Practice patterns that succeed in one region mayfail in other areas. The table of commonly usedprocedure codes for billing in LTC facilities maybe helpful to readers attempting to figure this outfor the first time. (page 12)

Variability also affects reimbursement in geriatricpsychiatry. Mastering the complexities of third-party billing and collection is critical. Geriatricspractice requires not only familiarity with

Medicare, which most often is theprimary payer, but also

proficiency collectingfrom secondaryinsurance plans andpossibly a patient’s

copayment. Somediscouraged practitioners

settle for the Medicarepayment for their long-termcare practice, cynicallyconcluding that the cost ofcollecting the copaymentwill not be worth the effort.Unfortunately, this belief isreinforced by Medicaidpayment policies that, in

WHILE NURSING HOME PSYCHIATRY IS THEQUINTESSENTIAL ACTIVITY OF GERIATRICPSYCHIATRY IT IRONICALLY ALSO IS THEAREA IN WHICH PRACTITIONERS AREBUFFETED BY THE GREATEST NUMBER OFFORCES THREATENING THE FINANCIALSUCCESS OF THEIR PRACTICES. Greaterclinical complexity, federal and state regulatoryrequirements, facility staff limitations, Medicaredocumentation guidelines, and billing hassles allmake nursing home care more complicated,demanding, and less efficient. At the same time,Medicare, Medicaid, and commercialinsurance payments do not reflect the greaterintensity of service provided, and Medicare evenimposes a fee reduction for facility-basedservices. To make matters worse,psychiatrists who provide high volumesof nursing home services may findthemselves subject to scrutiny forfraud and abuse by theirMedicare carriers. Geriatricpsychiatrists who remainundaunted by such difficultiesface the challenge of providinghigh quality, medically necessaryservices in a financially viable fashion. Howdo they do it? Canyou make a livingpracticing long-term carepsychiatry?

This issue of TheClinical View offers practice managementperspectives on long-termcare psychiatry. Dr.Anderson’s article discussesmany of the nuances oflong-term carereimbursement. Readers will find his analysisof the risks and opportunities of LTC practiceinsightful and his review ofcoding issues practical. Onecaveat: There is much regionalvariability in the nursing homeand assisted living industries.

Sponsored byThe American Associationfor Geriatric Psychiatry

INSIDETHISISSUE:PAGE 4Billing and Coding Issues in Long-Term Care

PAGE 6Assisted Living: The NewFace of Long-Term Care

PAGE 10Collecting From Coinsurers

1Viable Long-Term Care Practice

AUGUST 2004VOL. 2, ISSUE 3

This activity is supported by an unrestricted educational grant fromAstraZeneca Pharmaceuticals LP

PAGE 14CME Self-AssessmentViable Long-Term CarePractice

VIABLE LONG-TERM CARE PRACTICE

INTRODUCTIONBy Gary S. Moak, M.D., Editor-in-Chief

2 Viable Long-Term Care Practice

Author DisclosuresThe American Association for Geriatric Psychiatry requires that theauthors participating in a continuing medical education activity discloseto participants any significant financial interest or other relationship (1)with the manufacturer of any commercial services discussed in aneducation presentation, and (2) with any commercial supporters of theactivity. The authors reported the following:

Allan A. Anderson, M.D.—Reported no actual or potential conflict ofinterest in relation to this educational activity.

Elliott M. Stein, M.D.—Reported being on the speaker’s bureau ofAstraZeneca, Eli Lilly, Forest, GlaxoSmithKline, Novartis, and Pfizer.

Sandra S. Swantek, M.D.—Reported being on the speaker’s bureau ofFamily Home Health Services.

Accreditation StatementThe American Association for Geriatric Psychiatry (AAGP) isaccredited by the Accreditation Council for Continuing MedicalEducation to provide continuing medical education for physicians. The AAGP takes responsibility for the content, quality, and scientificintegrity of this CME activity.

Designation StatementThe American Association for Geriatric Psychiatry designates thiscontinuing medical education activity for up to 1.0 credit hour incategory 1 of the Physician’s Recognition Award of The AmericanMedical Association. Each physician should claim only those hours ofcredit that he/she actually spent in the educational activity.

Educational GrantThis activity is supported by an educational grant from AstraZenecaPharmaceuticals LP.

Intended AudienceThis activity is intended for psychiatrists.Release date: August 2004Expiration date: August 2005

Learning ObjectivesUpon completion of this activity, participants should be able to:

• Describe the positive aspects of psychiatric consultation in long-term care facilities.

• Adopt strategies that will help ensure a fiscally viable nursing home practice.

• Identify opportunities for geriatric psychiatry practice in Assisted Living Facilities, (ALFs).

• Discuss mental health care practice challenges in serving assisted living residents.

• Provide practical information for consumers evaluating ALFs.• Establish effective procedures to garner appropriate reimbursement

from coinsurers.• Review methods that could improve collection rates for long-term

care services.

The American Association for Geriatric Psychiatry7910 Woodmont Avenue, Suite 1050Bethesda, MD 20814301-654-7850www.AAGPonline.orgclinicalview@aagponline.org

Volume 2, Issue 3, August 2004

Editorial Advisory Board

Gary S. Moak, M.D., Editor-in-ChiefAssociate Professor of Clinical PsychiatryUniversity of Massachusetts Medical SchoolGeriatric Medical PsychiatryWestborough, MA

Allan A. Anderson, M.D.Medical Director and Director of Geriatric PsychiatryShore Behavioral Health ServicesCambridge, MD

David Greenspan, M.D.Clinical Assistant Professor of Psychiatry, UMDNJ-SOMMedical Director Carrier ClinicBelle Mead, NJ

David S. Harnett, M.D.Associate Clinical Professor of PsychiatryTufts University School of MedicineChief of Psychiatry, Lawrence Memorial Hospital ofMedford/Hallmark HealthMedford, MA

Alan Steinberg, M.D.Assistant Professor, Psychiatry and MedicineDirector of Geriatric Psychiatry Education ServicesState University of New York at Stony BrookGeriatric NeuropsychiatristEast End Neuropsychiatric AssociatesCentereach, NY

Sandra Swantek, M.D.Assistant Clinical ProfessorNorthwestern University, Feinberg School of MedicineMedical DirectorOlder Adult Behavioral Health ServicesWeiss Memorial HospitalChicago, IL

Contributing Authors

Allan A. Anderson, M.D. Medical Director and Director of Geriatric Psychiatry Shore Behavioral Health Services Cambridge, Maryland

Elliott M. Stein, M.D. Private Practice of Geriatric PsychiatryMiami Beach, Florida.

