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Coding for Mental Health in Today's Environment

•Evaluation and management
•Psychiatric services
•Diagnosis coding
•Documentation patterns
•DSM-IV vs. ICD-10-CM
•Nurse practitioner (NP)/physician assistant (PA) scope and supervision requirements
•Payer guidelines regarding billing for NP and PA
•Compensation/RVU methodology overview

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Coding for Mental Health in Today's Environment

  1. 1. Wednesday, May 17, 2017 FLORIDA COUNCIL FOR COMMUNITY MENTAL HEALTH Coding for Mental Health in Today’s Environment
  2. 2. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 1 Objectives  Evaluation and management (E/M) overview  Psychiatric services  Diagnosis coding  Documentation patterns  DSM-IV vs. ICD-10-CM  Nurse practitioner (NP)/physician assistant (PA) scope and supervision requirements  Payer guidelines regarding billing for NP and PA  Direct Billing  Incident-To Billing  Split/Shared Billing  Compensation/RVU methodology overview
  3. 3. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 2 Factors Influencing Provider Coding • Education  Knowledge base of educator  Time allowance/attention span  Method of teaching  Shadowing, web-based, in-person, individual, group  Method of learning  Repetitive, personal  Incentives  wRVU-based compensation  Bonuses
  4. 4. Evaluation and Management (E/M) Overview E/M Fundamentals
  5. 5. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 4 E/M Correct Coding  Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a Current Procedural Terminology (CPT)1 E/M code  It would not be medically necessary or appropriate to bill a higher level of E/M 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 1 Current Procedural Terminology (CPT® or CPT) is a registered trademark of the American Medical Association (AMA).
  6. 6. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 5 E/M Correct Coding (cont.)  Documentation should support the level of service performed and reported  The service should be documented during its performance, or as soon as practical after it is provided, in order to maintain an accurate medical record  The final E/M selection is not just about time Source: Pub 100-04, Ch 12, 30.6.1 - Selection of Level of Evaluation and Management Service (A. Use of CPT Codes)
  7. 7. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 6 E/M Elements  Key Elements  History  Exam  Medical Decision Making (MDM)  Contributory Elements  Counseling  Coordination of care  Nature of presenting problem  Time
  8. 8. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 7 Documentation Requirements  History of Present Illness (HPI)  A chronological description of the development of the patient’s illness from the first sign and/or symptom to present; often an area resulting in coding errors  Brief (one to three elements) or expanded (four or more elements)  Review of Systems (ROS)  A list of questions, arranged by organ system, designed to uncover dysfunction and disease  Problem pertinent (focused on issue only), expanded (two to nine systems), or complete (10 or more systems)  Past, Family, Social, History  Questions asked and answered to discover contributory factors  Documentation Tip: Do not document “non-contributory” without documenting what family history was obtained but not a factor
  9. 9. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 8 1995 Exam Guidelines Body Areas  Head, including the face  Neck  Chest, including breasts and axillae  Abdomen  Genitalia, groin, buttocks  Back, including spine  Each extremity Organ Systems  Constitutional (vital signs, general appearance)  Eyes  Ears, nose, mouth, throat  Cardiovascular  Respiratory  Gastrointestinal  Genitourinary  Musculoskeletal  Skin  Neurologic  Psychiatric  Hematologic/lymphatic/immunologic
  10. 10. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 9 E&M: Psychiatric Exam (1997) SYSTEM/ BODY AREA ELEMENTS OF EXAMINATION Constitutional  Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (may be measured and recorded by ancillary staff)  General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) Musculoskeletal  Assessment of muscle strength and tone (eg, flaccid cog wheel, spastic) with notation of any atrophy and abnormal movements  Examination of gait and station Psychiatric  Description of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities (eg, perseveration, paucity of language)  Description of thought processes including: rate of thoughts; content of thoughts (eg, logical vs. illogical, tangential); abstract reasoning; and computation Psychiatric  Description of associations (eg, loose, tangential, (Cont.) circumstantial, intact)  Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions  Description of the patient's judgment (eg, concerning everyday activities and social situations) and insight (eg, concerning psychiatric condition)  Orientation to time, place and person  Recent and remote memory  Attention span and concentration  Language (eg, naming objects, repeating phrases)  Fund of knowledge (eg, awareness of current events, past history, vocabulary)  Mood and affect (eg, depression, anxiety, agitation, hypomania, lability) Complete mental status examination including: Problem Focused: One to five elements identified by a bullet. Expanded Problem Focused: At least six elements identified by a bullet. Detailed: At least nine elements identified by a bullet. Comprehensive: Perform all elements identified by a bullet; document every element in a shaded box and at least one element in an unshaded box. CONTENT and DOCUMENTATION REQUIREMENTS 1997 SINGLE ORGAN SYSTEM EXAM LEVEL OFEXAM: Perform and Document
