Anthem Blue Cross and Blue Shield Medicaid (Anthem) Behavioral Health Symposium
1 AKYPEC-0694-15
Agenda
• Introductions • Housekeeping • Behavioral Health prior authorization (PA) process • Behavioral Health covered services • Break for lunch • Behavioral Health billing guidance • Questions and answers
2
Introduction
• Jennifer Ecleberry, Director, Provider Solutions, KY Medicaid Provider Relations
• Ken Groves, Manager, KY Medicaid Provider Relations • Jeff Sutherland, Director, KY Medicaid Behavioral Health • David Crowley, Manager, KY Medicaid Behavioral Health • Andrew Fox, Network Relations Specialist, KY Medicaid Behavioral
Health • Libby Ellington, Network Relations Specialist, KY Medicaid Provider
Relations • Mark Snyder, Clinical Programs Director, Behavioral Health • Tina Hurt, Network Support Manager, Behavioral Health • Alice Hudson, Director, Program Management, Reimbursement
Policy Management
3
Housekeeping
• Restroom locations • Please hold your questions until the end of the
session; there will be time for questions and answers
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Behavioral Health authorization process
5
Behavioral Health authorization process
Behavioral Health program goals • Right care, right place, right time services • Reduce inappropriate admissions and readmissions • Provide integrated, seamless delivery of physical and
behavioral health services • Disease management of chronic conditions often
involving physical health, behavioral health and substance use disorder comorbidities
• National Committee for Quality Assurance (NCQA) accreditation
• HEDIS® and other quality measure attainment *HEDIS is a registered trademark of the NCQA.
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Behavioral Health authorization process
Two distinct authorization processes, based upon the type of care requested • Telephonic review – Initial and concurrent review of
inpatient admissions and other higher levels of care – Contact the Utilization Management department, 24
hours a day, 7 days a week, for authorization at 1-855-661-2028
• Form review – Inpatient and all other levels of care – Completion of the required forms submitted via fax
(inpt: 1-877-434-7578; outpt: 1-800-505-1193) or web portal
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Behavioral Health authorization process
Clinical review • Clinical intake team performs initial reviews for
acute care via live calls or form review – Gives opportunity to discuss/review more
appropriate level of care when criteria for inpatients are not met
– Begins discussion of treatment and discharge planning, coordination of care needs and readmission issues
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Behavioral Health authorization process
• Concurrent reviewers or outpatient care managers review subsequent care or outpatient services – How reasons for admission are being addressed – If readmission, what is being done differently – Progress in treatment per treatment guidelines – Discharge planning and barriers to discharge – Discharge follow-up appointment within seven days – Coordination of care issues/needs – Family/support system and outpatient provider
involvement in treatment
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Does the service require authorization?
A number of services always require authorization, including inpatient, residential, partial hospital, intensive outpatient, psych and neuropsychological testing. If you are not sure, you can use the Precertification Lookup Tool to determine authorization requirements: https://mediproviders.anthem.com/ky/pages/precert.aspx
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Does the service require authorization?
11
How to request an authorization
• Contact the Utilization Management department, 24 hours a day, 7 days a week, for authorization at 1-855-661-2028
• Complete required forms and submit — By fax
• Inpatient and RTC: 1-877-434-7578 • Outpatient: 1-800-505-1193
— By web portal: http://www.availity.com/register-now-for-web-portal-access/
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How to request an authorization
13
Authorization request forms
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• Behavioral Health Initial Review Form • Concurrent Review Form • Discharge Note Form • Behavioral Health Outpatient Request Form • Psychiatric Testing Form • Coordination of Care Form
Concurrent Review Form_KY.pdf
Discharge Note Form_KY.pdf
KYKY_CAID_OTRForm.pdf
PF-AKY-0029-14 Coordination of Care F
Medical necessity criteria
• Chemical dependency: American Society of Addiction Medicine (ASAM) http://www.asam.org/
• Adult mental health: Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS), American Association of Community Psychiatrists http://www.communitypsychiatry.org/aacpassets/docs/publications/clinical_and_administrative_tools_guidelines/LOCUS%20Instrument%202010.pdf
• Children and adolescents (ages 6-18): The Child and Adolescent Service Intensity Instrument (CASII), American Academy of Child and Adolescent Psychiatry
• Early Childhood Service Intensity Instrument (ECSII), Ages 0-5, American Academy of Child and Adolescent Psychiatry