Sandra S. Swantek, M.D.Assistant Clinical ProfessorNorthwestern University, Feinberg School of MedicineMedical DirectorOlder Adult Behavioral Health ServicesWeiss Memorial HospitalChicago, IL

© All rights reserved including translation into other languages. No part of this publication may bereproduced or transmitted in any form or by any means—electronic or mechanical, includingphotocopying, recording, or any information storage and retrieval system—without permission inwriting from the American Association for Geriatric Psychiatry.

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August 2004The CLINICAL VIEW Geriatric Psychiatry in Long-Term Care

many states, leave the nursing home psychiatrist writing offmost of the copayment for Medicare/Medicaid patients. Asignificant number of nursing home patients and many, if notmost, assisted living patients have other forms of coinsurancethat will pay some or all of the Medicare copayment. Becauseof the 50 percent psychiatric limitation, meticulous attentionto collecting these payments may make or break a long-termcare practice. The article by Dr. Stein provides an overview ofthis area and many useful and practical tips for improvingyour collection rate for long-term care services. Readers maywish to refer to the Medicare Primer (see box, this page) toreview some basic concepts and terms either before or afterreading the articles by Drs. Stein and Anderson.

If the nursing home is the sine qua non of geriatric practice,then assisted living facilities are rapidly emerging as long-termcare settings of equal importance. The article by Dr. Swantekrounds out this issue of The Clinical View with a helpfulorientation to assisted living facilities and many of the issuesfaced by psychiatrists who elect to practice in these residentialprograms. A question frequently asked by attendees ofAAGP’s practice management workshops regards billing codesto use for assisted living visits. Psychiatrists alreadyexperienced in assisted living facilities may appreciate that thehome visit codes are absent from the table of commonly usedprocedure codes for long-term care. Many practitioners usethe home visit codes (99344-99350) for services provided topatients in their private apartments in assisted living facilities,as they might for similar services they provide in retirementcommunities, senior housing, or patients’ private residences.Some carriers actually have advised their providers to usethese codes, even though national Medicare policy states thathome visit codes are not to be used in any type of "facility"setting where residents receive personal care and assistance.Suffice it to say that this represents one (of many)controversial aspects of long-term care billing for which thecorrect answer is not entirely clear. At the time of thispublication, AAGP is working actively in collaboration withother LTC physician provider groups to bring aboutimprovements in the payment rates for domiciliary/custodialcare in assisted living facilities.

Long-term care psychiatry, done properly, is challenging,stimulating, gratifying, and time consuming. Passionatepractitioners should apply commensurate zeal to billing fortheir services so they can continue to offer them. We hopethis issue of The Clinical View provides insight into how tothink about long-term care practice. In the next issue, we willlook at the manifestations of personality disorders in long-term care settings and the roles of psychotherapy andbehavioral interventions. This will end Volume II on a morepositive note, focusing less on the frustrations of long-termcare practice and more on its professional richness.

GERIATRIC PSYCHIATRISTS WHO REMAIN UNDAUNTED BYSUCH DIFFICULTIES FACE THE CHALLENGE

OF PROVIDING HIGH QUALITY, MEDICALLY NECESSARYSERVICES IN A FINANCIALLY VIABLE FASHION.

HOW DO THEY DO IT? CAN ONE MAKE A LIVINGPRACTICING LONG-TERM CARE PSYCHIATRY?

LONG-TERM CARE REIMBURSEMENT PRIMER

MEDICARE Medicare is a federal government benefit for retirees or disabledpeople of all ages. It currently covers more than 49 millionbeneficiaries, making it the largest health insurance plan in theworld. It covers physician services, hospital care, short-term,rehabilitation care in a nursing home, and now offers a limitedprescription drug benefit. It is the most common primary payer ofnursing home psychiatric services.

MEDICAID Medicaid is a shared federal/state health insurance plan available tothose of limited financial means. It covers nursing home costs,including prescription drugs, for the majority of nursing homeresidents, and is the largest secondary payer of physician services fornursing home residents who have Medicare. Medicaid isadministered by the states.

MEDICARE CARRIER Medicare is administered by a group of regional or nationalinsurance companies that contract with the U. S. Department ofHealth and Human Services to process (and, it is hoped, pay)claims from providers for covered services.

THE PSYCHIATRIC LIMITATION Medicare imposes a fee reduction on outpatient psychiatric servicesexcept for diagnostic services and medical management ofAlzheimer’s Disease (ICD-9 codes 290xx or 331.0). This reductionis set at 62.5 percent of the allowed payment. The 62.5 percentreduction results in an effective 50 percent mental healthcopayment: Medicare’s 80 percent of 62.5 comes out to 50 percentof the original fee. A Medigap plan is required by federal regulationsto pay the other 50 percent of the original fee. Other coinsuranceplans are not bound by these regulations. Many will interpret theirresponsibility for the copayment to be limited to 20 percent of theMedicare amount. Thus, they may pay 20 percent of 62.5 percentof the full fee, or 12.5 percent. This leaves a remainder of 37.5percent that you are entitled to collect from the patient.

SECONDARY INSURANCE, COINSURANCE, MEDICARE SUPPLEMENT INSURANCE These terms often are loosely used in an interchangeable manner.They refer to plans that supplement Medicare by covering some orall of the Medicare copayment. These plans include commercialplans that patients purchase, plans offered by employers to retirees,and Medicaid. Medigap is a highly specific form of Medicaresupplement insurance (see below). Non-Medigap plans canestablish there own policies regarding coverage of the psychiatriccopayment (see “The Psychiatric Limitation”, above).

