Anthem Blue Cross and Blue Shield
Medicaid (Anthem) Behavioral
Health Symposium
AKYPEC-0694-15
1
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
4
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.
6
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
7
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
8
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
9
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
10
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-nowfor-web-portal-access/
12
How to request an authorization
13
Authorization request forms
•
•
•
•
•
•
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
PF-AKY-0029-14
Coordination of Care F
14
KYKY_CAID_OTRForm
.pdf
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/publication
s/clinical_and_administrative_tools_guidelines/LOCUS%20Instru
ment%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
15
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
16
LOCUS
LOCUS2010.pdf
Dimensions (Scores 1-5)
1. Risk of harm
2. Functional status
3. Medical, addictive and psychiatric comorbidity
4. Recovery environment
a.
b.
Level of stress
Level of support
5. Treatment and recovery history
6. Engagement
17
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
18
ECSII
Dimensions (Scores 1-5)
1. Safety
2. Child-caregiver relationships
3. Caregiving environment
a.
b.
Environmental supports
Environmental stressors
4. Functioning (developmental status)
5. Impact of problems
6. Services profile
a.
b.
c.
Service involvement
Service fit
Service effectiveness
19
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
21
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
22
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
23
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
24
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
25
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
26
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)
27
Inpatient/ER covered procedure codes
Procedure
code
Service description
100, 114, 120,
124, 134
Authorization
requirement
Limitations
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
Crisis Stabilization (per
Per diem
day)
No
None
S9485
Time/
event
28
Inpatient/ER covered procedure codes
Procedure
code
Service
description
99217 - 99223
Initial Hospital Care
99231 - 99233
Subsequent Hospital
Care
Authorization
requirement
Limitations
Per CPT
guidance
Yes
None
Per CPT
guidance
Yes
Yes
Time/event
99234 - 99236
Observation Care
Per CPT
guidance
99238 - 99239
Discharge Day
Management
Per CPT
guidance
Yes
99251 - 99255
Initial Hospital
Evaluation
Per CPT
guidance
Yes
99281 - 99285
Emergency
Department Visit
Per CPT
guidance
No
None
None
None
None
None
29
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
Per diem
Term Residential, per diem
Yes
None
H0019
Behavioral Health Long
Per diem
Term Residential, per diem
Yes
None
30
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
31
Intensive outpatient program covered
procedure codes
Procedure
code
H0004
H0015
S9480
Service
description
Mental Health
Intensive
Outpatient
Program
Alcohol and/or
drug services;
intensive
outpatient
treatment, per
diem
Intensive
Outpatient
Service per diem
Time/event
Authorization
requirement
Limitations
15 minutes
Yes
Psychiatric DX
Only
Event
Yes
Substance Use
DX Only
Per diem
Yes
None
32
ECT covered procedure codes
Procedure
code
104
90870
Service
description
Anesthesia for
Electroconvulsive
Therapy
Electroconvulsive
Therapy
Time/event
Single seizure
Authorization
requirement
Limitations
Yes
Psychiatric DX
Only
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 addon code
Event
No
None
90832
Individual Psychotherapy,
20-30 min
16-37
minutes
No
None
35
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
Individual Psychotherapy,
38-52 minutes
45-50 min
No
None
90834
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
36
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
37
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 multiplefamily group)
Event
No
None
38
Outpatient covered procedure codes
Procedure
code
Service
description
Time/event
Authorization
requirement
Limitations
Event
No
None
15 minutes
No
None
96151
Assessment
Health/Behavior
Subsequent
15 minutes
No
None
90875
Biofeedback, 2030 minutes
20-30 minutes
No
None
90899
96150
Unlisted
Psychiatric
Service or
Procedure
Assessment
Health/Behavior
Initial
39
Outpatient covered procedure codes
Procedure
code
90876
90887
99408
99409
Service
description
Biofeedback, 4550 minutes
Collateral Service
Alcohol and
substance (other
than tobacco)
abuse structure
screening
Alcohol and
substance (other
than tobacco)
abuse structure
screening
Time/event
Authorization
requirement
Limitations
45-50 minutes
No
None
Event
No
None
15-30 minutes
No
None
30 or more
minutes
No
None
40
Outpatient covered procedure codes
Procedure
code
Service description
99354
Prolonged visit used in
conjunction with OP
CPT code, 60 minutes
30 -74
minutes
No
99355
Prolonged visit used in
conjunction with OP
CPT code, 30 minutes
30 minutes
No
15 minutes
No
None
15 minutes
No
None
G0442
G0443
Annual alcohol misuse
screening, 15 minutes
Brief face-to-face
behavioral counseling
for alcohol misuse
Time/event
Authorization
requirement
Limitations
1 unit per day
(allowed with
99355) and
90837
2 units per day
(allowed with
99354) and
90837; cannot be
reported without
99354
41
Outpatient covered procedure codes
Procedure
code
99201 - 99215
(with appropriate
add on codes)
Service
description
Medication
Management
Time/event
Per CPT
guidance
Authorization
requirement
Limitations
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);
42