• Milliman Care Guidelines for procedures not included in the above criteria/tools
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ASAM
Dimensions 1. Acute intoxication and/or withdrawal potential 2. Biomedical conditions and complications 3. Emotional, behavioral or cognitive complications 4. Readiness to change 5. Relapse, continued use or continued problem
potential 6. Recovery living environment
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LOCUS
Dimensions (Scores 1-5) 1. Risk of harm 2. Functional status 3. Medical, addictive and psychiatric comorbidity 4. Recovery environment
a. Level of stress b. Level of support
5. Treatment and recovery history 6. Engagement
LOCUS2010.pdf
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CASII
Dimensions (Scores 1-5) 1. Risk of harm 2. Functional status 3. Co-occurrence of conditions: developmental,
medical, substance use and psychiatric 4. Recovery environment 5. Environmental support 6. Resiliency and/or response to services
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ECSII
Dimensions (Scores 1-5) 1. Safety 2. Child-caregiver relationships 3. Caregiving environment
a. Environmental supports b. Environmental stressors
4. Functioning (developmental status) 5. Impact of problems 6. Services profile
a. Service involvement b. Service fit c. Service effectiveness
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Covered Behavioral Health services through the state of Kentucky (FFS)
20
Covered Behavioral Health services through the state of Kentucky (FFS)
Longer term care and community alternatives for waiver program enrollees
• Waiver programs
– Intellectual Disabilities and Developmental Disabilities Waiver – Acquired Brain Injury Waiver – Acquired Brain Injury Long Term Care Waiver – Home and Community Based Waiver – Home Health – Michelle P. Waiver – Model II Waiver – Supports for Community Living Waiver
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Covered Behavioral Health benefits through Anthem
Covered Behavioral Health services • Inpatient hospitalization • Residential treatment • Partial hospitalization • Intensive outpatient program • Electroconvulsive therapy • Targeted case management • Outpatient services • Psychological testing
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Behavioral Health covered diagnoses
Psychiatric diagnostic ranges • 290-290.9 • 293-293.9 • 294-294.9 • 295-302.9 • 306-319 Substance use diagnostic ranges • 291-291.9 • 292-292.9 • 303-305.93
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Adult (18 years and older) Serious mental illness (SMI)
Psychotic disorders Mood/anxiety disorders Personality disorders
Schizophrenia Disorder Major Depressive Disorder
Schizoid/Schizotypal Personality Disorder
Schizophreniform Disorder
Dysthymic Disorder Obsessive Compulsive Personality Disorder
Schizoaffective Disorder Depressive Disorder NOS Histrionic Personality Disorder
Delusional Disorder Bipolar I/Bipolar II/Bipolar NOS Disorders
Dependent Personality Disorder
Unspecified Schizophrenia Spectrum/Other Psychotic Disorder
Cyclothymic Disorder
Antisocial Personality Disorder
Posttraumatic Stress/Other Specific Adjustment Reactions
Narcissistic/Avoidant/Borderline Personality/Personality NOS Disorders
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Children and youth (under 18 years of age) SMI
Psychotic disorders Mood disorders Schizophrenia Disorder Major Depressive Disorder
Schizophreniform Disorder Dysthymic Disorder
Schizoaffective Disorder Depressive Disorder NOS
Psychotic Disorder NOS Bipolar I/Bipolar II Disorders
Delusional Disorder Bipolar Disorder NOS Cyclothymic Disorder
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Children and youth (under 18 years of age) SMI
Anxiety disorders Disorders of infancy, childhood and adolescence
Anxiety Disorder Oppositional Defiant Disorder
Obsessive Compulsive Disorder Disruptive Behavior NOS Disorder
Generalized Anxiety Disorder Reactive Attachment Disorder
Acute Stress Disorder Conduct Disorders
Posttraumatic Stress/Other Specific Adjustment Reactions
Attention Deficit/Hyperactivity Disorder
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Children and youth (under 18 years of age) SMI
Pervasive developmental disorders
Other disorders
Autistic Disorder Intermittent Explosive Disorder
Asperger’s Disorder* Other Specific Trauma – Stressor Related Disorder*
Disruptive Mood Disregulation Disorder*
Adjustment Disorders (Under age of 8 years)
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Inpatient/ER covered procedure codes
Procedure code Service description Time/
event Authorization requirement Limitations
100, 114, 120, 124, 134
Inpatient Psychiatric (IMD allowed for ages
18-21) Yes Psychiatric DX
Only
116, 126, 136 Inpatient Detoxification Yes Substance Use DX Only
0762 23-Hour Observation Bed No None
0450 Emergency Room (MH and SU) No None
S9485 Crisis Stabilization (per day) Per diem No None
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Inpatient/ER covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
99217 - 99223 Initial Hospital Care Per CPT guidance
Yes None
99231 - 99233 Subsequent Hospital Care
Per CPT guidance
Yes None
99234 - 99236 Observation Care Per CPT guidance
