Anthem Blue Cross and Blue Shield Medicaid (Anthem) Behavioral Health Symposium
AKYPEC-0694-15
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Agenda • • • • • • •
Introductions Housekeeping Behavioral Health prior authorization (PA) process Behavioral Health covered services Break for lunch Behavioral Health billing guidance Questions and answers
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Introduction • Jennifer Ecleberry, Director, Provider Solutions, KY Medicaid Provider Relations • Ken Groves, Manager, KY Medicaid Provider Relations • Jeff Sutherland, Director, KY Medicaid Behavioral Health • David Crowley, Manager, KY Medicaid Behavioral Health • Andrew Fox, Network Relations Specialist, KY Medicaid Behavioral Health • Libby Ellington, Network Relations Specialist, KY Medicaid Provider Relations • Mark Snyder, Clinical Programs Director, Behavioral Health • Tina Hurt, Network Support Manager, Behavioral Health • Alice Hudson, Director, Program Management, Reimbursement Policy Management 3
Housekeeping
• Restroom locations • Please hold your questions until the end of the session; there will be time for questions and answers
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Behavioral Health authorization process
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Behavioral Health authorization process Behavioral Health program goals • Right care, right place, right time services • Reduce inappropriate admissions and readmissions • Provide integrated, seamless delivery of physical and behavioral health services • Disease management of chronic conditions often involving physical health, behavioral health and substance use disorder comorbidities • National Committee for Quality Assurance (NCQA) accreditation • HEDIS® and other quality measure attainment *HEDIS is a registered trademark of the NCQA.
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Behavioral Health authorization process Two distinct authorization processes, based upon the type of care requested • Telephonic review – Initial and concurrent review of inpatient admissions and other higher levels of care – Contact the Utilization Management department, 24 hours a day, 7 days a week, for authorization at 1-855-661-2028 • Form review – Inpatient and all other levels of care – Completion of the required forms submitted via fax (inpt: 1-877-434-7578; outpt: 1-800-505-1193) or web portal 7
Behavioral Health authorization process Clinical review • Clinical intake team performs initial reviews for acute care via live calls or form review – Gives opportunity to discuss/review more appropriate level of care when criteria for inpatients are not met – Begins discussion of treatment and discharge planning, coordination of care needs and readmission issues 8
Behavioral Health authorization process • Concurrent reviewers or outpatient care managers review subsequent care or outpatient services – How reasons for admission are being addressed – If readmission, what is being done differently – Progress in treatment per treatment guidelines – Discharge planning and barriers to discharge – Discharge follow-up appointment within seven days – Coordination of care issues/needs – Family/support system and outpatient provider involvement in treatment 9
Does the service require authorization? A number of services always require authorization, including inpatient, residential, partial hospital, intensive outpatient, psych and neuropsychological testing. If you are not sure, you can use the Precertification Lookup Tool to determine authorization requirements: https://mediproviders.anthem.com/ky/pages/ precert.aspx 10
Does the service require authorization?
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How to request an authorization • Contact the Utilization Management department, 24 hours a day, 7 days a week, for authorization at 1-855-661-2028 • Complete required forms and submit — By fax • Inpatient and RTC: 1-877-434-7578 • Outpatient: 1-800-505-1193 — By web portal: http://www.availity.com/register-nowfor-web-portal-access/
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How to request an authorization
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Authorization request forms • • • • • •
Behavioral Health Initial Review Form Concurrent Review Form Discharge Note Form Behavioral Health Outpatient Request Form Psychiatric Testing Form Coordination of Care Form Concurrent Review Form_KY.pdf
Discharge Note Form_KY.pdf
PF-AKY-0029-14 Coordination of Care F
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KYKY_CAID_OTRForm .pdf
Medical necessity criteria • Chemical dependency: American Society of Addiction Medicine (ASAM) http://www.asam.org/ • Adult mental health: Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS), American Association of Community Psychiatrists http://www.communitypsychiatry.org/aacpassets/docs/publication s/clinical_and_administrative_tools_guidelines/LOCUS%20Instru ment%202010.pdf • Children and adolescents (ages 6-18): The Child and Adolescent Service Intensity Instrument (CASII), American Academy of Child and Adolescent Psychiatry • Early Childhood Service Intensity Instrument (ECSII), Ages 0-5, American Academy of Child and Adolescent Psychiatry • Milliman Care Guidelines for procedures not included in the above criteria/tools 15
ASAM
Dimensions 1. Acute intoxication and/or withdrawal potential 2. Biomedical conditions and complications 3. Emotional, behavioral or cognitive complications 4. Readiness to change 5. Relapse, continued use or continued problem potential 6. Recovery living environment
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LOCUS LOCUS2010.pdf
Dimensions (Scores 1-5) 1. Risk of harm 2. Functional status 3. Medical, addictive and psychiatric comorbidity 4. Recovery environment a. b.
