WHATS MY CODE? CODING CASE STUDIES ONP EDUCATION CONFERENCE - PowerPoint PPT Presentation

WHAT’S MY CODE? CODING CASE STUDIES ONP EDUCATION CONFERENCE OCTOBER 2018

DIS CLAIMER Neither the presenter nor HealthCare Management Consultants, Inc have any relevant relationships or potential conflicts of interest to disclose. HEALTHCARE MANAGEMENT CONS ULTANTS , INC 2

AGENDA  Medical Necessity  Coding Guidelines for New and Established Patients  Coding Guidelines for Psychotherapy  Time Coding  What Auditors Look For  Other Documentation Issues  Case S tudies HEALTHCARE MANAGEMENT CONS ULTANTS , INC 3

MEDICAL NECES S ITY Per Medicare: "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.“ “Furthermore, all services must be sufficiently documented so the medical necessity is clearly evident. Medicare cannot pay for services for which the documentation does not establish the medical necessity.” HEALTHCARE MANAGEMENT CONS ULTANTS , INC 4

NEW P ATIENT E/ M CODES CODE HISTORY EXAM MEDICAL (1997 Guidelines) DECISION MAKING Primary Behavioral Care Health 99201 Chief complaint 1-5 bullet 1-5 bullet pts S traightforward 1-3 HPI pts Chief complaint 99202 6-11 bullet 6-8 bullet pts S traightforward 1-3 HPI pts 1 ROS Chief complaint 99203 12-17 bullet Minimum 9 Low Complexity >4 HPI* pts bullet pts 2-9 ROS 1 element PFSH 99204 Chief complaint 9 systems, Comprehensive Moderate >4 HPI* 2 bullet pts Exam Complexity Minimum 10 ROS in each of 9 99205 High Complexity 1 element each: PFSH systems HEALTHCARE MANAGEMENT CONS ULTANTS , INC 5 * Or status of 3 chronic conditions

NEW P ATIENT E/ M CODES The level of service is based on how the provider scores in all three key component category The lowest completed key component controls the level of the code For example, if the exam supports 99201, then 99201 is reported, even if the history and decision making support 99204 A new patient is a patient who either has never been seen in the practice before or has not seen a provider in the practice of the same specialty within the past three years HEALTHCARE MANAGEMENT CONS ULTANTS , INC 6

CODING GUIDELINES : PS YCHIATRIC DIAGNOS TIC EVALUATIONS  90791 - Psychiat ric diagnost ic evaluat ion  90792 - Psychiat ric diagnost ic evaluat ion wit h medical services Code 90791 report s a psychiat ric diagnost ic int erview exam including a complet e medical and psychiat ric hist ory, a ment al st at us exam, ordering of laborat ory and ot her diagnost ic st udies wit h int erpret at ion, and communicat ion wit h ot her sources or informant s. The psychiat rist t hen est ablishes a t ent at ive diagnosis and det ermines t he pat ient 's capacit y t o benefit from psychot herapy t reat ment . The pat ient 's condit ion will det ermine t he ext ent of t he ment al st at us exam needed during t he diagnost ic int erview. In det ermining ment al st at us, t he doct or looks for sympt oms of psychopat hology in appearance, at t it ude, behavior, speech, st ream of t alk, emot ional react ions, mood, and cont ent of t hought s, percept ions, and somet imes cognit ion. The diagnost ic int erview exam is done when t he provider first sees a pat ient , but may also be ut ilized again for a new episode of illness, or for re-admission as an inpat ient due t o underlying complicat ions. When a psychiat ric diagnost ic evaluat ion is performed alone, report code 90791. When medical services are provided in conj unct ion wit h t he psychiat ric diagnost ic evaluat ion, report code 90792. HEALTHCARE MANAGEMENT CONS ULTANTS , INC 7

RVU COMP ARIS ONS New Patient Psychiatric Diagnostic E/ M Codes Evaluation Codes Code RVU Code RVU 99201 1.23 90791 3.58 99202 2.10 90792 3.97 99203 3.04 99204 4.64 99205 5.82 HEALTHCARE MANAGEMENT CONS ULTANTS , INC 8

90791-90792 DOCUMENTATION EXPECTATIONS Date of service Legible documentation • • Chief complaint Authentication by the provider • • History of present illness For 90792, medical • • management documentation is Review of systems • also required Family and psychosocial • history Complete mental status exam • Assessment/Plan • Identified goals of treatment • Plan for follow-up • HEALTHCARE MANAGEMENT CONS ULTANTS , INC 9

