SYCH 2007.book Page 1 Wednesday, November 29, 2006 5:57 PM
Coding and Payment Guide for Behavioral Health Services An essential coding, billing and reimbursement resource for psychiatrists, psychologists and clinical social workers
SYCH 2007TOC.fm Page 1 Thursday, November 30, 2006 11:48 AM
Contents Introduction ..........................................................1 Coding Systems ...................................................1 Contents and Format of This Guide ......................2 The Reimbursement Process ..................................5 Coverage Issues ...................................................5 Payer Types .........................................................5 Payment Methodologies ........................................7 Calculating Costs .................................................9 Other Factors Influencing Payment ......................9 Participation in Medicare Plans ..........................18 Supplemental Medicare Coverage .......................20 Workers’ Compensation .....................................23 Documentation—An Overview ..............................25 Methods of Documentation ................................25 Fraud and Abuse ...............................................28 Compliance ........................................................30 Action Plan ........................................................31 Claims Processing ................................................33 What to Include on Claims .................................33 Clean Claims .....................................................34 The Health Insurance Portability and Accountability Act .......................................34 Processing the Claim ..........................................37 Collection Policies ..............................................38 The Appeals Process ...........................................39 Medicare Benefit Notices ....................................42 Automated Response Unit ..................................46 CMS-1500 .........................................................46 Electronic Claim Forms ......................................61 UB-92 ................................................................65 UB-04 ................................................................68 CPT Definitions and Guidelines ............................71 Structure of CPT ................................................71 CPT Coding Conventions ....................................71 Unlisted Procedures and Modifiers ....................71 80048–89399 Pathology and Laboratory .............74 90281–99600 Medicine ......................................81 Evaluation and Management Services ................93
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99201–99215 Office or Other Outpatient Services ...................................................103 99241–99255 Consultations ...........................107 99304–99310 Nursing Facility Services ...........110 CPT Index .......................................................... 125 ICD-9-CM Definitions and Guidelines ................. 129 The Structure of ICD-9-CM ..............................129 The Structure of the Alphabetic Index ..............129 The Structure of the Tabular List .....................129 001–139 Infectious & Parasitic Diseases ..........131 240-279 Endocrine,Nutritional and Metabolic Diseases,and Immunity Disorders .............131 290–319 Mental Disorders ...............................132 Supplementary Classifications V01–V85 and E800–E999 ..........................137 ICD-9-CM Index ................................................. 143 HCPCS Level II Definitions and Guidelines ........ 177 Introduction ....................................................177 HCPCS Level II—National Codes ......................177 Structure and Use of HCPCS Level II Codes .....177 HCPCS Level II Codes: Sections A–V ................177 The Conventions: Symbols and Modifiers ........178 HCPCS Level II Codes ......................................179 J Codes—Drugs Administered Other Than Oral Method .....................................................181 HCPCS Level II Index ......................................... 183 Medicare Official Regulatory Information .......... 185 Revisions to the CMS Manual System ...............185 National Coverage Determinations Manual .......186 Medicare Benefit Policy Manual ........................186 Pub100 References ...........................................187 Glossary ............................................................ 207 Correct Coding Initiative ................................... 237 Index ................................................................. 247
05 SYCH CPT D&G.fm Page 75 Thursday, November 30, 2006 11:25 AM
CPT Definitions and Guidelines
80152
Amitriptyline Amitriptyline is a tricyclic antidepressant and the prototype brand name is Elavil. Test specimens are frequently collected at the trough period, which is about 12 hours after the last dose when serum concentration is at its lowest. This is an effective approach to determine a therapeutic level of drug. Drug overdose may be reason for the test as well. Method is typically high performance liquid chromatography (HPLC) or gas liquid chromatograph (GLC). This drug may be prescribed for disorders outside of depressive states, such as chronic pain.
absorbed slowly and erratically by the gastrointestinal (GI) tract and a free plasma concentration may be assayed, depending on the type of treatment underway. Tegretol may be administered for such conditions as trigeminal neuralgia, epilepsy, and manic disorders. It is known for its anticonvulsant and pain management properties. Pub. 100-2, 15, 80 80160
This drug is also known as norpramine and is among the tricyclic antidepressants. Steady state test specimens are frequently collected at the trough period, which is about 12 hours after the last dose when serum concentration is at its lowest. This is an effective approach to determine a therapeutic level of drug. Overdose is also a reason to run this test. Method is high performance liquid chromatography (HPLC) or gas liquid chromatography (GLC).
Pub. 100-2, 15, 80 80154
Benzodiazepines Benzodiazepines encompass a family of mild sedatives, including diazepam (Valium) and ativan. These drugs may be assayed to determine therapeutic levels, or sometimes to determine levels in the system following overdose. Test specimens are frequently collected at the trough period, which is about 12 hours after the last dose when serum concentration is at its lowest. Method is high performance liquid chromatography (HPLC), gas liquid chromatography (GLC), or radioimmunoassay (RIA). This family of drugs may be prescribed for numerous conditions and disorders. Alcohol withdrawal is a common use for diazepam, as are muscle spasms.
