Coding for Billing

1. Coding for Billing

2. REMINDER: Please fill out unit evaluations

3. The presenter gratefully acknowledges theutility of the AAP Coding for Pediatrics 2013in the preparation of this presentation!

4. Learning Objectives • To increase understanding of adapting E/M & procedure codes to primary care-based child mental services • To describe basic applications of essential FTF procedure codes and strategies: 96110, Billing based on “Time spent counseling”, & Prolonged Service Codes • To review the key non-FTF codes relevant to PC-based child mental services

5. Why Should I Worry? • Proper coding enables higher quality, evidence-based care and practices • Proper coding -> over time, results in increased coverage & reimbursement of widely used codes • Codes change regularly • Coders, practice managers often out-of-date! • Experience of past PPP participants • $10-$15K of practice income recouped

6. 96127(for rating scales)

7. Rating Scales • Must be standardized • Informal checklists don’t qualify • Ex: ASQ-SE, PEDS, M-CHAT, Vanderbilt ADHD, SCARED, PSC, PHQ-9, Connor’s ADHD, CBCL, BASC-2, BRIEF, CDS • May assign one unit of 96110 for each form completed, scored, interpreted and noted in the medical record

8. 96127 Facts • No physician work included: premise is the scales are given to respondent, explained and scored by nonphysician • The physician work of interpreting the results and recording the results is included in the accompanying E/M work

9. Using 96127 w/ E/M • Most insurer’s computer software requires a modifier to get the procedure through their system • Modifier may be appended to the E/M code or to the procedure code, but modifiers are E/M and procedure specific • If at first you don’t succeed, try another tactic!

10. Modifiers: An Overview • -25: Significant, separately identifiable E/M service by the same physician on the same date of the procedure or other service • - 59: “modifier of last resort”, & indicates distinct service from others on same day • - 76: also indicates distinct service from others on same day. Not used by Medicaid (This is the modifier you use when you find an acute problem during a well check-up!)

11. Coding 96127 Examples

12. Sue’s Visit: Option 1 • 99383 (well-child, ages 7-11) • 99214-25 (99214 – Elements, MDM) • (2) 96127 (PSC, SCARED) This is for insurers who allow -25 and multiple units of a procedure

13. Sue’s Visit: Option 2 • 99383 • 99214-25 • 96127 • 96127-76 This is for insurers who permit -25, but want each procedure on a separate line AND who do not adhere to CMS guidelines

14. Sue’s Visit: Option 3 • 99383 • 99214 • 96127-59 • 96127-59 This could be used for payers who do not permit -25 use and who also follow CMS guidelines regarding -76.

15. Sue: Next Steps • Behavioral rating scales sent to Sue’s teacher and request for interim grades • Possible telephone call from family before next visit Is this all post-service work? Can this work be captured for payment?

16. Good News!: Non Face-to-Face Codes • 99339-99340: Home Care Plan Oversight • 99441-99449: Telephone Care • 0074T: Online E/M Services • 99080: Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting forms

17. Home Care Plan Oversight: I • 99339-99340 Individual physician supervision of a patient (patient not present) in home (or group home) requiring complex and multi-disciplinary care modalities • These 2 codes are for children w/ complex and chronic special healthcare needs living at home • Describes the work a physician provides on a monthly basis while performing complex supervision services to a patient in a home – (not skilled nursing facility)

18. Home Care Plan Oversight: II • Recurrent physician supervision of a complex patient or pt. who requires multidisciplinary care and ongoing physician involvement • Non-face-to-face • Reflect the complexity and time required to supervise the care of the pt. • Reported separately from E/M services • Reported by the MD who has the supervisory role in the pt’s. care or is the sole provider • Reported based on the amount of time spent/calendar month

19. Home Care Plan Oversight: III • Services less than 15 minutes reported for the month should not be billed • 99339: 15-29 minutes/month • 99340: greater than 30 minutes/month

20. Home Care Plan Oversight: IV • Services might include: • Regular physician development and/or revision of care plans • Review of subsequent reports of patient status • Review of related laboratory and other studies • Communication (including telephone care) for purposes of assessment or care decisions w/ healthcare professionals, family members, legal guardians or caregivers involved in patient care • Integration of new information into the medical tx. plan and/or adjustment of medical tx. • Attendance at team conferences/meetings • Development of extensive reports

