The secret to ensuring both proper payment and compliance is in the details.
Why is mental health coding so complex? Laurie Bouzarelos, MHA, CPC, asked and answered that question in her presentation “Coding and Billing for Psychiatry and Outpatient Mental Health Providers” at AAPC’s virtual HEALTHCON 2022, March 27-30.
Bouzarelos manages to take much of the complexity out of mental health coding for medical coders by providing them information and resources necessary to code correctly and in compliance with applicable regulations. Here’s an overview of her session.
Regulations Add Complexity
Healthcare is highly regulated and mental healthcare more so, and that’s a problem for many practices. “I often find providers are using a therapy-focused electronic health record (EHR), and for psychiatrists, that can result in some problems with documentation if they end up being audited,” Bouzarelos said. Low awareness of reimbursement guidelines, poor understanding of terminology, and obligations under payer contracts also add to the complexity of mental health coding and billing.
At the highest level, we have federal laws guiding all providers such as HIPAA, the Cures Act, and the No Surprises Act. Also at the federal level are rules handed down from the Centers for Medicare & Medicaid Services (CMS) such as the Medicare Physician Fee Schedule (MPFS).
At the state level, there are regulations for scope of practice, licensure, insurance commission, medical and professional boards, and practicing across state lines. Medicaid policies also vary by state.
And then layer the commercial payers and implications of payer mix, as well as billing guidelines for provider type, incident-to, and place of service. “Because mental health coding is complex, it is prone to error, and these providers, practices, and programs find themselves under scrutiny,” Bouzarelos said.
Learn From CERT
Bouzarelos, a healthcare consultant and founder of Provider Solutions in Centennial, Colo., recommends looking at CERT information and learning from these sources. The 2021 Medicare FFS Supplemental Improper Payments Report, Table D1, shows psychiatry is in ninth place for the highest projected improper payments, and has been steadily inching up. Insufficient documentation remains the primary reason for improper payments for psychiatrists, with an 87.5 percent error rate, for the 19.4 percent improper payment rate.
With an error rate approaching 20 percent, that hints to all practices providing mental health services likely to have documentation deficiencies, “and the biggest opportunity for improvement,” Bouzarelos said.
Documentation Requirements
Strong documentation is the foundation of a strong practice, Bouzarelos said. An excerpt from a commercial payer’s reimbursement policy illustrates minimum requirements providers must include when documenting psychotherapy:
- Start and stop times
- If telehealth, documented consent for psychotherapy via telehealth
- The patient’s name on each page of the record
- The date of service on each page of the record
- Type of service (individual, group, family, psychotherapy)
- Problem statement including diagnosis
- Support for medical necessity
- Service rendered, including therapeutic interventions (e.g., insight oriented, CBT, DBT, etc.)
- Person-centered detail such as behavior, description, or quotes
- Patient observation (e.g., mental status exam)
- Summary of progress, or lack thereof toward identified goals, which should result in change in plan or a new plan of care
“Strong documentation policies provide the basis for accurate coding and the foundation for a compliance plan,” Bouzarelos said before launching into coding of mental health services. Be sure the practice understands and incorporates CMS’ programs and commercial payer policies into their own documentation policies.
2021 Evaluation and Management (E/M) Service Guidelines apply to E/M services rendered by psychiatrists. She also pointed out two pages in the 1995 and 1997 Documentation Guidelines for Coding and Reporting for the psychiatry specialty exam that are still useful references. “It’s very important that there is a documented mental status exam in the chart; and if you check your payer guidelines, it is probably a required element for reimbursement,” Bouzarelos said.
Bouzarelos included a checklist she likes to use when reviewing charts, as shown in Figure 1.
Coding Behavioral Health Services
Even with proper documentation, coding the various types of mental health services is challenging. Coders need to understand the specific requirements for assessment codes, treatment codes, and E/M codes. Psychiatry services are represented by E/M services and under the Medicine section of CPT®, as are the health behavior codes.
