2010 UBO/UBU Conference

Title: Coding Mental Health

Session: W-5-1330

2

Objectives

Address questions received from the field– Coders– Providers

Multiple visits in one day Using Evaluation and Management codes in Mental

Health (MH)– Problem Focused (99201-99215)

Telephone Services – Privileged Providers (99441-99443) – Non-Privileged Providers (98966-98968)

CADAC and other Provider Extenders

3

Q & A

Can a Social Workers (not Case Management) use the Individual Psychotherapy with Medical Management? (90805, 90807, or 90809)

Probably Not – Only if they are qualified to address the “medical” –

CPT asst. Mar 2001: The medical management may include such services as a medical diagnostic evaluation (e.g., evaluation of co-morbid medical conditions, drug interactions, and physical examinations), drug management when indicated, physician orders, interpretation of laboratory or other medical diagnostic studies, and observations

4

Q & A

For Tier 2 secondary prevention should we use 99412 Preventive Med Counseling – 60 minutes? Can we use units for this code? The SASS group can last up to 6 hours

As long as the group participants don’t have an established illness or symptoms 99412 could be appropriate if the counseling is provided by a privileged provider. Instead of units of service prolonged services may be the better option (+99354, +99355) – Other options depending on provider, curriculum and

diagnoses, could be the Health and Behavior Assessment/Intervention code 96153, E&T for Patient Self-Management 98960-98962, or Group Psychotherapy 90853

5

Q & A

For PCS clearances should we use V68.09 for issue medical certificate or V70.5_7 fitness for duty?

MH fitness for duty encounters may assign both V70.5_7 primary and issue certificate V68.09 second. When there are other classifiable conditions addressed within the encounter, code the condition(s) sequentially after V70.5_7

6

Q & A

The MH coding handbook description for the services bundled under 90801 “typically 90-120 minute activity” says post-service work may include, “preparing a report or discussion with referral source” “…gathering collateral information exceeds 60 minutes, modifier 22 is used.” Please clarify what constitutes unusual services for this code

When collecting collateral information exceeds the typical time frame for the service minutes, use 22 modifier with documentation supporting the additional work required

7

Q & A

Use of V65.42_0 & V65.42_1: Do we have, or can we have, some better guidance on when to use these codes for alcohol related encounters? In relation to this topic, I see reference to V65.42_0 Alcohol Education and V65.42_1 Substance Abuse Counseling but no real definition or clarification which to use in which circumstance. In AHLTA when you select V65.42, a drop down menu appears showing V65.42_0 & V65.42_1. Are alcohol, marijuana, cocaine, etc. all thrown into the same category for V65.42_1? What substances are considered as "illicit drugs" since that is one search term that will get you to V65.42_0?

V65.42_0 is specific to alcohol education – there does not necessarily have to be abuse. V65.42_1 would be used when documented substance abuse is or has been taking place – Illicit is illegal

8

Q & A

In the areas where the guidelines reference using E&M codes 99201-99215, what providers can use those codes? Understanding that techs can’t use these codes, but what about the others?

All privileged providers may use E/M service codes when appropriate– When only MMSE performed– A consultation type service

1997 Documentation Guidelines has a psychiatric exam worksheet

9

Q & A

Interdisciplinary Collaboration – Codes 99366-99368; is it a correct interpretation that all providers involved in this process create an encounter in their particular MEPRS clinic and assign the appropriate code; i.e., BGA & BFD so that there would be two encounters created and coded?

With the understanding that the conference must be 30 minutes or more for each patient with face-to-face participation by a minimum of three qualified health care professionals from different specialties or disciplines and they must have each treated the patient within the previous 60 days

10

Q & A

Can 90889 be used only by Life Skills or can other providers use this code?

If a provider is qualified to prepare a report of a patient’s psychiatric status, history, treatment or progress (other than for legal or consultative purposes) for other physicians, agencies or insurance carriers, then, yes, they may use this code

11

Q & A

If ABC (Alcohol Brief Counseling) was done by a CADAC, we have reported 99211 and H0004 code (it was double RVU got from HCPCS and E&M according to the 2005 BH coding handbook. However, 2008 BH handbook didn’t mention about any HCPCS codes for CADAC. So it means, do not use HCPCS codes anymore for CADAC services? Just use 99211 E&M code?