21. Home Care Plan Oversight: V • Services NOT included in care plan oversight: • Travel time to and from the facility or place of domicile • Services furnished by ancillary or incident-to staff • Very low-intensity or infrequent supervision services included in the pre- and post-encounter work for an E/M service • Interpretation of lab or other dx. studies associated w/ a face-to-face E/M service • Informal consultations w/ health professionals not involved in the pt’s. care • Routine post-operative care

22. Home Care Plan Oversight: VI • This code should not be used for intermittent telephone care to discuss a single topic, such as one lab result or care change.. That would not be “complex and multidisciplinary care modalities.”

23. Home Care Plan Oversight: Log

24. Non-Face-To-Face Service Coding: Telephone Care • 9944x: Telephone E/M service provided by a physician to an established patient, parent or guardian NOT originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appt. • 99441: 5-10 min. medical discussion • 99442:11-20 min. medical discussion • 99443:21-30 min. medical discussion • 99449: CAP-PCP medical consultation (Minnesota)

25. Telephone Care • Telephone care levels may represent three levels of complexity –need to document this to support charge • Documentation should: • Be thorough • Fulfill the need for continuity of care • Describe the complexity of the call • Meet the requirements of the typical E/M visit • A general note including the key elements of hx. and medical decision-making • Time spent on call

26. Telephone Care • The call from the physician must be in response to a request from the patient or the family for this code to be used • (This rule does NOT apply to MN 99449 CAP-PC medical consultation codes)

27. School-Based Meetings • Code w/ 99211-15 (est. Patient E/M codes) –On the basis of time; add prolonged services face-to-face if patient is present –and non-FTF if patient is not present if needed: payers may not pay for this, however • If teachers are the principal attendees, these should not be coded with the Medical Team Conference codes (99366-99368) as these descriptors specify interdisciplinary team of health care providers

28. Time Reporting: CPT Counseling Rule • As of 2010, time must be used for code selection when the time spent in ‘counseling and coordination of care’ > 50% of the E&M visit • The 3 key components of history, PE, MDM may be ignored • Only time is used to select the level of care • A summary of the ‘counseling’ discussion should be included with the note • Does not include screening time • Reported separately, with modifier (-25) appended to E/M

29. Pearl • Time is your friend in reportingmental health/ behavioral health/ developmental-focused services. • ALWAYS think of time first as the appropriate basis for valuing the visit.

30. Time: Basis forParent-Only Meetings • How to code for counseling and care coordination: • May be used when the patient is present or when counseling a parent when the patient is not physically present • Document the discussion’s topic • When time spent in counseling and/or care coordination is over 50% of face-to-face time, CPT now says you must use this as the critical factor to qualify for a particular E/M service level • Pediatricians spends the majority of parent-only conference on counseling→code based on time!

31. Documentation Requirements toBill Based on Time • The total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care • The medical record must reflect the extend of counseling and/or coordination of care • Resident/NP/PA face to face time can not be included (except under specialty specific Medicaid contracts) • It is a good idea to document in a separate paragraph what documentation is supporting the counseling/coordination of care. This will make it easy to justify the time spent.

32. Good “I spent 40 minutes total time and 25 minutes was spent in counseling and coordination of care with the patient.” “I spent 40 minutes total time and more than 50% of the visit was spent in counseling and coordination of care with the patient.” Assume elaboration in documentation of what was discussed with the patient. Bad “I spent 10 minutes talking with the patient about her diagnosis” Why? Fails to show whether more than half the time of the visit was dedicated to counseling Time Examples

33. Prolonged Services(99354-99359) • No longer add-on codes-put on separate line • Reported in addition to other physician services, including E/M services at any level • Code series defining prolonged services by: • Site of service • Direct or without direct patient contact • Time • Total time for a given date, even if the time is not continuous • Time must be of 30 minutes or more

34. Prolonged Services

35. Prolonged Visit Coded on Complexity • If your E/M level was made based on complexity, AND • visit runs more than 30 minutes over the code time description, AND • total counseling/care coordination time is not > 50% • THEN you may add the prolonged service code to account & describe the extra time.