  11. 11. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 10 1995 vs. 1997 Exam Guidelines 1995 Requirements 1997 Requirements Problem-Focused Examination: • Limited to affected body area or organ system Problem-Focused Examination: • One to five element(s) identified by a bullet Expanded Problem-Focused Examination: • A limited examination of the affected body area or organ system and other symptomatic or related organ system(s) • Two to seven body areas or organ systems Expanded Problem-Focused Examination: • At least six elements identified by a bullet Detailed Examination: • An extended examination of the affected body area(s) and other symptomatic or related organ system(s) • Two to seven body areas or organ systems Detailed Examination: • At least twelve elements identified by a bullet Comprehensive Examination : • A general multi-system examination or a complete examination of a single organ system • Eight or more organ systems Comprehensive Examination: • Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border
  12. 12. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 11 MDM  The complexity of establishing a diagnosis and/or selecting a management option as measured by the:  Number of diagnoses and/or management options that must be considered  Risk of complications and/or morbidity or mortality, as well as co- morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options  Amount and/or complexity of data to be obtained, viewed, and analyzed
  13. 13. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 12 MDM: Amount and/or Complexity of Data Data Audit Points Rev and/or order clinical tests 1 Rev and/or order tests in CPT medicine section 1 Rev and/or order tests in CPT radiology section 1 Discuss test results w/ performing physician 1 Independent rev of image, tracing or specimen (This is where you get credit for non-billable 2nd reads) 2 Decision to obtain old records and/or hx from someone other than patient 1 Rev and summarization of old records and/or hx from someone other than patient 2 Amount and/or Complexity of Data
  14. 14. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 13 MDM: Table of Risk Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected Minimal • One self-limited or minor problem (e.g., cold, insect bite, tinea corporis) • Laboratory tests requiring venipuncture • Chest x-rays • EKG/EEG • Urinalysis • Ultrasound (e.g., echocardiography) • KOH prep • Rest • Gargles • Elastic bandages • Superficial dressings Low • Two or more self-limited or minor problems • One stable chronic illness (e.g., well-controlled hypertension, non-insulin-dependent diabetes, cataract, BPH) • Acute uncomplicated illness or injury (e.g., cystitis, allergic rhinitis, simple sprain) • Physiologic tests not under stress (e.g., pulmonary function tests) • Non-cardiovascular imaging studies with contrast (e.g., barium enema) • Superficial needle biopsies • Clinical laboratory tests requiring arterial puncture • Skin biopsies • Over-the-counter drugs • Minor surgery with no identified risk factors • Physical therapy • Occupational therapy • IV fluids without additives Moderate • One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment • Two or more stable chronic illnesses • Undiagnosed new problem with uncertain prognosis (e.g., lump in breast) • Acute illness with systematic symptoms (e.g., pyelonephritis, pneumonitis, colitis) • Acute complicated injury (e.g., head injury with brief loss of consciousness) • Physiologic test under stress (e.g., cardiac stress test, fetal contraction stress test) • Diagnostic endoscopies with no identified risk factors • Deep needle or incisional biopsy • Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization) • Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis, culdocentesis) • Minor surgery with identified risk factors • Elective major surgery (e.g., open, percutaneous, endoscopic) with no identified risk factors • Prescription drug management • Therapeutic nuclear medicine • IV fluids with additives • Closed treatment of fracture or dislocation without manipulation High • One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment • Acute or chronic illnesses or injuries that may pose a threat to life or bodily function (e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure) • An abrupt change in neurological status (e.g., seizure, TIA, weakness, or sensory loss) • Cardiovascular imaging studies with contrast with identified risk factors • Cardio electrophysiological tests • Diagnostic endoscopies with identified risk factors • Discography • Elective major surgery (e.g., open, percutaneous, or endoscopic) with identified risk factors • Emergency major surgery (e.g., open, percutaneous, or endoscopic) • Parenteral controlled substances • Drug therapy requiring intensive monitoring for toxicity • Decision not to resuscitate or to de-escalate care because of poor prognosis