The Air Force no longer mandates the use of the HCPCS H codes for CADACs, although the Army and Navy may. However, if you use them, then the appropriate E/M would be 99499 for the technician performing the ABC– 99211 has .18 RVUs, H0004 behavioral health counseling and

therapy per 15 min, has .32 (2010)

12

Q & A

A Life Skills provider didn't report office visit codes for most of cases (they use 99499 and appropriate CPT codes for their service), but 2008 coding guidelines showed they also may report office visit E&M codes (99201-99215) depends on case. Office visit E&M can be selected by time spent as well as by the 3 key components. Can providers select the between office visit E&M or 99499 with individual psychotherapy codes (this code also selected by time as well)?

The services performed will determine what series of codes would be appropriately used

13

Q & A

If our clinic does not have a CADAC currently assigned can one of the other 4Cs provide the service and code the encounters the same as the CADACs or do ADAPT services have to be by a CADAC? Before the guidance came out a provider would code the encounters done by a non-CADAC 4C with the education dx (V65.42 1) and 99499 (non-count, of course). The services were provided but the clinic lost capturing the services because the non-CADAC 4C could not use the H HCPCS or the 99211

If the technician is trained to provide specific services in ADAPT for group, therapies etc., they can perform the service and should code the E/M 99211 (or H codes if appropriate)

14

Q & A

Can a LCSW use an E/M code? Are there any other non-physician/NP that can use E/M codes?

In the DoD we allow privileged providers access to code all services that they are qualified to perform. In this case when a LCSW performs a service that would best be defined by an E/M code, then yes they may assign one

15

Q & A

Would a mental health provider ever use 99391-99397? (comprehensive preventive medicine E&M)

They wouldn’t use the E&M preventive codes, however it’s possible they could use preventive counseling codes 99401-99412

16

Q & A

Can coding at the HAWC for a 60-minute stress reduction class with a standard curriculum, be brought back to the MH B MEPRS clinic. I thought that this was a no count clinic? Is this for group or individual?

99412 is a group preventive medicine counseling code…when a privileged provider performs services in the HAWC, they may bring their documentation and code in their B MEPRS clinic – see AF Workload Guidance (unsure about Navy and Army)

17

Q & A

When a patient is seen in mental health for a physical condition without a mental health diagnosis present, the appropriate H&B (96150-96155) will normally apply. Can certain situations be coded according to the service the provider is telling us they are performing?

We code according to the documentation whether for a diagnostic interview or Health & Behavior Assessment/Intervention or E&M or psychotherapy

18

Q & A

Interdisciplinary Collaboration indicates use of the medical team conference codes, however most are not coded. Is that because 30 min time was not noted?

Yes, and then some. Many times there will be more than one patient’s care being discussed at these meetings. In order to code, there must be documentation supporting at least 30 minutes spent for each patient as well as at least 3 qualified healthcare professionals present that have treated the patient within the last 60 days

19

Q & A

I’ve seen overseas clearances coded 99366 – 68, however, if you read the description in the CPT book, none of the codes fit the overseas clearance because they are done by privileged providers with the patient and the family present. Can you please clarify this?

After the code definition of 99366 the parenthetical states when a physician performs these services face-to-face with patient and/or family they should assign E/M codes based on the services provided

20

Q & A

For 99201-99215, it is confusing to try to figure out when to use those as opposed to the 9080X psychotherapy codes, imagine trying to educate the providers when it’s hard to understand from the coder view. Experience says it is harder to train MH providers coding as opposed to the other specialties. What would be the easiest way to educate providers on E/M coding?

The office or other outpatient service E/M codes will be the exception not the rule in MH. Since we code according to the documentation – that will determine what code sets we use. Education on E/M should be based on the provider type and their understanding. Start with the basics

21

Q & A

About coding for pregnancy state, incidental, V22.2, in AHLTA when patient presents for problems having nothing to do with her pregnancy. It is a Medical or Axis III diagnosis, which MH providers typically do not code. Does this mean the MH providers are off the hook for this code? It is required per MHS.

Afraid not – this is used for population health across the services. When the provider states the pregnancy is incidental to the encounter, the code still needs to be assigned. Remember we cannot assume – it has to be stated – and ICD-9 coding rules override all others for pregnancies (Chapter 11). If pregnancy is not mentioned in documentation, it won’t be coded at all

22

Q & A

What are documentation requirements for pre-deployment screenings? Sample documentation from site: “Member was provided education on deployment and combat stress as well as coping with separation for deployment. Member cleared from a mental health perspective.” The note is coded as: V705.4 / 99402. Would a SOAP note be the appropriate format to capture what took place during this encounter?