MEDIGAP This is a form of Medicare supplement insurance which must meetstandards pursuant to Title VIII of the Social Security Act (theMedicare enabling federal legislation). State insurancecommissioners are required to establish procedures for certifyingthat these plans marketed to Medicare beneficiaries meet thesestandards. Medigap policies are required to pay the copayment forall Part B physician services covered by Medicare, including the50% copayment for “biologically based mental disorders”. Oneexception is Medigap group plans offered by employers to retirees.These Medigap plans are not bound by the same standards, andmay have restrictions regarding what they do or do not cover of thepsychiatric copayment.

August 2004The CLINICAL VIEW Geriatric Psychiatry in Long-Term Care

MANY GERIATRIC AS WELL AS GENERAL PSYCHIATRISTS HAVE FOUND PRACTICING IN LONG-TERM CARE FACILITIES TO BE A REWARDING PROFESSIONAL EXPERIENCE. There is asubstantial need for psychiatric evaluation and treatment of the elderly residing in theselocations. A number of financial barriers, however, may lead the clinician to avoid thispractice arena. First, travel time to and from facilities adds to the cost of delivering theservices. Second, Medicare reimbursement often is inadequate. The fees do not reflect thecomplexity of the services rendered. There also is a lower facility fee for services provided inthe nursing home (i.e., the fee for any service is somewhat lower in a long-term care settingthan the fee for the same service in your private office). Finally, in most nursing homes, mostof the residents have Medicare and Medicaid. Currently, most state Medicaid programs paylittle of the Medicare copayment for dually covered patients with Medicare and Medicaid.This means that, except for patients with Alzheimer’s Disease, for whom Medicare reimbursesat 80 percent of the fee schedule, psychiatrists may have to settle for 50 percent of theMedicare fee schedule as payment-in-full. As a result of these factors, psychiatrists may give upsome income in order to care for such patients.

BREAKING DOWN THE FINANCIAL BARRIERSThere are, however, some positive aspects of being a psychiatric consultant to long-term careresidents. For example, there is essentially no problem with “no shows” as there may be in theoffice practice. On the rare occasion when a patient is out of the facility, one can easily seeanother patient who may have been added to his or her list of consults. Additionally, withproper education and training, the facility staff can be instrumental in providing data onpatients through their direct observations and working with the patients on a regular basis. Byseeing nursing home patients, a psychiatrist helps to build better working relationships withprimary care physicians. This may lead to an increase in outpatient referrals.

To prevent the negative reimbursement issues from outweighing the positive aspects ofworking in long-term care settings, it is imperative to be on top of the financial issues. Overmany years I have been involved in various arrangements with area nursing homes. The most

BILLING AND CODING ISSUES IN LONG-TERM CAREBy Allan A. Anderson, M.D.

4 Viable Long-Term Care Practice

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August 2004The CLINICAL VIEW Geriatric Psychiatry in Long-Term Care

satisfying of these have been arrangements where I have beenpaid a stipend for some of the non-patient centered activities.One of the primary purposes of this stipend is the educationof facility staff. This includes formal in-service education andmore importantly the informal liaison that occurs regularlywhen I am rounding on patients. I often work with front-linecaregivers who display behavior that might provoke anAlzheimer Disease patient. I provide examples of behavioralapproaches or communication styles that might work betterwith that particular resident. I often take time to explain tonursing staff about the various treatment interventions Imake. Staff are often quite appreciative for these efforts.Receiving a monthly stipend covers such efforts as this is nota service that is covered by Medicare or other insurance.

Unfortunately the availability of such stipends depends on avariety of market forces. The availability of providers willingto provide mental health services to nursing homes createssupply and demand dynamics that affect facilities’ willingnessto pay stipends. Facilities’ budgets may be limited by state ratesetting policies and the percentage of their private payingresidents who pay a higher daily rate. Nursing homes havebeen under increased pressures to better manage their budgetswith their reimbursements having shrunk, especially since theProspective Payment System, (PPS) came into being in 1997.With PPS many services are “bundled” into a daily rate paidby Medicare and Medicaid, which includes social workservices but not physician services. Thus, nursing homes areexpected to have salaried social workers, but often thesesocial workers are not clinically trained and cannotcompetently offer psychotherapy services. Still, I believe it iseasy to argue how the stipend “pays for itself” with theprovision of improved communication and care leading tofewer injuries to patients and staff, fewer hours of sick timeand disability claims by staff, and improved morale amongstaff. Despite these arguments, stipends are still difficult toarrange.

BILLING NUTS AND BOLTSLet me review some of the nuts-and-bolts issues with regardsto billing and coding, beginning with some of the newer issueswith Assisted Living Facilities (ALFs). There is now a newcode for the place of service (POS) for ALFs, specifically code13. Prior to this being available, carriers differed in theirapproach to what POS code should be used. Some wouldallow clinicians to use the evaluation and management(E&M) codes for home visits (99344-99350). This might notwork if the individual had not notified Medicare of the ALFaddress as their new home address. The patient’s zip codemight not register with Medicare and the claim would not bepaid. Other carriers suggested or mandated clinicians to usethe domiciliary codes (99321-99333). Unfortunately, thesecodes reimburse very little compared to many other codespsychiatrists might use in other settings such as in the office,at the hospital, or at a nursing home setting. There are nonew Current Procedural Terminology (CPT) codes for POS13. Hopefully this will be addressed at some time by theAmerican Medical Association, which sets the CPT codes.

This leaves some question as to what codes to use. It seemsreasonable to use psychiatric service codes 90801 (psychiatricdiagnostic evaluation), 90862 (psychopharmacologic

management), and psychotherapy with E&M (90805 and90807). One could use a consultation code using the codes99241-99245. These codes are for office or other outpatientplaces of service and can be used in domiciliary, nursinghome, and custodial care assuming the service was requestedby a referring physician and a consultant’s report is sent. It isvital to check with your carrier to see what codes they suggestto use in the ALF setting. It may be necessary to be a bitassertive here. When I contacted my carrier I advised them ofmy plans to use the 90801 and 90862 codes as opposed to thedomiciliary codes. Keep in mind that often the carrierrepresentative you talk to may not know the current policywith regards to coding.