Level of stress Level of support
5. Treatment and recovery history 6. Engagement
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CASII Dimensions (Scores 1-5) 1. Risk of harm 2. Functional status 3. Co-occurrence of conditions: developmental, medical, substance use and psychiatric 4. Recovery environment 5. Environmental support 6. Resiliency and/or response to services
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ECSII Dimensions (Scores 1-5) 1. Safety 2. Child-caregiver relationships 3. Caregiving environment a. b.
Environmental supports Environmental stressors
4. Functioning (developmental status) 5. Impact of problems 6. Services profile a. b. c.
Service involvement Service fit Service effectiveness 19
Covered Behavioral Health services through the state of Kentucky (FFS)
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Covered Behavioral Health services through the state of Kentucky (FFS) Longer term care and community alternatives for waiver program enrollees • Waiver programs – Intellectual Disabilities and Developmental Disabilities Waiver – Acquired Brain Injury Waiver – Acquired Brain Injury Long Term Care Waiver – Home and Community Based Waiver – Home Health – Michelle P. Waiver – Model II Waiver – Supports for Community Living Waiver
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Covered Behavioral Health benefits through Anthem Covered Behavioral Health services • Inpatient hospitalization • Residential treatment • Partial hospitalization • Intensive outpatient program • Electroconvulsive therapy • Targeted case management • Outpatient services • Psychological testing
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Behavioral Health covered diagnoses Psychiatric diagnostic ranges • 290-290.9 • 293-293.9 • 294-294.9 • 295-302.9 • 306-319 Substance use diagnostic ranges • 291-291.9 • 292-292.9 • 303-305.93 23
Adult (18 years and older) Serious mental illness (SMI) Psychotic disorders
Mood/anxiety disorders
Personality disorders
Schizophrenia Disorder
Major Depressive Disorder
Schizoid/Schizotypal Personality Disorder
Schizophreniform Disorder
Dysthymic Disorder
Obsessive Compulsive Personality Disorder
Schizoaffective Disorder Depressive Disorder NOS Histrionic Personality Disorder Delusional Disorder
Bipolar I/Bipolar II/Bipolar NOS Disorders
Dependent Personality Disorder
Unspecified Schizophrenia Spectrum/Other Psychotic Disorder
Cyclothymic Disorder
Antisocial Personality Disorder
Posttraumatic Stress/Other Specific Adjustment Reactions
Narcissistic/Avoidant/Borderline Personality/Personality NOS Disorders
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Children and youth (under 18 years of age) SMI Psychotic disorders
Mood disorders
Schizophrenia Disorder
Major Depressive Disorder
Schizophreniform Disorder
Dysthymic Disorder
Schizoaffective Disorder
Depressive Disorder NOS
Psychotic Disorder NOS
Bipolar I/Bipolar II Disorders
Delusional Disorder
Bipolar Disorder NOS Cyclothymic Disorder
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Children and youth (under 18 years of age) SMI Anxiety disorders
Disorders of infancy, childhood and adolescence
Anxiety Disorder
Oppositional Defiant Disorder
Obsessive Compulsive Disorder
Disruptive Behavior NOS Disorder
Generalized Anxiety Disorder
Reactive Attachment Disorder
Acute Stress Disorder
Conduct Disorders
Posttraumatic Stress/Other Specific Adjustment Reactions
Attention Deficit/Hyperactivity Disorder
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Children and youth (under 18 years of age) SMI Pervasive developmental disorders
Other disorders
Autistic Disorder
Intermittent Explosive Disorder
Asperger’s Disorder*
Other Specific Trauma – Stressor Related Disorder* Disruptive Mood Disregulation Disorder* Adjustment Disorders (Under age of 8 years)
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Inpatient/ER covered procedure codes
Procedure code
Service description
100, 114, 120, 124, 134
Authorization requirement
Limitations
Inpatient Psychiatric (IMD allowed for ages 18-21)
Yes
Psychiatric DX Only
116, 126, 136
Inpatient Detoxification
Yes
Substance Use DX Only
0762
23-Hour Observation Bed
No
None
0450
Emergency Room (MH and SU)
No
None
Crisis Stabilization (per Per diem day)
No
None
S9485
Time/ event
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Inpatient/ER covered procedure codes Procedure code
Service description
99217 - 99223
Initial Hospital Care
99231 - 99233
Subsequent Hospital Care
Authorization requirement
Limitations
Per CPT guidance
Yes
None
Per CPT guidance
Yes
Yes
Time/event
99234 - 99236
Observation Care
Per CPT guidance
99238 - 99239
Discharge Day Management
Per CPT guidance
Yes
99251 - 99255
Initial Hospital Evaluation
Per CPT guidance
Yes
99281 - 99285
Emergency Department Visit
Per CPT guidance
No
None
None
None None None
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Residential covered procedure codes Procedure code
Service description
Time/ event
Authorization requirement
Limitations
1001
Psychiatric Residential Treatment Facility
Per diem
Yes
Psychiatric DX Only
H0010
Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient)
Per diem
Yes
Substance Use DX Only
H0018
Behavioral Health Short Per diem Term Residential, per diem
Yes
None
H0019