Yes None
99238 - 99239 Discharge Day Management
Per CPT guidance Yes None
99251 - 99255 Initial Hospital Evaluation
Per CPT guidance Yes None
99281 - 99285 Emergency Department Visit
Per CPT guidance No None
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Residential covered procedure codes
Procedure code Service description Time/
event Authorization requirement Limitations
1001 Psychiatric Residential Treatment Facility Per diem Yes Psychiatric DX
Only
H0010
Alcohol and/or drug services; sub-acute
detoxification (residential addiction program
inpatient)
Per diem Yes Substance Use DX Only
H0018 Behavioral Health Short Term Residential, per diem Per diem Yes None
H0019 Behavioral Health Long Term Residential, per diem Per diem Yes None
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Partial hospitalization covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
H0035
Mental health partial
hospitalization, treatment, less than 24 hours
Less than 24 Hours Yes Psychiatric DX
Only
H2012 Behavioral health
day treatment; per hour
60 minutes Yes None
T2012 Children’s Day Treatment, Per
Diem Per diem Yes None
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Intensive outpatient program covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
H0004
Mental Health Intensive
Outpatient Program
15 minutes Yes Psychiatric DX Only
H0015
Alcohol and/or drug services;
intensive outpatient
treatment, per diem
Event Yes Substance Use DX Only
S9480 Intensive
Outpatient Service per diem
Per diem Yes None
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ECT covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
104 Anesthesia for
Electroconvulsive Therapy
Yes Psychiatric DX Only
90870 Electroconvulsive Therapy Single seizure Yes Psychiatric DX
Only
33
Targeted case management covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
T1017 Targeted Case
Management, each 15 minutes
15 minutes Yes None
T2023 Targeted Case Management, SMI Per month Yes 1 unit per month/
SMI DX Only
T2023 HF Targeted Case Management,
Substance Use Per month Yes 1 unit per month
T2023 TG Targeted Case Management,
Complex Per month Yes 1 unit per month
T2023 UA Targeted Case Management, SED Per month Yes 1 unit per month/
SED DX Only
34
Outpatient covered procedure codes
Procedure code Service description Time/
event Authorization requirement Limitations
90791 Psychiatric Diagnostic Interview Event No None
90792 Psychiatric Diagnostic
Evaluation with Medical Services
Event No None
90785 Interactive complexity add-
on code Event No None
90832 Individual Psychotherapy, 20-30 min
16-37 minutes No None
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Outpatient covered procedure codes
Procedure code Service description Time/event Authorization
requirement Limitations
90833 Psychotherapy 30
minutes add-on code to appropriate E/M code
16-37 minutes No None
90834 Individual Psychotherapy, 45-50 min 38-52 minutes No None
90836 Psychotherapy 45
minutes add-on code to appropriate E/M code
38-52 minutes No None
90837 Individual Psychotherapy, 60 minutes
53 or more minutes No None
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Outpatient covered procedure codes
Procedure code Service description Time/event Authorization
requirement Limitations
90838 Psychotherapy 60
minutes add-on code to appropriate E/M code
53 or more minutes No None
90839 Crisis Psychotherapy (first 60 minutes) 30-74 minutes No None
90840 Crisis Psychotherapy (each additional 30
minutes) 30 minutes No None
90845 Psychoanalysis 45-50 minutes No None
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Outpatient covered procedure codes
Procedure code Service description Time/event Authorization
requirement Limitations
90846 Family psychotherapy
(without the patient present)
Event No None
90847
Family psychotherapy (conjoint
psychotherapy) (with patient present)
Event No None
90849 Multiple-family group psychotherapy (with
patient present) Event No None
90853 Group psychotherapy
(other than of a multiple-family group)
Event No None
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Outpatient covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
90899
Unlisted Psychiatric Service or Procedure
Event No None
96150 Assessment
Health/Behavior Initial
15 minutes No None
96151 Assessment
Health/Behavior Subsequent
15 minutes No None
90875 Biofeedback, 20-30 minutes 20-30 minutes No None
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Outpatient covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
90876 Biofeedback, 45-50 minutes 45-50 minutes No None
90887 Collateral Service Event No None
99408
Alcohol and substance (other
than tobacco) abuse structure
screening
15-30 minutes No None
99409
Alcohol and substance (other
than tobacco) abuse structure
screening
30 or more minutes No None
40
Outpatient covered procedure codes
Procedure code Service description Time/event Authorization
requirement Limitations
99354 Prolonged visit used in
conjunction with OP CPT code, 60 minutes
30 -74 minutes No
1 unit per day (allowed with 99355) and
90837
99355 Prolonged visit used in
conjunction with OP CPT code, 30 minutes
30 minutes No
2 units per day (allowed with 99354) and
90837; cannot be reported without