Lastly, one attractive aspect of treating ALF patients, at leastfrom a financial perspective, is that there are far fewerMedicare-Medicaid patients in these facilities, so collectionrates for the Medicare copayments are much higher. Thiscertainly may not be the case uniformly across the country asthere are regional changes where Medicaid patients are fillingALF beds.

What about billing and coding issues in nursing homesettings? Clinicians should evaluate what services they areoffering and then compare this with the possible CPT codesthat could be used. For example, there are a number ofdifferent ways that an initial visit can be coded. One can usethe initial nursing home visit codes for evaluation andmanagement (codes 99301-99303), the initial psychiatricevaluation code (90801), or the inpatient consultation codes(99251-99255) which apply to nursing home services eventhough nursing homes are considered outpatient places ofservices. Review of the fee schedule will demonstrate that feesvary. Providing that you are delivering and documenting thehigher level consultation by using the higher consultationcodes, you will maximize your reimbursement for this initialvisit. Please be certain when using the consult codes thatthere has been an order for your consultation and that youprovide a written consultation report to the referringphysician. Writing your consultation note, filed in thepatient’s chart, meets this requirement in the nursing home.

For follow-up visits it is typically more reasonable to use asubsequent nursing home visit code (99311-99313) orpsychopharmacologic management code (90862) as opposedto the follow-up consultation codes (99261-99263). Thesecodes are intended for infrequent use to complete the initialconsultation or for a new visit in response to a new order for are-consultation. Additionally, I am often asked to provide asecond opinion on issues of medical-decision capacity. Inmany states there is a requirement for the opinion of twophysicians in this area. The 9927X series could be utilized forthis purpose. These are codes for “confirmatoryconsultations.”

REGULAR REVIEW TO MAXIMIZE REIMBURSEMENT Finally, it is always advisable to perform some regular reviewof your long-term care practice. Reviewing the mix of patientsyou see, the codes you use, and the rate of reimbursement forsuch patients can help guide appropriate changes to maximizeyour reimbursement, and in turn, help you maintain a fiscallyviable nursing home practice.

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Assisted living is a rapidly growing segment of the senior housing industry.The Assisted Living Quality Coalition, representing both consumer and provider associations, defines assisted living as: A congregate residential setting that provides or coordinates personal services, 24-hour supervision and assistance(scheduled and unscheduled), activities, and health-related services. They are designed to minimize the need to move; toaccommodate individual residents’ changing needs and preferences; to maximize resident's dignity, autonomy, privacy,independence, and safety; and to encourage family and community involvement.

In spite of the growing popularity of assisted living, little attention has been given to the mental health concerns of theresidents of ALFs. However, assisted living may provide a supportive environment for these individuals, offeringsupervision, assistance and health care services in a home-like setting. In this somewhat structured setting, older adultsexperience a unique mix of security and independent living, privacy and companionship, as well as physical and socialwell being.

ASSISTED LIVING: THE NEW FACE OFLONG-TERM CARE

By Sandra Swantek, M.D.

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August 2004The CLINICAL VIEW Geriatric Psychiatry in Long-Term Care

Mr. W Leaves Home

Mr. W was a 79-year-old widower living alone in a home in aneighborhood experiencing gentrification. He had no knownfamily. No one visited his home. A new neighbor noted Mr. Wstruggling to cut his grass, and subsequently visited his homefinding him without heat and electricity and living in squalor.The neighbor brought him to the attention of authorities andeventually, Mr. W was assigned a guardian who moved him toan Assisted Living Facility (ALF). Mr. W was unhappy withthe placement, feeling that “crooks” had “kidnapped” him. Hebegan scouring the alleys of his new neighborhood, collecting thematerials he needed for the day he would move back home. Hereturned regularly to his old home and was deeply distressedwhen he discovered a “For Sale” sign out front. He returned tothe ALF angry and belligerent. Mr. W’s behavior becameincreasingly erratic and included hoarding newspapers and oldfood. Concerns that people would steal things resulted in Mr.W’s refusal of any housekeeping help. Administrative concernsregarding the risk of vermin and the impact on other residentsgrew daily. The administrator asked the primary care physician(PCP) for help with the problem. The primary care physicianasked for an evaluation by a geriatric psychiatrist.

The geriatric psychiatrist entering Mr. W’s apartment found anelderly man who enjoyed talking about philosophy and music.He would not share any information about his past other thanto say he left his country because of war. His environment wasdisorganized and malodorous. Mr. W spoke English as hissecond language and would not cooperate with a mental statusexamination due to his concern that this information would beused against him. He did agree to a complete physical exam thatrevealed diminished vision but no other physical problems.Following consultation with the guardian, staff, and the PCP, anattempt to build an alliance began with weekly visits to Mr. W’sapartment. These visits eventually convinced Mr. W toreluctantly allow the removal of old food items from hisapartment. He refused psychotropic medication. He livedcontinuously on the edge of posing a definitive risk to himselfand others. The treatment team monitored closely but never feltthe criteria for involuntary hospitalization were met. Concernsregarding apartment cleanliness eventually extended to concernsregarding Mr. W’s personal hygiene. Mr. W did not agree withthese concerns. A fall and subsequent hip fracture led tohospitalization and the patient was discharged to a nursinghome.

Mr. W’s story illustrates the role of assisted living inproviding shelter for the older adult. Although he feltimprisoned, the ALF provided Mr. W with a level ofindependence impossible in a more structured setting. Thecare team worked in concert to provide personalized carethat maximized Mr. W’s autonomy while recognizing hisneeds and limitations and simultaneously respecting theneeds and rights of his ALF neighbors.

Mental Health in ALFs

Older adults in assisted living endure multiple losses andchanges prior to their arrival, making them vulnerable todepressive illness. Evidence has been reported of theincreasing prevalence of depression occurring in olderadults as they move from independent living (10 percent)to the more structured setting of the nursing home (40 to90 percent). Little is known about the prevalence ofclinical or sub-clinical depression, dementia, or behavioraldisorders related to dementia in the assisted livingpopulation. A recent national survey of ALFs estimatedthat one-third of ALF residents suffer moderate to severecognitive impairment.

