Behavioral Health Billing and Coding Guide for Montana FQHCs & - - PowerPoint PPT Presentation

Behavioral Health Billing and Coding Guide for Montana FQHCs & Primary Care Providers

Virna Little, PsyD, LCSW-R, SAP, CCM Laura Leone, MSSW, LMSW

Objectives

• Answer questions specific to FQHC and Primary

Care behavioral health provider sustainability

• Provide more detailed information on codes

available to optimize services clinically and financially

• Provide overview of billing terminology and

guidelines

• Understand billing guidelines tool

Primary Care & FQHC Billing Tip Sheets

Guide Sheet Categories

• Category ( type of code such as behavioral

health vs. care coordination)

• Code
• Payer ( Medicaid, Medicare, Commercial)
• Type of Provider
• Documentation requirements
• Comments

Billing Guideline Sheets

• Notice variations in payers and providers these

are important to pay attention too

• Commercial payers, while not major part of

payer mix important to optimize revenue

• Fee for Service codes vs “Process”
• Meant to be a guide, information changes often!

Suggestions for Use

• Make a list of all of the codes you are currently

using

• Compare to guide and review opportunities for
• ptimization

Current Procedural Technology (CPT)

• Common medical code set
• Developed by the American Medical Association
• Establishes standardization across insurers
• Updated regularly/annually
• Reflects the services performed by the

doctor/clinician/therapist, specifically what they do to assess, diagnose, or treat a condition

Knowing the Basics

• HCPCS—Healthcare Common Procedure Coding System

developed by CMS

– Level I codes for medical services, identical to CPT – Level II HCPCS codes are for products, supplies, and services not included in the CPT codes

• CPT is a 5-digit code. Examples:

– 99408: Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes. (99409: greater than 30 minutes)

• Guidelines in CPT manual instruct about when best to use certain

codes or multiple codes

• Modifiers – 2-digit add-ons to the CPT code

– May be numeric or alphanumeric – Allows for additional complexity and customization

More of the Basics

• HCPCS – Healthcare Common Procedure Coding System
• Used by Medicare and Medicaid
• Became universal when HIPPA became effective in 2002.
• www.hcpcs.codes provides look-up and coding procedures
• G Codes – Temporary codes assigned before CPT #
• H Codes – Alcohol and Drug Abuse Treatment

Services/Rehabilitative Services

• RBRVS – Resource-Based Relative Value Scale effective

1992, establishes Relative Value Units (RVUs for each CPT code adjusted by geography.

• ICD-10 – International Classification of Diseases (10th Edition)

released 2017 with updating coming on October 1, 2017 and will be called 2018 ICD-10-CM

Considerations

• Payer
• Licensure/ Staffing
• Organization Type ( substance use)
• Commonly used modifiers for billing
• AJ Clinical social worker Used to bill for services provided by a licensed

clinical social worker

• AF Psychiatrist Used to bill for services provided by a psychiatrist

Documentation

• Because the CPT code used for billing should most accurately

reflect the service rendered, the provider’s documentation must support its use

• Notes should thoroughly document what was done for the

patient and why. Examples of items to be covered:*

– Patient type (established or new) – Basis for treatment (assessed condition and history) – Why it’s medically necessary (likely progression of condition if left untreated) – Description of counseling and goal setting for plan of care – Start and end time of visit – Complexity and severity – Prescriptions – Other associated recommendations – Appropriate signatures

As Example

• Behavioral Health Codes (90832)
• Clinical Necessity ( most common issue)
• Four Components
• 1. Diagnosis
• 2. Assessment of Symptoms
• 3. Evidence Based Treatment
• 4. Progress Towards Plan

Weave behavioral health into other CQI and compliance processes

Licensed Addiction Counselors and Licensed Clinical Professional Counselors

• Medicare does not recognize counselors – they cannot be direct billed or

incident too billed or billed under another profession.

• Considerations for FQHC providers to add substance use to federal

scope as well as any state requirements for addiction counselors

• For LACs to be reimbursed, the primary care setting must be a rural

health clinic or be a State Approved Substance Use provider.

• Some third party payers recognize counselors, others do not, important

to review plan by plan and perhaps include in contracting

• LPC’s can use collaborative care codes for third party and Medicare but

cannot do individual visits unless third party payer allows

• LPC’s and LAC’s can provide transitions of care and chronic care

management services, with exception of provider visit

Additional Considerations

Providers in Training

• Recognized and billable by some third party

payers, should check with each individual plan

• Non prescribers cannot bill Medicare for in

training providers

• Some thoughts about how to use for billable and

include billable provider in session for documented amount of time ( i.e. treatment planning etc. vs. longer parts of assessment )

• Not billable to Medicaid in primary care setting

Payer Mix

Who pays you?

Know Your Payers !