Psychiatry
Check payer guidelines for frequency allowance of 90791 Psychiatric diagnostic evaluation — it is not a once-in-a-lifetime code. Typically, you can bill this code once per six to 12 months or anytime there is a significant change in patient status, diagnosis, or treatment plan. This code cannot typically be reported with any other code on that date of service, “definitely not with any E/M or ABA, and not with most other codes,” Bouzarelos said. You’re also limited by provider type, state, and plan. Documentation requirements include history, mental status exam, and recommendations (individualized treatment plan).
An opportunity for improvement for many psychiatrists is to tighten up documentation around prescription drug management, Bouzarelos said. Add complete details at every visit for how the prescription was issued (hard copy, electronic), where the prescription was sent, and other details such as dosage and refills. Also worth noting are patient instructions, side effects, drug monitoring plan, prescription medications managed by other providers, and over-the-counter medications.
CPT® 90792 Psychiatric diagnostic evaluation with medical services describes diagnostic assessment with medical services and has a built-in E/M component. Check payer guidelines, but typically you can bill this code once per six to 12 months or any time there is a significant change in patient status, diagnosis, or treatment plan. Psychiatrists, psychiatric nurse practitioners, and clinical nurse specialists working under state scope of practice may bill this code. Documentation should include a history, mental status exam, E/M, prescriptions, review/order of labs or studies, and recommendations for the patient’s treatment plan.
Psychotherapy
Time-based psychotherapy codes include:
90832 Psychotherapy, 30 minutes with patient
90834 Psychotherapy, 45 minutes with patient
90837 Psychotherapy, 60 minutes with patient
Psychotherapy for crisis (90839, +90840) is appropriate when the presenting problem is life-threatening or complex and requires immediate attention to a patient in high distress. An urgent assessment, a patient history, a complete mental status exam, and an immediate plan or disposition for the patient are all required documentation.
All psychotherapy codes are time-based. Bill these codes only once per date, even if time is not continuous on that date. The codes are payable in all settings, and any provider working within their licensure and scope of service may provide these services. Do not report psychotherapy codes on the same day as the assessment codes (90791, 90792). Also, anything less than 16 minutes is not billable.
Psychoanalysis and Other Psychiatric Services
Psychoanalysis (90845) is performed by using methods of intense observation and analytical skill to investigate the patient’s past experiences, unconscious motivations, and internal conflicts, as well as contributing mental conditions. As such, only a psychiatrist with the credentials to practice analytic therapy may provide this service.
Documentation should include a list of patient complaints and conditions, focus of treatment, treatment framework and modality, frequency and estimated length of treatment, family and friend support system, community care plan/support, and alternative care plan if patient does not show improvement. Documentation time, review of history in the medical record, and peer consultation are included in the code. A separate E/M service is not billable with psychoanalysis.
Other psychiatric services or procedures, such as electroconvulsive therapy, hypnotherapy, and biofeedback training are less common in the outpatient mental health practice. But, Bouzarelos said, “If you have practitioners interested in providing these services, be sure the CPT® codes are included in your contracts.”
Family and Group Psychotherapy
Family and group psychotherapy (90846-90849, 90853) and individual therapy can be billed on the same date of service, but check your payer guidelines; even if allowed, “sometimes you’re going to have to submit notes, every time, to get paid,” Bouzarelos said. Family therapy cannot be billed with ABA codes.
Best practice is for the provider to include comments in the note to make it evident who was there, patterns of behavior, and what was worked on.
Multi-family and group therapy codes include reviewing records, communicating with other providers, observing and interpreting patterns of behavior, communication between family and patient, and decision making.
Each patient record must have patient-specific details, including participation, contributions, and reactions of each participant. “It is not acceptable to copy and paste the same exact note for every patient throughout,” Bouzarelos said. Prior authorization may be required.
For psychotherapy sessions exceeding 80 minutes, you may be able to bill a face-to-face prolonged service code (99354-99355) in the outpatient setting if the additional service is more than 30 minutes past the first hour or more than 15 minutes past the additional 30 minutes. “Strangely enough, these may require prior authorization, which most people don’t plan on these experiences being prolonged service,” Bouzarelos said. Consequently, it’s hard to get prior authorization in the moment, and these services are often denied as bundled. “I would encourage you to try and get these added to your contracts, if you can,” she added.
Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS)
TMS is a growing service for psychiatrists, according to Bouzarelos. It is a non-invasive technique using an FDA-approved device to apply brief magnetic pulses to the brain. There are three codes for this service:
90867 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management
90868 subsequent delivery and management, per session
90869 subsequent motor threshold re-determination with delivery and management
TMS treatment is prescribed by a psychiatrist (or also a neurologist in some states) who has been trained in the specific use of the TMS device. CPT® 90868, however, may be furnished under direct supervision of any qualified physician when ordered by a psychiatrist, per a Novitas local coverage determination. “In the U.S., we are finding that TMS is approved for major depressive disorder [F32.2-F33.2] only,” Bouzarelos noted. In other countries, TMS is being used to treat many psychiatric diagnoses, but TMS is still considered “investigational and experimental” in the U.S.
Central Nervous System Assessments/Tests
Bouzarelos then moved from psychiatry to psychological/neuropsychological testing, reported with CPT® codes 96116 and +96121. There’s a helpful table for all the codes in this section in the 2022 CPT® Professional on page 818. As with the other codes, required elements generally include a referral, diagnostic assessment, treatment plan, prior authorization, testing, evaluation, and report.
Health Behavior Assessments
Health behavior assessment codes (CPT® 96156-96171) are used by psychologists, particularly in multidisciplinary clinics, such as team clinics, children’s hospitals, etc., where a psychologist is part of the care team and they provide an assessment or an evaluation of the patient’s response to the disease, the illness, the injury, coping strategies, motivation, and their adherence to the medical treatment. The assessment is conducted through health-focused clinical interviews, observation, clinical decision making, and working with other providers on the care team.
What’s Required for an ITP?
An individualized treatment plan (ITP) must:
Typically be done within three visits or 14 days;
Be individualized, not templated;
Include the diagnosis and tie back to the initial assessment (E/M or 90791, 90792);
Include type, frequency, and duration of services;
Have measurable goals with specific timeframes; and
Be signed by the provider and the patient.
These are time-based and face-to-face codes. A medical diagnosis is required. For group and family health behavior assessments (CPT® codes 96164-96171), be sure that the documentation supports the code being billed. As with the psychotherapy codes, if you have the family there, be sure documentation includes details about who was present. Health behavior assessment and treatment provided by a physician or QHCP should be billed with the appropriate E/M code.
Psychiatric Collaborative Care Codes
Bouzarelos also talked about the opportunity to use additional codes in the E/M section of CPT®, including psychiatric collaborative care (99492-99494) and behavioral health integration (99484).
This article only scratches the surface of what Bouzarelos covered in her HEALTHCON session. The information-packed session gave attendees plenty to process before going back to their employers with concepts for improving revenue and compliance of the mental health services furnished by their providers. You may contact Laurie Bouzarelos at LBouzarelos@ProviderSolutionsConsulting.com with questions about her presentation.
What Is SBIRT?
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an early intervention tool practices can use to make sure individuals with non-dependent substance use get help before the person needs more extensive or specialized treatment.
For this, we have HCPCS Level II codes for Medicare (G2011, G0396-G0397) and Medicaid (G0396-G0397, G0442-G0444, and H0049-H0050) and commercial plan codes (E/M CPT® codes 99408-99409).
Qualified healthcare professionals who meet the qualifications defined in the Medicare Benefit Policy Manual, Chapter 15 may bill for this service.
Documentation requirements for each patient encounter include:
Start and stop times or total face-to-face time with the patient (some SBIRT HCPCS Level II codes are time-based)
Patient’s progress, response to treatment changes, and diagnosis revision
Rationale for ordering diagnostic and other ancillary services (or ensure reason is easily inferred)
Assessment, clinical impression, and diagnosis
Date and legible provider identity
Physical exam findings and prior diagnostic test results
Plan of care
Encounter reason and relevant history
Identification of appropriate health risk factors
Make past and present diagnoses accessible for treating and consulting physicians.
For More Information: https://www.aapc.com/blog/85141-take-the-complexity-out-of-behavioral-health-coding/