99354
G0442 Annual alcohol misuse screening, 15 minutes 15 minutes No None
G0443 Brief face-to-face
behavioral counseling for alcohol misuse
15 minutes No None
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Outpatient covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
99201 - 99215 (with appropriate
add on codes)
Medication Management
Per CPT guidance No
Four (4) services, per physician/
nurse practitioner (non psychiatrist), per member, per
twelve (12) months. - 2 units per follow-up for
medication management/
therapy (1 unit = 15 minutes);
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Outpatient covered procedure codes
Procedure code Service description Time/event Authorization
requirement Limitations
G0442 Annual alcohol misuse screening, 15 minutes 15 minutes No None
G0443 Brief face-to-face
behavioral counseling for alcohol misuse, 15 minutes
15 minutes No None
H0001 Alcohol and/or drug assessment Event No Substance
Use DX Only
H0002
Behavioral health screening to determine eligibility for admission to treatment
program
Event No None
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Outpatient covered procedure codes
Procedure code Service description Time/event Authorization
requirement Limitations
H0003
Alcohol and/or drug screening; laboratory
analysis of specimens for presence of alcohol and/
or drugs
Event No Substance Use DX Only
H0006 Alcohol and/or drug case management Event No Substance Use
DX Only
H0031 Mental Health
Assessment by non-physician
Event No None
H0032 Mental Health Service Plan Development by
non-physician Event No None
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Outpatient covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
H0038 Self-help/peer support; per 15
minutes 15 minutes No None
H0040 Assertive
Community Treatment; monthly
Per month Yes 1 unit per month
H0046 Mental Health Services NOS Event No None
H0047 Alcohol and/or drug brief treatment Event No Substance Use
DX Only
H0050
Alcohol and/or Drug Service, Brief
Intervention; per 15 minutes
15 minutes No Substance Use DX Only
45
Outpatient covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
H2010 Comprehensive
medication services; per 15 minutes
15 minutes No
Four (4) services, per physician (non psychiatrist), per
member, per twelve (12) months. - 2
units per follow-up for medication
management/therapy (1 unit = 15
minutes);
H2011 Crisis Intervention Services; per 15
Minutes 15 minutes No None
Q3014 Telehealth Event No None
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Outpatient covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
H2019 Therapeutic Behavioral Services 15 minutes Yes None
H2021 Comprehensive
Community Supports (per 15 minutes)
15 minutes Yes None
H2021 HM Community Support
Services: Paraprofessional
15 minutes Yes None
H2021 HN Community Support
Services: Professional
15 minutes Yes None
H2021 HS Community Support Services: Parent to
Parent 15 minutes Yes None
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Outpatient covered procedure codes
Procedure code
Service description Time/event Authorization
requirement Limitations
S5145 Therapeutic Foster Care Per diem Yes None
S9484
Crisis intervention mental health
services; per hour /Mobile Crisis
60 minutes No None
T1007
Alcohol and/or substance abuse
services, treatment plan
development and /or modification
Event No Substance Use DX Only
T1016 Case
management, each 15 minutes
15 minutes No None
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Outpatient covered procedure codes: psychological testing
Procedure code Service description Time/event Authorization
requirement Limitations
96101 Psychological Testing 60 minutes Yes None
96102 Psychological Testing,
administered by technician
60 minutes Yes None
96103 Psychological Testing,
administered by a computer
60 minutes Yes None
96116 Neurobehavioral status exam (clinical) 60 minutes Yes None
96118 Neuropsychological Testing 60 minutes Yes None
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Outpatient covered procedure codes: psychological testing
Procedure code
Service description Time/event Authorization
requirement Limitations
96119 Neuropsych
Testing Admin by Technician
60 minutes Yes None
96120 Neuropsych
Testing Admin by Computer
60 minutes Yes None
96105 Assessment of Aphasia 60 minutes No None
96110 Developmental Screening 60 minutes No None
96111 Developmental Testing 60 minutes No None
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Break for lunch
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Behavioral Health billing guidance
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Objectives
• Define medical coding • What is HIPAA compliance and transaction
accuracy • Coding tools • Descriptions of coding terminology • Appropriate use of modifiers • Forms required for submission of encounter
data (claims) • Behavioral Health specific coding guidelines
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Medical coding
• Medical coding is a system designed to represent and report medical services, procedures and supplies supported in the medical documentation to appropriately define medical necessity of such services rendered.
