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Anthem Blue Cross and Blue Shield Medicaid (Anthem) Behavioral Health Symposium

1 AKYPEC-0694-15

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 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


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


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

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• 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

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https://mediproviders.anthem.com/ky/pages/precert.aspx

https://mediproviders.anthem.com/ky/pages/precert.aspx

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-now-for-web-portal-access/

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http://www.availity.com/register-now-for-web-portal-access/

http://www.availity.com/register-now-for-web-portal-access/

How to request an authorization

13

Authorization request forms

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• 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

KYKY_CAID_OTRForm.pdf

PF-AKY-0029-14 Coordination of Care F

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/publications/clinical_and_administrative_tools_guidelines/LOCUS%20Instrument%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

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http://www.asam.org/

http://www.communitypsychiatry.org/aacpassets/docs/publications/clinical_and_administrative_tools_guidelines/LOCUS Instrument 2010.pdf



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

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LOCUS

Dimensions (Scores 1-5) 1. Risk of harm 2. Functional status 3. Medical, addictive and psychiatric comorbidity 4. Recovery environment

a. Level of stress b. Level of support

5. Treatment and recovery history 6. Engagement

LOCUS2010.pdf

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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

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ECSII

Dimensions (Scores 1-5) 1. Safety 2. Child-caregiver relationships 3. Caregiving environment

a. Environmental supports b. Environmental stressors

4. Functioning (developmental status) 5. Impact of problems 6. Services profile

a. Service involvement b. Service fit c. Service effectiveness

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Covered Behavioral Health services through the state of Kentucky (FFS)

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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

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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

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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

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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

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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

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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

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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)

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Inpatient/ER covered procedure codes

Procedure code Service description Time/

event Authorization requirement Limitations

100, 114, 120, 124, 134

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

S9485 Crisis Stabilization (per day) Per diem No None

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Inpatient/ER covered procedure codes

Procedure code

Service description Time/event Authorization

requirement Limitations

99217 - 99223 Initial Hospital Care Per CPT guidance

Yes None

99231 - 99233 Subsequent Hospital Care

Per CPT guidance

Yes None

99234 - 99236 Observation Care Per CPT guidance

Yes None

99238 - 99239 Discharge Day Management

Per CPT guidance Yes None

99251 - 99255 Initial Hospital Evaluation

Per CPT guidance Yes None

99281 - 99285 Emergency Department Visit

Per CPT guidance No None

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Residential covered procedure codes



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 Term Residential, per diem Per diem Yes None

H0019 Behavioral Health Long Term Residential, per diem Per diem Yes None

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Partial hospitalization covered procedure codes

Procedure code



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

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Intensive outpatient program covered procedure codes

Procedure code



H0004

Mental Health Intensive

Outpatient Program

15 minutes Yes Psychiatric DX Only

H0015

Alcohol and/or drug services;

intensive outpatient

treatment, per diem

Event Yes Substance Use DX Only

S9480 Intensive

Outpatient Service per diem

Per diem Yes None

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ECT covered procedure codes

Procedure code



104 Anesthesia for

Electroconvulsive Therapy

Yes Psychiatric DX Only

90870 Electroconvulsive Therapy Single seizure Yes Psychiatric DX

Only

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Targeted case management covered procedure codes

Procedure code



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

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Outpatient covered procedure codes



90791 Psychiatric Diagnostic Interview Event No None

90792 Psychiatric Diagnostic

Evaluation with Medical Services

Event No None

90785 Interactive complexity add-

on code Event No None

90832 Individual Psychotherapy, 20-30 min

16-37 minutes No None

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Procedure code Service description Time/event Authorization


90833 Psychotherapy 30

minutes add-on code to appropriate E/M code


90834 Individual Psychotherapy, 45-50 min 38-52 minutes No None




90837 Individual Psychotherapy, 60 minutes

53 or more minutes No None

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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

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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 multiple-family group)

