Behavioral Health Coding that Works in Primary Care

1. Behavioral Health Coding that Works in Primary Care Mary Jean Mork, LCSW April 16 & 17, 2009

2. Workshop Outline • Our program background • Reimbursement big picture and problems • Your questions about reimbursement • Process for addressing problems • Products to organize our thinking • Your challenges and successes

3. Learning Objectives Attendees will: • Be able to identify who to involve in order to better understand the regulatory and payment situation for integrated care in your own setting • Receive tools to help organize the facts around payment and licensing at home

4. Mental Health Integration in Maine

5. Our Mental Health Integration Program:Primary Care/Mental Health Teams • Primary Care sites • Rural Health Clinics (RHC) • Federally Qualified Health Centers (FQHC) • Hospital owned practices • Private practices • Local Mental Health Partners • Specialty Mental Health agencies • Hospital owned Behavioral Health organizations • Community Mental Health Centers

6. The Goal: Creating a sustainable model of mental healthcare in primary care

7. The Problems with Integrated Care • No one seems to know how to get paid • Mental Health regulations and licensing expectations don’t fit the primary care setting • Confidentiality vs. “shared records” • Lack of clarity and understanding about present practices • Complicated licensing and reimbursement rules without accessible experts

8. Examples from our Program • A Psych NP working in a privately owned primary care practice is unable to bill for Psychiatric services for 3 years due to lack of Psychiatric Supervision “physically located on site.” Is this correct? • An LCSW is employed by a mental health center but working in a primary care practice. How should she bill? • An LCPC wants to work for a primary care practice, but is not employed by an agency. Will this work?

9. Why is this so complicated?

10. Some Background Information • AMA determines E&M and CPT codes • CMS (Centers for Medicare & Medicaid Services) determines if and how they will reimburse the codes for Medicare www.cms.hhs.gov • Medicaid determines what should be adopted on state level (as long as not in violation of CMS rule)

11. Various Payers and Various Rules • Medicare • Medicaid • Commercial Insurers • Mental Health vs Medical codes • Licensing rules

12. Medicare • Variation exists in the interpretation and application of the Federal program rules and guidelines • Fiscal Intermediaries often have a more narrow interpretation than Medicare law allows • Creates misunderstanding of policies and confusion at the practice level • Denies reimbursement for allowable procedures

13. Medicare • Louisiana Regional Medicare Carrier – PBSI Medicare Services • www.lamedicare.com • Search site for Local Coverage Determinations (LCD’s) – www.lamedicare.com/provider/medpolb/polmanindex1.asp • Look for H&B codes • Or – Find someone in your organization who does this all the time and make them your friend!

14. Medicaid • States have flexibility in defining covered mental health services • Can choose to contract with managed care • Billing requires both a diagnosis and a procedure code • Some states limit procedures, providers and/or practices that can use these codes

15. Commercial Insurance • Inconsistencies among various insurers • Lack of clarity around covered services • Difficulty finding “experts” to answer specific questions about reimbursement • Carve outs • Other problems?

16. Coding that Works

17. Evaluation & Management (E&M) • Use E&M codes 99201-99201 or 99211-99215 whenever possible • Services must be medically necessary • Practitioner must be practicing within their scope of practice • Used in conjunction with a medical or psychiatric diagnosis

18. Health and Behavior Codes: Consider Their Use

19. Using Health & Behavior Codes • Patients with underlying physical illness or injury • Where biopsychosocial factor may be affecting medical treatment • Patients with cognitive capacity for the approach • Physician documents need • Assessment not duplicate of other assessment

20. Documentation - Assessment • Onset and History of physical illness • Clear rationale for H&B • Assessment outcome including: • Mental status and • Cognitive ability for treatment • Goals and expected duration of intervention • Length of time for assessment

21. Documentation - Intervention • Capacity • Intervention • Clearly defined • How this will improve compliance • Goals of intervention • Response to intervention • Rationale for frequency • Length of time for intervention

22. Examples

23. Billing for the H&B • Medical diagnosis • Medical bill – not mental health • Billed by practice with Mental Health Provider: • Hospital license • Primary care office • Rural Health Clinic • Federally Qualified Health Center

24. What have been your challenges in billing and licensing?

25. How can you figure this out for your setting? • Make friends with your billers and coders • Make connections at the state level for Medicaid. Talk to the Provider Relations folks • Find your Medicare site (www.lamedicare.com) and see what is available for you • Talk with other providers doing this work

26. Consider a Work Group • Representatives from all aspects of the reimbursement spectrum: • Billers and coders • Audit specialists • Clinicians • Primary Care Practice Manager • Mental Health Program Manager • Physician/Psychiatrist • Focus on all levels • Information and ongoing learning are key • Celebrate successes (and awareness) along the way

27. Work Group Strategies • Understand the current rules • Identify opportunities and barriers that affect sustainability • Use understanding of current rules to: • recommend most effective way to organize services • maximize reimbursement for integrated care • Target barriers with highest priority and/or are most likely to be able to change

28. Organizing Information “The Grid”

30. Components within “the Grid” • Coding Category • Coding number for service • Discipline of Provider allowed to bill for service • Codes by insurer • Psychiatric Services by type of license • Practice site able to bill for code, funding source, provider and license

31. Where to begin • What is the discipline of your mental health practitioner? • What service will they deliver and what code will be used? • Under what license? • Where will the service be delivered? • Which insurance will be billed? What are the rules for that insurer?

32. How have you addressed your reimbursement challenges?

33. Share your good ideas and useful information