• Coding is an integral step in the reimbursement process.
• Coding is instrumental to the mortality (death) and morbidity (disease) statistics maintained internationally.
• There are formalized rules and regulations set forth by the governing agencies for coding standards and requirements.
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HIPAA
• Developed to combat waste, fraud and abuse in the health care delivery systems.
• Required all covered entities to comply with electronic transactions (837) and code set provisions.
• Transferrable language to describe services performed.
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Coding tools
• Current procedural terminology (CPT) American Medical Association (AMA)
• Health Care Common Procedure Coding System Level II (HCPCS) CMS
• International Classification of Diseases 9th edition Clinical Modifications (ICD-9-CM) WHO until October 1, 2015
• Diagnostic and Statistical Manual (DSM-5) APA until October 1, 2015
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CPT
• Category I is divided into six sections; two of which are most utilized in your profession
• Published by AMA • Codes are five digit numeric • Updated once yearly (rarely twice) • Laboratory (80300-80299) • Evaluation and management (E/M) (99201-
99499) • Medicine/psychiatry (90785-90911)
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Evaluation and management (99201-99499)
New vs. established patient • New patient is one who has not received any
professional services from any practitioner of the exact same specialty and subspecialty that belong to the same group practice within the past three year period.
• Established patient has received professional services from the physician or any physician in the exact same specialty and subspecialty group practice.
58
Evaluation and management (99201-99499)
• Location distinctions • Office or outpatient setting (physician office or an outpatient or ambulatory
facility) – 99201-99215 – 99241-99245 Consultation – 99281-99288 Emergency Room Services
• Hospital observation services (used when the patient is designated/admitted for the purpose of observation; doesn’t have to be in area designated as “OBSERVATION”) – 99217-99220 – 99231-99236* (two categories)
• Hospital inpatient services (services provided in a hospital or “partial” hospital setting) – 99221-99239 Initial, subsequent, discharge – 99251-99255 Consultations
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Evaluation and management (99201-99499)
There are seven components; six of which are used to define the code for the service rendered. 1. History (PFSH) 2. Examination (ROS) 3. Medical decision making (MDM) 4. Counseling 5. Coordination of care 6. Nature of presenting problem 7. Time
60
Laboratory (80300-80377)
2015 AMA implemented new section in CPT to identify therapeutic drug assay, drug assay and chemistry. • Therapeutic – Performed to monitor clinical
response to known prescription medication (80150-80299).
• Presumptive – Identifies possible use or nonuse of a drug or drug class (80300-80304).
• Definitive – Qualitative or quantitative test to identify specific drugs and associated metabolites (80320-80377).
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Laboratory (80300-80377)
• When codes are billed separately, they are considered unbundled and will be rebundled through our code editing system.
• Subject to National Correct Coding Initiatives (NCCI) Medically Unlikely Edits (MUE).
• Technical and professional components may be applicable for these procedures to submit charges for the portion of the service performed.