• Know your payer mix
• Know what they pay for
• Know who they pay for
• Know how much you should get paid
• Know why the deny claims
• Know who credentials your providers

Payer Spreadsheet

Provider Title CODES

• Medicaid
• Medicare
• Commercial

• Medicaid
• Medicare
• Commercial

• Medicaid
• Medicare
• Commercial

• Medicaid
• Medicare
• Commercial

• Medicaid
• Medicare
• Commercial

• Medicaid
• Medicare
• Commercial

• Medicaid
• Medicare
• Commercial

• Medicaid
• Medicare
• Commercial

Workflows and Sustainability

• Often need to be modified based on

sustainability plan or efforts

• Workflows can also be used not just for clinical

services but for points in a process like prior authorizations or access initiatives

• Include codes in workflows and pathways

Pathways

Coding - Not Just for Money!

• Code for tracking and billing
• Coding helps paint the picture ( grant dollars)
• Quality dollars (advanced directives)
• Can you add to time and complexity

( social determinants)

• Do you have codes attached to all of

Screenings and tools ? Population Health Grant funding – external reporting

Screening Codes

• GO444 used for PHQ2
• G8510 used for PHQ9 with score <10
• G8431 used for PHQ9 with score ≥ 10
• Tool must be recorded in record.

Maternal Depression Screening

Type of Screening Billing Code Type of Reimbursement Prenatal depression screening Appropriate Evaluation and Management (E & M) visit code + the HCPCS Code— H1005 (prenatal care, at risk enhanced service package) Reimbursed as part of the prenatal care visit. Only reimbursed if provided with an E & M visit or a significant procedure. Postpartum depression screening For a positive screening result, bill CPT Code G8431 along with the “HD”

• modifier. A documented follow-up plan

is required. For a negative screening result, bill CPT Code G8510 with the “HD” modifier. CPT Code 99420 is no longer used Reimbursed in addition to the E &M

• visit. Submit two claims— one for the E

& M visit and one for the screen. Screening can be reimbursed up to three times within the infant’s first year of life.

Medicare Components in Grid

• Transitions of Care
• Chronic Care Management
• Collaborative Care

BHI Coding Summary

BHI Code Behavioral Health Care Manager or Clinical Staff Threshold Time Activities Include:

CoCM First Month

(G0502) (CPT 99492)

First 70 minutes per calendar month

• Initial Assessment
• Outreach/engagement
• Entering patients in registry
• Psychiatric consultation
• Brief intervention

CoCM Subsequent Months (GO503) (CPT

99493)

60 minutes per calendar month

• Tracking + Follow-up
• Caseload Review
• Collaboration of care team
• Brief intervention
• Ongoing screening/monitoring
• Relapse Prevention Planning

Add-on CoCM (Any month) (G0504) (CPT

99494)

Each additional 30 minutes per calendar month

• Same as Above

General BHI (G0507)

(CPT 99484)

At least 20 minutes per calendar month

• Assessment + Follow-up
• Treatment/care planning
• Facilitating and coordinating

treatment

• Continuity of care

25

Transitions of Care

• CPT Code 99495 covers communication with the patient or

caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves medical decision making

• f at least moderate complexity and a face-to-face visit within 14

days of discharge. The location of the visit is not specified. The work RVU is 2.11.

• CPT Code 99496 covers communication with the patient or

caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves medical decision making

• f high complexity and a face-to-face visit within seven days of
• discharge. The location of the visit is not specified.
• Helps to track transitions, prepare for VBP, puts a system in place as

well as some potential revenue.

CCM-99490

• Chronic care management services, at least 20

minutes of clinical staff time directed by a physician

• r other qualified health care professional, per

calendar month, with the following required elements:

• Multiple (two or more) chronic conditions expected

to last at least 12 months, or until the death of the patient,

• Chronic conditions place the patient at significant

risk of death, acute exacerbation/decompensation,

• r functional decline,
• Comprehensive care plan established, implemented,

revised,

• 90791- Diagnostic Evaluation/Intake
• 90832 - Psychotherapy, 30 minutes
• 90834 - Psychotherapy, 45 minutes
• 90837 - Psychotherapy, 60 minutes
• 90839 - Psychotherapy for crisis
• 90853 – Group Psychotherapy
• 90846 – Family/Couples Psychotherapy w/o
• 90847 - Family/Couples Psychotherapy w/ Pt

Common Billing Codes for Therapy

• 90792- Psychiatric Evaluation
• 99212 -Medication Management
• 99213 - Medication Management
• 99214 - Medication Management
• Use above E&M Codes and then add on a

therapy code if needed

Common Billing Codes for Psychiatry

SBIRTing Much?

• Screening – H0049
• Brief Interventions- documentation is key !
• Referral – how can you track them both internal

and external?

• Treatment – internal or external, perhaps

consults

• SBIRT Codes vs different pieces-

Often viewed all or nothing !

What is a

• A 90839!
• May not need authorization
• Discontinue 60 minute visits that are not a crisis
• Helps with VBP
• Again, helps to paint the picture!
• Use add on code with
• 90840 for each additional 30 minutes beyond

the first 74 minutes

Upcoming Webinars

• Implementing Collaborative Care

Part 1:

• Friday May 25th 11-12pm MST
• Implementing Collaborative Care

Part 2:

• Wednesday June 20th 2-3pm MST
• Suicide safer care
• Tuesday July 17th 1:30-2pm MST

Questions/Thoughts

Virnalittle@msn.com LauraL@TheNationalCouncil.org