Behavioral Health Long Per diem Term Residential, per diem
Yes
None
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Partial hospitalization covered procedure codes Procedure code
Service description
Time/event
Authorization requirement
Limitations
H0035
Mental health partial hospitalization, treatment, less than 24 hours
Less than 24 Hours
Yes
Psychiatric DX Only
H2012
Behavioral health day treatment; per hour
60 minutes
Yes
None
T2012
Children’s Day Treatment, Per Diem
Per diem
Yes
None
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Intensive outpatient program covered procedure codes Procedure code H0004
H0015
S9480
Service description Mental Health Intensive Outpatient Program Alcohol and/or drug services; intensive outpatient treatment, per diem Intensive Outpatient Service per diem
Time/event
Authorization requirement
Limitations
15 minutes
Yes
Psychiatric DX Only
Event
Yes
Substance Use DX Only
Per diem
Yes
None
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ECT covered procedure codes Procedure code 104 90870
Service description Anesthesia for Electroconvulsive Therapy Electroconvulsive Therapy
Time/event
Single seizure
Authorization requirement
Limitations
Yes
Psychiatric DX Only
Yes
Psychiatric DX Only
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Targeted case management covered procedure codes Procedure code
Service description
Time/event
Authorization requirement
Limitations
T1017
Targeted Case Management, each 15 minutes
15 minutes
Yes
None
T2023
Targeted Case Management, SMI
Per month
Yes
1 unit per month/ SMI DX Only
T2023 HF
Targeted Case Management, Substance Use
Per month
Yes
1 unit per month
T2023 TG
Targeted Case Management, Complex
Per month
Yes
1 unit per month
T2023 UA
Targeted Case Management, SED
Per month
Yes
1 unit per month/ SED DX Only
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Outpatient covered procedure codes Procedure code
Service description
Time/ event
Authorization requirement
Limitations
90791
Psychiatric Diagnostic Interview
Event
No
None
90792
Psychiatric Diagnostic Evaluation with Medical Services
Event
No
None
90785
Interactive complexity addon code
Event
No
None
90832
Individual Psychotherapy, 20-30 min
16-37 minutes
No
None
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Outpatient covered procedure codes
Procedure code
Service description
Time/event
Authorization requirement
Limitations
90833
Psychotherapy 30 minutes add-on code to appropriate E/M code
16-37 minutes
No
None
Individual Psychotherapy, 38-52 minutes 45-50 min
No
None
90834
90836
Psychotherapy 45 minutes add-on code to appropriate E/M code
38-52 minutes
No
None
90837
Individual Psychotherapy, 60 minutes
53 or more minutes
No
None
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Outpatient covered procedure codes Procedure code
Service description
Time/event
Authorization requirement
Limitations
90838
Psychotherapy 60 minutes add-on code to appropriate E/M code
53 or more minutes
No
None
90839
Crisis Psychotherapy (first 60 minutes)
30-74 minutes
No
None
90840
Crisis Psychotherapy (each additional 30 minutes)
30 minutes
No
None
90845
Psychoanalysis
45-50 minutes
No
None
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Outpatient covered procedure codes Procedure code
Service description
Time/event
Authorization requirement
Limitations
90846
Family psychotherapy (without the patient present)
Event
No
None
90847
Family psychotherapy (conjoint psychotherapy) (with patient present)
Event
No
None
90849
Multiple-family group psychotherapy (with patient present)
Event
No
None
90853
Group psychotherapy (other than of a multiplefamily group)
Event
No
None
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Outpatient covered procedure codes Procedure code
Service description
Time/event
Authorization requirement
Limitations
Event
No
None
15 minutes
No
None
96151
Assessment Health/Behavior Subsequent
15 minutes
No
None
90875
Biofeedback, 2030 minutes
20-30 minutes
No
None
90899
96150
Unlisted Psychiatric Service or Procedure Assessment Health/Behavior Initial
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Outpatient covered procedure codes Procedure code 90876 90887
99408
99409
Service description Biofeedback, 4550 minutes Collateral Service Alcohol and substance (other than tobacco) abuse structure screening Alcohol and substance (other than tobacco) abuse structure screening
Time/event
Authorization requirement
Limitations
45-50 minutes
No
None
Event
No
None
15-30 minutes
No
None
30 or more minutes
No
None
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Outpatient covered procedure codes Procedure code
Service description
99354
Prolonged visit used in conjunction with OP CPT code, 60 minutes
30 -74 minutes
No
99355
Prolonged visit used in conjunction with OP CPT code, 30 minutes
30 minutes
No
15 minutes
No
None
15 minutes
No
None
G0442 G0443
Annual alcohol misuse screening, 15 minutes Brief face-to-face behavioral counseling for alcohol misuse
Time/event
Authorization requirement
Limitations 1 unit per day (allowed with 99355) and 90837 2 units per day (allowed with 99354) and 90837; cannot be reported without 99354
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Outpatient covered procedure codes Procedure code
99201 - 99215 (with appropriate add on codes)