Outpatient covered procedure codes
Procedure
code
Service description
Time/event
Authorization
requirement
Limitations
G0442
Annual alcohol misuse
screening, 15 minutes
15 minutes
No
None
Brief face-to-face
behavioral counseling for 15 minutes
alcohol misuse, 15 minutes
No
None
G0443
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
43
Outpatient covered procedure codes
Procedure
code
H0003
H0006
H0031
H0032
Service description
Alcohol and/or drug
screening; laboratory
analysis of specimens for
presence of alcohol and/
or drugs
Alcohol and/or drug case
management
Mental Health
Assessment by nonphysician
Mental Health Service
Plan Development by
non-physician
Time/event
Authorization
requirement
Limitations
Event
No
Substance Use
DX Only
Event
No
Substance Use
DX Only
Event
No
None
Event
No
None
44
Outpatient covered procedure codes
Procedure
code
H0038
H0040
H0046
H0047
H0050
Service
description
Self-help/peer
support; per 15
minutes
Assertive
Community
Treatment; monthly
Mental Health
Services NOS
Alcohol and/or drug
brief treatment
Alcohol and/or Drug
Service, Brief
Intervention; per 15
minutes
Time/event
Authorization
requirement
Limitations
15 minutes
No
None
Per month
Yes
1 unit per month
Event
No
None
Event
No
Substance Use
DX Only
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/therap
y (1 unit = 15
minutes);
H2011
Crisis Intervention
Services; per 15
Minutes
15 minutes
No
None
Q3014
Telehealth
Event
No
None
46
Outpatient covered procedure codes
Procedure
code
H2019
H2021
H2021 HM
H2021 HN
H2021 HS
Service
description
Therapeutic
Behavioral Services
Comprehensive
Community Supports
(per 15 minutes)
Community Support
Services:
Paraprofessional
Community Support
Services:
Professional
Community Support
Services: Parent to
Parent
Time/event
Authorization
requirement
Limitations
15 minutes
Yes
None
15 minutes
Yes
None
15 minutes
Yes
None
15 minutes
Yes
None
15 minutes
Yes
None
47
Outpatient covered procedure codes
Procedure
code
S5145
S9484
T1007
T1016
Service
description
Therapeutic
Foster Care
Crisis intervention
mental health
services; per hour
/Mobile Crisis
Alcohol and/or
substance abuse
services,
treatment plan
development and
/or modification
Case
management,
each 15 minutes
Time/event
Authorization
requirement
Limitations
Per diem
Yes
None
60 minutes
No
None
Event
No
Substance Use
DX Only
15 minutes
No
None
48
Outpatient covered procedure codes:
psychological testing
Procedure
code
Service description
Time/event
Authorization
requirement
Limitations
96101
Psychological Testing
60 minutes
Yes
None
60 minutes
Yes
None
60 minutes
Yes
None
60 minutes
Yes
None
60 minutes
Yes
None
96102
96103
96116
96118
Psychological Testing,
administered by
technician
Psychological Testing,
administered by a
computer
Neurobehavioral status
exam (clinical)
Neuropsychological
Testing
49
Outpatient covered procedure codes:
psychological testing
Procedure
code
96119
96120
Service
description
Neuropsych
Testing Admin by
Technician
Neuropsych
Testing Admin by
Computer
Time/event
Authorization
requirement
Limitations
60 minutes
Yes
None
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
50
Break for lunch
51
Behavioral Health
billing guidance
52
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
53
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.
54
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.
55
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
56
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) (9920199499)
• Medicine/psychiatry (90785-90911)
57
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
59
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).
61
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.
62
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
68
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
Licensure modifiers cont.
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)
Licensed Psychological
Practitioner (LPP)
Licensed Professional Clinical
Counselor (LPCC)
HO
Physician Assistant (PA)
U1
U8
Psychologist
AH
HO
Certified Alcohol & Drug Counselor U6
(CADC)
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
70
Modifier usage
Reimburse
/info
Service type modifier
(NOTE: Not all codes
within a section may
be affected)
E/M
Modifier
Description
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
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
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
E/M
71
Modifiers cont.
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
72
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; nonphysician
— 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
82
Examples coding from ICD-9-CM to ICD-10CM (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)
83
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
84
Place of service (POS)
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 FacilityPartial 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.
85
Forms
86
CMS 1450/UB04
• 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
87
CMS 1450
88
CMS 1500 (electronic version 837)
• 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
89
CMS 1500
90
Clinical edits
91
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
92
Code editing projects
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
EX Codes axx-dxx, N10
93
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
94
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
95
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.
96
Claim scenarios
97
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
98
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
99
Questions and
answers
100