1

Among those already participating in CC Medicaid Program, 2 main factors contributing to revenue loss: 1. Low caseloads 2. Not billing for qualifying services being provided

-Both under-billing and not capturing retainage

Lost Revenue in CCMP

2

• 135 primary care practices currently participating in CCMP • 75% average Depression screening rate • 25% average screening yield (those screened positive)

• Anxiety 19% prevalence

• Avg. number patients screened positive: 219 • Avg. patient enrollment: 31 • Avg. newly enrolled each month: 6 • Avg. patients actively engaged: 22

Prevalence in CCMP sites

3

• Average number of Medicaid patients billed per month: 10 • 12 missed patient per month; $16,200 per site per year • 12% of patients have had a least 1 retainage claim

submitted; Over $600,000 missed • 22,120 claims that denied and were never resubmitted. At

$112.50 each, that would’ve been an additional $2.5M

CCMP Billing

Collaborative Care Missed Financial Opportunity

Virna Little,PsyD, LCSW-r, SAP, CCM

Why this Webinar and Why Now?

• Under billing • Under coding • Disconnect from financial team • Many senior leaders (CEO/CFO) don’t

recognize revenue potential • Not just direct and case rate opportunity but

impacts for quality dollars

Now You Know Collaborative Care Lets Bill for It !!!

• Primary Care of ANY kind ( 28, hospital based, specialty, private practice)- IF YOU DO PRIMARY CARE YOU ARE IN !

• Staffing - Types of licensure impacts billing codes, services, and reimbursements directly-IF YOU HAVE MASTERS LEVEL BEHAVIORAL HEALTH STAFF YOU ARE IN!

• Payers- variations in billing collaborative care across payers –IF YOU HAVE PAYERS YOU ARE IN !

Reimbursement Across the Board !

• Medicaid and Medicare reimburse case rates

for collaborative care • Third party payers are reimbursing Medicare codes (let us know if you don’t get paid)

Payer Spreadsheet Provider Title CODES

All Professionals

ALL but RN

BSW, Social Worker, Psychologist, Licensed Counselor ONLY

Psychiatrist, Psychiatric NP, Psychiatric PA ONLY

96150 96151 99366 99367 99368 98967 98968 90853 90791 90832 90834 90837 90853 99211 99213 99214

BSW • Medicaid • Medicare • Commercial Social Worker • Medicaid

• Medicare

• Commercial Psychologist • Medicaid • Medicare • Commercial Licensed Counselor • Medicaid • Medicare • Commercial Psychiatrist • Medicaid • Medicare • Commercial Psychiatric NP • Medicaid • Medicare • Commercial Psychiatric PA • Medicaid • Medicare • Commercial RN • Medicaid • Medicare

• Commercial

Coding

• Codes for depression screening are WAY underutilized

• Optimize use of screening codes keeping in mind special populations ( prenatal)

• Most practices are screening for depression few are optimizing for revenue –even for FQHC you have other payers

• May be screening but not noting results

BHI Coding Summary non FQHC

BHI Code Behavioral Health Care

Manager or Clinical Staff Threshold Time

Activities Include:

CoCM First Month (G0502) (CPT 99492)

First 70 minutes per calendar month

• Initial Assessment • Outreach/engagement • Entering patients in registry • Psychiatric consultation • Brief intervention

CoCM Subsequent Months (GO503) (CPT 99493)

60 minutes per calendar month

• Tracking + Follow-up • Caseload Review • Collaboration of care team • Brief intervention • Ongoing screening/monitoring • Relapse Prevention Planning

Add-on CoCM (Any month) (G0504) (CPT 99494)

Each additional 30 minutes per calendar month

• Same as Above

General BHI (G0507) (CPT 99484)

At least 20 minutes per calendar month

• Assessment + Follow-up • Treatment/care planning • Facilitating and coordinating

treatment • Continuity of care

7

BHI Coding Summary FQHC

BHI Code Behavioral Health Care

Manager or Clinical Staff Threshold Time

Activities Include:

CoCM First Month (G0512)

First 70 minutes per calendar month

• Initial Assessment • Outreach/engagement • Entering patients in registry • Psychiatric consultation • Brief intervention

CoCM Subsequent Months (GO511)

60 minutes per calendar month

• Tracking + Follow-up • Caseload Review • Collaboration of care team • Brief intervention • Ongoing screening/monitoring • Relapse Prevention Planning

8

Warm Hand-offs

• To bill or not to bill…….. • Workflows that support billing (empty slots, hand-offs for

billable payers) • What do I code if I do bill? • How do I measure abstract revenue for doing hand-offs? • What is an effective hand-off? • Who to use for hand-offs (non billable)

WARM HAND-OFFS ARE CRITICAL FOR INTEGRATED CARE; WARM HAND-OFF MANGEMENT IS A KEY ELEMENT FOR SUSTAINABILITY REVIEW OF SAME DAY SERVICES REIMBURSEMENT