Pub. 100-2, 15, 80 80164
Pub. 100-2, 15, 80 80157
Carbamazepine; free This drug, also known as Tegretol, is an enzyme inducer. Specimen collection is by venipuncture. Test specimens for free drug concentrations may be collected near peak levels about two to eight hours after ingestion. Methods include high performance liquid chromatography (HPLC) or gas liquid chromatography (GLC). This drug is
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Pub. 100-2, 15, 80 80166
Doxepin This drug is also known as sinequam or adapin. This drug is classified as a tricyclic antidepressant (TCA). Steady state test specimens are frequently collected at the trough period, which is about 12 hours after the last dose when serum concentration is at its lowest. This is an effective approach to determine a therapeutic level of drug. Overdose may also prompt this test. Method is high performance liquid chromatography (HPLC), gas liquid chromatography (GLC), gas chromatography-mass spectrometry (GC-MS), and radioimmunoassay (RIA). Pub. 100-2, 15, 80
80168
Ethosuximide This drug may also be known as zarontin. This is an anti-convulsant medication. Test specimens may be drawn during peak and trough periods, which is shortly after administration of zarontin and again just before the next administration when serum concentration is at its lowest. Methods include high performance liquid chromatography (HPLC), radioimmunoassay (RIA), and microbiology assay. Pub. 100-2, 15, 80
CPT codes only © 2006 American Medical Association. All Rights Reserved.
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CPT Definitions & Guidelines
Carbamazepine; total This drug, also known as Tegretol, is an enzyme inducer. Blood specimen collection is by venipuncture. CSF is obtained by spinal puncture, which is reported separately. Test specimens for total levels are frequently collected at the trough period, which is about 12 hours after the last dose when serum concentration is at its lowest. This is an effective approach to determine a therapeutic level of drug. This drug is absorbed slowly and erratically by the GI tract and a total concentration may be required, depending on the treatment underway. Methods include high performance liquid chromatography (HPLC) or gas liquid chromatography (GLC). Tegretol may be administered for such conditions as trigeminal neuralgia, epilepsy, and manic disorders. It is known for its anticonvulsant and pain management properties.
Dipropylacetic acid (valproic acid) This drug is also known as depakene. This drug is often used to treat seizures. Test specimens are frequently collected at the trough period, which is about 12 hours after the last dose when serum concentration is at its lowest. This is an effective approach to determine a therapeutic level of drug. Method is gas liquid chromatography (GLC), gas chromatography-mass spectrometry (GC-MS), and enzyme immunoassay (EIA).
Pub. 100-2, 15, 80 80156
Desipramine
SYCH 2007.book Page 133 Wednesday, November 29, 2006 5:57 PM
ICD-9-CM Definitions and Guidelines
Coding Tip Vascular dementia (290.4x) is dementia or psychosis resulting from multiple infarcts and is attributable to degenerative arterial disease of the brain. When assigning code 290.4x, use an additional code to identify cerebral atherosclerosis. Coexisting senile or presenile dementia may be difficult to differentiate clinically.
Example •
Vascular dementia with delirium due to cerebral arteriosclerosis is coded as: 290.41, Vascular dementia with delirium, and 437.0, Cerebral arteriosclerosis.
Coding Tip Alcohol-induced mental disorders (291) are psychoses resulting from excessive alcohol consumption, usually associated with nutritional deficits. This category excludes alcoholism without psychosis, which is classified to category 303. However, when alcohol dependence or abuse results in a psychotic condition, code both the psychotic condition and the dependence (303) or abuse (305.0x).
Example •
Alcoholic withdrawal due to chronic alcoholism is coded as 291.81 and 303.90.
Alcohol withdrawal delirium (291.0) is delirium resulting from the abrupt cessation of the use of alcohol by an individual who habitually consumes alcohol. Alcohol withdrawal delirium is characterized by clouded consciousness, disorientation, fear, illusions, delusion, hallucinations, tremor, and sometimes fever. Alcohol-induced persisting amnestic disorder (291.1) is the prominent and lasting reduction of memory span, including loss of recent memory, disordered time appreciation and confabulation, occurring in alcoholics, usually as a sequel to alcoholic psychosis. Alcoholic-induced persisting dementia (291.2) is a nonhallucinatory dementia associated with alcoholism but without features of delirium tremens or Korsakov’s psychosis.
