Coding and Compliance Training

Coding and Compliance TrainingPsychiatrists

Objectives

Remember the principles of compliance and their importance to your practice

Review teaching physician rules

Assure knowledge to appropriately document and bill in Psychiatry

School of Medicine Compliance 843-8638

Compliance is important to reimbursement

Providing medically necessary services

Meeting documentation requirements

Understanding appropriate billing

Understanding and applying coding and compliance conventions improves reimbursement and the quality of the medical record documentation.

Providing good care while billing accurately and confidently requires:


Good documentation and billing practices make for good patient care.

Who’s Looking:

Recovery Audit Contractors (RACS)—Medicare, Medicaid and commercial insurers pay third party contractors to recoup inappropriately documented or billed services

Office of Inspector General (OIG), Health & Human Services—works with the Department of Justice to investigate suspected abuse or fraudulent claims

Routine error rate testing and auditing programs

Compliance is important to reimbursement


Types of Psychiatric Services

Psychiatric diagnostic evaluation

Evaluation and Management services (E&Ms)

Psychotherapy

– Individual

– For crisis

– Group settings

Procedures/other


Psychiatric Diagnostic Evaluation with Medical ServicesCPT Code 90792

Must include documentation of: History Mental status Indicated physical exam elements Recommendations

Also includes, as appropriate: Communicating with family or other sources Ordering and/or reviewing of diagnostic studies


90792 is a comprehensive service used once per evaluation (even if two sessions are required)

If reported more than once per episode of illness, documentation is required to establish medical necessity.

May not be reported on the same day as an E&M service or psychotherapy

In certain, rare circumstances family members, guardians, or significant others may be seen in lieu of the patient.


Psychiatric Diagnostic Evaluation-CPT Code 90792

For Interactive Complexity—add code 90785

Reports additional work due to specific communication factors that complicate the delivery of a psychiatric procedure

Interactive complexity factors are typically present with patients who:have individuals legally responsible for their care such as minors or adults

with guardians request others to be involved in their care during the visit or require the involvement of third parties such as child welfare agencies

At least one of the following must be present:Need to manage maladaptive communicationCaregiver emotions or behavior that interfere with caregivers assistance in

implementing the treatment plan Evidence or disclosure of a sentinel event and mandated report to third partyUse of play equipment, other physical devices, interpreter or translator for a

patient who — Is not fluent in the language of the physician— Hasn’t developed or has lost expressive language skills or receptive

communication skills to understand the provider


Psychotherapy – for billing purposes

Defined as the treatment for mental illness and behavioral disturbances in which the therapist, through definitive therapeutic communication, attempts to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development.

Includes ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement of family member(s) or others in the treatment process.

Maintenance psychotherapy is not usually covered. Well-documented sessions for helping a patient maintain his/her highest level of functioning, such as a patient with borderline personality disorder, may be covered on a case-by case basis.


Documentation of Psychotherapy Services

The note for each encounter must include:

The amount of time spent in psychotherapy,

The therapeutic maneuvers employed during the session such as behavior modification, supportive, or interpretive interactions and

The purpose of the psychotherapy

Additionally, a periodic summary of goals, progress towards goals, and an updated treatment plan must be included in the medical record


Psychotherapy without medical evaluation and management services:

90832 (16-37 minutes)90834 (38-52 minutes)90837 (53 or more minutes)

Psychotherapy time may include face to face time with family members as long as the patient is present for part of the service.

Do not bill psychotherapy codes for sessions less than 16 minutes duration.

Interactive complexity is reported by also billing 90785

Psychotherapy Services


Psychotherapy with evaluation and management services are reported with an E&M service and a psychotherapy add-on code:

90833 (16-37 minutes)90836 (38-52 minutes)

90838 (53 or more minutes)

If less than 16 minutes, no psychotherapy is billable.

E&M with Additional Psychotherapy Services


E&M service with Psychotherapy

Requires differentiating E&M history gathering, physical exam and decision making from psychotherapy

The time spent in psychotherapy must be documented separately from the E&M service.

Example documentation:

“The patient was seen for a total of 50 minutes. 25 Minutes was spent in psychotherapy. The psychotherapy was supportive in nature with the goal of continuing remission of the patient’s depressive symptoms and to help the patient in coping with his cognitive deficits.“


The E&M level is chosen before the amount of time spent in psychotherapy.

Psychotherapy inherently includes some ongoing assessment

An E&M service with psychotherapy may not be billed based on time counseling.

Prolonged services may not be reported with an E&M and psychotherapy.

The OIG is actively reviewing E&Ms with psychotherapy for appropriate documentation



In most cases, the level of E&M service when billed with a psychotherapy add-on is expected to be a lower level than an E&M service without psychotherapy because the frequency of evaluation of the patient when psychotherapy is

part of the treatment plan psychotherapy includes ongoing assessment that may not be also

billed as E&M services

Benchmark data from academic psychiatrists compiled by the Association of American Medical Colleges shows over 50% are billed at 99213 when psychotherapy is also performed:


99211 99212 99213 99214 99215

2.1% 17.6% 54.4% 24.9% 0.9%


Billing Psychotherapy with an E&M service


Choosing the Correct Outpatient Category

Outpatient E&M Categories• Consultation• New• Established


Use of Consultation Codes

Outpatient Consult Codes: 99241-99245

Use when expert opinion or advice is requested by an appropriate source involved in patient’s care

Does not include patients “referred for management of a condition” or self referred

Use outpatient consultation codes only one time per request, subsequent visits are established

Written or verbal request must be documented in the rendering providers note and the consultant's opinion communicated by written report to the requesting provider.