  15. 15. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 14 Time  Time may be the key or controlling factor to qualify the use of a particular E/M service provided certain conditions have been met:  Counseling and/or coordination of care (COC) dominates (more than 50%) the patient encounter  Applies to E/M services only  Must be face-to-face time in office; floor time in the hospital or nursing home setting  Documentation supports counseling/COC  Documentation of total visit time and time spent in counseling/COC (i.e., include an example of what needs to be or has been done)
  16. 16. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 15 Time: Risks  Using time as a work-around to documenting history, exam, and MDM  Combining E/M time with the time spent performing other procedures/services  Not documenting time:  Assuming time captured in EHR  Too difficult to keep up with – if the time is not documented then the appropriate level is billed based on components
  17. 17. Clinic Visit Types
  18. 18. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 17 New Patient vs. Established Patient Visits New Patient ▪ A new patient is defined as someone who has never been seen by you or a physician in the group OR who has not been seen by you or a physician in the group for at least three years ▪ Applicable E/M codes are 99201-99205 ▪ Require all three key components Established Patient ▪ An established patient is defined as someone who has been seen by you or a physician in the same specialty in your group within the previous three years ▪ Applicable E/M codes are 99211-99215 ▪ Requires two of the three key components ▪ Many payer auditors require MDM to be one of the two
  19. 19. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 18 Outpatient Consultations ▪ A consultation is a visit resulting from a request from another medical provider ▪ Applicable E/M codes are 99241-99245 ▪ Requires all three key components ▪ Remember the three Rs:  Request for opinion or advice from one provider to another provider  Render and document consultation service  Complete a written report and forward to the requesting physician ▪ Bill codes 99201-99215 if the requirements are not met
  20. 20. Hospital Visit Types
  21. 21. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 20 Initial vs. Subsequent Hospital Care Days Initial Hospital Care Day ▪ Applicable E/M codes are 99221- 99223 ▪ Requires all three key components ▪ Must have at least a detailed history and examination in order to bill even the lowest level E/M code within the category (99221) ▪ All third-party payers will discount a service to a subsequent patient visit (99231-99233) if the history and examination is not at least a detailed level Subsequent Hospital Care Day ▪ Applicable E/M codes are 99231- 99233 ▪ All third-party payers expect to see lower E/M levels (99231 and 99232) closer to the discharge date ▪ Requires two of the three key components ▪ Many payer auditors require MDM to be one of the two
  22. 22. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 21 Inpatient Consultations ▪ An inpatient consultation is a visit resulting from a request from another medical provider ▪ Applicable E/M codes are 99251-99255 ▪ Requires all three key components ▪ Remember the two Rs:  Request for opinion or advice from one provider to another provider  Render and document consultation service  Not necessary to do a separate report for services documented within a “shared” record
  23. 23. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 22 Documenting an Inpatient Consult  The documentation within the shared record should support the request:  Documented within physician orders  Documented within requesting provider’s notes  The reason should be clearly documented within the consulting provider’s notes  The recommendations do not have to be separately documented within a shared note  If the documentation does not meet the consultation requirements, then the appropriate E/M service (e.g., subsequent or admission) should be billed  If it is the first time the consulting provider is seeing a Medicare patient and all three key components are documented, an inpatient admission (99221-99223) can be reported  Admitting physician will have to append modifier -AI
  24. 24. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 23 Discharge Day Management ▪ Applicable E/M codes are 99238 (30 minutes or less) and 99239 (more than 30 minutes). They include:  Final examination of the patient (not required for Medicare but documentation must support a face-to-face encounter)  Discussion of the hospital stay  Instructions for continuing care to relevant caregivers  Preparation of discharge records, prescriptions, and referral forms  Report per the date of the actual visit, regardless of the date the patient is really discharged  Actual time spent must be documented in order to bill 99239  If admission and discharge services provided on the same day, bill 99234-99236
  25. 25. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 24 Bottom-Line: Document  Why did you see the patient today?  What was planned vs. unplanned?  What did you do today?  Diagnoses assessed, history taken, exam performed, etc.  What MDM was required?  Lab results, values, etc.  What is the update from the previous visit?  What plan resulted?  Orders, prescriptions, other plan – and WHY?