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Medicine/psychiatry (+90785-90899)
• Interactive complexity (+90785) — Communications factors that complicate the delivery of a
psychiatric procedure. • Diagnostic procedures (90791-90792) — Biopsychosocial assessment including history, mental status and
recommendations. • Psychotherapy (90832-90838) — Treatment of mental illness and behavioral disturbances through
definitive therapeutic communications — Face to face services with patient and/or family members — Patient must be present for some or all of the services — Medical evaluation and management services may be performed,
but time spent on the E/M is not included in treatment time
63
Medicine/psychiatry (+90785-90899)
• Crisis therapy (90839-+90840) — Presenting problem is life threatening or
complex, requiring immediate attention — Includes mobilization of resources to defuse
the crisis — Codes used to report total face-to-face time
providing psychotherapy for crisis
64
Medicine/psychiatry (+90863)
Pharmacologic management • Includes prescribing and review of medication • List separately in addition to the primary
procedure • Created for medication management when
provided on the same day as psychotherapy • Utilized by qualified health professionals who
may not report E/M codes, but may prescribe
65
Time elements
• Units for time element codes are only reported once the treatment has reached a midpoint
• Psychotherapy has a 30-minute timeframe (16-37 minutes) – Must be 16 minutes or more of face-to-face with patient and/or
family – Time elements used to meet the time criteria for an E/M is not
included – Counseling and coordination of care is not included in the time
element for psychotherapy • Psychotherapy has a 45-minute timeframe (38-52 minutes)
– Must be 38 minutes or more of face-to-face with the patient and/or family
• Psychotherapy has a 60-minute timeframe (53+minutes) – Include face-to-face with patient and/or family
66
Modifiers
67
Modifiers
Modifiers are mainly used when • Procedure or service is performed more than
once or by more than one provider • Procedure or service was increased or reduced
due to patient circumstances • Only a portion was completed or there are
separate components for that particular code set • Unusual difficulties • Two or more modifiers may be used to append or
detail a particular procedure or service
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Licensure modifiers
Degree/licensure HIPAA modifier
Degree/licensure HIPAA modifier
Psychiatrist AF Community Support Staff Member
UC
Advanced Registered Nurse Practitioner (APRN)
SA Psychiatric Resident U3
Certified Social Worker (CSW) U4 Peer Counselor U7 Professional Equivalent HN Psychiatric Registered Nurse U2 Licensed Professional Counselor Associate (LPCA)
U4 Licensed Clinical Social Worker (LCSW)
AJ
Certified Prevention Professional HM Registered Nurse AD, BSN or Diploma
TD
Certified Psychological Assoc. U8 Physician AM
69
70
Degree/licensure HIPAA modifier
Degree/licensure HIPAA modifier
Marriage and Family Therapist Associate (MFTA)
U4 Mental Health Associate (MHA) U5
Licensed Marriage & Family Therapist (LMFT)
HO Physician Assistant (PA) U1
Licensed Psychological Practitioner (LPP)
U8 Psychologist AH
Licensed Professional Clinical Counselor (LPCC)
HO Certified Alcohol & Drug Counselor (CADC)
U6
Certified Professional Art Therapist (ATR-BC)
HO Registered Nurse with BS degree (RN)
TD
Licensed Professional Art Therapist Associate
U4 Licensed Associate Behavior Analyst (LABA)
U4
Licensed Behavior Analyst (LBA) HO Per diem U9
Licensure modifiers cont.
Modifier usage
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Modifier Description
Reimburse/info
Service type modifier (NOTE: Not all codes within a section may be affected)
25 Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service: the physician may need to indicate that on the day a procedure or service identified by a CPT code was performed.
R E/M
59 Distinct Procedural Service -is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
I
24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure.
I E/M
XF Separate encounter, a service that is distinct because it occurred during a separate encounter
I
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
I
Modifiers cont.
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Modifier Description Reimburse/info
HA Child/adolescent program I
HD Pregnant/parenting women's program I
HE Mental health program I
HF Substance abuse program I
HG Opioid addiction treatment program I
HQ Group setting I
U1 – UD Medicaid level of care (1-13) as defined by the state or health plan
I
CPT summary
• Development of codes by the AMA • Divided into three categories • Category I is for services and procedures
performed by a physician or non-physician practitioner
• Codes are five digit numeric • E/M services are determined by location, patient
status, performance
73
HCPCS level II
• HCPCS codes are created by CMS • Updated quarterly by CMS • HCPCS are used to report procedures and services for
patients the same way CPT are utilized • They are HIPAA-mandated codes and contain specific codes
designated for Medicaid only • Medicare- and Medicaid-specific covered codes — State Medicaid agency codes T1000-T5999 (designed for
use by Medicaid to establish codes for items for which no permanent national codes exist; these are not used by Medicare)
• Codes begin with a single letter followed by four digits
74
HCPCS level II (H0001-H2037) (T1000-T9999)
• H0001-H2037 Alcohol and drug abuse treatment services codes were developed for state Medicaid agencies to identify mandated mental health services that included: — H0031 Mental Health Assessments; non-
physician — H2021 Community Based Wrap Around Service
• T1000-T9999 Designed for Medicaid state agencies which describes nursing and home health related services, substance abuse treatment and certain training related procedures
75
ICD-9-CM
• Developed to describe the circumstance of a patient’s condition.