• 90791- Diagnostic Evaluation/Intake • 90832 - Psychotherapy, 30 minutes • 90834 - Psychotherapy, 45 minutes • 90837 - Psychotherapy, 60 minutes • 90839 - Psychotherapy for crisis • 90853 - Group Psychotherapy • 90846 - Family/Couples Psychotherapy w/o Pt • 90847 - Family/Couples Psychotherapy w/Pt

Common Billing Codes for Therapy

• 90792 - Psychiatric Evaluation • 99212 - Medication Management • 99213 - Medication Management • 99214 - Medication Management

• Use above E&M Codes and then add on a therapy

code if needed

Common Billing Codes for Psychiatry

NYS Medicaid Maternal Depression Screening Guidelines

• Billing Guidance • If maternal depression screening is provided postpartum by the maternal

healthcare provider, the service can be reimbursed in addition to the E&M visit. Effective September 1, 2016 for FFS and November 1, 2016 for MMC, providers should bill for this service using CPT code G8431 in conjunction with the “HD” modifier for a positive depression screen of the mother and G8510 in conjunction with the “HD” modifier when the screening returns a negative result. These two new “G” series codes replace CPT code 99420 (The Administration and Interpretation of Health Risk Assessment Instrument - Health Hazard Appraisal) currently being used for maternal depression screening. Upon the effective date outlined above, the CPT code 99420 will no longer be active in the Medicaid billing system.

• If maternal depression screening is performed on the same day as the infant's primary care visit (E&M) by the infant's healthcare provider, one claim can be submitted for both services using the appropriate “G” series code (G8431/G8510) with the HD modifier under the infant's Medicaid identification number. Alternatively, providers may bill this service separately under the mother’s Medicaid identification number.

Depression Screening Simplified Behavioral Health Screening Utilization: Depression

Code Description

1. G8431 (with HD modifier)

# of individuals screening for clinical depression is documented as being positive and a follow-up plan is documented.

1. G8510 (with HD modifier, replaces 99420)

# of individuals screening for clinical depression is documented as negative, a follow-up plan is not required

1. CPT code 96127

# of individuals screened with a brief emotional/behavioral assessment with scoring and documentation, per standardized instrument

1. G0444 # individuals receiving annual depression screening, 15 minutes

1. CPT 96161

Administration of caregiver-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument - Maternal depression screening during well-child visit, billed using child’s ID number.

Service Optimization

• Transitions of Care • Chronic Care Management • Collaborative Care

PRACTICES OFTEN DON’T KNOW THEY CAN USE ALL OF THESE WITH INDIVIDUAL PATIENTS; Medicare patients can be enrolled in all

Collaborative Care Helpful Information (and CFO FAQ’s!!)

• Can I bill for individual visits and the case rate for Collaborative Care ?

• How many patients should be on a caseload for my population ?

• Do Medicare Advantage plans pay Collaborative Care codes?

• What about third party payers / commercial plans ?

• Is there support available to help my organization implement Collaborative Care ?

Scheduling

• Large revenue loss • Expanded access • Gap - full schedules and open slots • Not training front desk (how to cancel, pre-

appointment) • Shadow scheduling • Scheduling out by clinicians • Not incorporating open access

Input Calculation Benchmark

Workbook Template Updated 05/02/2017 Linked Information

= User-entered value = Calculated field (not editable) = Suggested benchmark (editable) = Information copied from another cell

Team Member FTE Total Hours per Week

Suggested Hours per Week (Based on 40:3 ratio)

Care Management Service Category

Percentage (%) of Total Hours

per Week Hours per Week Service Units

Generated Hours per Service

Unit

Avg. length of warm connection Avg. length of phone calls

Staffing and Service Delivery

STAFFING

Hours per week per 1.0 FTE at your organization

WEEKLY TIME AND EFFORT ALLOCATION AND SERVICE UNIT GENERATION: CARE MANAGER

Total Care Manager Hours per Week

Indirect Care Coordination and Administrative Tasks Charting Registry Management Psychiatric Consultation Team Communication Other (Clinical Supervision, Staff Meetings, Training, etc.)

Subtotal: Indirect Care Coordination and Administrative Tasks

Unassigned Time [Target = 0%] 100.0% (Green checkmark indicates value is at target)

WEEKLY TIME AND EFFORT ALLOCATION AND SERVICE UNIT GENERATION: PSYCHIATRIC CONSULTANT

Reimbursable Direct Care Services Avg. length of assessment visit Avg. length of ongoing visits Avg. length of group visit divided by Avg. # of participants

Non-Reimbursable Direct Care Services

Care Manager 0.0 Psychiatric Consultant 0.0

Direct Treatment: Assessment Visit 0.75 Direct Treatment: Ongoing Visits 0.50 Group Treatment 0.25

Subtotal: Reimbursable Direct Care Services

Warm Connection (Non-Billable) 0.25 Care Management Telephonic Services 0.25

Subtotal: Non-Reimbursable Direct Care Services

Total Psychiatric Consultant Hours per Week

Psychiatric Consultant Service Category

Percentage (%) of Total Hours per

Week Hours per Week Service Units

Generated Hours Per Service

Unit

Indirect Care and Administrative Tasks Registry Management Psychiatric Consultation Charting Direct PCP Communication Other (Reseach, Staff Meetings, Training, etc.)

