Coding and Compliance Training

1. Coding and Compliance Training Psychologists and Social Workers

2. Objectives • Review principles of compliance and its importance to your practice • Describe services you may bill and their appropriate documentation • Provide Current Procedural Terminology (CPT) codes used for billing School of Medicine Compliance 843-8638

3. Compliance is important to reimbursement Providing good care while billing accurately and confidently requires: • Doing only what is medically necessary • Documenting what you do • Billing what you document • Performing only services within your scope of practice Understanding and applying coding and compliance conventions improves reimbursement as well as the quality of the medical record documentation. School of Medicine Compliance 843-8638

4. Compliance is important to reimbursement Good documentation and billing practices make for good patient care. Who’s Looking: Recovery Audit Contractors (RACS)—Medicare and Medicaid and Commercial payers reimburse these contractors to recoup inappropriately billed services Office of Inspector General (OIG), Health & Human Services—works with the Department of Justice to investigate suspected abuse or fraudulent practices Routine error rate testing and auditing programs School of Medicine Compliance 843-8638

5. Types of Services • Psychiatric diagnostic evaluation • Psychotherapy • Individual • For crisis • Group settings • Procedures/other • Psychological or neuropsychological tests • Health-behavior assessments School of Medicine Compliance 843-8638

6. Psychiatric Diagnostic Evaluation-CPT Code 90791 Must include documentation of: • History, • mental status and • recommendations Also includes, as appropriate: • Communicating with family or other sources • Ordering and/or reviewing of diagnostic studies School of Medicine Compliance 843-8638

7. Psychiatric Diagnostic Evaluation-CPT Code 90791 • 90791 reports a comprehensive service, used once per evaluation, or required re-evaluation • Code 90792 includes medical services and may not be reported by psychologists and social workers • May not be reported on the same day as an evaluation and management service by a psychiatrist or psychiatric nurse practitioner • Psychotherapy may not be reported on the same day • If reported more than once per episode of illness, documentation is required to establish medical necessity. • In certain, rare circumstances family members, guardians, or significant others may be seen in lieu of the patient. School of Medicine Compliance 843-8638

8. For Interactive Complexity—also code 90785 • Refers to specific communication factors that complicate the delivery of a psychiatric procedure • Interactive complexity factors are typically present with patients who: • have individuals legally responsible for their care such as minors or adults with guardians • request others to be involved in their care during the visit or • require the involvement of third parties such as child welfare agencies • At least one of the following must be present: • Need to manage maladaptive communication • Caregiver emotions or behavior that interferes with caregivers assistance in implementing the treatment plan • Evidence or disclosure of a sentinel event and mandated report to third party • Use of play equipment, other physical devices, interpreter or translator for a patient who • Is not fluent in the language of the physician • Hasn’t developed or has lost expressive language skills or receptive communication skills to understand the provider School of Medicine Compliance 843-8638

9. Psychotherapy services • Defined as the treatment for mental illness and behavioral disturbances in which the therapist, through definitive therapeutic communication, attempts to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development. • Include ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement of family member(s) or others in the treatment process. • Maintenance psychotherapy is not usually covered. Well-documented sessions for helping a patient maintain his/her highest level of functioning, such as a patient with borderline personality disorder, may be covered on a case-by case basis. School of Medicine Compliance 843-8638

10. Documentation of psychotherapy services The note for each encounter must include: • The amount of time spent in psychotherapy, • The therapeutic maneuvers employed during the session such as behavior modification, supportive, or interpretive interactions and • The purpose of the psychotherapy Additionally, a periodic summary of goals, progress towards goals, and an updated treatment plan must be included in the medical record School of Medicine Compliance 843-8638

11. Psychotherapy services • Psychotherapy without medical evaluation and management services: • 90832 (16-37 minutes) • 90834 (38-52 minutes) • 90837 (53 or more minutes) • Psychotherapy time may include face to face time with family members as long as the patient is present for part of the service. • Do not bill psychotherapy codes for sessions less than 16 minutes duration. • Interactive complexity is reported by also billing 90785 School of Medicine Compliance 843-8638

12. Psychotherapy for crisis • Psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status exam and a disposition. • The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma. • The presenting problem is typically life threatening or complex and requires immediate attention to a patient in high distress. • Report the total duration of time face to face with the patient and/or with the family. • The patient must be present for at least some portion of the service. School of Medicine Compliance 843-8638

13. Psychotherapy for crisis • 90839 is billed for the first 60 minutes • Add 90840 for each additional 30 minutes after the initial hour • Psychotherapy for crisis of less than 30 minutes is reported with standard psychotherapy codes School of Medicine Compliance 843-8638

14. Other Psychotherapy services The following services are not time-based: • Family psychotherapy - medically necessary treatment of the family unit when maladaptive behaviors of family members are exacerbating the patient’s illness in the treatment process. • 90846 without the patient present • 90847 patient and family • 90849 multiple family group psychotherapy • 90853 Group psychotherapy - personal and group dynamics are discussed, allowing emotional catharsis, instruction, insight and support • 90845 Psychoanalysis (not reimbursed by most insurers) School of Medicine Compliance 843-8638

15. Psychotherapy services Psychotherapy is not covered if: • Documentation indicates that dementia has caused significant cognitive deficiency to prohibit establishing a therapeutic relationship. • Patient suffers from profound mental retardation. School of Medicine Compliance 843-8638

16. Central Nervous System Assessments Clinical Psychologists may bill: • 96101 – Psychological testing (includes assessment of emotionality, intellectual abilities, personality and psychopathology, eg MMPI, Rorschach, WAIS) • 96116 – Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg acquired knowledge, attention, language, memory, planning and problem solving and visual spatial abilities. • 96118 – Neuropsychological testing (eg Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test) • 96125 – Standardized cognitive performance testing (eg Ross Information Processing Assessment) School of Medicine Compliance 843-8638

17. Central Nervous System Assessments • It is expected that the administration of these tests will generate material that will be formulated into a report. • A minimum of 31 minutes must be provided to report any of the testing “per hour” codes (psychologist’s or physician’s time) • Bill both time spent face-to-face with the patient and interpreting and preparing the report • Bill the quantity of hours spent School of Medicine Compliance 843-8638

18. Where To Get Help • http://www.med.unc.edu/compliance • School of Medicine Compliance Office 919-843-8638 • Heather Scott, CPC, SOM Compliance Officer • Dana Petty, CPC, SOM Compliance Review Analyst • Nirmal Gulati, MS, CPC, SOM Compliance Auditor • Tracy Riggs, FNP, SOM Compliance Consultant School of Medicine Compliance 843-8638