Coding Tip Idiosyncratic alcohol intoxication (291.4) excludes acute alcohol intoxication, which is classified to category 305 for patients that are not diagnosed as having alcoholism or category 303 if associated with alcoholism. Alcoholic-induced psychotic disorder with delusions (291.5) is paranoid psychosis as evidenced by delusional jealousy and is associated with alcoholism.
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Unspecified alcohol-induced mental disorders (291.9) includes all the not otherwise specified cases of alcoholic psychoses.
Coding Tip Code 291.0, 291.3, and 291.81 cover the various severity of symptoms associated with withdrawal. ICD-9-CM has placed “Excludes” notes with these subcategories to alert the coder that these three codes may not be used in combination with each other. Also, the coder must use the code that describes the highest level of symptom severity exhibited by the patient. In other words, the hierarchy of severity is as follows: 291.0 Withdrawal with hallucinations, delirium, delirium tremens 291.3 Withdrawal with hallucinosis 291.81 Withdrawal Alcohol induced sleep disorders (291.82) include circadian sleep disruptions, hypersomnia, insomnia and parasomnia sleep disorders that are a result of and/or alcohol use. Insomnia is frequently associated with Alcoholism. In fact, many people rely on alcohol to achieve sleep. Alcohol is a depressant that acts as a sedative, yet once the sedating effect of the alcohol wears off, the second phase of sleep is disturbed or disrupted. Drug-induced mental disorders (292) include organic brain syndrome associated with drug abuse, dependence, or use. Additional E codes are to be used to identify the drug. Also assign additional codes for indicating drug dependence (304.0x–304.9x). The coding guidelines for assigning druginduced mental disorders are very similar to the guidelines for coding alcohol-induced psychoses. The subcategories include drug withdrawal (292.0), paranoid and/or hallucinatory states induced by drugs (292.1), pathological drug intoxication (292.2), and other (292.8) and unspecified (292.9) drug-induced mental disorders. Drug induced sleep disorders (292.85) include circadian sleep disruptions, hypersomnia, insomnia and parasomnia sleep disorders that are a result of drug use. Some medications are due to either drug use (similar to the effects of alcoholism) or as a secondary effect of prescribed medications. Some SSRI medications have been found to be contributor to REM sleep behavior disorders. As well, some antipsychotic agents cause significant weight gain that result in sleep apnea. Transient organic psychotic conditions (293) are conditions characterized by clouded consciousness, confusion, disorientation, illusions, and frequently vivid hallucinations. Typically, they are due to some inter- or extra-cerebral toxic, infectious, metabolic, or other systemic disturbance, and generally are reversible. These conditions are not associated with alcohol or drug use. Excluded also from this category are dementia conditions associated with arteriosclerosis and senility.
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ICD-9-CM Definitions and Guidelines
Idiosyncratic alcohol intoxication (291.4) is a unique behavioral pattern including belligerence, after the intake of relatively small amounts of alcohol. This behavior is not due to excessive consumption and is without conspicuous neurological signs of intoxication.
Other specified alcohol-induced mental disorders (291.8) includes alcohol withdrawal or abstinence syndrome without hallucinations, delirium, or delirium tremens.
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Medicare Official Regulatory Information physician within these definitions are subject to any limitations imposed by the State on the scope of practice.
Chapter
Title
Thirteen
Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services
Fourteen
Medical Devices
Fifteen
Covered Medical and Other Health Services
Sixteen
General Exclusions from Coverage
Pub100 References Pub. 100-1, Chapter 3, Section 30 Outpatient Mental Health Treatment Limitation
Expenses for diagnostic services (e.g., psychiatric testing and evaluation to diagnose the patient’s illness) are not subject to this limitation. This limitation applies only to therapeutic services and to services performed to evaluate the progress of a course of treatment for a diagnosed condition.
Pub. 100-1, Chapter 3, Section 30.1 Status of Patient The limitation is applicable to expenses incurred in connection with the treatment of an individual who is not an inpatient of a hospital. Thus, the limitation applies to mental health services furnished to a person in a physician’s office, in the patient’s home, in a skilled nursing facility, as an outpatient, and so forth. The term “hospital” in this context means an institution which is primarily engaged in providing to inpatients, by or under the supervision of a physician(s): •
Diagnostic and therapeutic services for medical diagnosis, and treatment, and care of injured, disabled, or sick persons;
•
Rehabilitation services for injured, disabled, or sick persons; or
•
Psychiatric services for the diagnosis and treatment of mentally ill patients.
Pub. 100-1, Chapter 3, Section 30.2 Disorders Subject to Mental Health Limitation The term “mental, psychoneurotic, and personality disorders” is defined as the specific psychiatric conditions described in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Third Edition - Revised (DSM-III-R). If the treatment services rendered are for both a psychiatric condition and one or more nonpsychiatric conditions, the charges are separated to apply the limitation only to the mental health charge. Normally HCPCS code and diagnoses are used. Where HCPCS code is not available on the claim, revenue code is used. If the service is primarily on the basis of a diagnosis of Alzheimer’s Disease (coded 331.0 in the International Classification of Diseases, 9th Revision) or Alzheimer’s or other disorders (coded 290.XX in DSM-III-R), treatment typically represents medical management of the patient’s condition (rather than psychiatric treatment) and is not subject to the limitation.
