Behavioral Health Billing and Coding Guide for Montana FQHCs & Primary Care Providers Virna Little, PsyD, LCSW-R, SAP, CCM Laura 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 (10 th 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 Components 1. Diagnosis 2. Assessment of Symptoms 3. Evidence Based Treatment 4. Progress Towards Plan Weave behavioral health into other CQI and compliance processes
Additional Considerations 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
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
Who pays you? Payer Mix
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 Spreadsheet Provider Title CODES ALL but BSW, Social Worker, Psychologist, Psychiatrist, Psychiatric NP, Psychiatric RN Licensed Counselor ONLY PA ONLY All Professionals 96150 96151 99366 99367 99368 98967 98968 90853 90791 90832 90834 90837 90853 99211 99213 99214 BSW • Medicaid • Medicare • Commercial Social W orker • Medicaid • Medicare • Commercial Psychologist • Medicaid • Medicare • Commercial Licensed Counselo r • Medicaid • Medicare • Commercial Psychiatrist • Medicaid • Medicare • Commercial Psychiatric NP • Medicaid • Medicare • Commercial Psychiatric PA • Medicaid • Medicare • Commercial RN • 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 Reimbursed as part of the prenatal care Management (E & M) visit code + the visit. HCPCS Code— H1005 (prenatal care, at Only reimbursed if provided with an E & risk enhanced service package) M visit or a significant procedure. Postpartum depression screening For a positive screening result, bill CPT Reimbursed in addition to the E &M Code G8431 along with the “HD” visit. Submit two claims— one for the E modifier. A documented follow-up plan & M visit and one for the screen. is required. Screening can be reimbursed up to three For a negative screening result, bill CPT times within the infant’s first year of life. Code G8510 with the “HD” modifier. CPT Code 99420 is no longer used
Medicare Components in Grid • Transitions of Care • Chronic Care Management • Collaborative Care
25 BHI Coding Summary Behavioral Health Care Activities Include: BHI Code Manager or Clinical Staff Threshold Time First 70 minutes per calendar • Initial Assessment CoCM First Month Outreach/engagement • month (G0502) (CPT 99492) • Entering patients in registry • Psychiatric consultation • Brief intervention • Tracking + Follow-up 60 minutes per calendar CoCM Subsequent • Caseload Review month Months (GO503) (CPT Collaboration of care team • • Brief intervention 99493) • Ongoing screening/monitoring • Relapse Prevention Planning Each additional 30 minutes • Same as Above Add-on CoCM (Any per calendar month month) (G0504) (CPT 99494) At least 20 minutes per • Assessment + Follow-up General BHI (G0507) Treatment/care planning • calendar month (CPT 99484) • Facilitating and coordinating treatment • Continuity of care
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