• Currently the national standard coding language used to define a patient’s condition, diagnosis, disease, injury, anomaly or any other reason for a medical service, procedure or supply.
• Revisions are made annually and published in early spring to become effective October 1 by the AHA.
• Codes must be used for all services performed on or after the effective date. Providers and payers must keep up with changes and accept/code appropriately.
76
ICD-9-CM
• Diagnosis codes identify and justify the medical necessity of services
• List first the primary diagnosis, condition, problem or reason for the medical service or procedure (chief complaint) — Assign a ICD-9-CM diagnosis code to the highest
level of specificity using the appropriate fourth or fifth digit
— Distinguish between acute and chronic conditions — Chronic complaints or secondary diagnoses are
coded only when treatment is provided for that condition
— Be as specific in describing the condition or illness of the patient as possible
77
ICD-9-CM
• There are three volumes to the ICD-9-CM —Volume 1 contains the tabular list of disease (arranged
numerically); there are nineteen chapters established by etiology or body system
—Volume 2 contains the alphabetic index of diseases —Volume 3 contains both an alphabetic index to
procedures and surgical procedures used by facilities
• ICD-9-CM were designed for claims and benefit administration to be expedited and consistent for reimbursement consideration.
78
ICD-9-CM
• Volume 1 — Contains the tabular list of disease (arranged
numerically); there are nineteen chapters established by etiology or body system (001-999.9)
— There are two supplementary classifications — V codes (V01-V84) are supplementary classifications
of factors influencing health status and contact with health services
— E codes (E800-E999) explain the condition under which a diagnosis happened (occurred)
79
ICD-9-CM
• Define the reason chiefly responsible for the service provided
• Identify any causes or conditions that affect the treatment of the primary condition
• Tell the story as completely as possible; code to the highest level of specificity
• Complete with codes that help describe events or reason appropriately with V and E codes
• Improved medical record documentation
80
ICD-10-CM
• The 10th revision of morbidity coding • WHO maintains the history behind and
implementation of changes • Exceeds its predecessor in the number of
concepts and codes (extends from 17,000 ICD-9-CM to 90,000 ICD-10-CM)
• Incorporates greater clinical detail and specificity than ICD-9-CM and has been updated to be consistent with current clinical practice
81
ICD-9-CM vs. ICD-10-CM The difference
ICD-9-CM ICD-10-CM • 3-5 characters in length • Approximately 14,000 codes • First digit may be alpha (E or V) or
numeric; digits 2-5 are numeric • Limited space for adding new codes • Lacks detail • Lacks laterality • Difficult to analyze data due to
nonspecific codes • Codes are nonspecific and do not
adequately define diagnoses needed for medical research
• Does not support interoperability because it is not used by other countries
• 3-7 characters in length • Approximately 68,000 available codes • Digit one is alpha; digits 2-7 are alpha
or numeric • Flexible for adding new codes • Very specific • Has laterality • Specificity improves coding accuracy
and richness of data for analysis • Detail improves the accuracy of data
used for medical research • Supports interoperability and the
exchange of health data between other countries and the United States
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Examples coding from ICD-9-CM to ICD-10-CM (compressed)
ICD-9-CM • 295.00 Schizophrenia disorder Simple
unspecified condition • 304.00 Opioid type dependence, unspecified ICD-10-CM • F20.89 Other schizophrenia (Cenesthopathic
schizophrenia, Simple schizophrenia) • F11.20-F11.29 (one to multiple)
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Opioid dependence
F11.20 Opioid dependence, uncomplicated
F11.220 Opioid dependence with intoxication, uncomplicated
F11.221 Opioid dependence with intoxication delirium
F11.222 Opioid dependence with intoxication with perceptual disturbance
F11.229 Opioid dependence with intoxication, unspecified
F11.23 Opioid dependence with withdrawal
F11.24 Opioid dependence with opioid-induced mood disorder
F11.250 Opioid dependence with opioid-induced psychotic disorder with delusions
F11.251 Opioid dependence with opioid-induced psychotic disorder with hallucinations
F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified
F11.281 Opioid dependence with opioid-induced sexual dysfunction
F11.282 Opioid dependence with opioid-induced sleep disorder
F11.288 Opioid dependence with other opioid-induced disorder
F11.29 Opioid dependence with unspecified opioid-induced disorder
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Place of service (POS)
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POS code/name POS description
11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
51 Inpatient Psychiatric Facility
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
52 Psychiatric Facility-Partial Hospitalization
A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.
53 Community Mental Health Center
A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility.