Service description
Medication Management
Time/event
Per CPT guidance
Authorization requirement
Limitations
No
Four (4) services, per physician/ nurse practitioner (non psychiatrist), per member, per twelve (12) months. - 2 units per follow-up for medication management/ therapy (1 unit = 15 minutes);
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Outpatient covered procedure codes Procedure code
Service description
Time/event
Authorization requirement
Limitations
G0442
Annual alcohol misuse screening, 15 minutes
15 minutes
No
None
Brief face-to-face behavioral counseling for 15 minutes alcohol misuse, 15 minutes
No
None
G0443
H0001
Alcohol and/or drug assessment
Event
No
Substance Use DX Only
H0002
Behavioral health screening to determine eligibility for admission to treatment program
Event
No
None
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Outpatient covered procedure codes Procedure code
H0003
H0006 H0031
H0032
Service description Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/ or drugs Alcohol and/or drug case management Mental Health Assessment by nonphysician Mental Health Service Plan Development by non-physician
Time/event
Authorization requirement
Limitations
Event
No
Substance Use DX Only
Event
No
Substance Use DX Only
Event
No
None
Event
No
None
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Outpatient covered procedure codes Procedure code H0038
H0040 H0046 H0047
H0050
Service description Self-help/peer support; per 15 minutes Assertive Community Treatment; monthly Mental Health Services NOS Alcohol and/or drug brief treatment Alcohol and/or Drug Service, Brief Intervention; per 15 minutes
Time/event
Authorization requirement
Limitations
15 minutes
No
None
Per month
Yes
1 unit per month
Event
No
None
Event
No
Substance Use DX Only
15 minutes
No
Substance Use DX Only
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Outpatient covered procedure codes Procedure code
Service description
Time/event
Authorization requirement
Limitations
H2010
Comprehensive medication services; per 15 minutes
15 minutes
No
Four (4) services, per physician (non psychiatrist), per member, per twelve (12) months. - 2 units per follow-up for medication management/therap y (1 unit = 15 minutes);
H2011
Crisis Intervention Services; per 15 Minutes
15 minutes
No
None
Q3014
Telehealth
Event
No
None
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Outpatient covered procedure codes Procedure code H2019 H2021
H2021 HM
H2021 HN
H2021 HS
Service description Therapeutic Behavioral Services Comprehensive Community Supports (per 15 minutes) Community Support Services: Paraprofessional Community Support Services: Professional Community Support Services: Parent to Parent
Time/event
Authorization requirement
Limitations
15 minutes
Yes
None
15 minutes
Yes
None
15 minutes
Yes
None
15 minutes
Yes
None
15 minutes
Yes
None
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Outpatient covered procedure codes Procedure code S5145
S9484
T1007
T1016
Service description Therapeutic Foster Care Crisis intervention mental health services; per hour /Mobile Crisis Alcohol and/or substance abuse services, treatment plan development and /or modification Case management, each 15 minutes
Time/event
Authorization requirement
Limitations
Per diem
Yes
None
60 minutes
No
None
Event
No
Substance Use DX Only
15 minutes
No
None
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Outpatient covered procedure codes: psychological testing Procedure code
Service description
Time/event
Authorization requirement
Limitations
96101
Psychological Testing
60 minutes
Yes
None
60 minutes
Yes
None
60 minutes
Yes
None
60 minutes
Yes
None
60 minutes
Yes
None
96102
96103 96116 96118
Psychological Testing, administered by technician Psychological Testing, administered by a computer Neurobehavioral status exam (clinical) Neuropsychological Testing
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Outpatient covered procedure codes: psychological testing Procedure code 96119
96120
Service description Neuropsych Testing Admin by Technician Neuropsych Testing Admin by Computer
Time/event
Authorization requirement
Limitations
60 minutes
Yes
None
60 minutes
Yes
None
96105
Assessment of Aphasia
60 minutes
No
None
96110
Developmental Screening
60 minutes
No
None
96111
Developmental Testing
60 minutes
No
None
50
Break for lunch
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Behavioral Health billing guidance
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Objectives • Define medical coding • What is HIPAA compliance and transaction accuracy • Coding tools • Descriptions of coding terminology • Appropriate use of modifiers • Forms required for submission of encounter data (claims) • Behavioral Health specific coding guidelines 53
Medical coding • Medical coding is a system designed to represent and report medical services, procedures and supplies supported in the medical documentation to appropriately define medical necessity of such services rendered. • Coding is an integral step in the reimbursement process. • Coding is instrumental to the mortality (death) and morbidity (disease) statistics maintained internationally. • There are formalized rules and regulations set forth by the governing agencies for coding standards and requirements.