  26. 26. Psychiatric Services
  27. 27. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 26 Psychiatric Diagnostic Procedures  Unlike E/M codes, there are no bullets or “formula” to determine the code  CPT code 90791 – Psychiatric diagnostic evaluation:  This is an integrated biopsychosocial assessment, including history, mental status, and recommendations  The evaluation may include communication with family or other sources and review and ordering of diagnostic studies  CPT code 90792 – Psychiatric diagnostic evaluation with medical services:  This is an integrated biopsychosocial and medical assessment, including history, mental status; it requires other physical examination elements as indicated, and recommendations  The evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies
  28. 28. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 27 Psychotherapy  CPT codes 90832 – 90838:  Time-based codes  Psychotherapy is the treatment of mental illness and behavioral disturbances in which the physician or other qualified healthcare professional attempts to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development  These are for face-to-face services with patient and/or family member  Psychotherapy services can be reported with an E/M on the same day by the same provider if it is significant and separate; the E/M code is reported with modifier -25  The type and level of E/M service is selected first based upon the key components of history, examination, and MDM
  29. 29. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 28 Psychotherapy (cont.)  Time associated with activities used to meet criteria for the E/M service is not included in the time used for reporting the psychotherapy service  If you see that your providers are frequently reporting these codes together, it is recommended that an internal review be conducted to verify that the documentation supports the need for both services
  30. 30. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 29 Psychotherapy (cont.)  CPT codes 90839 and 90840 – Psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status exam, and a disposition  The treatment includes psychotherapy mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma  The presenting problem is typically life threatening or complex and requires immediate attention to a patient in high distress  ICD-10 codes that reflect a risk diagnosis should be expected
  31. 31. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 30 Other Psychotherapy CPT Codes 90845 • Psychoanalysis 90846 • Family psychotherapy (without patient present) 90847 • Family psychotherapy (with patient present) 90849 • Multiple-family group psychotherapy 90853 • Group psychotherapy (other than a multiple-family group)
  32. 32. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 31 Other Psychiatric Services or Procedures CPT Codes 90863 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services 90865 Narcosynthesis for psychiatric diagnostic and therapeutic purposes 90867-90869 Therapeutic repetitive TMS treatment 90870 Electroconvulsive therapy 90875-90876 Individual psychophysiological therapy incorporating biofeedback with psychotherapy (time-based codes) 90880 Hypnotherapy
  33. 33. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 32 Other Psychiatric Services or Procedures CPT Codes (cont.) 90882 Environment intervention for medical management purposes on a psychiatric patient’s behalf with agencies, employers, or institutions 90885 Psychiatric evaluation of hospital records, other psychiatric reports, psychometric and/or projective tests, and other accumulated data for medical diagnostic purposes 90887 Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data, to family or other responsible persons, or advising them how to assist patient 90889 Preparation of report of patient’s psychiatric status; history; treatment; or progress for other individuals, agencies, or insurance carriers 90899 Unlisted psychiatric service or procedure
  34. 34. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 33 E/M vs. Psychiatric Services  Why are psychiatrists billing inpatient admissions instead of psychiatric diagnostic evaluations?  99221 – wRVU 3.00  99222 – wRVU 3.25  99223 – wRVU 1.92  90791 – wRVU 3.00  90792 – wRVU 3.25  To bill the higher E/M levels, the provider must document a complete ROS and HPI, which is often difficult or unnecessary to the patient’s condition
  35. 35. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 34 Common Diagnosis Coding and Documentation Issues  Psychiatric diagnoses are very specific, and often providers do not document to the highest level of specificity  In the inpatient setting, the rounding providers often document different diagnoses  DSM-IV vs. ICD-10-CM variances  Not documenting time for psychotherapy services  Lack of documentation to support the continued need for inpatient stay  Limited documentation for follow-up visits in the hospital setting  Psychotherapy service notes often do not thoroughly reflect the discussion of therapy  Many providers document their services based on time, and often the total amount of time exceeds a normal working day