55 Residential Substance Abuse Treatment Facility
A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
56 Psychiatric Residential Treatment Center
A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.
57 Non-residential Substance Abuse Treatment Facility
A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.
Forms
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CMS 1450/UB04
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• Electronic version 837I • Effective March 1, 2007 (deadline July 1, 2007) • Additional fields added to accommodate NPI,
additional diagnosis codes fields and a specific DRG field and NDC numbers
• ICD-9-CM diagnosis and procedures only accepted • Principal diagnosis codes are required for all inpatient
and outpatient • National Uniform Billing Committee (NUBC) and the
State Uniformed Billing Committee (SUBC) determine format and updates
CMS 1450
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CMS 1500 (electronic version 837)
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• Replaced the HCFA 1500 effective February 2012 implemented February 7, 2007 (modified July 2014)
• Answers the needs of most health insurers • Revisions were made to accommodate the
implementation of the National Provider Identifier (NPI) • Ability to include NPI and insurers’ PIN in box (17)
referring physician; (31) rendering physician; (32) facility services rendered; and (33) billing provider information
• The six claims lines have been divided to accommodate submission of NPI, anesthesia time and NDC drug information
CMS 1500
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Clinical edits
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NCCI
• Federally mandated to promote national correct coding methodologies and control improper coding leading to inappropriate payment
• Based on coding policies defined by AMA CPT manual, national societies, national and local policies
Two types of NCCI edits
1. Procedure-to-procedure edits implemented January 1, 1996 a. Are assigned to either the column one/column two correct coding edit files b. Applies to:
i. Physicians/practitioners ii. Outpatient hospital services iii. Durable medical supplies
2. MUE implemented January 1, 2007 a. A maximum unit of service that a provider would report under most circumstances for
a single beneficiary on a single date of service for HCPCS/CPT code b. Not all HCPCS/CPT procedures have a MUE c. Applies to:
i. Physician/practitioners ii. Outpatient hospital services iii. Durable medical supplies
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Code editing projects
EX Codes axx-dxx, N10
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Utilize PAM (policy administration module) of ClaimCheck to create clinically appropriate edits based on Anthem policy and/or industry standards.
→ Single procedure or diagnosis → Procedure to diagnosis → Procedure to procedure → Member age or gender → Unit limits → Frequency → Place of service → Provider specialty → Market or product specific
iHealth
• A health care analytics company contracted to assist us in identifying inappropriately paid claims.
• Provides prepayment solution in a real-time environment through a Facets interface.
• Similar and an addition to McKesson’s ClaimCheck® with added functionality and flexibility.
• To be employed as a “final filter” before professional and outpatient facility claims are paid – same as ClaimCheck.
• Implemented November 1, 2013 • EX Codes i00 – i81
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What is the key difference?
ClaimCheck audits the claim from the provider’s point of view • Same member, same provider, same DOS • Limited use of time span or provider groupings/specialty
• PAM can be configured more broadly – resources consuming
iHealth reviews claims from the member’s point of view • What services could’ve been done across providers for this member
(takes modifiers and specialty into consideration) • How often can this service be provided
• Looks across providers and time span
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Conclusion
Medical coding is based on the foundations of three areas: • Current procedural terminology (CPT) • Health Care Common Procedure Coding System
(HCPCS) • International Classification of Diseases 9th edition
Clinical Modifications (ICD-9-CM) (ICD-10 effective October 1, 2015)
Working together, much like a sentence, to provide an effective and efficient mechanism to reimburse providers for services and procedures performed.
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Claim scenarios
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Coding example
• Member presented with concerns about his ability to return to work and face his coworkers – Nature of the presenting problem was documented
• Established patient • Problem focused • Problem focused examination • Low complexity medical decision making
– Time spent in therapy was 25 minutes
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Example II
A 15-year-old being treated for depression and alcohol abuse and on an antidepressant and an inhaler for asthma presented today with both divorced parents who disagree over how to address the patient’s recent alcohol binge. Concern over boarding school or following treatment plan. Nature of presenting problem: • Interval history obtained from parents and patient; this included details of
recent alcohol use along with exploration of other drug use, medication compliance, side effects and beneficial effects
• Suicide risk explored • Psychiatric specialty exam is completed and decision on medication (50
minutes) • Patient focuses on feelings of embarrassment of new rules in father’s home
and encounter which he was drunk in front of her friends • Parents increasingly argue with each other over the treatment
recommended by the psychiatrist
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Questions and answers
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