Coding 101 The Partnership TOT, September 22, 2008 Taken from “Beginning Coding”, “Intermediate Coding”, and “I Hate Coding” by Dianne Demers

2 Welcome and Expectations

3 Objectives The Participant will be able to ● Define CPT, ICD 9, and DSM 4 Coding ● Explain the reasons why appropriate coding and documentation is so important in SBHC settings. ● Demonstrate correct use of CPT and ICD 9 codes ● Explain the rational for conducting routine medical record review and coding compliance audits in SBHC settings

4 Coding Background and Terminology

5 Coding Definition Coding is an alphanumeric system used to translate medical procedures and services into data Coding is an alphanumeric system used to translate medical procedures and services into data

6 Types of Coding Current Procedural Terminology (CPT) International Classification of Diseases (ICD-9 Clinical Modification - CM) Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR)

7 Coding Is Not The Same As Billing

8 Coding is Medicare Drive Pediatrics was not considered in original coding guidelines, so some of the things we do in SBHCs may not fit well Pediatrics was not considered in original coding guidelines, so some of the things we do in SBHCs may not fit well

9 SBHC Coding There is no difference between coding in a SBHC and any other setting – the coding assumptions are the same. There is no difference between coding in a SBHC and any other setting – the coding assumptions are the same. You provide the same level of care regardless of the location. You provide the same level of care regardless of the location.

10 Why Code Correctly? ● Reimbursement depends on it. ● Codes describe the services you provide ● Codes justify these services ● Services not documented “never happened” PS: Never code for the purpose of getting more money

11 The Coding Process has 2 Parts 1. “What you did” = CPT 2. “Why you did it” = ICD-9 or DSM-4 TR YOU MUST ALWAYS USE BOTH a what and a why (NO EXCEPTIONS)

12 When a provider is under- coding they tell the wrong story This wrong story is:  SBHC Providers are seeing very few patients with multiple problems.  SBHC Providers should see more patients since they are not seeing complicated patients.  The SBHC should decrease the number of physicians and add more mid-level providers.

13 There Are Two Coding Guidelines & 1997 Both 1995 and 1997 guidelines are approved for use by CMS Both 1995 and 1997 guidelines are approved for use by CMS Agencies may specify use of 1995 or 1997 guidelines Agencies may specify use of 1995 or 1997 guidelines 1997 guidelines are more specific than 1995 in the examination portion (they are more computer friendly) 1997 guidelines are more specific than 1995 in the examination portion (they are more computer friendly) New guidelines have been proposed, but have not yet been accepted New guidelines have been proposed, but have not yet been accepted

14 Coding Guidelines 1995 vs This lecture is based on the 1995 guidelines because they are 15 pages long vs. 57 pages of the 1997 version. This lecture is based on the 1995 guidelines because they are 15 pages long vs. 57 pages of the 1997 version. s/1995dg.pdf

15 Fraud Intentional deception or misrepresentation Intentional deception or misrepresentation ● Deliberately billing for services not performed ● Unbundling of services ● Intentionally submitting duplicate claims

16 Abuse Improper billing practices Improper billing practices ● Billing for non-covered services ● Misusing codes on a claim form

17 Errors Accept it, you will make them. Accept it, you will make them. Your best defense is having a plan for your coding and being able to explain it. Your best defense is having a plan for your coding and being able to explain it.

18 Coding Does Not Equal Good Medicine

19 But - Coding is Good Documentation

20 CPT Codes document: Level of Service Level of Service Procedures Provided Procedures Provided

21 Examples of CPT codes Evaluation & Management Evaluation & Management Preventive Health

22 ICD-9 and DSM4 Codes document: The reason behind the visit (They must support the CPT codes)

23 General Coding Principles Coding gets you paid for your services Coding gets you paid for your services Coding can be used to justify the need for services to your funders Coding can be used to justify the need for services to your funders

24 Coding with ICD-9 ICD-9 codes have 3, 4 or 5 digits ICD-9 codes have 3, 4 or 5 digits ● The greater the number of digits, the higher the specificity ● Use a 5-digit code when it exists ● Use a 4-digit code only if there is no 5- digit code with the same category ● Use a 3-digit code only if there is no 4- digit code within the same category PS: Omitting the required 4 th or 5 th digit will result in the denial of a claim. Do not add any additional digits, even zero

