goal: Creating a sustainable model of mental healthcare in primary care

7 The Problems with Integrated Care No one seems to know how to get paid Mental Health regulations and licensing expectations don’t fit the primary care setting Confidentiality vs. “shared records” Lack of clarity and understanding about present practices Complicated licensing and reimbursement rules without accessible experts

8 Examples from our Program A Psych NP working in a privately owned primary care practice is unable to bill for Psychiatric services for 3 years due to lack of Psychiatric Supervision “physically located on site.” Is this correct? An LCSW is employed by a mental health center but working in a primary care practice. How should she bill? An LCPC wants to work for a primary care practice, but is not employed by an agency. Will this work?

9 Why is this so complicated?

10 Some Background Information AMA determines E&M and CPT codes CMS (Centers for Medicare & Medicaid Services) determines if and how they will reimburse the codes for Medicare Medicaid determines what should be adopted on state level (as long as not in violation of CMS rule)

11 Various Payers and Various Rules Medicare Medicaid Commercial Insurers Mental Health vs Medical codes Licensing rules

12 Medicare Variation exists in the interpretation and application of the Federal program rules and guidelines –Fiscal Intermediaries often have a more narrow interpretation than Medicare law allows –Creates misunderstanding of policies and confusion at the practice level –Denies reimbursement for allowable procedures

13 Medicare Louisiana Regional Medicare Carrier – PBSI Medicare Services Search site for Local Coverage Determinations (LCD’s) – ndex1.asp ndex1.asp Look for H&B codes Or – Find someone in your organization who does this all the time and make them your friend!

14 Medicaid States have flexibility in defining covered mental health services Can choose to contract with managed care Billing requires both a diagnosis and a procedure code –Some states limit procedures, providers and/or practices that can use these codes

15 Commercial Insurance Inconsistencies among various insurers Lack of clarity around covered services Difficulty finding “experts” to answer specific questions about reimbursement Carve outs Other problems?

16 Coding that Works

17 Evaluation & Management (E&M) Use E&M codes 99201-99201 or 99211- 99215 whenever possible Services must be medically necessary Practitioner must be practicing within their scope of practice Used in conjunction with a medical or psychiatric diagnosis

18 Health and Behavior Codes: Consider Their Use

19 Using Health & Behavior Codes Patients with underlying physical illness or injury Where biopsychosocial factor may be affecting medical treatment Patients with cognitive capacity for the approach Physician documents need Assessment not duplicate of other assessment

20 Documentation - Assessment Onset and History of physical illness Clear rationale for H&B Assessment outcome including: – Mental status and –Cognitive ability for treatment Goals and expected duration of intervention Length of time for assessment

21 Documentation - Intervention Capacity Intervention –Clearly defined –How this will improve compliance –Goals of intervention –Response to intervention Rationale for frequency Length of time for intervention

22 Examples

23 Billing for the H&B Medical diagnosis Medical bill – not mental health Billed by practice with Mental Health Provider: –Hospital license –Primary care office –Rural Health Clinic –Federally Qualified Health Center

24 What have been your challenges in billing and licensing?

25 How can you figure this out for your setting? Make friends with your billers and coders Make connections at the state level for Medicaid. Talk to the Provider Relations folks Find your Medicare site ( and see what is available for Talk with other providers doing this work

26 Consider a Work Group Representatives from all aspects of the reimbursement spectrum: –Billers and coders –Audit specialists –Clinicians –Primary Care Practice Manager –Mental Health Program Manager –Physician/Psychiatrist Focus on all levels Information and ongoing learning are key Celebrate successes (and awareness) along the way

27 Work Group Strategies Understand the current rules Identify opportunities and barriers that affect sustainability Use understanding of current rules to: –recommend most effective way to organize services –maximize reimbursement for integrated care Target barriers with highest priority and/or are most likely to be able to change

28 Organizing Information “The Grid”


30 Components within “the Grid” Coding Category Coding number for service Discipline of Provider allowed to bill for service Codes by insurer Psychiatric Services by type of license Practice site able to bill for code, funding source, provider and license

31 Where to begin What is the discipline of your mental health practitioner? What service will they deliver and what code will be used? Under what license? Where will the service be delivered? Which insurance will be billed? What are the rules for that insurer?

32 How have you addressed your reimbursement challenges?

33 Share your good ideas and useful information

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