Results from a four-state study (Watson et al, 2003) suggestthat depression is common, frequently untreated, andrelated to an increased rate of nursing home placementand mortality. Depression was independently associatedwith high medical co-morbidity, social withdrawal,psychosis, and agitation. Severely depressed assisted livingresidents had twice the number of deaths within the year,compared with non-depressed residents. Fewer than 20percent of the depressed assisted living residents receivedantidepressant medications.

When the administrators of 94 ALFs in Michigan werequestioned about mental health problems, they reporteddementia and depression as the two most common mentalhealth problems. The most common behavior problemswere resistance to care and wandering (Wagenaar, 2003).

ALFs Gain in Popularity, Lack Consistent Regulation

Derived from a Scandinavian model for senior living,assisted living first emerged in the United States during themid-1980s. In 1998, assisted living units accounted forabout 75 percent of new senior housing. Today, there arenearly 40,000 facilities housing almost one millionindividuals in this country. Nearly all facilities provide 24-hour staff, three meals daily, and housekeeping. Manyprovide medication reminders and help with bathing anddressing. Fewer than half report having a full-timeregistered nurse on staff.

Admitting criteria generally restrict admissions to olderadults with mild to moderate impairments. More than halfof new assisted living residents move in directly from theirhomes. Most require assistance with one or two activitiesof daily living (ADL), as compared with nursing facilityresidents who require assistance with three or more ADLs.Assistance with medications may take the form of areminder, supervision or administration by the staff. Facilitystaff may supervise, assist or administer medication forapproximately 86 percent of the assisted living facilityresidents. Assistance often becomes a point of contentionfor the previously independent older adult who is strugglingto maintain a sense of personal dignity and autonomy. This

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August 2004The CLINICAL VIEW Geriatric Psychiatry in Long-Term Care

places special demands on the facility staff to employ sophisticated behavioral intervention techniques to ensure thatpatients receive their medication.

In spite of those demands, no national educational and training minimum requirements exist for unlicensed personnelcharged with caring for older adults in ALFs. Minimum requirements specified in individual states vary from no trainingat all to that required of nursing assistants in skilled nursing facilities. Staff training is needed to ensure quality of care,quality of life, and resident safety. Geriatric psychiatrists provide an important resource for consultation and education,assisting facilities in developing a plan for dealing with mental health issues in their facilities.

Unlike nursing homes that are federally regulated, state government oversees assisted living facilities; therefore,regulations and services vary widely. To date, the involvement of state and federal governments with assisted living hasbeen minimal when compared to other segments of long-term care.

In many areas, assisted living is a long-term alternative available only to older adults with significant financial reserves.Currently, 75 percent of all assisted living residents are self-pay. Out-of-pocket monthly expenses range anywhere from$1,500 to $5,000, beyond the means of the individual with little more than Medicare or Medicaid as their support.

UNLIKE NURSING HOMES THAT ARE FEDERALLY REGULATED, STATE GOVERNMENT OVERSEES ASSISTED LIVING FACILITIES;

THEREFORE, REGULATIONS AND SERVICES VARY WIDELY.

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References Cohen GD, Blank K, Cohen, CI et al, “Mental HealthProblems in Assisted Living Residents: The Physician’s Rolein Treatment and Staff Education,” Geriatrics. 2003;February; 58(2) 44-54.

Golant SM, “Do Impaired Older Persons With Health CareNeeds Occupy U.S. Assisted Living Facilities? An Analysisof Six National Studies,” Journal of Gerontology Series B,Psychological Sciences and Social Sciences. 2004; March; 59:S68-S79.

Hawes C, Phillips CD, Rose M et al, “A National Survey ofAssisted Living Facilities,” Gerontologist. 2003; 43(6)875-882.

Wagenaar DB, Mickus M, Luz C, et al, “An Administrator’sPerspective on Mental Health in Assisted Living,” PsychiatricServices. 2003; December; 54:1644-1646.

Watson LC, Garrett JM, Sloane PD, et al, “Depression inAssisted Living: Results From a Four-State Study,” AmericanJournal of Geriatric Psychiatry. 2003; October; 11:534-542.

Other ResourcesNational Center for Assisted Living (NCAL) www.ncal.org.

National Center for Assisted Living. “2001 Facts andTrends: The Assisted Living Sourcebook.” Washington, DC:National Center for Assisted Living, American Health CareAssociation.

Medicare does not cover assisted living expenses. Some ofthe services provided in assisted living may be paid underSupplementary Security Income (SSI) and Social ServicesBlock Grant programs. Many states presently reimburse orplan to reimburse for assisted living as a Medicaid service.Less than 10 percent of residents currently receiveMedicaid assistance.

As relatively healthy residents become increasinglyimpaired, they require more staff assistance. The restrictivedischarge criteria of many ALFs guarantee that the mostimpaired residents will eventually be transferred to adifferent site, perhaps the home of a relative or to a nursinghome. Residents who have moderate to severe cognitiveimpairment, have behavioral symptoms or need nursingcare are frequently asked to move to a long-term carefacility. The philosophy of individual ALFs differs greatlyand thus, while one facility may promote transfer to ahigher level of care, other ALFs will strive to provideappropriate services for the older adult aging in place.

The Committee on Aging of the Group for theAdvancement of Psychiatry (CAGAP) proffers 10principles for mental health care in ALFs (published inGeriatrics by Cohen, GD et al). These principles encouragepersonalized care that maximizes independence whilerecognizing each resident’s mental health strengths, needs,and limitations. CAGAP advises facilities to incorporatemental health care concepts into facility policies includingongoing education of staff regarding the identification andtreatment of mental health problems, regular screening ofresidents for mental illness, active collaboration betweenthe patient, family, the staff, primary care provider, andgeriatric psychiatrist.

ALFs represent a promising housing opportunity that willallow older adults to maintain a measure of independencewhile receiving necessary support and assistance with dailyactivities. Residents of these settings experience mentalhealth problems that may go unrecognized or untreated,resulting in significant, possibly life-threatening, emotionaldistress. Acting as consultant, educator or treatingphysician, the psychiatrist can make a significantcontribution to the health and well being of the ALFresident suffering from mental illness.

Advice for Patients and Their Families

Geriatric psychiatrists often participate in the transitiontheir patients make into ALFs. In advising patients andfamilies about long-term care decisions it is important tourge them to look beyond glossy marketing materials.Assisted living is a varied and evolving concept.