  36. 36. NPP Scope and Supervision Requirements
  37. 37. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 36 NPP Scope of Practice CMS Guidelines:  Services allowed are such as those traditionally reserved for physician  The supervising physician/substitute should have experience and/or expertise in the same area of medicine as the NP/PA
  38. 38. Payer Guidelines
  39. 39. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 38 Three Different Billing Scenarios  Direct Billing: 85% of Physician Fee Schedule  Certain NPPs (NPs, PAs, Certified Nurse Specialists, Clinical Psychologists) can be credentialed and can bill under their own provider number  Medicare reimburses on a percentage of the Physician Fee Schedule  Other payers may not recognize NPPs and services would be billed and reimbursed under the physician’s National Provider Identifier (NPI)  Incident-To Billing: 100% of Physician Fee Schedule  This is a physician-directed services/team  Service is billed under physician’s NPI  Shared/Split Billing: 85% or 100% of Physician Fee Schedule  NPPs and physicians “share/split” a patient visit  Service can be billed under NPP’s or physician’s NPI
  40. 40. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 39 Medicare and Medicaid NPP Reimbursement  Medicare and Medicaid have the most specific guidance for NPP billing:  85% of the Physician Fee Schedule for services which include independent MDM by NP/PA  100% of the Physician Fee Schedule under the supervising physician on-site for incident-to services  Medicaid requires the provider of service to bill for the service rendered under his or her own NPI
  41. 41. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 40 Incident-To and Split/Shared Visits  Incident-to and split/shared services are both documentation and billing concepts that can be used to report services performed by a NP/PA
  42. 42. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 41 Clinic Visit Types ▪ New Patient Visits ▪ The service must be billed under the NPP’s NPI ▪ Established Patient Visits ▪ An established problem can be billed under physician’s NPI ▪ A new problem must be billed under the NPP’s NPI ▪ Consultations ▪ The service must be billed under the NPP’s NPI
  43. 43. Payer Guidelines Direct Billing
  44. 44. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 43 NPP Direct Billing Criteria for Medicare and Medicaid  NPP bills services directly to Medicare/Medicaid  Must meet Medicare/Medicaid’s credentialing requirements  Can bill in any setting allowable under scope of practice (office, inpatient and outpatient hospital, etc.)  Can provide any services allowed under their scope of practice, but will only be reimbursed for covered services  Should have a collaborative agreement with physician or group of physicians
  45. 45. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 44 NPP Medicare Direct Billing Services  Office:  New patient  Established patient with new problem/condition  Consultation  Hospital:  NPP-only service, no physician E/M, same date  Critical care
  46. 46. Payer Guidelines Incident-To Billing
  47. 47. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 46 Incident-To Service Definitions  What is an incident-to service?  When services are provided by auxiliary personnel under direct physician supervision, they may be covered as incident-to services  Services performed by the NPP are billed under the physician's NPI  What are auxiliary personnel?  Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician  The supervising physician may also be an employee, leased employee, or independent contractor of the legal entity billing and receiving payment for the services or supplies
  48. 48. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 47 Incident-To Requirements  It must be an integral, though incidental, part of a physician’s professional service  It is commonly rendered without charge, or included in the physician's bill  It is of a type commonly furnished in an office/clinic  It is furnished under direct supervision of the physician
  49. 49. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 48  Is the payer private, Medicare, or Medicaid?  Is the patient new or established?  Is the patient presenting with only established problems, or are there new problems that need to be addressed?  Is this a consultation?  Was the service incident-to?  Where were the services provided?  Which provider do I bill under? When Can an NPP Bill Incident-To?