25 ICD-9-CM Codes Range from to V82.9 They identify: They identify: ● Diagnoses ● Symptoms ● Conditions ● Problems ● Complaints ● Other reason for the procedure, service, or supply provided

26 ICD-9-CM Codes Three volumes Three volumes ● Volume 1 Tabular List of Diseases ● Notes all exclusive terms and 5 th -digit instructions ● Volume 2 Alphabetic Index of Diseases ● Does not contain detail – Do Not code from this volume ● Volume 3 Procedures ● Used almost exclusively for hospital services PS: (All 3 Volumes are generally found in one binding)

27 “V” Codes For circumstances other than disease or injury For circumstances other than disease or injury Three categories: Three categories: ● Problem – Could affect overall health status, but is not a current illness or injury ● Ex.: V14.2 Personal history of allergy to sulfonamines ● Service – Circumstances other than illness or injury ● Ex.: V68.1 Issue of a repeat prescription ● Factual – Certain facts that do not fall into the “problem” or “service” categories

28 “V” Codes Can be used as a: Can be used as a: ● Solo Code ● Principal code ● Secondary code May represent check-ups, screenings, administrative requests, prescription refills May represent check-ups, screenings, administrative requests, prescription refills

29 Rules for Coding Outpatient Visits

30 Determine Type of Office Visit Evaluation and Management Evaluation and Management New Patients vs. Established Patients Preventive Health Visits Preventive Health Visits New Patients vs. Established Patients New Patients vs. Established Patients Counseling Visits Counseling Visits Medical Visit – talker only Medical Visit – talker only Mental Health Visits Mental Health Visits New Patients vs. Established Patients

31 Determine Medical Necessity Services are reasonable and necessary for the diagnosis and treatment of illness or injury. Services are reasonable and necessary for the diagnosis and treatment of illness or injury. All payors define necessity differently All payors define necessity differently Clinical rationale must be documented through coding. Clinical rationale must be documented through coding. You cannot write more, to get paid more. You cannot write more, to get paid more.

32 Determine Chief Complaint The reason for the patient’s visit The reason for the patient’s visit ● S of a SOAP note Codes used must relate to chief complaint or they are invalid Codes used must relate to chief complaint or they are invalid And, the chief complaint must be documented in the chart And, the chief complaint must be documented in the chart

33 Evaluation/Management (E / M) Services Used for acute care visits Used for acute care visits Five levels of service Five levels of service Seven components within the levels Seven components within the levels ● Key components – history, exam and medical decision making ● Contributory components – counseling, coordination of care, nature of presenting problem, and time

34 Evaluation/Management (E / M) Services Beginning information about coding deals with the three key components: Beginning information about coding deals with the three key components: ● History ● Examination ● Medical Decision Making

35 Evaluation/Management (E / M) Services There are 5 Levels of service 1. Minimal 2. Self-Limited or Minor 3. Low Severity 4. Moderate Severity 5. High Severity

36 Most Problems Are Not Level 1 Level 1 is: Level 1 is: ● “A problem that may not require the presence of the physician, but service is provided under the physician’s supervision.” ● This is a non-provider visit ● Documentation is required – but flow sheet is sufficient ● If this level is used, it states that the expertise of a medical provider is not necessary

37 CPT Codes Used for E/M Visits New Patients New Patients Level Level Level Level Level Established Patients

38 Coding Steps

39 Coding Steps First Step - Determine if your patient is: First Step - Determine if your patient is: A New Patient or An Established Patient

40 Definition of a new patient: It is the patient’s first visit to the provider It is the patient’s first visit to the provider The patient has not received any professional services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years. The patient has not received any professional services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years. PS: Any time a patient is seen in an Emergency Room they are considered a new patient

41 If your patient does not meet the definition of a New Patient, then they are an Established Patient

42 Coding Steps Second Step - determine the level of service for the visit, Second Step - determine the level of service for the visit, To do this you need to determine the level of service for each key component separately There are 3 key components They are: 1. History (HPI, ROS, PFSH) 2. Examination 3. Medical Decision Making

43 Coding Steps New Patients Within the 3 key components, there are 5 levels of service Within the 3 key components, there are 5 levels of service Remember to Consider the Key Components separately: Remember to Consider the Key Components separately: ● HPI, ROS, PFSH ● Examination ● Medical Decision Making