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HIPAA • Developed to combat waste, fraud and abuse in the health care delivery systems. • Required all covered entities to comply with electronic transactions (837) and code set provisions. • Transferrable language to describe services performed.
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Coding tools • Current procedural terminology (CPT) American Medical Association (AMA) • Health Care Common Procedure Coding System Level II (HCPCS) CMS • International Classification of Diseases 9th edition Clinical Modifications (ICD-9-CM) WHO until October 1, 2015 • Diagnostic and Statistical Manual (DSM-5) APA until October 1, 2015 56
CPT • Category I is divided into six sections; two of which are most utilized in your profession • Published by AMA • Codes are five digit numeric • Updated once yearly (rarely twice) • Laboratory (80300-80299) • Evaluation and management (E/M) (9920199499) • Medicine/psychiatry (90785-90911) 57
Evaluation and management
(99201-99499)
New vs. established patient • New patient is one who has not received any professional services from any practitioner of the exact same specialty and subspecialty that belong to the same group practice within the past three year period. • Established patient has received professional services from the physician or any physician in the exact same specialty and subspecialty group practice. 58
Evaluation and management • •
•
•
(99201-99499)
Location distinctions Office or outpatient setting (physician office or an outpatient or ambulatory facility) – 99201-99215 – 99241-99245 Consultation – 99281-99288 Emergency Room Services Hospital observation services (used when the patient is designated/admitted for the purpose of observation; doesn’t have to be in area designated as “OBSERVATION”) – 99217-99220 – 99231-99236* (two categories) Hospital inpatient services (services provided in a hospital or “partial” hospital setting) – 99221-99239 Initial, subsequent, discharge – 99251-99255 Consultations 59
Evaluation and management
(99201-99499)
There are seven components; six of which are used to define the code for the service rendered. 1. History (PFSH) 2. Examination (ROS) 3. Medical decision making (MDM) 4. Counseling 5. Coordination of care 6. Nature of presenting problem 7. Time 60
Laboratory (80300-80377) 2015 AMA implemented new section in CPT to identify therapeutic drug assay, drug assay and chemistry. • Therapeutic – Performed to monitor clinical response to known prescription medication (80150-80299). • Presumptive – Identifies possible use or nonuse of a drug or drug class (80300-80304). • Definitive – Qualitative or quantitative test to identify specific drugs and associated metabolites (80320-80377). 61
Laboratory (80300-80377) • When codes are billed separately, they are considered unbundled and will be rebundled through our code editing system. • Subject to National Correct Coding Initiatives (NCCI) Medically Unlikely Edits (MUE). • Technical and professional components may be applicable for these procedures to submit charges for the portion of the service performed. 62
Medicine/psychiatry (+90785-90899) • Interactive complexity (+90785) — Communications factors that complicate the delivery of a psychiatric procedure. • Diagnostic procedures (90791-90792) — Biopsychosocial assessment including history, mental status and recommendations. • Psychotherapy (90832-90838) — Treatment of mental illness and behavioral disturbances through definitive therapeutic communications — Face to face services with patient and/or family members — Patient must be present for some or all of the services — Medical evaluation and management services may be performed, but time spent on the E/M is not included in treatment time 63
Medicine/psychiatry (+90785-90899) • Crisis therapy (90839-+90840) — Presenting problem is life threatening or complex, requiring immediate attention — Includes mobilization of resources to defuse the crisis — Codes used to report total face-to-face time providing psychotherapy for crisis
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Medicine/psychiatry (+90863) Pharmacologic management • Includes prescribing and review of medication • List separately in addition to the primary procedure • Created for medication management when provided on the same day as psychotherapy • Utilized by qualified health professionals who may not report E/M codes, but may prescribe
65
Time elements • Units for time element codes are only reported once the treatment has reached a midpoint • Psychotherapy has a 30-minute timeframe (16-37 minutes) – Must be 16 minutes or more of face-to-face with patient and/or family – Time elements used to meet the time criteria for an E/M is not included – Counseling and coordination of care is not included in the time element for psychotherapy • Psychotherapy has a 45-minute timeframe (38-52 minutes) – Must be 38 minutes or more of face-to-face with the patient and/or family • Psychotherapy has a 60-minute timeframe (53+minutes) – Include face-to-face with patient and/or family 66