ES TABLIS HED P ATIENT E/ M CODES CODE HISTORY EXAM (1997 Guidelines) MEDICAL DECISION Primary Behavioral MAKING Care Health 99211 May not require presence of a physician 99212 Chief complaint 1-5 bullet 1-5 bullet pts S traightforward 1-3 HPI pts 99213 Chief complaint 6-11 bullet 6-8 bullet pts Low Complexity 1-3 HPI pts 1 ROS 99214 Chief complaint 12-17 bullet Minimum 9 Moderate >4 HPI* pts bullet pts Complexity 2-9 ROS 1 element PFSH 99215 Chief complaint 9 systems, Comprehensive High Complexity >4 HPI* 2 bullet pts Exam Minimum 10 ROS in each of 9 1 element each: PFSH systems HEALTHCARE MANAGEMENT CONS ULTANTS , INC 10 * Or status of 3 chronic conditions

Examples: New Problems Examples: Follow-Up Problems Scenario Level of Decision Scenario Level of Decision Making Making New problem, Low complexity Follow-up singular stable Straightforward acute or improved problem uncomplicated Follow-up singular Low complexity New problem, Moderate problem w exacerbation acute complexity Follow-up two problems, Low complexity complicated both stable or improved New patient, Moderate Follow-up two problems, Moderate complexity exacerbation complexity one or both mildly chronic problem exacerbated New patient, High complexity Follow-up 3 problems, Moderate complexity suicidal ideation stable or improved Follow-up 3 problems, one Moderate complexity or more mildly exacerbated Follow-up 2 problems, High complexity both severely exacerbated HEALTHCARE MANAGEMENT CONS ULTANTS , INC 11 (i.e. suicidal)

ES TABLIS HED P ATIENT E/ M CODES The level of service is based on the level of medical decision making supported by either the history and/ or exam Coding Tip: Accomplish Determine whatever your level of S upport it level of medical with your exam is decision history clinically making appropriate HEALTHCARE MANAGEMENT CONS ULTANTS , INC 12

E/ M TIME CODING When more than half of the encounter is counseling and/or coordination of care, the encounter may be coded based on time Code Typical Time Code Typical Time 99201 10 minutes 99211 5 minutes 99202 15 minutes 99212 10 minutes 99203 30 minutes 99213 15 minutes 99204 45 minutes 99214 25 minutes 99205 60 minutes 99215 40 minutes HEALTHCARE MANAGEMENT CONS ULTANTS , INC 13

E/ M TIME CODING DOCUMENTATION REQUIREMENTS Clinical documentation as appropriate to support the medical necessity of the encounter and time spent providing it The total face to face time with the billing provider The fact that more than half of the encounter was counseling (or was coordination of care, or both) The nature of the counseling (if coordination of care, the nature of the coordination of care; if both, then documentation of both the counseling and the coordination of care) Example: “ I spent 25 minutes face to face with the patient, more than half of that time was spent counseling the patient on coping strategies” HEALTHCARE MANAGEMENT CONS ULTANTS , INC 14

BEHAVIORAL HEALTH ES TABLIS HED P ATIENT ENCOUNTERS  Psychotherapy  Coded based on time spent in psychotherapy  E/ M Code  Based on key components; or  Based on time  E/ M Code + Psychotherapy  E/ M code based on key components; and  Psychotherapy code based on time spent in psychotherapy HEALTHCARE MANAGEMENT CONS ULTANTS , INC 15

P ATIENT PRES ENCE  E/M codes have an expectation of the patient presence  Psychiatric Diagnostic Evaluation codes state that other informants may be seen in lieu of the patient  Individual psychotherapy codes require that the patient be present for most or all of the encounter HEALTHCARE MANAGEMENT CONS ULTANTS , INC 16

PS YCHOTHERAPY CODES Code Description Time Requirement 90832 Psychotherapy, 30 minutes with patient 16-37 minutes 90833 Psychotherapy, 30 minutes with patient when performed with 16-37 minutes an evaluation and management service 90834 Psychotherapy, 45 minutes with patient 38-52 minutes 90836 Psychotherapy, 45 minutes with patient when performed with 38-52 minutes an evaluation and management service 90837 Psychotherapy, 60 minutes with patient >53 minutes 90838 Psychotherapy, 60 minutes with patient when performed with >53 minutes an evaluation and management service HEALTHCARE MANAGEMENT CONS ULTANTS , INC 17

PS YCHOTHERAPY CODES Date of Service Time spent in psychotherapy Type of therapeutic intervention Documentation of intervention Target symptoms Diagnoses Progress toward treatment goals Status Legible signature HEALTHCARE MANAGEMENT CONS ULTANTS , INC 18

OTHER CODING IS S UES  Cloning  Inconsistent documentation  Gender accuracy  Grammar  Encounter is accurate to the patient and to the encounter HEALTHCARE MANAGEMENT CONS ULTANTS , INC 19