This would be “OK” documentation, although total time needs to be mentioned, but not for the 99402 unless more detail is provided as this is a timed code for approx. 30 minutes. SOAP would be an appropriate format for this documentation

23

Q & A

What constitutes a complete mental status exam: 1-5 bullets or 6 or more bullets or ? Complete psychiatric history including presenting illness, past history, family history, and complete mental status exam encompasses the intra-service work for 90801

We would only count bullets if we were assigning an E/M code for the service and should follow the ‘97 single system psychiatric exam. If the complete mental status exam is part of a psychiatric diagnostic interview, 90801 would probably be more appropriate in this case

24

Q & A

Regarding deployment codes, V70.5 4,5,6 series, if deployment is mentioned, are the deployment codes always primary?

Even though ICD-9-CM indicates V70.5 is a PDx, It is appropriate at times to use V70.5_X in a secondary position in the MHS when the patient presents for a primary complaint that is stated as deployment related, i.e. being seen for headaches that started when deployed

Q & A

Our military Social Worker has been coding overseas clearances for all family members as 99211 or 99212. Review of questionnaire with each family member and time 5-10 minutes documented each family member. 99212 over 15 minutes. In reviewing the workload guidelines one area states appropriate E/M then the other area states the count and non count guidance and states to count it is only one family member and with the greatest need that will be coded for count. Can you clarify this?

Our MH providers were not allowed to use E/M codes until this guidance came out – see next slides for documentation and coding example.

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AF Example

The SNC meets with a family of four for a travel screening interview. He identifies a mental health history for the FM/H and meets with the husband separately for about 10 minutes during the relocation clearance appointment. During this time, the SNC performs a problem focused history, a problem focused psychiatric exam and straightforward medical decision making discussing with the patient which medications have been used over the past year, how many sessions the husband has attended with the off-base psychologist, and assesses the patient’s compliance with treatment recommendations provided in the medical record. The other family members proceed with the family member relocation clearance process and have no clinical issues identified. The SNC summarizes this information on the AF 1466 and staffs the case with the SGH to recommend forwarding the information to the gaining base for determination of travel recommendations. The SNC also explains to the FM/H that he meets the requirements for mandatory enrollment of the sponsor in EFMP and obtains consent to hold a separate appointment with the sponsor to initiate the enrollment. 

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27

Example

The SNC codes E&M 99201 with the appropriate diagnosis code for the time spent interviewing the patient and reviewing records, and for consulting with other medical providers  

The SNC documents and codes E&M 99499 and ICD-9-CM V68.09 issue of medical certificate for the remaining three family members

28

Q & A

Does the provider have to have a face-to-face with the supervisor or commander in order to provide environmental intervention for medical management on the patient’s behalf? Can this be done over the phone in conjunction with an encounter (patient and provider session)?

The provider usually will see the “environment” in order to perform an intervention (workplace accommodations) for the patient’s medical management (condition) – in order to code these as 90882, it must be a face-to-face meeting, otherwise it would be classified as a phone service

29

Q & A

I’m having problems coding Healthy Living groups. Is 90853 group psychotherapy or is 99412 preventive counseling more appropriate?

Healthy Living classes given by a privileged provider is 99412 as long as it’s preventive in nature. Techs should use 99211

30

Q & A

When a patient has been seen in the MH clinic and is either done with treatment or just quit coming, AMA or otherwise, how do you report the termination of care review?

If the review of records for termination of care meets the criteria of 90885, then they can report it…if it doesn’t meet the criteria, then it’s administrative in nature and not a codable service

31

Q & A

What justifies a 2nd/3rd coding of 90801 for the same patient within a small timeframe? For instance: Provider LCSW sees patient A for anxiety; she does intake 90801 and refers patient to Provider B (psychiatrist) for medicine management. Provider B Psychiatrist performs his own intake and codes 90801 seven days later

There should be a clear delineation between the services the providers are coding for. We call it medical necessity. As long as it’s documented then there shouldn't be a problem even in short time frames– Example clearly shows delineation even if they were

in the same MEPRS clinic

32

Q & A

I met with the Neuropsychologists and their question is how do they get credit for reviewing all the tests. They said it takes about 6 hours of their time. They do the tests on one day and then the next day they review the tests. Would 96118 be an appropriate code for that? And when would it be appropriate for the providers use the code 96116? The coding edits say you cannot use that code with 90801

If they’re reviewing the psych testing, the interpretation and report is included in the test codes so 96118 is only reported once, even if the interpretation and report is finished on a different day. Code 96116 is if the psychologist is face-to-face with the patient and objectively assessing the areas described in the code. It’s a bundled code to include the face-to-face time performing the exam, reviewing and interpreting the test results and writing a report (not necessarily face-to-face)

33

Q & A

Mental Health says that a drug abuse counselor (CADAC) can do intake 90801, and E/M code 99215, and all this work is co-signed by the Clinical Provider. What is your answer?