Modifiers
67
Modifiers Modifiers are mainly used when • Procedure or service is performed more than once or by more than one provider • Procedure or service was increased or reduced due to patient circumstances • Only a portion was completed or there are separate components for that particular code set • Unusual difficulties • Two or more modifiers may be used to append or detail a particular procedure or service
68
Licensure modifiers Degree/licensure
HIPAA modifier
Degree/licensure
HIPAA modifier
Psychiatrist
AF
Community Support Staff Member
UC
Advanced Registered Nurse Practitioner (APRN)
SA
Psychiatric Resident
U3
Certified Social Worker (CSW)
U4
Peer Counselor
U7
Professional Equivalent
HN
Psychiatric Registered Nurse
U2
Licensed Professional Counselor Associate (LPCA)
U4
Licensed Clinical Social Worker (LCSW)
AJ
Certified Prevention Professional
HM
Registered Nurse AD, BSN or Diploma
TD
Certified Psychological Assoc.
U8
Physician
AM
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Licensure modifiers cont. Degree/licensure
HIPAA modifier
Degree/licensure
HIPAA modifier
Marriage and Family Therapist Associate (MFTA)
U4
Mental Health Associate (MHA)
U5
Licensed Marriage & Family Therapist (LMFT) Licensed Psychological Practitioner (LPP) Licensed Professional Clinical Counselor (LPCC)
HO
Physician Assistant (PA)
U1
U8
Psychologist
AH
HO
Certified Alcohol & Drug Counselor U6 (CADC)
Certified Professional Art Therapist (ATR-BC)
HO
Registered Nurse with BS degree (RN)
TD
Licensed Professional Art Therapist Associate
U4
Licensed Associate Behavior Analyst (LABA)
U4
Licensed Behavior Analyst (LBA)
HO
Per diem
U9
70
Modifier usage Reimburse /info
Service type modifier (NOTE: Not all codes within a section may be affected)
E/M
Modifier
Description
25
Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service: the physician may need to indicate that on the day a procedure or service identified by a CPT code was performed.
R
59
Distinct Procedural Service -is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
I
24
Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure.
I
XF
Separate encounter, a service that is distinct because it occurred during a separate encounter
I
XP
Separate practitioner, a service that is distinct because it was performed by a different practitioner
I
E/M
71
Modifiers cont. Modifier
Description
Reimburse/info
HA
Child/adolescent program
I
HD
Pregnant/parenting women's program
I
HE
Mental health program
I
HF
Substance abuse program
I
HG
Opioid addiction treatment program
I
HQ
Group setting
I
U1 – UD
Medicaid level of care (1-13) as defined by the state or health plan
I
72
CPT summary • Development of codes by the AMA • Divided into three categories • Category I is for services and procedures performed by a physician or non-physician practitioner • Codes are five digit numeric • E/M services are determined by location, patient status, performance
73
HCPCS level II • HCPCS codes are created by CMS • Updated quarterly by CMS • HCPCS are used to report procedures and services for patients the same way CPT are utilized • They are HIPAA-mandated codes and contain specific codes designated for Medicaid only • Medicare- and Medicaid-specific covered codes — State Medicaid agency codes T1000-T5999 (designed for use by Medicaid to establish codes for items for which no permanent national codes exist; these are not used by Medicare) • Codes begin with a single letter followed by four digits 74
HCPCS level II (H0001-H2037)
(T1000-T9999)
• H0001-H2037 Alcohol and drug abuse treatment services codes were developed for state Medicaid agencies to identify mandated mental health services that included: — H0031 Mental Health Assessments; nonphysician — H2021 Community Based Wrap Around Service • T1000-T9999 Designed for Medicaid state agencies which describes nursing and home health related services, substance abuse treatment and certain training related procedures 75
ICD-9-CM • Developed to describe the circumstance of a patient’s condition. • Currently the national standard coding language used to define a patient’s condition, diagnosis, disease, injury, anomaly or any other reason for a medical service, procedure or supply. • Revisions are made annually and published in early spring to become effective October 1 by the AHA. • Codes must be used for all services performed on or after the effective date. Providers and payers must keep up with changes and accept/code appropriately. 76