  50. 50. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 49 Medicare Incident-To Guidelines  Office only, incident-to is not recognized in a facility setting (e.g., hospital, nursing facility, etc.)  Established patient with established problem = established plan of care  Cannot bill incident-to for an established patient with a new problem  Physician is on-site/direct supervision provided  Physician sees patient at a frequency showing involvement in the patient’s care plan; this means that the physician is required to periodically evaluate the patient and update the plan of care accordingly
  51. 51. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 50 Direct Personal Supervision  Each visit/occasion of service by auxiliary personnel does not need to be at the actual rendition of a personal professional service by the physician  Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide  The physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services  If auxiliary personnel perform services outside the office setting (e.g., in a patient's home or in an institution other than a hospital or skilled nursing facility [SNF]), their services are covered incident-to a physician's service only if there is direct supervision by the physician
  52. 52. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 51 Supervising vs. Ordering Physician  Regardless of the ordering physician, the service should be billed under the supervising physician’s NPI and name  The billing physician on the claim form should be consistent with the on-site physician who is providing direct supervision
  53. 53. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 52 Private Payers  Private payers have different rules regarding NPP billing  PYA recommends that the top three to five payers be contacted to confirm whether the NPP service can be billed incident-to under a physician’s NPI  If the payer allows incident-to billing under the physician and provides no further guidance:  Recommend: Bill under the supervising physician on-site or designated for supervision that day  Follow state supervision and collaboration rules
  54. 54. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 53 Incident-To Vs. Direct NPP Billing Incident-To  No new patients  No new problems  Physician in suite  Not at hospital or SNF  Physician directs patient care  Full payment  Code at any level Direct Billing  Any patient  Any problem  Location of physician is not an issue  Any point of service  NPP in control  85% of fee  Code at any level
  55. 55. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 54 Documentation Requirements  For incident-to services, the medical record must document:  Services provided by office personnel whom the physician directly supervises and who represent a direct financial expense  Physician review of the qualified provider’s chart notes in order to monitor treatment progress  Physician signature indicating the physician is actively involved in the patient’s course of treatment  Physician must be immediately available (present in the office suite)  Solo providers must directly supervise the care  In group practices, if the ordering physician is not available, any physician of the group may provide direct supervision
  56. 56. Payer Guidelines Split/Shared Billing
  57. 57. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 56 Split/Shared Simply Stated  A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally performs a substantive portion of an E/M visit face-to-face with the same patient on the same date of service  A substantive portion of an E/M visit involves all or some portion of the history, exam, or MDM key components of an E/M service  Both providers (NPP and physician) must have a documented face-to-face encounter with the patient  The physician and NPP must be employed by the same employer
  58. 58. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 57 Split/Shared Simply Stated (cont.)  The level of service is based on the combined documentation of both providers, and the documentation must clearly identify what was personally performed by each provider  The physician cannot merely co-sign or complete an attestation similar to a teaching physician statement  If the documentation meets the requirements, the visit can be billed under the physician’s NPI, as opposed to the NPP’s NPI
  59. 59. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 58 Split/Shared Visit Locations  Hospital inpatient or outpatient  Emergency department  Hospital observation  Hospital discharge  Office or clinic (uncommon)
  60. 60. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 59 Split/Shared Visits Are Not Allowed…  In an SNF or nursing facility setting  For procedures  In a patient’s home or domiciliary site  For critical care services and other time-based CPT codes
  61. 61. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 60 Payer Notes Regarding Split/Shared Visit  NPP and physician document a portion of the E/M service (same patient, same date of service)  Bill under physician  Note: Co-signature does not count  Must include some E/M elements  For example: “Saw patient and agree with above, heart and lungs clear”  Medicaid and some third-party payers require that the service be billed under the NPP’s NPI, and do not recognize the split/shared billing methodology
  62. 62. Compensation/RVU Methodology Overview Fundamentals of Provider Reimbursement
  63. 63. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 62  Physician Practice (Non-Facility)  A physician’s private practice location, office, clinic; a freestanding entity for reimbursement purposes  Provider-Based Clinic (Facility)  An outpatient department of the hospital; paid differently than a freestanding clinic  Recent law has impacted the prior popularity of acquiring and establishing provider-based clinic locations  Hospital (Facility)  Could include services that are ancillary in nature (lab test, x-ray), inpatient services (patient kept overnight for a series of days), and/or outpatient or observation services (patient may stay overnight but discharge is anticipated within a shorter timeline than inpatient care) These terms represent location, setting, or place of service Important Terms
  64. 64. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 63 Important Terms  Fee-for-Service  A schedule that pays a provider based on the volume of services rendered; generally relates to Physician Services  Example: If Medicare pays $50 for an office visit and Dr. Smith does two of them, he would get $100  This is a type of reimbursement schedule  Providers are financially incentivized to see more patients
