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THE MOST BASIC FUNDAMENTALS

A. Codes are assigned as a method of recording:

• The reason for a visit (diagnosis codes)

• The work performed during a visit (CPT & HCPCS codes)

• Any consideration for third‐party reimbursement

B. Assignment of codes can be complicated and many variables may apply to code selection.

C. Ultimately, it is the responsibility of the clinician to assure that proper codes are assigned for their services.

D. Codes assigned must be a mirror‐image match between code and information documented in the medical record.

WHO PAYS WHAT?

Remember – the diagnosis code must represent diagnoses evaluated today and CPT codes represents work performed today.

Sometimes services are provided for which there will be no payment.

The presence of a code is not a payment guarantee.

Third‐party payers may decide what they will and what they will not reimburse Decision based on:

a. what services, [codes]

b. which professionals [credentials]

MEDICARE /MEDICAID FQHC ENCOUNTER

Billable FQHC encounters (visit) are:

- Medically necessary and between a core provider and a patient

FQHC core services – Physician services, including costs for contracted physician services, to the extent covered in Washington

statute and administrative code. Contracted physicians must be identified in the FQHC’s Core Provider Agreement. The contracted physician must be a preferred provider and receive an identification number from the Provider Enrollment Section at the Agency.

Mid-Level Practitioner (PAs, ARNPs and CNMs) services – To the extent covered in Washington statute and administrative code, including costs for contracted mid-level practitioner services.

Clinical Psychologist services – Per the medical mental health benefit for individuals not eligible for the RSN Access to Care Standards OR the mental health benefit for services provided through an RSN contract for individuals meeting the RSN Access to Care Standards.

Licensed Clinical Social Worker services (LCSWs) – Per the medical mental health benefit for individuals not eligible for the RSN (Regional Support Network) Access to Care Standards OR the mental health benefit for services provided through an RSN contract for individuals meeting the RSN Access to Care Standards.

Visiting Nurse Home Health services (in designated areas where there is a shortage of home health agencies) – To the extent covered in Washington statute and administrative code.

Non-Billable FQHC encounters (visit) are:

• Medically necessary

• Provided by a non-core FQHC provider

• Follow documentation guidelines for provider services

• Billed out as a BH001 zero charge code for all psych services

Common misconception:

- “If we aren’t billing for it, I don’t need to document”.

False! – Any patient encounter requires proper charting regardless of reimbursement. If documentation is missing the billing department will send a worklog task requesting completion.

MEDICARE /MEDICAID FQHC ENCOUNTER

PSYCHOTHERAPY TIPS ON TIME

Document actual time in all records

• Face‐to‐face time is actual time

• No extra for pre‐ or post‐service work

Consider modifiers:

• 52 if time less than code specifies

• 22 if time greater than code specifies

BIG CHANGES IN PSYCHIATRY CODING

C P T C O D E S F R O M

P A S T Y E A R S

90801

&

90802Old Psychiatric

Diagnostic Interview

Examinations

C O M M O N N E W C P T C O D E S

90792 Psychiatric Dx. Evaluation medical

Psychiatric Diagnostic Evaluation

with medical service by MD, DO, NP, or PA

May add 90785 Interactive Complexity

90791

Psychiatric Dx. Evaluation non-medical

May add 90785 Interactive Complexity

BIG CHANGES IN PSYCHIATRY CODINGC P T C O D E S F R O M

P A S T Y E A R S

90862Old "Medication

management"

C O M M O N N E W C P T C O D E S

99201-99215 E/M Codes

Medical clinicians may assign CPT E/M visit codes

based on history, exam and MDM or qualifying time.

Note: E/Ms coded with a Psychotherapy code today may not be coded based on time.

BIG CHANGES IN PSYCHIATRY CODING

90805 90807 90809

Old Psychotherapy with

medical evaluation and

management

90833 - 30 min90836 - 45 min90838 - 60 min

May add E/M based on Hx/Ex/MDM

Psychotherapy provided

by MD, DO, NP or PA

C P T C O D E S F R O M

P A S T Y E A R S

C O M M O N N E W C P T C O D E S

BIG CHANGES IN PSYCHIATRY CODING

90804 90806 90808

Old Psychotherapy without

medical evaluation and

management

90832 - 30 min90834 - 45 min90837 - 60 min

May add E/M based on Hx/Ex/MDM

Psychotherapy provided

by MD, DO, NP or PA

C P T C O D E S F R O M

P A S T Y E A R S

C O M M O N N E W C P T C O D E S

• INTERACTIVE COMPLEXITY +90785ADD ON CODEREFERS TO SPECIFIC COMMUNICATION FACTORS THATCOMPLICATE THE DELIVERY OF A PSYCHIATRIC SERVICE.

COMMON FACTORS INCLUDE MORE DIFFICULT COMMUNICATIONWITH DISCORDANT OR EMOTIONAL FAMILY MEMBERS ANDENGAGEMENT OF YOUNG AND VERBALLY UNDEVELOPED ORIMPAIRED PATIENTS.

TYPICAL PATIENTS HAVE THIRD PARTIES SUCH AS PARENTS,GUARDIANS, OTHER FAMILY MEMBERS, INTERPRETERS,LANGUAGE TRANSLATORS, COURT OFFICERS…SCHOOLS INVOLVEDIN THEIR PSYCHIATRIC CARE.

BIG CHANGES IN PSYCHIATRY CODING

REFERENCES AND MATERIALS

Federally Qualified Health Centers (FQHC) Medicaid Provider Guide

http://hrsa.dshs.wa.gov/billing/fqhc.html

http://codinghelp.com/

http://codinghelp.com/downloads/

Billing/Coding Downloadable Documents