Behavioral Health CPT Code Changes for 2013 Hoosier HealthWise / Healthy Indiana Plan Behavioral Health Serving Hoosier Healthwise and Healthy Indiana Plan
MDWise
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Behavioral Health CPT Code Changes Behavioral Health CPT Code Changes • Effective 1/1/13 The Centers for Medicare and Medicaid Services (CMS) accepted the proposed changes in behavioral h lth d health codes as did the state of Indiana (IHCP Bulletin did th t t f I di (IHCP B ll ti BT201253) • Professional organizations participate in the CPT process and are a good source of independent information about code use
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Behavioral Health CPT Code Changes Behavioral Health CPT Code Changes • The changes include the use of Evaluation and Management g g (E&M) Codes as well as add‐ on codes to reflect the length and complexity of the interaction • The use of E&M codes ensures that certain aspects of the p patient’s health are monitored and documented given that g many psychiatric medications can effect weight, blood sugars, etc. • Only medical personnel with the ability to prescribe medications may use the E&M codes with add –on medications may use the E&M codes with add on codes codes 3
Behavioral Health CPT Code Changes Behavioral Health CPT Code Changes • It is important to carefully review the E&M codes to understand the time and intensity associated with each outpatient visit code • The E&M codes are now intended to replace the previous CPT Codes that included medical management and evaluation (CPT Codes 90805 90807 90809 90811 90813 and 90862) (CPT Codes 90805, 90807, 90809, 90811, 90813 and 90862) • The MCE’s expect minimal use of the interactive complexity add‐on code (CPT Code 90785) – The interactive complexity add‐on code replaces CPT Codes which were not often used Codes which were not often used 4
Behavioral Health CPT Code Changes Behavioral Health CPT Code Changes Examples of the use of Interactive Complexity p p y Add‐On Code (CPT Code 90785) • Involvement of other individuals (parent, guardian) who are l ll legally responsible for care ibl f • Involvement of other individuals such as interpreters, etc. • Involvement of third parties such as schools, parole/ Involvement of third parties such as schools parole/ probation officers, child welfare, etc.; • The patient has impaired language skills such as aphasia.
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Behavioral Health CPT Add‐On Behavioral Health CPT Add On Codes Codes Add‐on codes: Add‐on codes will deny if not filed with the correct respective codes CPT Code 90785 • May only be used when very specific communication factors complicate the delivery of psychotherapy • May only be used with the following CPT codes – Diagnostic evaluation codes: 90791 and 90792 – Hospital Psychotherapy codes: 90832, 90834, and 90837 – Psychotherapy when performed with an evaluation and management (E&M) Psychotherapy when performed with an evaluation and management (E&M) service: CPT codes 90833, 90836, 90838, 99201‐99255, 99304‐99337, and 99341‐99350 – Group psychotherapy: CPT code 90853 CPT Code 90833 • 30 minute psychotherapy add‐on code (16‐37 minutes) • May only be used with Evaluation and Management Codes (Medication Management) • May only be used by medical professionals with prescriptive authority 6
Behavioral Health CPT Add‐On Behavioral Health CPT Add On Codes Codes CPT Code 90836 • 45 minute psychotherapy add‐on code (38‐52 minutes) py py ( ) • May only be used with Evaluation and Management Codes (Medication Management) • May only be used by medical professionals with prescriptive authority CPT Code 90838 • 60 minute psychotherapy add‐on code (53 minutes or more) • May only be used with Evaluation and Management Codes (Medication Management) • May only be used by medical professionals with prescriptive authority