Consumers should identify the services they want andneed, then shop around. Those evaluating assisted livingshould:

• Make multiple visits at different times of the day and week.

• Talk to staff and residents and their family members. Ask whether the services offered are actually delivered.

• Discuss psychosocial activities and support as well as mental health services.

• Examine prices and ask which services are included and which services might initiate a price increase.

• If medication services are utilized, determine who communicates medication changes to the facility and how they will be monitored.

• As some older adults have difficulty living with personsmore disabled than they are, it is important to inquire about the criteria for discharge. This will alert the consumer to the level of disability they will be expected to tolerate in their environment.

August 2004The CLINICAL VIEW Geriatric Psychiatry in Long-Term Care

Medicare coverage of mental health services isfragmented and subject to arbitrary anddiscriminatory limitations. Although the

copayment for most services covered by Medicare is 20percent, current law requires a 50 percent copayment forservices furnished by psychiatrists and other health careprofessionals for the treatment of ICD-9 mental disorders.This limit, which dates back to the inception of theMedicare program in 1965, is based on the outmodedassumption that all mental illness is chronic and requiresunlimited therapeutic services.

Nursing home practice poses additional reimbursementchallenges that require clinicians to exercise greaterdiligence in claims submission and payment collection.This discussion will provide guidelines and tips forimplementing collection procedures that should improvecompensation for the clinician’s services.

For payment purposes, Medicare treats nursing homes asoutpatient places-of-service subject to the 50 percentpsychiatric reduction. One exception to this is medicalmanagement services to patients with Alzheimer’s Disease,(ICD-9 codes 290.xx or 331.0) and related disorders.Secondary insurance might cover the other 50 percent ofthe Medicare outpatient copayment or may only pay 12.5percent (see the Medicare Billing Primer on page 3 for anexplanation of the12.5 reimbursement rate). The amountpaid depends on whether the secondary insurance policy(sometimes referred to as coinsurance) is a Medigap policyand subject to governmental policy, or is an independentlyprovided Medicare supplemental policy, such as insuranceprovided by a former employer or by a trade union. Attimes, payment might be handled by a behavioral healthcarve-out subdivision of a company or by an outsidemanaged care organization (MCO) subcontractor.

By Elliott M. Stein, M.D.

Collecting

fromcoin

surers

10 Viable Long-Term Care Practice

Nursing home practice poses additionalreimbursement challenges that require

clinicians to exercise greater diligence inclaims submission and payment collection.

11Viable Long-Term Care Practice

August 2004The CLINICAL VIEW Geriatric Psychiatry in Long-Term Care

When a patient’s insurance is based on employment, verifythe name of the patient's former company, and even thedivision where they worked. Policies based on employmentmay have special billing addresses, coverage, and reviewprovisions.

Contact the insurance company at the first visitRegardless of where the patient is first seen, always contactthe secondary insurance company at the time of the firstvisit to verify the company’s billing address. It is helpful toverify that the patient’s insurance identification number iscorrect and that they are still eligible for services under theplan. Ask if prior authorization is required (generallyneeded for managed carve-outs). At that time, alwaysrequest an authorization number, which is often required inorder to receive payment. Furthermore, ask if separateauthorization numbers are required for inpatient andoutpatient services, or for services provided at otherlocations. Some companies require a number in onelocation, but not in another. If you are told that anauthorization number is not required, record the name ofthe individual who provided the information and keep thisinformation with the patient’s records. Also request thatthe individual responding at the insurance company enterinto the patient’s computer file that no authorization isrequired. If you are at all uncomfortable with the responsesyou receive, ask to speak to a supervisor to verify theinformation.

Verify company billing addressesSome insurance companies have one billing address foroffice visits and a different one for hospital visits. Somecompanies have different billing addresses for mentalhealth claims. Remember that an insurance companygenerally will not forward a claim that is sent to the wrongaddress. In order to receive payment, it is yourresponsibility to make sure the billing address is correct. Ifyou do not receive payment within a reasonable amount oftime, follow up to verify the billing address.

Find out about variability among policiesInsurance policies, even within a single company, vary andyou should become familiar with these policy variables suchas:

• Deductible amounts may vary.• Mental health care may be covered in an outpatient

setting by some policies and in an inpatient setting by others.

• Some policies/companies pay patients directly for office-based services, but then may pay the doctor directly for hospital-based services.

Psychiatric Coverage by Secondary Payers

Secondary payersMedicare Supplemental Insurance is variously called“Coinsurance” or “Secondary Insurance.” A certain type ofsecondary insurance plan, known as Medigap meets aspecific set of federally mandated guidelines for coverage.Secondary insurance policies may be purchased by thepatient or paid for by others, such as a former employerthat provides this coverage as a retirement benefit.Secondary insurance policies typically pay the 20 percentcopayment. There may be deductibles, however, as well aslimitations on mental health benefits. The insurance policymay or may not be a managed plan. Medigap plans arerequired to cover the copayment for any services coveredby Medicare.

Medigap paymentIn late December 2002, the Centers for Medicare andMedicaid Services published a program memorandumclarifying that “the Medigap issuer is generally responsiblefor the 50 percent of the Medicare allowed amount forMedicare Part B outpatient mental health services.”

The requirement that Medigap insurers cover the 50percent copayment has actually been in force since 1990,but inconsistently applied by Medicare carriers. As a resultof advocacy by the American Association for GeriatricPsychiatry (AAGP), the American Psychiatric Association(APA), the National Association of InsuranceCommissioners, the federal government, and others, thenew memorandum directly addresses the issue and shouldclarify once and for all that Medigap insurance is to coverthe 50 percent copayment. Your local Medicare carriershould have published listings of their Medigap partners.

Tips for Coinsurance Billing

Developing procedures that follow the suggestions belowshould help ensure appropriate reimbursement. Theprocess may be time consuming and, at times, frustrating,but if approached with diligence and organization, it canresult in proper reimbursement.