The issuance by a State of a license to practice medicine constitutes legal authorization. Temporary State licenses also constitute legal authorization to practice medicine. If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, the local standards determine whether a particular physician has legal authorization. If State licensing law limits the scope of practice of a particular type of medical practitioner, only the services within the limitations are covered. NOTE: The term physician does not include such practitioners as a Christian Science practitioner or naturopath.
Pub. 100-2, Chapter 15, Section 30
Medicare Information
Regardless of the actual expenses a beneficiary incurs for treatment of mental, psychoneurotic, and personality disorders while the beneficiary is not an inpatient of a hospital at the time such expenses are incurred, the amount of those expenses that may be recognized for Part B deductible and payment purposes is limited to 62.5 percent of the Medicare allowed amount for these services. The limitation is called the outpatient mental health treatment limitation. Since Part B deductible also applies the program pays for about half of the allowed amount recognized for mental health therapy services.
The issuance by a State of a license to practice medicine constitutes legal authorization. Temporary State licenses also constitute legal authorization to practice medicine. If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, the local standards determine whether a particular physician has legal authorization. If State licensing law limits the scope of practice of a particular type of medical practitioner, only the services within the limitations are covered.
Physician Services B3-2020, B3-4142 A. General Physician services are the professional services performed by a physician or physicians for a patient including diagnosis, therapy, surgery, consultation, and care plan oversight. The physician must render the service for the service to be covered. (See Publication 1001, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §70, for definition of physician.) A service may be considered to be a physician’s service where the physician either examines the patient in person or is able to visualize some aspect of the patient’s condition without the interposition of a third person’s judgment. Direct visualization would be possible by means of x-rays, electrocardiogram and electroencephalogram tapes, tissue samples, etc. For example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram reading that has been transmitted via telephone (i.e., electronically rather than by means of a verbal description) is a covered service. Professional services of the physician are covered if provided within the United States, and may be performed in a home, office, institution, or at the scene of an accident. A patient’s home, for this purpose, is anywhere the patient makes his or her residence, e.g., home for the aged, a nursing home, a relative’s home. B. Telephone Services Services by means of a telephone call between a physician and a beneficiary, or between a physician and a member of a beneficiary’s family, are covered under Medicare, but carriers may not make separate payment for these services under the program. The physician work resulting from telephone calls is considered to be an integral part of the prework and postwork of other physician services, and the fee schedule amount for the latter services already includes payment for the telephone calls. See the Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” §270, for coverage of telehealth services. C. Consultations A consultation may be paid when the consulting physician initiates treatment on the same day as the consultation. It is only after a transfer of care has occurred that evaluation and management (E&M) services may not be billed as consultations; they must be billed as subsequent office/outpatient visits.
Pub. 100-1, Chapter 3, Section 30.3
Therefore, if covered, a consultation is reimbursable when it is a professional service furnished a patient by a second physician at the request of the attending physician. Such a consultation includes the history and examination of the patient as well as the written report, which is furnished to the attending physician for inclusion in the patient’s permanent medical record. These reports must be prepared and submitted to the provider for retention when they involve patients of institutions responsible for maintaining such records, and submitted to the attending physician’s office for other patients.
Diagnostic Services
To reimburse laboratory consultations, the services must:
The mental health limitation does not apply to tests and evaluations performed to establish or confirm the patient’s diagnosis. Diagnostic services include psychiatric or psychological tests and interpretations, diagnostic consultations, and initial evaluations. However, testing services performed to evaluate a patient’s progress during treatment are considered part of treatment and are subject to the limitation.
•
Be requested by the patient’s attending physician;
•
Relate to a test result that lies outside of the clinically significant normal or expected/established range relative to the condition of the patient;
•
Result in a written narrative report included in the patient’s medical record; and
•
Require medical judgment by the consultant physician.
Pub. 100-1, Chapter 5, Section 70 Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery or dental medicine (within the limitations in subsection §70.2), doctor of podiatric medicine (within the limitations in subsection §70.3), or doctor of optometry (within the limitations of subsection §70.5), and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a State in which he/she performs this function. The services performed by a
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A consultation must involve a medical judgment that ordinarily requires a physician. Where a nonphysician laboratory specialist could furnish the information, the service of the physician is not a consultation payable under Part B. The following indicators can ordinarily distinguish attending physician’s claims: •
Therapeutic services are included on the bill in addition to an examination;
CPT codes only © 2006 American Medical Association. All Rights Reserved.
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