44 Example - New Patient The Level of Service for a new patient visit is determined by the lowest level of service (1 through 5) of the three key components HPI, ROS, PFSH4 Examination4 Medical Decision Making 3 This is the lowest level

45 Coding Steps Established Patients Again Consider the Key Components Separately: Again Consider the Key Components Separately: ● HPI, ROS, PFSH ● Examination ● Medical Decision Making The level of service (1 – 5) is determined by the level that appears in 2 of the three components, or by the middle level The level of service (1 – 5) is determined by the level that appears in 2 of the three components, or by the middle level

46 Example – Established Patient HPI, ROS, PFSH 3 This is the middle level EXAM2 Medical Decision Making4

47 Why is this?

48 Answer... There has to be a system, and this is what AMA came up with.

49 Coding Jeopardy/ Match Game

50 How to Steps of Coding

51 How to Steps of Coding: Determine Level of Medical Decision Making Determine Level of History Component Determine Level of Physical Examination (You will need to reference the chart – examination notes for this)

52 Determine Level of Medical Decision Making Medical Decision Making consists of three sections: Medical Decision Making consists of three sections: ● Diagnosis or Management Problems ● Diagnostic Procedures ● Treatment of Management Options Level is determined by the level found in two of the three categories – or the middle number if all three are different Level is determined by the level found in two of the three categories – or the middle number if all three are different

53 Determine Level of Medical Decision Making Section I: Diagnosis or Management of Problems One self- limited or minor problem Two or more self- limited or minor problems One stable chronic condition Acute uncomplicated illness One or more chronic illnesses with complications Two or more stable chronic conditions Undiagnosed new problem w/uncertain prognoses Acute illness with systemic symptoms Acute complicated injury One or more chronic illness with severe complications Acute or chronic illness or injury that is life or limb threatening Abrupt change in neurologic status

54 Determine Level of Medical Decision Making Section II: Diagnostic Procedures Lab X-ray EKG UA Ultrasound, etc. Venipuncture KOH Physiologic tests not under stress Pulmonary Function Barium Enema Arterial puncture Skin biopsies Physiologic tests under stress- cardiac stress tests Diagnostic endoscopies with no risk factors Deep needle or incisional biopsy Obtained fluid from body Cardiovascular imaging with contrast Invasive diagnostic tests Cardiac Electrophysiological tests Diagnostic endoscopies with identified risk factors Discography

55 Determine Level of Medical Decision Making Section III: Treatment or Management Options Rest Gargles Elastic bandages Dressings OTCs Minor surgery PT OT IVs without additives Minor surgery with risk factors Elective major surgery— no risk factors Prescription drug management IV fluids with additives Closed facture or dislocation treatment w/o manipulation Therapeutic nuclear medicine Elective Surgery with identified risk factors Emergency major surgery Parenteral controlled substances Drug treatment requiring intensive monitoring Decision not to resuscitate or de- escalate care because of poor prognosis

56 How to Steps of Coding: Determine Level of History Component History component consists of three sections: History component consists of three sections: ● History of Present Illness (HPI) ● Review of Systems (ROS) ● Patient, Family, and Social History (PFSH)

57 Determine Level of History Component Section I: History of Present Illness Location Location Quality Quality Severity Severity Duration Duration Timing Timing Context Context Modifying factors Modifying factors Associated signs and symptoms Associated signs and symptoms

58 Determine Level of History Component Section II: Review of Systems Constitutional symptoms (fever, wt loss, etc.) Constitutional symptoms (fever, wt loss, etc.) Eyes Eyes Ears, nose, mouth, throat Ears, nose, mouth, throat Cardiovascular Cardiovascular Respiratory Respiratory Gastrointestinal Gastrointestinal Genitourinary Genitourinary Musculoskeletal Musculoskeletal Integumentary (skin and/or breast) Integumentary (skin and/or breast) Neurologic Neurologic Psychiatric Psychiatric Endocrine Endocrine Hematologic/lymphatic Hematologic/lymphatic Allergic/immunologic Allergic/immunologic