  65. 65. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 64 Charges, Payments, and Cost  Charges are the amount the hospital lists as the price for services; very few pay this “sticker price”  Payment or Reimbursement is the amount the hospital actually receives in cash for its services  Private insurers, public insurers, self-pay patients, and the uninsured all pay different amounts for the same services; payment can be either more or less than what it costs the hospital to provide a given service  Cost is what it actually costs the hospital to provide the services
  66. 66. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 65 Reimbursement Methodologies  Hospitals  Percent of Charge  Per Diems  Case Rate Payment  Diagnosis-Related Groups (DRGs)  Medical Severity DRGs  Global  Ambulatory Patient Groupings  Ambulatory Payment Classifications  Other  Carve-Outs  Professional Services  Fee-For-Service Discounts  Fee Schedules  Payment Based on Resource-Based Relative Value Scale (RBRVS)  Capitation  Withholds  Pools  Case Rates
  67. 67. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 66 RBRVS  RBRVS developed to better align physician payments with costs  Payments for services are determined by the resource costs to provide them  Relative Value Units (RVUs) are used to rank the costs  Work RVUs (wRVUs) are updated annually  Entire system is reviewed every five years by law
  68. 68. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 67 RBRVS (cont.)  Conversion factor (CF) is used to determine payment when multiplied by total RVU; CF is updated annually  Adjustments to the fee schedule:  Geographic adjustment  Budget neutrality factor (BNF), also known as budget neutrality adjustment  If changes in schedule, change outlays in excess of $20 million
  69. 69. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 68 Work RVU Analyses  Physician wRVU – The relative level of time, skill, training, and intensity to provide a given service; a code with a higher wRVU takes more time, intensity, or some combination of these two  Analysis Considerations  Personally performed services  Modifier use  Date of service vs. posting date  Location (does it matter?)  Global surgical period
  70. 70. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 69 Medicare Part A Hospital insurance plan for the elderly Financed through social security taxes At age 65 years, patients who have paid >10 years into SSI are automatically enrolled Those <65 years of age who are totally and permanently disabled may enroll after 24 months of disability Those with ESRD on HD usually enrolled without wait period Medicare Part B Insures the elderly for physicians’ services Financed by federal taxes and monthly premiums from beneficiaries Available to those eligible for Medicare Part A who elect to pay the Medicare Part B premium of $147/month (2015), adjusted upward according to income Medicare Government-Financed Insurance
  71. 71. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 70 Why Is Medicare So Important?  Medicare is typically a significant payer for most physicians (and hospitals); in some cases, it could be the largest payer in a physician’s or hospital’s payer mix  Medicare’s fee schedules are publicly available and published annually (with updates), so they are a reliable and available source of information
  72. 72. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 71 Medicaid: Government-Financed Insurance  Medicaid (varies by state)  Federal program administered by the states  Federal financing for low-income patients  Federal government  Pays between 50% and 76% of total Medicaid costs  Requires that a broad set of services be covered, including hospital, physician, laboratory, x-ray, prenatal, preventive, nursing home, and home health services  EACH STATE has its own Medicaid program and fee schedule(s)  Medicaid is generally an undesirable payer for physicians because the reimbursement is typically pretty low (less than Medicare, sometimes 70-80% of Medicare)
  73. 73. Compensation/RVU Methodology Overview What About Employed Physicians?
  74. 74. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 73 Productivity or Work RVU Metrics
  75. 75. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 74 What Is a Work RVU?  A wRVU is a numerical value intended to reflect the physician’s:  Time  Effort/Skill  Intensity  Associated with a specific service (as represented by a CPT code)  Examples:  An office visit for a new patient (CPT code 99203) has 1.42 work RVUs  An office visit for an established patient (CPT code 99213) has 0.97 work RVUs  wRVU values are published annually (with quarterly updates) by the Centers for Medicare & Medicaid Services (CMS)
  76. 76. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 75 Total Relative Value Unit Components (tRVU)WorkRVU • wRVU • Physician’s (Provider) time, effort, technical skill, judgement, stress, and amortization of education PracticeExpenseRVU • peRVU • Direct expenses related to supplies, non- MD labor, the pro-rata cost of equipment used, and an amount for indirect expenses MalpracticeRVU • mpRVU • The cost of malpractice risk for the procedure
  77. 77. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 76 Relative Value Units  Relative Value Units (RVUs) are established by CMS within the RBRVS to establish:  Relative difficulty associated with each procedure; accounts for time, skill, and intensity (Physician Work)  Costs associated with each procedure, which includes equipment, supplies, and staff (Practice Expense “PE”)  Costs associated with malpractice/liability for each procedure (Malpractice Expense)  The Physician Work portion is reflected in a wRVU
  78. 78. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 77 Determining Medicare Reimbursement (MPFS) Total RVU Conversion Factor $35.8887 Medicare Reimbursement Rate $$$
  79. 79. Compensation/RVU Methodology Overview Examples
  80. 80. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 79 tRVU Example: 99213 wRVU • 0.97 work RVUs • Always the same value, regardless of setting (facility or non-facility) PracticeExpenseRVU* • Non-Facility • 1.01 PE RVU • Facility • 0.4 PE RVU MalpracticeRVU* • Non-Facility • 0.07 MP RVU • Facility • 0.07 MP RVU *PE and Malpractice RVUs represent national, unadjusted amounts; specific, locality-adjusted amounts will vary
  81. 81. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 80 tRVU Example: 99213 (cont.)  Total RVUs (non-facility) = 2.05  Total RVUs (facility) = 1.44  Total RVUs are higher in the non-facility setting  Why?