ICD-9-CM • Diagnosis codes identify and justify the medical necessity of services • List first the primary diagnosis, condition, problem or reason for the medical service or procedure (chief complaint) — Assign a ICD-9-CM diagnosis code to the highest level of specificity using the appropriate fourth or fifth digit — Distinguish between acute and chronic conditions — Chronic complaints or secondary diagnoses are coded only when treatment is provided for that condition — Be as specific in describing the condition or illness of the patient as possible
77
ICD-9-CM • There are three volumes to the ICD-9-CM — Volume 1 contains the tabular list of disease (arranged numerically); there are nineteen chapters established by etiology or body system — Volume 2 contains the alphabetic index of diseases — Volume 3 contains both an alphabetic index to procedures and surgical procedures used by facilities • ICD-9-CM were designed for claims and benefit administration to be expedited and consistent for reimbursement consideration.
78
ICD-9-CM • Volume 1 — Contains the tabular list of disease (arranged numerically); there are nineteen chapters established by etiology or body system (001-999.9) — There are two supplementary classifications — V codes (V01-V84) are supplementary classifications of factors influencing health status and contact with health services — E codes (E800-E999) explain the condition under which a diagnosis happened (occurred)
79
ICD-9-CM • Define the reason chiefly responsible for the service provided • Identify any causes or conditions that affect the treatment of the primary condition • Tell the story as completely as possible; code to the highest level of specificity • Complete with codes that help describe events or reason appropriately with V and E codes • Improved medical record documentation
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ICD-10-CM • The 10th revision of morbidity coding • WHO maintains the history behind and implementation of changes • Exceeds its predecessor in the number of concepts and codes (extends from 17,000 ICD-9-CM to 90,000 ICD-10-CM) • Incorporates greater clinical detail and specificity than ICD-9-CM and has been updated to be consistent with current clinical practice 81
ICD-9-CM vs. ICD-10-CM The difference ICD-9-CM
ICD-10-CM
• • •
• • •
• • • • •
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3-5 characters in length Approximately 14,000 codes First digit may be alpha (E or V) or numeric; digits 2-5 are numeric Limited space for adding new codes Lacks detail Lacks laterality Difficult to analyze data due to nonspecific codes Codes are nonspecific and do not adequately define diagnoses needed for medical research Does not support interoperability because it is not used by other countries
• • • • • •
3-7 characters in length Approximately 68,000 available codes Digit one is alpha; digits 2-7 are alpha or numeric Flexible for adding new codes Very specific Has laterality Specificity improves coding accuracy and richness of data for analysis Detail improves the accuracy of data used for medical research Supports interoperability and the exchange of health data between other countries and the United States
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Examples coding from ICD-9-CM to ICD-10CM (compressed) ICD-9-CM • 295.00 Schizophrenia disorder Simple unspecified condition • 304.00 Opioid type dependence, unspecified ICD-10-CM • F20.89 Other schizophrenia (Cenesthopathic schizophrenia, Simple schizophrenia) • F11.20-F11.29 (one to multiple)
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Opioid dependence F11.20
Opioid dependence, uncomplicated
F11.220
Opioid dependence with intoxication, uncomplicated
F11.221
Opioid dependence with intoxication delirium
F11.222
Opioid dependence with intoxication with perceptual disturbance
F11.229
Opioid dependence with intoxication, unspecified
F11.23
Opioid dependence with withdrawal
F11.24
Opioid dependence with opioid-induced mood disorder
F11.250
Opioid dependence with opioid-induced psychotic disorder with delusions
F11.251
Opioid dependence with opioid-induced psychotic disorder with hallucinations
F11.259
Opioid dependence with opioid-induced psychotic disorder, unspecified
F11.281
Opioid dependence with opioid-induced sexual dysfunction
F11.282
Opioid dependence with opioid-induced sleep disorder
F11.288
Opioid dependence with other opioid-induced disorder
F11.29
Opioid dependence with unspecified opioid-induced disorder 84
Place of service (POS) POS code/name
POS description
11 Office
Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
51 Inpatient Psychiatric Facility
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
52 Psychiatric FacilityPartial Hospitalization
A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.