Verify the patient’s insurance informationThe billing information on the face sheet of the nursinghome chart may be incomplete or inaccurate. It may behelpful to verify the insurance company informationdirectly with the patient’s family or responsible party beforea claim is submitted. At each subsequent visit ask about,and note, any changes in a patient's insurance coverage.Individuals may change insurance companies or go onMedicaid or company policies may change.

Other Steps You Can Take to Ensure Payment

Communicate with the patient, family or guardian Encourage the patient to be your ally in dealing with theinsurer. Sometimes a phone call from them to theinsurance company will result in you getting paid. After all,they are the insurance company’s customers. Also, unlessyou have an agreement not to bill them, they are going toget the bill if the insurance company does not pay you.

The patient or family can help. Ifthe secondary insurance is througha person’s former employer, ask thepatient to contact the employer tofile a complaint. Remember theemployer is paying the insurancepremium, so a call from them tothe insurer may have more effectthan a call from you.

Write letters of complaintYou will need a written releasefrom the patient or legal guardianto write a letter of complaint. Youcan write to your state insurancecommissioner to complain abouthow your claim was handled by theinsurance company. You also canwrite to the attorney general inyour state if you believe thecompany is guilty of fraudulentpractices.

If the insurance is fromemployment and the patientcannot contact the employer, writeto the U.S. Department of Laborand include a copy of all of yournotes showing your attempts tocollect payment. Also, attach

billing summaries showing services provided, amountsbilled, and Medicare remittance notices indicating theamounts due from the patient’s coinsurance.

Notify the patient or their family about theirresponsibilities for payment Give your patient a notice about the 50 percent Medicarepsychiatric fee reduction. Have your patients sign a noticethat they have been informed of their responsibility for the50 percent copayment, if their coinsurance or secondaryinsurer does not pay you in a timely manner. Thisresponsibility notice indicates that even though you haveaccepted Medicare assignment, your acceptance of theirsecondary insurance has some limitations.

Dealing with Coinsurance Payers

File claims on timeTimely filing is vital for many secondary insurance policiesand companies. Some companies, such as Group HealthIncorporated (GHI) and Value Options, may have policiesthat will not pay any claim filed more than 90 days afterthe date of the Medicare payment. If a patient's bill is notpaid within 30 days of billing, call the insurance companyto verify that they did receive the claim.

Retain records of allcorrespondenceA company may indicate that theynever received the claim, or thatthe person or the service is notcovered or that they have eitheralready paid you or they havealready paid the patient.

Follow up with the secondaryinsurance companySecondary insurance usually payswithin 30 days. Some companiestake as long as 60 days to pay, butafter 30 days you should follow-up.Though your records may show aMedicare crossover billing tookplace, the secondary insurancecompany may tell you they neverreceived a bill. This can happeneven when a paper claim wassubmitted.

Secondary insurance may becarved out to a managed careorganization in which you do notparticipate. In addition, thesecondary mental health carve-outcompany may not pay for patientswith a diagnosis of dementia,while, at the same time, the patient's secondary insurancecompany does not pay for psychiatrists.

Watch for inconsistent practicesSometimes the insurance companies will pay for some daysof service and refuse to pay for other, identical, services.When you call again, you may get many different, or evencontradictory, explanations for denying the same claim.Some excuses include: “didn’t receive it,” “not eligible,”“need records sent,” or “Medicare already paid more thanthe insurance fee.” Sometimes they just do not process theclaim, but may fail to tell you so when you inquire, inhopes that you will not follow-up further.

12 Viable Long-Term Care Practice

Billing Codes for Long-Term Care

Service CPT Codes

NURSING HOME

Initial VisitsInitial psychiatric diagnostic 90801Initial inpatient consultation 99251-99255Initial nursing home visit 99301-99303

Subsequent VisitsPsychopharmacologic management 90862Subsequent nursing home visit 99311-99313

Subsequent inpatient consultation 99261-99263Individual psychotherapy with E&M 90817/90819

ASSISTED LIVING FACILITIES

Initial VisitsInitial psychiatric diagnostic evaluation 90801Domiciliary or rest home visit 99321-99323

Subsequent VisitsPsychopharmacologic management 90862 Individual psychotherapy w/E&M 90817/90819Domiciliary or rest home visit 99331-99333

NOTE: This information has been carefully reviewed and represents the most current opinions of this issue’s authors. However, please consult your local carrier as policies may vary. Table does not include office or other outpatient codes or home visit codes, which may be used by someproviders under some conditions (please see editor’s introduction and article by Dr. Anderson)

August 2004The CLINICAL VIEW Geriatric Psychiatry in Long-Term Care

Summary–Be ProactiveBe aware of some potential obstacles that you mayencounter. This will help you prepare claims correctly andreduce the frustrations of dealing with some insurancecompanies. Do not expect the insurance company to letyou know what is wrong with a claim. As the submitter,you need to be proactive and persistent.

• Always call the company.• Document to whom you spoke and exactly what

they told you. Get the person’s name. If they say there is no claim on file, get the fax number and verify the billing address.

• Fax the claim and then call to make sure it is received, even if you have a fax verification. Ask to fax the claim directly to the person with whom you are speaking.

• Call back in two weeks if you do not receive payment.

• Persistence counts. Companies usually record every telephone call with you. Again, get the representative’sname and keep notes.

• If, for some reason, they refuse to pay you, do not let it end there. Let them know you intend to file a complaint.

• Before filing a complaint, ask to speak to a supervisor and go up the chain of command within the company.

• Secondary insurance companies frequently delay payment by asking you for copies of your treatment notes, hospital records, and so forth. You must obtain these in a timely manner and comply with their request.

• You should already have a patient release of information on file for purposes of obtaining payment.

Bill the patientIf you make a good faith effort to bill and collect thisinsurance and still have not been paid (e.g., after 60 days,or 90 days, whichever you decide), then the patient'sacknowledgment that they are responsible for the paymentnow applies. If the coinsurance does not pay in a timelymanner, bill the patient. If the patient is covered byMedicaid, however, you cannot bill them for the 50percent copayment.