59 Determine Level of History Component Section III: Patient, Family and Social History Past medical history Past medical history ● Medication allergies Patient’s family history Patient’s family history Patient’s social history Patient’s social history ● Age-appropriate review of past and current activities ● Tobacco usage

60 History Component Matrix (Number of components of each HPI, ROS & PFSH required for each level) New Established HPI01144 ROS PFSH00012

61 How to of Coding Steps: Determine Level of Physical Examination Constitutional Constitutional Eyes Eyes Ears, Nose, Mouth, Throat Ears, Nose, Mouth, Throat Cardiovascular Cardiovascular Respiratory Respiratory Gastrointestinal Gastrointestinal Genitourinary Genitourinary Musculoskletal Musculoskletal Skin Skin Neurologic Neurologic Psychiatric Psychiatric Hematologic/Lympatic/Immunologic Hematologic/Lympatic/Immunologic

62 Determine Level of Physical Examination: # of body systems required for each level New Established Exam

63 Coding Matrix Example: New PatientEstablished Patient History33 Exam22 Medical Decision Making 33 Level of Coding23

64 Coding Matrix Example: New PatientEstablished Patient History44 Exam22 Medical Decision Making 44 Level of Coding24

65 Coding Exercise

66 Coding Exercise for Evaluation/ Management Services Suzy Q is a 16 y/o female with c/o severe “female” cramps - worse than usual. She states she took Midol and it only helped a little. She is a new patient. Document on the exam and encounter form to a level 3, using audit sheet as reference.

67

68

69 How to Verify this is correct level of documentation to support level 3

70

71 Count the components HRI 1 - Midol ROS 1 - cramps PFSH - 0 ___________ Level 3 Exam 1-const 2-Abd 2-Abd 3-back 3-back 4-genito 4-genito____________ Level 3 Med Decision - acute/uncomp - OTCs ___________ Level 3

72

73 Preventive Services

74 Preventive Services These visits include a comprehensive history and examination, as well as appropriate counseling/anticipatory guidance/risk factor reduction, interventions, and the ordering of age-appropriate laboratory/diagnostic procedures. These visits include a comprehensive history and examination, as well as appropriate counseling/anticipatory guidance/risk factor reduction, interventions, and the ordering of age-appropriate laboratory/diagnostic procedures.

75 Preventive Services “Comprehensive” in a preventive service examination is not synonymous with a “comprehensive” E/M examination. “Comprehensive” in a preventive service examination is not synonymous with a “comprehensive” E/M examination.

76 Preventive Service Codes AgeNewEstablished <

77 Preventive Services Appropriate ICD-9 codes would be: V20.2 for a Routine Infant or Child Health Check V20.2 for a Routine Infant or Child Health Check V70.3 for a Sports Physical V70.3 for a Sports Physical

78 Preventive Services Additional services provided at the time of the visit should be reported with their specific CPT codes listed separately: Additional services provided at the time of the visit should be reported with their specific CPT codes listed separately: ● Examples: ● Snellen Test ● Laboratory ● Immunizations ● Administration of Immunizations

79 Mental Health Services

How do you document mental health services? Who documents mental health services? Who documents mental health services? Where are mental health services documented? 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? How do mental health providers and primary care providers share information about mental health services?

“We can’t bill for mental health services, so why code?” You should still document in order to: 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

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

Mental Health Diagnostic Codes

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

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

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

Substance Abuse/Dependence Alcohol Dependence/ Alcohol Abuse Alcohol Dependence/ Alcohol Abuse Amphetamine Dependence/ Amphetamine Abuse Amphetamine Dependence/ Amphetamine Abuse Cannabis Dependence/ Cannabis Abuse Cannabis Dependence/ Cannabis Abuse Cocaine Dependence/ Cocaine Abuse Cocaine Dependence/ Cocaine Abuse Hallucinogen Dependence/ Hallucinogen Abuse Hallucinogen Dependence/ Hallucinogen Abuse Inhalant Dependence/ Inhalant Abuse Inhalant Dependence/ Inhalant Abuse Nicotine Dependence Nicotine Dependence Opioid Dependence/ Opioid Abuse Opioid Dependence/ Opioid Abuse Phencyclidine Dependence/ Phencyclidine Abuse Phencyclidine Dependence/ Phencyclidine Abuse Sedative, Hypnotic, or Anxiolytic Dependence/ Sedative, Hypnotic, or Anxiolytic Abuse Sedative, Hypnotic, or Anxiolytic Dependence/ Sedative, Hypnotic, or Anxiolytic Abuse Polysubstance Dependence Polysubstance Dependence Other (or Unknown) Substance Dependence Other (or Unknown) Substance Dependence Other (or Unknown) Substance Abuse 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

Mental Health Procedural Codes

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

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

Psychiatric Therapeutic Procedures CPT Codes – 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. 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.