Technicians may not assign 90801 as they do not make the clinical diagnosis. Even if a privileged provider tried to report both, a psychiatric diagnostic interview examination and an E/M service it would be double dipping because 90801 is, in our MH world, their evaluation and management code. If the services were better represented by an E/M code that’s fine, but only one or the other, not both

34

Q & A

Use of 90801 Initial psychiatric diagnostic interview examination. This CPT code can be used by the psychologist, psychiatrist, and social worker. Question is: is the 90801 specific to new to clinic or new to doctor? The reason I ask was patient was seen by psychiatrist here, then care is transfer over to psychiatrist P.A. here, with same diagnosis. I say the P.A. cannot use 90801 in this scenario

90801 can be used more than once for the same patient in the same clinic, but the documentation must clearly reflect that a second diagnostic interview was conducted, and why

35

Provider Q & A

CLEARANCES, to include, deployment, PCS, re-training, security, PRP, etc. I wonder if the other clearances will also use procedure code V68.0x issue medical certificate, and CPT code 90885 for Record Reviews which do not find any MH, ADAPT or FAP hx?

90885 is a clinician review and evaluation of the patient’s medical records, psychiatric tests and other pertinent recorded data for the purpose of gaining a medical diagnosis and insight into the patient’s present condition. For administrative-type reviews and issuance of certificates, the V68.09 and 99499 would be appropriate

36

Provider Q & A

If an MH, ADAPT, or FAP case is found with a successful treatment termination summary, are they still coded the same, although the clinic did not meet with the member?

No, this would be administrative as the diagnosis was already established and treatment was finished (V68.09, 99499)

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Provider Q & A

Are AHLTA TelCons not to be used for MH purposes anymore?

Of course they can be. The criterion for phone services have gotten much stricter so there shouldn’t be as many coded. MH will follow the same guidance as all other providers (2011 CPT© code set rules)

38

Provider Q & A

If an ADM walks into the MHC in crisis and we only assess risk and schedule the member for a full intake on another day, what Procedure Code should be used 90801 or 90804/6/8 for individual therapy?

Probably use a problem-focused E/M service code (99201-99215) unless you performed the individual therapy or the entire intake at the time of the initial walk- in

Documentation will rule the day

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Provider Q & A

When we enter an intake encounter into AHLTA, does all the psychosocial hx (family, meds, tx hx, upbringing, exercise, work history, financial, legal, etc.) have to be documented or will a summary be sufficient when using procedure code 90801?

The basic documentation previously discussed that falls into 90801 – a history summary can be used when it covers these areas and supports the code

40

Provider Q & A

How should termination notes be coded, as a general follow up? What information should be included in the AHLTA record?

Only a follow-up if the encounter is face-to-face. Code the services you provided. The note in AHLTA should support the services that are provided– Record review

Administrative

41

Provider Q & A

Throughout the handbook the term “Documented, but not coded” is used. Does this mean documented in the MH Chart, but not entered into AHLTA?

If there is an encounter that needs to be documented it should be in AHLTA as well as the MH record whether it’s “coded” or not…– Assign appropriate diagnoses, 99499

42

Provider Q & A

High-risk case staffing meetings with interdisciplinary team of providers is NOT entered into AHLTA only the MH chart—is this correct?

If it is a codable service, it needs to be in AHLTA or, if the information is pertinent for other provider treatment of the patient, if it’s not codable or pertinent information, then the MH entry should be sufficient– Refer to slide 9 for coding/documentation

requirements on high-risk case staffing/medical team conferences

43

Provider Q & A

All case management between CC & other agencies in regards to an ADM is NOT codable—is this correct? All that is documented in the MHC chart

For correct reporting of case management services see Appendix H in the DoD guidelines

44

Provider Q & A

What is a single system psychiatric exam worksheet? Is this what all MHC should be using for intakes or risk evaluations?

There is an example of the single system exam worksheet in the 1997 documentation guidelines. The use of the worksheet will be for use with E&M codes when they are appropriate for the encounter. This will generally be the exception, not the rule for MH coding

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Provider Q & A

What is the difference between Units of Service and Modifiers? Can you elaborate some more as to when we would use either one?