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Behavioral Health CPT Codes Not Linked to E&M Codes & d 2013 CPT Code
Definition
90791 + 90785 (Interactive complexity add‐on) 90792 + 90785 (Interactive complexity add‐on)
PSYCHIATRIC DIAGNOSTIC EVALUATION PSYCHIATRIC DIAGNOTSTIC EVALUATION WITH MEDICAL SERVICES
90832
INDIVIDUAL PSYCHOTHERAPY 30 MINUTES
90834 INDIVIDUAL PSYCHOTHERAPY 45 MINUTES 90837* Anthem / MDWise require authorization unless INDIVIDUAL PSYCHOTHERAPY 60 MINUTES otherwise noted in PPT 90832 + 90785 (Interactive complexity add‐on)
INDIVIDUAL PSYCHOTHERAPY INTERACTIVE, 30 MINUTES
90834 + 90785 (Interactive complexity add‐on)
INDIVIDUAL PSYCHOTHERAPY INTERACTIVE, 45 MINUTES
90846
FAMILY MEDICAL PSYCHOTHERAPY FAMILY MEDICAL PSYCHOTHERAPY
90847
FAMILY MEDICAL PSYCHOTHERAPY (CONJOINT)
90853
GROUP PSYCHOTHERAPY
90853 + 90785 (Interactive complexity add‐on)
INTERACTIVE GROUP PSYCHOTHERAPY 8
Behavioral Health Common Outpatient CPT Crosswalk i lk 2012 CPT Code Definition
2013 CPT Code
90801
PSYCHIATRIC DIAGNOSTIC EVALUATION
90791 + 90785 (Interactive complexity add‐on) l dd )
90802
PSYCHIATRIC DIAGNOTSTIC EVALUATION WITH 90792 + 90785 (Interactive MEDICAL SERVICES complexity add‐on)
90804
INDIVIDUAL PSYCHOTHERAPY 30 MINUTES
90832
90805
INDIVIDUAL PSYCHOTHERAPY 30 MINUTES INDIVIDUAL PSYCHOTHERAPY 30 MINUTES WITH MED EVALUATION
E&M + 90833 (30 minute E&M + 90833 (30 i t psychotherapy add‐on)
90806
INDIVIDUAL PSYCHOTHERAPY 45 MINUTES INDIVIDUAL PSYCHOTHERAPY 45 MINUTES
90834 9
Behavioral Health Common Outpatient CPT Crosswalk i lk 2012 CPT C d Definition 2012 CPT Code D fi iti INDIVIDUAL PSYCHOTHERAPY 45 MINUTES 90807 WITH MED EVAL 90808
2013 CPT Code 2013 CPT C d E&M + 90836 (45 minute psychotherapy add‐on)
90813
INDIVIDUAL PSYCHOTHERAPY 60 MINUTES INDIVIDUAL PSYCHOTHERAPY 60 MINUTES 90837 INDIVIDUAL PSYCHOTHERAPY INTERACTIVE, 30 90832 + 90785 (Interactive MINUTES complexity add‐on) E&M + 90833 (30 minute INDIVIDUAL PSYCHOTHERAPY 30 MINUTES INDIVIDUAL PSYCHOTHERAPY 30 MINUTES psychotherapy add‐on) and 90785 h th dd ) d 90785 WITH MED EVAL (Interactive complexity add‐on) INDIVIDUAL PSYCHOTHERAPY INTERACTIVE, 45 90834 + 90785 (Interactive MINUTES complexity add‐on) E&M 90836 (45 i t E&M + 90836 (45 minute psychotherapy add‐on) and 90785(Interactive complexity add‐ INDIVIDUAL PSYCHOTHERAPY 45 MINUTES on) WITH MED EVAL
90846
FAMILY MEDICAL PSYCHOTHERAPY
90810
90811 90812
90846 10
Behavioral Health Common Outpatient CPT Crosswalk i lk 2012 CPT C d Definition 2012 CPT Code D fi iti
2013 CPT C d 2013 CPT Code
90847
FAMILY MEDICAL PSYCHOTHERAPY (CONJOINT) 90847
90853
GROUP PSYCHOTHERAPY GROUP PSYCHOTHERAPY
90857
INTERACTIVE GROUP PSYCHOTHERAPY
90853 90853 + 90785 (Interactive complexity add‐on)
90862
PHARMACOLOGIC MANAGEMENT (BRIEF) PHARMACOLOGIC MANAGEMENT (BRIEF)
E&M
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Outpatient Evaluation and Management p g Codes
Evaluation and Management OP Codes Evaluation and Management OP Codes
Definition
99201‐99205
Office or Other Outpatient Services, New Patient
99211‐99215
Office or Other Outpatient Services, Established Patient
99241‐99245
Office or Other Outpatient Consultations, New or Established Patient
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Anthem Authorization Processes
Serving Hoosier Healthwise and Healthy Indiana Plan Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies Inc The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. INW3673‐PP 02/2013
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Behavioral Health CPT Add‐On Behavioral Health CPT Add On Codes Codes Anthem: • Participating providers do not require prior‐authorization for E&M services (99201‐99205 and 99211‐99215) with add‐on codes 90833 or 90836 dd d 90833 90836 • Participating providers are allowed 12 90838 add‐on codes per year without authorization codes per year without authorization • Participating providers do not require authorization for Crisis Intervention Codes 90839 and 90840