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,

Reimbursement – who can bill? What are the rules governing who can bill for mental health diagnosis/treatment in your state? What are the rules governing who can bill for mental health diagnosis/treatment in your state? ● Most states accept physicians (MD), clinical psychologists (CP), licensed clinical social workers (LCSW) ● However, each State has its own rules and many will pay for other professionals

Coverage Issues A provider should know what services are covered. A provider should know what services are covered. Services must be documented and medically necessary in order for payment to be made. 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?

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

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

Documentation and Coding: Fraud and Abuse Services MUST be medically necessary (determined by payers based on a review of services billed) 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. 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 Services performed by a non-licensed provider particularly as “incident to” using the PIN of the licensed provider

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

Action Steps for Mental Health Coding Improvements Action Steps for Mental Health Coding Improvements T

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

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

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? 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 procedural codes represent all services provided (including those not billed for)? Do diagnostic codes represent all diagnostic categories (including those not billed for)? Do diagnostic codes represent all diagnostic categories (including those not billed for)?

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

Understand State Program and Provider Coverage Issues Research State Program Information 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 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 Invite Medicaid Representatives to your facility or visit them to present Behavioral Health Program and clearly understand the requirements

Determine Reimbursement Estimates Obtain reimbursement rates by provider type for state and other programs 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. 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. Assure you have a complete understanding of program parameters re: Individual Therapy, Case Management, Special Behavioral Health Services, etc.

106 Common Pitfalls in Coding

107 ICD-9 CM ( Clinical Modification ) Coding Guidelines Order to list ICD-9 codes Coding Order is Important 1. Acute Reason patient is being seen needs to be listed first. 2. Co-morbid diagnosis affecting treatment of principal diagnosis are listed next. 3. List all other documented conditions coexisting at the time of the visit that require or affect patient care, treatment or management. Chronic diseases may be listed as often as they are treated

108 ICD-9-CM Coding Guidelines DO NOT CODE: DO NOT CODE: ● Conditions previously treated that no longer exist. ● Conditions that do not affect treatment or management at the current visit. ● Rule-out, suspected, questionable or probable diagnoses.

109 ICD-9-CM Coding Guidelines Review of Systems Documentation Cannot say “all other negative” Cannot say “all other negative” Must list pertinent and negative findings Must list pertinent and negative findings Must have a way to determine which systems were reviewed Must have a way to determine which systems were reviewed A check list is acceptable A check list is acceptable

110 About Time With the Patient Do not base your level of service on time spent with patient. Do not base your level of service on time spent with patient. Time only comes into play if you are billing for counseling within an acute visit or if all you are doing is counseling Time only comes into play if you are billing for counseling within an acute visit or if all you are doing is counseling

111 Sports Physicals They are not meant to be comprehensive physicals – their focus is different They are not meant to be comprehensive physicals – their focus is different Check for an appropriate form Check for an appropriate formwww.aafp.org You can bill for a complete PE and a sports PE within the same year You can bill for a complete PE and a sports PE within the same year

112 Acute Problems within a Comprehensive Physical When doing a preventive health visit (V20.2) and there is a separate health acute problem – you can list both the preventive health visit code (first) and the acute visit code (second) – BUT THERE MUST BE ICD-9 CODES THAT JUSTIFY BOTH When doing a preventive health visit (V20.2) and there is a separate health acute problem – you can list both the preventive health visit code (first) and the acute visit code (second) – BUT THERE MUST BE ICD-9 CODES THAT JUSTIFY BOTH (the billing department must add a modifier) (the billing department must add a modifier)

113 Be sure to know the Reason for the Visit

114 Late Effects of Burns Late effects means the burn has healed. There should not be dressing changes.

115 Counseling Visits Counseling visits are when client comes in to discuss a problem only. No hands are laid on the patient. Counseling visits are when client comes in to discuss a problem only. No hands are laid on the patient.

