Diagnostic and Procedural Diagnostic and Procedural CodingCoding

ObjectiveObjective

To improve diagnostic andprocedural coding for mental health screening, assessment, referral, and intervention

How do you document mental How do you document mental health services?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?

What we’ll cover…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

Why Code???Why Code???

““We can’t bill for mental health We can’t bill for mental health services, so why code?”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

Why Code Why Code CorrectlyCorrectly?? 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

General Coding PrinciplesGeneral Coding Principles

General Coding PrinciplesGeneral Coding PrinciplesThe purpose of codes is to document

services providedDocumented services are likely to be

paidServices not documented “never

happened”Never “upcode” for the purpose of getting

more moneyMost likely, you are undercoding

General Coding Principles General Coding Principles (cont.)(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!

General Coding Principles General Coding Principles (cont.)(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)

DocumentationDocumentation

Where to document codes?

• Encounter Form• Database

BOTH (if separate):mental health chart ANDmedical record

Mental Health Diagnostic Mental Health Diagnostic CodesCodes

Coding SystemsCoding 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.

Anxiety DisordersAnxiety Disorders300.01 Panic Disorder Without Agoraphobia

300.21 Panic Disorder With Agoraphobia

300.22 Agoraphobia Without History of Panic Disorder

300.29 Specific PhobiaSpecify type: Animal Type/Natural Environment Type/Blood-Injection-Injury Type/Situational Type/Other Type

300.23 Social PhobiaSpecify if Generalized

300.3Obsessive-Compulsive DisorderSpecify if With Poor insight

309.81 Posttraumatic Stress DisorderSpecify if Acute/ChronicSpecify if With Delayed Onset

308.3 Acute Stress Disorder

300.02Generalized Anxiety Disorder

300.00Anxiety Disorder NOS

Depressive DisordersDepressive Disorders

296.xx Major Depressive Disorder– .2x Single Episode– .3x Recurrent

300.4 Dysthymic Disorder

Specify if Early Onset/Late OnsetSpecify With Atypical Features

311 Depressive Disorder NOS

Disruptive Behavior DisordersDisruptive Behavior Disorders 314.xx Attention-Deficit/Hyperactivity Disorder

– .01 Combined Type – .00 Predominantly Inattentive Type – .01 Predominantly Hyperactive-Impulsive Type

314.9 Attention-Deficit/Hyperactivity Disorder NOS

312.xx Conduct Disorder – .81 Childhood-Onset Type – .82 Adolescent-Onset Type– .89 Unspecified Onset

313.81 Oppositional Defiant Disorder

312.9 Disruptive Behavior Disorder NOS

Substance Abuse/DependenceSubstance Abuse/Dependence 303.90 Alcohol Dependence/305.00 Alcohol Abuse 304.00Amphetamine Dependence/305.70 Amphetamine Abuse 304.30 Cannabis Dependence/305.20 Cannabis Abuse 304.20 Cocaine Dependence/305.60 Cocaine Abuse 304.50 Hallucinogen Dependence/305.30 Hallucinogen Abuse 304.60 Inhalant Dependence/305.90 Inhalant Abuse 305.1 Nicotine Dependence 304.00 Opioid Dependence/305.50 Opioid Abuse 304.60 Phencyclidine Dependence/305.90 Phencyclidine Abuse 304.10 Sedative, Hypnotic, or Anxiolytic Dependence/305.40 Sedative,

Hypnotic, or Anxiolytic Abuse 304.80 Polysubstance Dependence 304.90 Other (or Unknown) Substance Dependence 305.90 Other (or Unknown) Substance Abuse

The following specifiers apply to Substance Dependence as noted:With Psychological Dependence/Without Psychological DependenceEarly Full Remission/Early Partial Remission/Sustained Full Remission/Sustained Partial Remission In a Contained Environment On Agonist Therapy

Documentation of Diagnostic Documentation of Diagnostic CodesCodes

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.

Mental Health Procedural Mental Health Procedural CodesCodes

Coding SystemsCoding 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.

Evaluation & Management (E&M) CodesEvaluation & Management (E&M) Codes

99201 – 99215 New and Established Patient Office Visits

99241 - 99245 Consultations

99361 - 99362 Case Management Services, Team Conferences

99371 - 99373 Case Management Services, Telephonic

Mental Health Procedure Mental Health Procedure CodesCodes

90801 - 90802 Psychiatric Diagnostic or Evaluative Interview Procedures

90804 - 90829 Psychotherapy90804 - 90815 Office or Other Outpatient Facility90810 - 90815 Interactive Psychotherapy90816 - 90829 Inpatient Hospital, Partial

Hospital or Residential Care Facility

90845 - 90857 Other Psychotherapy

90862 - 90889 Other Psychiatric Services or Procedures

Psychiatric Therapeutic ProceduresPsychiatric Therapeutic Procedures

CPT Codes 90804 – 90889

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 CodesE&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, 90829.

ReimbursementReimbursement

Who can bill?

Fraud and Abuse

Who can bill?Who can bill?

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

Who Can Bill?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

Coverage IssuesCoverage 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?

How Much are you Paid?How Much are you Paid?

Reimbursement– Reductions in reimbursement rates by

provider typePhysician - not discountedClinical Psychologist - discountedLCSW - further

discountedOther - discounted if

covered

Reimbursement IssuesReimbursement Issues

E&M codes are limited to physicians, Pas, NPs, nurses

Same is true for 90805, 90807, 90809 codes

An E&M (992XX) and a therapy (908XX) cannot be billed on the same date of service to most Medicaid programs

Documentation and Coding:Documentation and Coding:Fraud and AbuseFraud 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

Elements of “Incident To”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

Work plan SuggestionsWork plan Suggestions

Actions Step:Actions Step:Review Program ServicesReview 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

Action Step:Action Step:Review and Modify Encounter FormReview 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)?

Action Step:Action Step:Review and Modify Documentation ProceduresReview 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?

Action Step:Action Step:Understand State Understand State ProgramProgram and and Provider Provider Coverage IssuesCoverage Issues

Research State Program Information www.cms.gov (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

Questions to AnswerQuestions 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?”

Action Step:Action Step:Determine Reimbursement EstimatesDetermine 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.