Subtotal: Indirect Care and Administrative Tasks Reimbursable Direct Care Services

Avg. length of assessment visit Avg. length of ongoing visits

Unassigned Time [Target = 0%] 100.0% (Green checkmark indicates value is at target)

Annualized Reimbursable Direct Care Service Units Direct Treatment: Direct Treatment:

Assessment Ongoing Group Treatment Total

Service Units

Per 1.0 FTE

ANNUALIZED REIMBURSABLE DIRECT CARE SERVICES

Working Weeks Per Year

Single Point in Time Caseload Capacity Number of individuals feasible to have on the caseload at any point in time across all Care Managers Projected Annual Caseload Capacity Number of unique individuals feasible to serve over one year across all Care Managers

Projected Average Monthly Caseload Turnover Number of cases opened and closed each month, based on above estimate of number of individuals possible to serve over one year

Average Count of Direct Care Service Units Provided Avg. number of contacts per episode of care

CASELOAD AND MONTHLY CASE VOLUME

Average Weeks Elapsed Between First and Last Direct Care Service Avg. number of weeks per episode of care

Direct Treatment: Assessment Visit 1.00 Direct Treatment: Ongoing Visits 0.50

Subtotal: Reimbursable Direct Care Services

Care Manager Psychiatric Consultant

Total: Annualized Reimbursable Direct Care Service Units

Input Calculation

Linked Information

= User-entered value

= Calculated field (not editable) = Information copied from another cell

Workbook Template Updated 05/02/2017

Projected Number of Patients Served per Calendar Month Percent (%) of Patients Eligible for CoCM Case Rate Total Number of Patients Eligible for CoCM Case Rate

Minutes/Month Percent (%) of

Eligible Patients Avg. Number Reimbursement

of Patients Amount Total

Unassigned Patients [Target = 0%] 100% (Green checkmark indicates value is at target)

Average Monthly Reimbursement for Patients Eligible for CoCM Case Rate

Add up CoCM case rate percentages in column G of Net Financial Impact worksheet

Average Monthly Reimbursement per Eligible Patient

Use this value for CoCM case rate in Net Financial Impact worksheet (column D; Monthly Reimbursement per Case)

Not Seen $ - 70 Initial Minutes $ 142.84 100 Initial Minutes $ 208.88 130 Initial Minutes $ 274.92 60 Subsequent Minutes $ 126.33 90 Subsequent Minutes $ 192.37

Insert additional rows above the last line Total Monthly Reimbursement for Eligible Patients

BUSINESS CASE FOR BEHAVIORAL HEALTH PRO FORMA MODEL

1500 4200

1500 4200

15 minutes 11 minutes

Average Visit Scheduled Time Estimated time saved by diverting to a behaviorist Average visits per hour Transition training time

3 16 hours

Core Assumptions: Panel size Encounters Payer Mix

Medicaid Medicare Commercial Sliding fee scale

40% 12%

8% 40%

$135 16% 50%

SBIRT screenings that triage for intevention Projected proportion that could be diverted to Behaviorist Slots created as a result of integration model 246.4 $ 29.62

$ 57.69

Average Reimbursement per visit Medicare SBIRT Reimbursement

G0396 G0397

Medicaid SBIRT Reimb H0049 H0049 H0050

$24.00 $48.00

Estimated Medicare SBIRT Screens Estimated Medicaid SBIRT Screens Estimated Medicare Screen & Intervention Estimated Medicaid Screen & Intervention Medicare encounters Medicaid encounters

504 1680

80.64 268.8

504 1680

Provider Hourly Rate RN Hourly Rate Medical Assistant Hourly Rate Behaviorist Hourly Rate

$ 72.00 $ 27.60 $ 15.60

$39.06 $81,250 25% Benefits $65,000 Base salary 2080 Hours worked a year

Costs S

Screening

Salary Resource Time Lost Revenue Totals

I Intervention $ 40,625.00 $ 40,625.00 T Transition Costs $ 1,843.20 16 $6,480 $ 8,323.20

Subtotal $ 48,948.20 Revenue

X Screening Reimbursement $ 55,248.48 $ 55,248.48 P Gains in Productivity $33,264.00 $33,264 R Reimbursement for Screen and Treatment $ 8,714.76 $ 8,714.76

$ 97,227.24

Net Business Case $ 48,279.04

Questions/Thoughts

vlittle@sph.cuny.org