You are entitled to be paid for your work. You acceptedassignment of Medicare payment and are not permitted tobill the patient for the portion Medicare is supposed to pay,per the fee schedule. However, you are not required toaccept the secondary payment. You are doing that as acourtesy or because it is convenient, and it usually worksout. If the secondary insurance company does not pay as itshould, it will cost you time and money to pursue thisclaim. If you have persistent problems with a secondaryinsurance company, you may want to let the patient knowyou are going to bill them up front. Then, file a claim andreturn the money to the patient if you get paid.

Determine whether the patient received paymentThere are some companies that will only pay the patient,particularly if the services took place in an office. It is notuncommon for the patient to receive the copayment checkfrom the insurance company and then fail to turn it over toyou. This is especially common in nursing home practice.You may be in communication with one family memberwho serves as healthcare proxy or guardian. There may beanother person, not uncommonly in a distant state, whohandles the patient’s financial affairs. This person mayreceive your copayment check. They may not know what itis for or they may make no effort to give it to you unlessyou ask for it. You can determine whether this occurred bya follow-up telephone call to the insurance company. Toavoid this situation, it is wise to check ahead of time with anew patient’s insurance company to determine theirpolicies.

Waive the co-paymentFinally, you are permitted to waive collection of thecopayment, but only on a limited case-by-case basis. Youmust have some supporting documentation in your patientfile, e.g., that “after discussion with the patient of theirresponsibility for the Medicare 50 percent copayment, youhave agreed to waive collection of the copayment for thispatient because of the patient’s current economicsituation”.

13Viable Long-Term Care Practice

August 2004The CLINICAL VIEW Geriatric Psychiatry in Long-Term Care

14 Viable Long-Term Care Practice

August 2004Viable Long-Term Care Practice

The Clinical View, Volume 2, Issue 3

On the answer form located on the next page, please circle the letter thatcorresponds to the single most appropriate answer for each of thefollowing questions.

The deadline to receive credit is one calendar year from the date ofpublication. A CME Certificate will be sent to you, should you earn apassing grade of at least 70 percent.

1. For the purposes of billing, Medicare considers psychiatric careadministered in nursing homes to be:

A. An office visitB. A hospital stayC. An inpatient place of serviceD. An outpatient place of service

2. Generally, you must file claims with secondary insurance payers within:A. 30 daysB. 60 daysC. 90 daysD. Six months

3. If, after several attempts, you have been unable to collect on a claim,you should:

A. Ask your patient's family to interveneB. Write your state insurance commissionerC. Have your patient sign a clause acknowledging their responsibility

if the claim goes unpaidD. Drop your efforts because your staff has already spent too much

time trying to collect

4. One advantage of practicing in a long-term care setting is A. There is no problem with "no shows"B. The cost of delivering the serviceC. Medicare reimbursement is adequateD. Long-term patients also receive Medicaid, increasing the rate

of reimbursement

5. Stipends offered to psychiatrists practicing in a nursing home are rareopportunities because

A. Nursing homes are under pressure to keep costs downB. The same services are covered by MedicareC. A stipend does not "pay for itself" through fewer injuries and staff

hours lostD. They are not allowed under government regulations

6. The new place-of-service (POS) code for patients in assisted livingfacilities is

A. 9B. 11C. 13D. 15

7. Assisted Living Facility administrators in Michigan report the two mostcommon mental health problems among their patients are

A. Resistance and wanderingB. Depression and dementiaC. Schizophrenia and Alzheimer’s DiseaseD. Sexual disinhibition and screaming

8. The increased prevalence of depressive illness occurring in older adultsas they move from independent living to the more structured setting of thenursing home is:

A. 40 to 90 percentB. 10 to 40 percentC. 40 to 70 percentD. 50 to 80 percent

9. Of all ALF residents, the percentage of those who are self-paying is:A. 25 percentB. 33 percentC. 50 percentD. 75 percent

10. A national survey of ALFs estimates that the number of their residentswho suffer moderate or severe cognitive impairment is:

A. One-halfB. One-thirdC. One-fourthD. One-fifth

Relevance in your practice:Very Relevant Irrelevant5 4 3 2 1

Amount of knowledge gained:Great None5 4 3 2 1

Level of material presented:Too Advanced Too Simple5 4 3 2 1

Overall evaluation of activity:Excellent Poor5 4 3 2 1

Hour(s) spent reading this issue? (circle one)

1.0 1.25 1.5

Would you recommend this publication to a colleague?

Yes No

Ideas for future publications and/or your comments:

Viable Long-Term Care Practice: CME Self-Assessment Test Answer Form

Please circle the letter that corresponds to the single mostappropriate answer and fax this page to the American Associationfor Geriatric Psychiatry at 301-654-4137 or mail your response to:

American Association for Geriatric PsychiatryEducation Department7910 Woodmont Avenue, Suite 1050Bethesda, MD 20814

Expiration Date: August 2005

1. a b c d

2. a b c d

3. a b c d

4. a b c d

5. a b c d

6. a b c d

7. a b c d

8. a b c d

9. a b c d

10. a b c d

Fax: 301-654-4137

15Viable Long-Term Care Practice

Personal Information

I certify that I have completed this educational activity and test. Expiration date: August 2005

Name

Degree

Address

Address

City

State Zip

Phone Email

Activity Evaluation

You must complete this evaluation to ensure processing of your self-assessment test.

Please circle your answer.

Have the following educational objectives of this activity been met?

Describe the positive aspects of psychiatricconsultation in long-term care facilities.

Adopt strategies that will help ensure a fiscally viablenursing home practice.

Identify opportunities for geriatric psychiatry practice inAssisted Living Facilities, (ALFs).

Discuss mental health care practice challenges inserving assisted living residents.

Provide practical information for consumers evaluating ALFs.

Establish effective procedures to garner appropriatereimbursement from coinsurers.

Review methods that could improve collection ratesfor long-term care services.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Comments:

Personal Information/Evaluation/CME Self-Assessment Test Answer Form August 2004

Volume 2, Issue 4

Eclecticism in Nursing Home Psychiatry: Using Your Whole Bag of Tricks• Psychotherapy in the Nursing Home• Dealing with Difficult Personality Disorders• Behavioral Interventions

American Association for Geriatric Psychiatry7910 Woodmont Avenue, Suite 1050Bethesda, MD 20814

Upcoming Issues of The Clinical View: Geriatric Psychiatry in Long-Term Care