Event No None

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Procedure code



90899

Unlisted Psychiatric Service or Procedure

Event No None

96150 Assessment

Health/Behavior Initial

15 minutes No None

96151 Assessment

Health/Behavior Subsequent

15 minutes No None

90875 Biofeedback, 20-30 minutes 20-30 minutes No None

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Procedure code



90876 Biofeedback, 45-50 minutes 45-50 minutes No None

90887 Collateral Service Event No None

99408

Alcohol and substance (other

than tobacco) abuse structure

screening


99409

Alcohol and substance (other

than tobacco) abuse structure

screening


40




99354 Prolonged visit used in

conjunction with OP CPT code, 60 minutes

30 -74 minutes No

1 unit per day (allowed with 99355) and

90837

99355 Prolonged visit used in

conjunction with OP CPT code, 30 minutes

30 minutes No

2 units per day (allowed with 99354) and

90837; cannot be reported without

99354

G0442 Annual alcohol misuse screening, 15 minutes 15 minutes No None

G0443 Brief face-to-face

behavioral counseling for alcohol misuse

15 minutes No None

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Procedure code



99201 - 99215 (with appropriate

add on codes)

Medication Management

Per CPT guidance 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);

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G0442 Annual alcohol misuse screening, 15 minutes 15 minutes No None

G0443 Brief face-to-face

behavioral counseling for alcohol misuse, 15 minutes

15 minutes No None

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

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H0003

Alcohol and/or drug screening; laboratory

analysis of specimens for presence of alcohol and/

or drugs

Event No Substance Use DX Only

H0006 Alcohol and/or drug case management Event No Substance Use

DX Only

H0031 Mental Health

Assessment by non-physician

Event No None

H0032 Mental Health Service Plan Development by

non-physician Event No None

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Procedure code



H0038 Self-help/peer support; per 15

minutes 15 minutes No None

H0040 Assertive

Community Treatment; monthly

Per month Yes 1 unit per month

H0046 Mental Health Services NOS Event No None

H0047 Alcohol and/or drug brief treatment Event No Substance Use

DX Only

H0050

Alcohol and/or Drug Service, Brief

Intervention; per 15 minutes

15 minutes No Substance Use DX Only

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Procedure code



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/therapy (1 unit = 15

minutes);

H2011 Crisis Intervention Services; per 15

Minutes 15 minutes No None

Q3014 Telehealth Event No None

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Procedure code



H2019 Therapeutic Behavioral Services 15 minutes Yes None

H2021 Comprehensive

Community Supports (per 15 minutes)

15 minutes Yes None

H2021 HM Community Support

Services: Paraprofessional

15 minutes Yes None

H2021 HN Community Support

Services: Professional

15 minutes Yes None

H2021 HS Community Support Services: Parent to

Parent 15 minutes Yes None

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Procedure code



S5145 Therapeutic Foster Care Per diem Yes None

S9484

Crisis intervention mental health

services; per hour /Mobile Crisis

60 minutes No None

T1007

Alcohol and/or substance abuse

services, treatment plan

development and /or modification

Event No Substance Use DX Only

T1016 Case

management, each 15 minutes

15 minutes No None

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Outpatient covered procedure codes: psychological testing



96101 Psychological Testing 60 minutes Yes None

96102 Psychological Testing,

administered by technician

60 minutes Yes None

96103 Psychological Testing,

administered by a computer

60 minutes Yes None

96116 Neurobehavioral status exam (clinical) 60 minutes Yes None

96118 Neuropsychological Testing 60 minutes Yes None

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Outpatient covered procedure codes: psychological testing

Procedure code



96119 Neuropsych

Testing Admin by Technician

60 minutes Yes None

96120 Neuropsych

Testing Admin by Computer

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

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Break for lunch

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Behavioral Health billing guidance

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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

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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.

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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.

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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

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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) (99201-

99499) • Medicine/psychiatry (90785-90911)

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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.

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• 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

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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

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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).

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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


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

70



Marriage and Family Therapist Associate (MFTA)

U4 Mental Health Associate (MHA) U5

Licensed Marriage & Family Therapist (LMFT)

HO Physician Assistant (PA) U1

Licensed Psychological Practitioner (LPP)

U8 Psychologist AH

Licensed Professional Clinical Counselor (LPCC)

HO Certified Alcohol & Drug Counselor (CADC)

U6

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

Licensure modifiers cont.

Modifier usage

71

Modifier Description

Reimburse/info

Service type modifier (NOTE: Not all codes within a section may be affected)

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 E/M

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 E/M

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

Modifiers cont.

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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

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; non-

physician — 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

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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-10-CM (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)

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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

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Place of service (POS)

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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 Facility-Partial 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.

http://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html






Forms

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CMS 1450/UB04

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• 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

CMS 1450

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CMS 1500 (electronic version 837)

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• 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

CMS 1500

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Clinical edits

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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

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Code editing projects

EX Codes axx-dxx, N10

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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

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

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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

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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.

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Claim scenarios

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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

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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

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Questions and answers

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