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Anthem Prior‐Authorization Behavioral Health Data Sharing Form • Anthem requires notification via the Behavioral Health Data q Sharing Form within 5 business days of the diagnostic interview (CPT Codes 90791 and 90792) • Upon receipt of the Behavioral Health Data Sharing Form an U i t f th B h i l H lth D t Sh i F authorization will be issued for 12 sessions (in addition to 90791 / 90792) • The CPT Codes which are included in the 12 session authorization are the “bucket codes” • Services outside the “bucket codes” require CPT specific S i id h “b k d ” i CPT ifi authorization
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Anthem Bucket Codes Anthem Bucket Codes 2013 CPT Code
Definition
90832
INDIVIDUAL PSYCHOTHERAPY 30 MINUTES INDIVIDUAL PSYCHOTHERAPY 30 MINUTES
90834
INDIVIDUAL PSYCHOTHERAPY 45 MINUTES
INDIVIDUAL PSYCHOTHERAPY 45 MINUTES WITH E&M + 90836 (45 minute psychotherapy add‐on) MED EVAL
90832 + 90785 (Interactive complexity add‐on)
INDIVIDUAL PSYCHOTHERAPY INTERACTIVE, 30 MINUTES
E&M + 90833 (30 minute psychotherapy add‐on) INDIVIDUAL PSYCHOTHERAPY 30 MINUTES WITH and 90785 (Interactive complexity add‐on) MED EVAL 16
Anthem Bucket Codes Anthem Bucket Codes 2013 CPT Code
Definition
90834 + 90785 (Interactive complexity add‐on)
INDIVIDUAL PSYCHOTHERAPY INTERACTIVE, 45 MINUTES
E&M + 90836 (45 minute psychotherapy add‐on) INDIVIDUAL PSYCHOTHERAPY 45 MINUTES WITH and 90785(Interactive complexity add‐on) MED EVAL 90846
FAMILY MEDICAL PSYCHOTHERAPY
90847
FAMILY MEDICAL PSYCHOTHERAPY (CONJOINT)
90853
GROUP PSYCHOTHERAPY
90853 + 90785 (Interactive complexity add on) 90853 + 90785 (Interactive complexity add‐on)
INTERACTIVE GROUP PSYCHOTHERAPY INTERACTIVE GROUP PSYCHOTHERAPY 17
Anthem Prior‐Authorization Outpatient Treatment Request Forms (OTR) • Authorization for services beyond the 12th session may be obtained via the submission of the OTR • Specific CPT Code authorization is not required if services S ifi CPT C d h i i i i d if i requested are in the “bucket list” • If services requested are outside of the If services requested are outside of the “bucket bucket list list” then then the specific codes requested should be included on the OTR
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CENPATICO AUTHORIZATION PROCESSES • Cenpatico did not change the authorization requirements for p g q the 2013 code changes. • Participating providers are entitled to the initial assessment (90791 or 90792) and 5 therapy services without requiring authorization. Those new codes are 90832, 90834, 90837. , , Once used, additional services will require authorization using an Outpatient Treatment Request Form (OTR).
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• As a reminder, Cenpatico will allow 2 services of , p different treatment types on the same date of service (e.g.: 90834 and 90847) Each treatment type will be applied to an authorization separately. pp p y • Cenpatico will not require authorization of the new crisis codes of 90839 or 90840 These codes will crisis codes of 90839 or 90840. These codes will replace 99058 previously used for emergency service.
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• No authorization will be required for Medication Management by a psychiatrist or participating Nurse Management by a psychiatrist or participating Nurse Practitioner up to a maximum of 20 services per rolling calendar year. • 99354 – 99357 are add‐on codes which replaced 90809 and 90815 These codes require authorization as they have in 90815. These codes require authorization as they have in the past.