36. Panel & DiscussionQ & A

37. Summary • Understanding Coding & Billing is essential to enable doing quality PC mental healthcare services – someone has to “mind the store”! • Business managers, coders, etc., often out-of-date. How will I ensure continued updating in my practice setting? • Codes vary setting to setting, company by company, state-by-state, and year-to-year • Which of these 4 key coding opportunities need to be further investigated, and possibly put into my practice?

38. Resources • www.aap.org/sections/schoolhealth • www.aap.org/mentalhealth • www.aacap.org • www.schoolpsychiatry.org • http://www.mnpsychconsult.com (for Minnesota PCPs and CAPs!!) Lwegner@med.unc.edu

39. Appendix of Basic Coding Information

40. CPT and ICD-9-CM • ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification • Why the service was done • Information collected by payers to manage risk (preexisting conditions; refused diagnoses) • CPT: Current Procedural Terminology • What was done • Provides the basis for payment

41. ICD-9-CM • ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification • Why the service was done • Information collected by payers to manage risk (preexisting conditions; refused diagnoses) • Important point: The Health Insurance Portability and Accountability (HIPAA) Act of 1996 requires payers and physicians to use ICD-9-CM. As revised ICD-9-CM codes are activated, you must use these updated codes. Obviously, these codes explain to payers the specific reason a patient was seen.

42. ICD-9-CM • The reason for the service (visit) • The first diagnostic code reflects the condition the professional is actively managing: • “the reason for the visit” • Subsequently listed codes • Factors important to condition #1 • Coexisting conditions tx. and mgment of #1 • If a child is seen for a residual condition (e.g. hearing deficit), code this first with the cause of the condition as a secondary ICD-9-CM code (e.g. meningitis)

43. ICD-9-CM “The Top→Down View” • Code to the highest degree of specificity • Code to the highest degree of certainty for the encounter such as symptoms, signs, abnormal test results • Probable, suspected, questionable, or rule out should not be coded • List the ICD-9-CM code that is identified as the main reason for the service first, then list co-existing conditions • Chronic disease treated on an ongoing basis may be coded • Do not code for conditions previously tx that no longer exist

44. ICD-9-CM • Do code only the conditions/problems you are actively managing at the time of the visit and diagnoses affecting the current status of the child • Do not code for previously treated conditions • May include conditions existing at the time of the patient’s initial contact as well as conditions developing subsequently affecting treatment • Dx. relating to a pt.’s previous medical problems w/ no bearing on the present condition are not coded.

45. ICD-9-CM • Do not code dx. listed as “rule out,”“probable” or “suspected” –they are not established in out-patient practice • Do code to the highest degree of certainty • Do not code symptoms if a dx. has been made: Ex.: If a child w/ dx’d ADHD is seen for routine med. monitoring and headaches are reported w/ meds.: code 314.01 first, then headache as #2.

46. NEC and NOS • Residual Categories • NEC: Not elsewhere classifiable: conditions specifically named in the medical record but not specifically listed under a code description • NOS: Not otherwise specified: a diagnostic statement lacking detail in describing a specific condition (e.g. 314.9 unspecified hyperkinetic syndrome)

47. Pearls • Code the diagnosis to the highest level of certainty (the words in the descriptor) • Code the diagnosis to the highest level of specificity (the numbers in the descriptor)

48. Pearls • Remember, a chronic condition, such as ADHD or depression, managed on an ongoing basis may be coded and reported as many times as applicable to the patient’s treatment. • The level of the E/M visit may change as the complexity of the child’s needs change.

49. CPT and MH Coding • Current Procedure Terminology = CPT • A tabular listing of almost all known encounters w/patients • Published annually (Oct. 1) by the AMA • Includes codes for cognitive, procedural and supplies • Services may be provided in any location • Codes not limited to specialty: ANY physician may use any code • Codes should be chosen most accurately describing the service provided

50. RVU Components ofMedical Provider Work • Pre-, intra-, post- service work • Time to perform the service • Technical skill and physical effort • Mental skill and judgment • Psychological stress associated with iatrogenic risk