53 Community Mental Health Center
A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility.
55 Residential Substance Abuse Treatment Facility
A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
56 Psychiatric Residential Treatment Center
A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.
57 Non-residential Substance Abuse Treatment Facility
A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. 85
Forms
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CMS 1450/UB04 • Electronic version 837I • Effective March 1, 2007 (deadline July 1, 2007) • Additional fields added to accommodate NPI, additional diagnosis codes fields and a specific DRG field and NDC numbers • ICD-9-CM diagnosis and procedures only accepted • Principal diagnosis codes are required for all inpatient and outpatient • National Uniform Billing Committee (NUBC) and the State Uniformed Billing Committee (SUBC) determine format and updates
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CMS 1450
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CMS 1500 (electronic version 837) • Replaced the HCFA 1500 effective February 2012 implemented February 7, 2007 (modified July 2014) • Answers the needs of most health insurers • Revisions were made to accommodate the implementation of the National Provider Identifier (NPI) • Ability to include NPI and insurers’ PIN in box (17) referring physician; (31) rendering physician; (32) facility services rendered; and (33) billing provider information • The six claims lines have been divided to accommodate submission of NPI, anesthesia time and NDC drug information
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CMS 1500
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Clinical edits
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NCCI • •
Federally mandated to promote national correct coding methodologies and control improper coding leading to inappropriate payment Based on coding policies defined by AMA CPT manual, national societies, national and local policies
Two types of NCCI edits 1. Procedure-to-procedure edits implemented January 1, 1996 a. Are assigned to either the column one/column two correct coding edit files b. Applies to: i. Physicians/practitioners ii. Outpatient hospital services iii. Durable medical supplies 2. MUE implemented January 1, 2007 a. A maximum unit of service that a provider would report under most circumstances for a single beneficiary on a single date of service for HCPCS/CPT code b. Not all HCPCS/CPT procedures have a MUE c. Applies to: i. Physician/practitioners ii. Outpatient hospital services iii. Durable medical supplies 92
Code editing projects
Utilize PAM (policy administration module) of ClaimCheck to create clinically appropriate edits based on Anthem policy and/or industry standards. → Single procedure or diagnosis → Procedure to diagnosis → Procedure to procedure → Member age or gender → Unit limits → Frequency → Place of service → Provider specialty → Market or product specific
EX Codes axx-dxx, N10
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iHealth • A health care analytics company contracted to assist us in identifying inappropriately paid claims. • Provides prepayment solution in a real-time environment through a Facets interface. ® • Similar and an addition to McKesson’s ClaimCheck with added functionality and flexibility. • To be employed as a “final filter” before professional and outpatient facility claims are paid – same as ClaimCheck. • Implemented November 1, 2013 • EX Codes i00 – i81
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What is the key difference? ClaimCheck audits the claim from the provider’s point of view • Same member, same provider, same DOS • Limited use of time span or provider groupings/specialty • PAM can be configured more broadly – resources consuming
iHealth reviews claims from the member’s point of view • What services could’ve been done across providers for this member (takes modifiers and specialty into consideration) • How often can this service be provided • Looks across providers and time span
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Conclusion Medical coding is based on the foundations of three areas: • Current procedural terminology (CPT) • Health Care Common Procedure Coding System (HCPCS) • International Classification of Diseases 9th edition Clinical Modifications (ICD-9-CM) (ICD-10 effective October 1, 2015) Working together, much like a sentence, to provide an effective and efficient mechanism to reimburse providers for services and procedures performed. 96
Claim scenarios
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Coding example • Member presented with concerns about his ability to return to work and face his coworkers – Nature of the presenting problem was documented • Established patient • Problem focused • Problem focused examination • Low complexity medical decision making – Time spent in therapy was 25 minutes
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Example II A 15-year-old being treated for depression and alcohol abuse and on an antidepressant and an inhaler for asthma presented today with both divorced parents who disagree over how to address the patient’s recent alcohol binge. Concern over boarding school or following treatment plan. Nature of presenting problem: • Interval history obtained from parents and patient; this included details of recent alcohol use along with exploration of other drug use, medication compliance, side effects and beneficial effects • Suicide risk explored • Psychiatric specialty exam is completed and decision on medication (50 minutes) • Patient focuses on feelings of embarrassment of new rules in father’s home and encounter which he was drunk in front of her friends • Parents increasingly argue with each other over the treatment recommended by the psychiatrist 99
Questions and answers
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