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Quarter MDwise Behavioral Health Updates 2013
whw1
MDwise Behavioral Health 2013 Updates MDwise Behavioral Health 2013 Updates • Indiana Indiana Health Coverage Programs (IHCP) reviewed the 2013 Health Coverage Programs (IHCP) reviewed the 2013 annual Healthcare Common Procedure Coding System (HCPCS) code updates and announced coverage and billing guidelines to providers in BT20153 dated December 18, 2012.
Slide 23 whw1
Should it not be BT201253 william h woodruff, 2/26/2013
MDwise Behavioral Health 2013 Updates MDwise Behavioral Health 2013 Updates Psychiatric Diagnostic Interview P hi t i Di ti I t i • CPT code 90791 or 90792 (Interactive Interview) • 1 Unit per member, per billing provider, per rolling 12 12‐months allowed with no PA. 2 units are allowed th ll d ith PA 2 it ll d without PA when member is separately evaluated both by a physician an advanced practice nurse or both by a physician, an advanced practice nurse or HSPP and another mid‐level practitioner.
MDwise Behavioral Health 2013 Updates MDwise Behavioral Health 2013 Updates I iti l 12 Th Initial 12 Therapy Visits per billing provider PA rule: Vi it billi id PA l • • • • •
CPT code: 90832 Psychotherapy Office 30 min 90832 Psychotherapy Office 30 min 90834 Psychotherapy Office 45 min 90846 Family medical psychotherapy 90847 Family Psychotherapy conjoint
Group Therapy Visits included in 12 initial visits but not Group Therapy Visits included in 12 initial visits but not interchangeable: • 90853 Group Psychotherapy
MDwise Behavioral Health 2013 Updates MDwise Behavioral Health 2013 Updates • After the initial diagnostic interview (90791 or 90792), e e a d ag os c e e (90 9 o 90 9 ), member can receive up to twelve (12) therapy sessions without PA per billing provider. Individual and Family therapy sessions can be used interchangeably, therefore h i b di h bl h f authorization applies to this group of codes. • Group sessions can be provided as part of the initial 12 sessions without PA, however PA for group sessions are , g p not interchangeable with individual and family therapy sessions and must be specifically requested.
MDwise Behavioral Health 2013 Updates MDwise Behavioral Health 2013 Updates 19 Medication Management visit per billing provider PA rule • 99201‐99203, New patient, office • 99211‐99213, Existing patient, office • 99241‐99242, Consultation, office • After the initial diagnostic interview (90791 or 90792), PA is not required for the first 19 visits per billing provider for this group of codes. (Service provided by a psychiatrist or nurse practitioners/clinical nurse specialists who have prescription authority ) All other therapy visits for these codes beyond initial 19 require PA See authority.) All other therapy visits for these codes beyond initial 19 require PA. See NOTE below for authorization application guideline. • 90833 Individual Psychotherapy with medical E/M 30min and 90836 Individual Psychotherapy with medical E/M 45 min may be reimbursed in conjunction with y py / y j these E/M codes and do not require a separate authorization. • Interactive Complexity (CPT code 90785) is an add‐on code to this CPT group and does not require a separate authorization.
MDwise Behavioral Health 2013 Updates MDwise Behavioral Health 2013 Updates Extended therapy visits: Extended therapy visits: • 90837 90837 – 60 minute code that replaces 90808 will not be 60 minute code that replaces 90808 will not be interchangeable as it also will need a separate PA.
Requires Prior Authorization
MDwise Behavioral Health 2013 Updates MDwise Behavioral Health 2013 Updates • • • • • • •
Crisis Codes – No Prior Authorization Required 90839 ‐ Psychotherapy for Crisis first 60 minutes 90840‐ Psychotherapy for Crisis; each additional 30 minutes One unit of service may be reimbursed per day One unit of service may be reimbursed per day. Providers who spend less than 30 minutes total rendering psychotherapy of crisis must bill using CPT code 90832 or 90833. 90839 & 90840 may not be billed in conjunction with CPT codes 90791 or 90839 & 90840 may not be billed in conjunction with CPT codes 90791 or 90792, or psychotherapy codes 90832‐90838. CPT code 90840 is an add‐on to 90839 and may not be used as a stand‐ alone code 90840 is used to report additional 30 minute blocks of time alone code. 90840 is used to report additional 30‐minute blocks of time beyond the first 60 minutes of psychotherapy for crisis.