Behavioral Health Billing and Coding Guide for Montana

FQHCs & Primary Care Providers

Virna Little, PsyD, LCSW-R, SAP, CCMLaura 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 optimization

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 Components1. Diagnosis2. Assessment of Symptoms3. Evidence Based Treatment4. Progress Towards PlanWeave 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 SpreadsheetProvider Title CODES

All ProfessionalsALL but RN

BSW, Social Worker, Psychologist, Licensed Counselor ONLY

Psychiatrist, Psychiatric NP, Psychiatric PA ONLY

96150 96151 99366 99367 99368 98967 98968 90853 90791 90832 90834 90837 90853 99211 99213 99214

BSW• Medicaid• Medicare• CommercialSocial Worker• Medicaid• Medicare

• CommercialPsychologist• Medicaid• Medicare• CommercialLicensed Counselor• Medicaid• Medicare• CommercialPsychiatrist• Medicaid• Medicare• CommercialPsychiatric NP• Medicaid• Medicare• CommercialPsychiatric PA• Medicaid• Medicare• CommercialRN• 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 SummaryBHI 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 SubsequentMonths (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 of 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 of 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 or 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, or 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