Documenting Consultations

Documentation of a consultation request must be clearly

stated in the note:

WRONG: Mr. Patient referred by Dr. Jones for

management of GERD symptoms.

RIGHT: “Mr. Patient is seen in consultation at the

request of Dr. Jones for evaluation of abdominal pain.”


New Patient

New Patient CPT codes: 99201-99205

Has not received any professional evaluation and management (E&M) services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years, including inpatient, outpatient or emergency room.

A patient would still be considered “new” if a diagnostic procedure was billed without an E&M visit charge.


Established Patient

Established Patient CPT codes: 99212-99215

Has received an E&M service from the division

within the past three years—any venue inpatient,

emergency room or consultations


Visit Components

Consults and new patient visits must include all three of the following components – established patient visits must include any two of the three:

History– History of present illness Documenting History

– Review of systems History example

– Past family and social history

Physical examination 1995 Physical Exam

1997 Single Organ Exams

Medical decision Making– Diagnosis and management options Documenting MDM

– Amount and complexity of data reviewed– Overall risk Risk Table

Click these links for more information


Psychotherapy for crisis

Psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status exam and a disposition.

The treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma.

The presenting problem is typically life threatening or complex and requires immediate attention to a patient in high distress.

Report the total duration of time face to face with the patient and/or with the family.

The patient must be present for at least some portion of the service.


90839 is billed for the first 60 minutes

Add 90840 for each additional 30 minutes after the initial hour

Psychotherapy for crisis of less than 30 minutes is reported with standard psychotherapy codes


Psychotherapy for crisis

The following services are not time-based:

Family psychotherapy - medically necessary treatment of the family unit when maladaptive behaviors of family members are exacerbating the patient’s illness in the treatment process.

90846 without the patient present

90847 patient and family

90849 multiple family group psychotherapy

90853 Group psychotherapy - personal and group dynamics are discussed, allowing emotional catharsis, instruction, insight and support

90845 Psychoanalysis (not reimbursed by most insurers)


Other Psychotherapy Services

Psychotherapy is not covered if:

Documentation indicates that dementia has caused significant cognitive deficiency to prohibit establishing a therapeutic relationship.

Patient suffers from profound mental retardation.


Psychotherapy services

Clinical Psychologists may bill:

96101 – Psychological testing (includes assessment of emotionality, intellectual abilities, personality and psychopathology, eg MMPI, Rorschach, WAIS)

96116 – Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg acquired knowledge, attention, language, memory, planning and problem solving and visual spatial abilities.

96118 – Neuropsychological testing (eg Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test)

96125 – Standardized cognitive performance testing (eg Ross Information Processing Assessment)


Central Nervous System Assessments

It is expected that the administration of these tests will generate material that will be formulated into a report.

A minimum of 31 minutes must be provided to report any of the testing “per hour” codes (psychologist’s or physician’s time)

Bill both time spent face-to-face with the patient and interpreting and preparing the report

Bill the quantity of hours spent


Central Nervous System Assessments

Medicare’s Teaching Physician (TP) Attestation Requirement

The teaching physician (TP) does not have to duplicate any resident documentation.

The TP must be present during performance of the resident’s key portions of the service or personally repeat the key portions

The TP must personally document his or her presence for E&M services.

Documentation by a resident of the presence and participation of the TP is not sufficient.

The resident note alone, the TP note alone or a combination of the two may be used to support the level of service billed.

Documentation may be dictated and typed, or a computer-inserted statement if it is initiated by the TP.


Medicare’s Examples of Unacceptable TP notes

1. "Agree with above." followed by legible countersignature or identity;

2. "Rounded, Reviewed, Agree." followed by legible countersignature or identity;

3. "Discussed with resident. Agree." followed by legible countersignature or identity;

4. "Seen and agree." followed by legible countersignature or identity; 5. "Patient seen and evaluated." followed by legible countersignature

or identity; and 6. A legible countersignature or identity alone.

The preceding six and similar statements don’t make it possible to determine whether the TP was present, evaluated the patient, and/or had any involvement with the plan of care.


Medicare Guidelines for Supervision of Psychotherapy

• The TP presence requirement met by concurrent observation of the service by video or one-way mirror.

• Must be present for entire period of time billed if psychotherapy code is used.


Medicaid Requirements

Medicaid requires that the TP be "immediately available" to the

resident and patient and use "direct supervision". Direct supervision

does not necessarily mean that the TP must be present in the room

when the service is performed. The degree of supervision is the

responsibility of the TP and is based on the skill, level of training and

experience of the resident as well as the complexity and severity of

the patient's condition. Written documentation in the medical

record for Medicaid patients must clearly designate the supervising

physician and be signed by that physician.


Where To Get Help

• http://www.med.unc.edu/compliance

• School of Medicine Compliance Office 919-843-8638

Heather Scott, CPC, SOM Compliance Officer

Dana Petty, CPC, SOM Compliance Review Analyst

Nirmal Gulati, MS, CPC, SOM Compliance Auditor

Tracy Riggs, FNP, SOM Compliance Consultant


Documents

Coding and Compliance Training