116 Example Dietary Surveillance & Counseling There must be a dietary problem in order to justify this code. There must be a dietary problem in order to justify this code.

117 Be Specific with the codes you use

Throat Pain EXCLUDES: EXCLUDES: ● Dysphagia ● Neck pain ● Sore throat 462 ● Chronic 472.1

119 AGAIN - About Over-coding and Under-coding CPT and ICD-9 codes must always relate CPT and ICD-9 codes must always relate The first ICD-9 code you use drives the relationship to the CPT code The first ICD-9 code you use drives the relationship to the CPT code

120 Coding Compliance Audit

121 Poor example incorrect coding for documentation See Handouts of Completed Note Sample 10a (handout 9) & Encounter Form 10a (handout 10)

122

123

124 Analysis of incorrect coding for documentation

125 Coding Audit Cheat Sheet Top half of form PATIENT IDENTIFIER____10a CODING AUDIT CHEAT SHEET TYPE OF SERVICE PROVIDED: Preventive Health – New patient______ Preventive Health – Established patient______ Counseling Services– No Physical Complaint Is time recorded in chart? YES _____NO _____ Is a counseling code used? YES _____ NO _____ Evaluation / Management Visit: where counseling determines time Is the total time of the visit recorded YES _____NO _____ Is the time spent in counseling recorded YES _____ NO _____ Is a counseling code used? YES _____ NO _____ Evaluation / Management Visit – NEW PATIENT Evaluation / Management Visit – ESTABLISHED PATIENT CPT & ICD-9 CODES USED CPT CODES: ICDE-9 CODES: DO THE CPT/ICD-9 CODES CORRELATE? YES __ X ___NO ______

126 Coding Audit Cheat Sheet Bottom Half of Form HISTORY AND EXAMINATION New New Established Established HPI HPI ROS ROS PFSH PFSH EXAM EXAM CHART AUDIT LEVELS FOR E/M VISITS HPI, ROS, PFSH 3 NEW PATIENT LEVEL 2 HPI, ROS, PFSH 3 NEW PATIENT LEVEL 2 Lowest level supports level EXAMINATION 2 ESTABLISHED PT LEVEL ____ EXAMINATION 2 ESTABLISHED PT LEVEL ____ 2 of 3 or middle level supports level MEDICAL DECISION MAKING 3 MEDICAL DECISION MAKING 3

127 Medical Decision Making Section I: Diagnosis or Management of Problems One self- limited or minor problem Two or more self- limited or minor problems -One stable chronic condition -Acute uncomplicated illness One or more chronic illnesses with complications Two or more stable chronic conditions Undiagnosed new problem w/uncertain prognoses Acute illness with systemic symptoms Acute complicated injury One or more chronic illness with severe complications Acute or chronic illness or injury that is life or limb threatening Abrupt change in neurologic status

128 Medical Decision Making Section II: Diagnostic Procedures Lab X-ray EKG UA Ultrasound, etc. Venipuncture KOH Physiologic tests not under stress Pulmonary Function Barium Enema Arterial puncture Skin biopsies Physiologic tests under stress- cardiac stress tests Diagnostic endoscopies with no risk factors Deep needle or incisional biopsy Obtained fluid from body Cardiovascular imaging with contrast Invasive diagnostic tests Cardiac Electrophysiological tests Diagnostic endoscopies with identified risk factors Discography Other levels of Diagnostic procedures do not usually apply to SBHC, but you only need to have 2 of the 3 areas of medical decision making to agree.

129 Medical Decision Making Section III: Treatment or Management Options Rest Gargles Elastic bandages Dressings OTCs Minor surgery PT OT IVs without additives Minor surgery with risk factors Elective major surgery— no risk factors Prescription drug management IV fluids with additives Closed facture or dislocation treatment w/o manipulation Therapeutic nuclear medicine Elective Surgery with identified risk factors Emergency major surgery Parenteral controlled substances Drug treatment requiring intensive monitoring Decision not to resuscitate or de- escalate care because of poor prognosis

130 Unfortunately – Because of this documentation/coding error - you will not get paid for this visit. This is why it is very important to verify that charting supports all levels of coding decision making.

131 Questions & Answers