  82. 82. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 81 CPT Code wRVU Variance Analysis
  83. 83. Additional Validation of Productivity Time Study
  84. 84. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 83 Physician Time Study Analysis  Used to understand the amount of time required, on average, to perform a single service (or a series of services)  Can be used to test the reasonableness of highly productive physician utilization data
  85. 85. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 84 Psychiatric Time Study Trending Data CPT Code CPT Description 2016 Medicare Time Study Pre- Service Time (minutes) 2016 Medicare Time Study IntraService Time (minutes) 2016 Medicare Time Study Post- Operative/Service Time (minutes) 2016 Medicare Time Study Total Time (minutes) +90785 Psytx complex interactive 0 0 11 11 90791 Psych diagnostic evaluation 10 60 20 90 90792 Psych diag eval w/med srvcs 10 60 20 90 90832 Psytx pt&/family 30 minutes 5 30 10 45 +90833 Psytx pt&/fam w/e&m 30 min 0 30 3 33 90834 Psytx pt&/family 45 minutes 5 45 10 60 +90836 Psytx pt&/fam w/e&m 45 min 0 45 3 48 90837 Psytx pt&/family 60 minutes 5 60 10 75 +90838 Psytx pt&/fam w/e&m 60 min 0 60 3 63 90839 Psytx crisis initial 60 min 10 60 20 90 +90840 Psytx crisis ea addl 30 min 0 30 0 30 90845 Psychoanalysis 5 45 11 61 90846 Family psytx w/o patient 0 50 0 50 90847 Family psytx w/patient 5 50 21 76 90849 Multiple family group psytx 11 84 14 109 90853 Group psychotherapy 2 14 8 24 90865 Narcosynthesis 0 90 0 90 90870 Electroconvulsive therapy 10 20 5 36 90875 Psychophysiological therapy 10 25 10 45 90876 Psychophysiological therapy 10 50 10 70 90880 Hypnotherapy 8 50 40 98 90882 Environmental manipulation 0 0 0 0 90885 Psy evaluation of records 0 0 0 60 90887 Consultation with family 10 50 28 88 90889 Preparation of report 0 0 0 0 90899 Psychiatric service/therapy 0 0 0 0 Psychiatry CPT Codes
  86. 86. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 85 Benchmark Time Analysis Results September 2014 to August 2015 Provider Total Pre-Service Time (in Hours) Total Intra-Service Time (in Hours) Total Post-Service Time (in Hours) Total Professional Service Time (in Hours) FTE-Equivalent (Based upon 2,000 Annual Hours) Dashboard >2.0 >1.5 >1.25 Provider A, MD 580 1,925 1,049 3,554 1.78 Provider B, MD 464 2,020 658 3,142 1.57 September 2015 to February 2016 (Annualized) Provider Total Pre-Service Time (in Hours) Total Intra-Service Time (in Hours) Total Post-Service Time (in Hours) Total Professional Service Time (in Hours) FTE-Equivalent (Based upon 2,000 Annual Hours) Dashboard >2.0 >1.5 >1.25 Provider A, MD 530 2,453 1,072 4,054 2.03 Provider B, MD 409 2,005 607 3,021 1.51 Note: FY16 data has been annualized based on a six-month period.
  87. 87. Prepared for Florida Council for Community Mental Health May 17, 2017 Page 86 Questions?
  88. 88. PERSHING YOAKLEY & ASSOCIATES, P.C. 800.270.9629 | www.pyapc.com Lori Baker, CPC, CHCA-F, RHIA lbaker@pyapc.com Thank you! Denise Hall-Gaulin, RN dgaulin@pyapc.com

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