Units of service are used generally with time-based codes or medication doses…a hint would be if the code definition says something to the effect of “each 15 minutes” you see the patient for an hour with this definition and you have 4 units of service – more often used with therapies (PT, OT, Nutrition)

Modifiers provide the means to indicate a service has been altered by circumstance but has not changed in the definition of the code – e.g., group therapy – a patient gets out of hand after 15 minutes and the rest of the session is cancelled – modifier 52 “reduced services” may be appropriate

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Multiple Visits in One Day

Individual therapy with someone who has or will have marital therapy on the same day with a provider within the same MEPRS (CPT code example 90804 and 90847)

Same scenario but the provider is under a different MEPRS

Individual therapy with someone who has or will have individual and/or group therapy the same day in ADAPT with a provider with the same MEPRS (CPT code example 90804 and 90804 or 90853)

47

Provider Q & A

For ABC visits. Our coding people here have told us to use 99408 E&M and leave CPT blank; but my clinic supervisor has concerns that we will not get credit for seeing patients if we don’t have a CPT code. Will we get credit for seeing patients for ABC visits in ADAPT if the CPT code is left blank?

Alcohol Brief Counseling (ABC) is delivered in one-on-one appointments and each session, if conducted by a privileged provider is coded using the appropriate E&M Preventive Medicine counseling code: 99401 (15 minutes), 99402 (30 minutes), 99403 (45 minutes), 99404 (60 minutes). If the ABC intervention is delivered by a CADAC who has been trained to conduct ABC, each encounter would be coded 99211

We would only use 99408 if the patient has been diagnosed with a substance use disorder

48

Provider Q & A

How ought one to code in AHLTA for peer review? Would a 5-10 min record review for peer review purposes count for a 90885 CPT code?

A peer review actually is an administrative "mission- specific" QA check that would not be considered an encounter. These, you should document your time as administrative in your timesheet MEPRS and not in AHLTA

49

Provider Q & A

For security clearances, if a technician reviews a MH record, consults with a provider, provider does an eyes-on for the patient, is the proper coding: CPT 90885, tech listed as paraprofessional?

Technicians may not assign 90885 as they are not qualified to make a medical diagnosis statement. They should assign 99211 for any face-to-face with the patient for these types of things if you (privileged provider) are not performing any aspect of the services rendered. If this is not a face-to-face encounter the review is administrative and not coded

If you as the provider, reviewed the techs documentation with the patient AND added your ownership to the AHLTA encounter, you could code the type of face-to-face service rendered

50

Provider Q & A

Similar question as the last one: If the tech reviews the record for a patient that is NOT present for an appointment, finds no red flags, consults with a provider, but the provider does not meet with the patient, how is this coded?

This is administrative in nature and is not a codable service, the tech should document it in AHLTA and use the appropriate diagnosis code and the E&M of 99499

51

Provider Q & A

If a provider meets with a patient for 45 minutes face-to-face, then spends 15 minutes documenting care, is the CPT coding reflecting a 45 minutes of care or the total of 60 minutes? In this scenario, is the proper CPT code 90806 (45-50 min therapy) or 90806 with a 22 Modifier for increased services (to account for the total of 60 minutes spent on the patient)?

Time spent documenting is not considered part of the therapy time, it’s a necessary administrative evil of seeing patients and bundled into the service provided, so this scenario would be 90806 only

52

Provider Q & A

I’m having a hard time figuring out what to code the new parenting class I started last week. I’ve got the 99412 figured out but for the V code I was told to use V65.49_9 other specified counseling. Well that isn’t loaded in our system or there is something wrong. Is that the best procedure code to use or can I look at using something different? The class is focused on birth to 6; all the children are over 6 months and this is not focused on newborn care

I think that V65.49_9 would probably be the best diagnosis code for this class since we don't have anything specific to parenting. V65.49 is “other specified counseling” and the MHS has the extender 9 on it. I’m not sure why you can’t bring it up in AHLTA, it’s been around for awhile. I’d check with your AHLTA trainer to see why you can’t bring it up. If all else fails, then V65.40 is “counseling, not otherwise specified”

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Multiple Visits in One Day

Individual therapy with someone who has or will have marital therapy on the same day with a provider within the same MEPRS (CPT code example 90804 and 90847)

Individual therapy with someone who has or will have individual and/or group therapy the same day in ADAPT with a provider with the same MEPRS (CPT code example 90804 and 90804 or 90853)

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Multiple Visits in One Day

Same scenario but the provider is under a different MEPRS

Individual therapy on the same day before/after the psychiatrist sees for medication evaluation/follow up (CPT code example 90804 and 90862)

Individual therapy with someone who has been in a Healthy Living Group session on the same day within the same MEPRS (CPT code example 90804 and 99411)

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Questions

Questions?

Questions?

Questions?