12/2/2014

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2014 Psychology and Mental Health Auditing Update

John Burns, CPC, CPMA, CPC-I, CEMC

Senior Consultant & Auditor, NAMAS Instructor

Just Some Basic Facts • Initial services are typically captured with 90791 or

90792 (diagnostic interviews) but new patient E&M option exists

• Add-on codes are those preceded by the (+) symbol in CPT® and can not be reported alone

• “Interactive” complexity (+90785) may be a consideration but must be supported by documentation (e.g., more complex)

• Time (as defined by CPT®) is critical to assign psychotherapy codes (16min, 38min, 53+min)

• Laws in your state will dictate non-physician services reportable by these providers (e.g., social workers, psychologists, nurse practitioners, etc.)

Pharmacologic Management

• In 2013 –CPT code 90862 (pharmacologic management) was deleted o CPT code +90863 added in 2013.

o Per CPT, “for pharmacologic management with psychotherapy services performed by a physician or other qualified health care professional who may report evaluation and management codes, use the appropriate evaluation and management codes 99201-99255, 99281-99285, 99304-99337, 99341-99350 and the appropriate psychotherapy with evaluation and management service 90833, 90836, 90838”

o Time for the pharmacologic mgt is not to be counted toward the psychotherapy code selection.

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The Psychiatric Diagnostic Interview 90791 – psychiatric diagnostic interview (non-MD)

90792 - psychiatric diagnostic interview with medical

services

• These new codes may require “interactive complexity” (e.g.,

communication barriers, emotional family members,

interpreters, translators, child welfare agencies, use of play

equipment, abuse/neglect, etc.)

o For Interactive complexity, report add-on CPT® code +90785

o CMS has stated that the interactive complexity add-on code 90785 should not be billed to Medicare solely for the purpose of translation or interpretation services.

• New patient E&M codes may be used in lieu of CPT® code

90792 (psychiatric diagnostic interview with medical services),

per APA

Psychiatric Therapeutic Procedures • CPT® codes 90832 - +90838 (replacements for 90804-

90829) represent psychotherapy for the treatment of

mental illness and behavioral disturbances.

• Clinical psychologists (CPs) and clinical social workers

(CSWs) cannot bill for psychotherapy services that include

medical evaluation and management services under

Medicare

• The times listed refer to face-to-face time and the time

does not need to be continuous

90832 and +90833 [“30 minutes”] (16-37 minutes)

90834 and +90836 [“45 minutes”] (38-52 minutes)

90837 and +90838 [“60 minutes”] (53+ minutes)

What To Consider When Auditing 1. Type and level of E&M is selected first

Based on the “key components of History, Examination and Medical Decision Making (MDM) Always place emphasis on MDM for

established and subsequent visits (2/3 codes)

2. Time spent and documented

E&M time not included in psychotherapy code selection (no “double-dipping) Having a separately documented “therapy

note” demonstrating specific time separate for the E&M is suggested

E&M codes are only to be reported by MD, NP, etc

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Psychotherapy For Crisis • 90839 and +90840 have been created to report

therapy for “crisis” (“high distress under complex or life-threatening circumstances that require urgent and immediate attention”)

90839 – first 30-74 minutes +90840 – each additional 30 minutes (@75th min)

• For problems documented to be “life threatening”

or “require immediate attention to a patient in high distress”

• Not to be reported in addition to diagnostic interviews (90791 or +90792) o Total duration of time must be documented to support

o Developed at request of Nat’l Assn of Social Workers (they can’t report high level E&Ms)

What About Psych Sessions Lasting Greater Than 60 Minutes?

• Psychologists who conduct sessions that require more than 60 minutes

should continue to do so and will bill using the new 90837. Regardless of how long the session lasts, the

reimbursement will be based on the payment amount ultimately associated with 90837.

• Auditors need to carefully assess the provider’s documentation of time

Evaluation and Management Coding

• Psychiatrists and mental health professionals

need to understand E&M

• E&M codes are the most highly scrutinized codes

in terms of audit

• Require knowledge of 3 “key” components

o History

o Examination

o Medical Decision Making (the “trump card”)

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From APA: The CMS-1500

Evaluation & Management (E&M) Services

• Who are you seeing? o New, initial, established, subsequent, consultation, etc.

o A new patient is one who has not received any face to face professional service from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty/subspecialty who belongs to the same group practice within the past three years

• Where are you seeing them? o Outpatient, inpatient, emergency department, etc.

Office and Other Outpatient Services

• 99201-99205 o New patient visits

o Require all 3 “key” components

o Remember new patients have not received professional services within previous three (3) years

• 99211-99215 o Established patient visits

o Require 2 of the 3 “key” components (*MDM*)

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Hospital Inpatient Services

• 99221-99223 (Initial Hospital Care [“Admits”]) o Defined as the “first hospital inpatient encounter by the admitting

physician”

o Requires 3/3 “key” components

• 99231-99233 (Subsequent Care [“Rounds”]) o “Clustering” levels of E/M for subsequent hospital visits can be an

audit target (CMS 10/00)

o Requires 2/3 “key” components (*MDM*)

History- Subjective

• Chief complaint – clear, concise statement detailing the reason the patient is presenting today, usually in the patient’s own words

o According to CMS, the CC may be combined

with the HPI

• HPI (history of present illness)

• ROS (review of system)

• PFSH (past, family, social history) o Military history added to the social history component

History of Present Illness-HPI

• Location – where the problem is located (e.g. brain disorder)

• Quality – how does is feel – (strong ideations)

• Severity – how bad is it (1 – 10 for intensity)

• Duration – how long (3 days)

• Timing – when does the symptom(s) occur (worse in am)

• Context - what happen to caused it (family argument)

• Modifying factors - what did the patient do in an attempt to alleviate their symptoms (not taking meds)

• Associated signs and symptoms – what else is bothering the patient. (suicidal ideation)

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Review of Systems-(ROS) • An inventory of the body systems of the patient to

determine if the patient is experiencing additional

signs and/or symptoms

• Expand on remarkable symptoms

• A complete ROS – 10 or more systems – Positive or

pertinent negative responses must be individually

documented with a statement that all other

systems are negative. In the absence of such a

notation, at least ten systems must be individually

documented.

Past, Family, and Social History-(PFSH)

• Past history – patient’s experience with illness and/or injury

• Family history – patient’s family experience with illness

• Social history – age relevant review of the patient’s social activities o Military history (2015)

History Documentation Reminders • CC, ROS and PFSH may be listed as separate

elements of history or included in documentation of the HPI

• Provider can use and get credit for history elements (not HPI) obtained at another visit as long as it is relevant and referenced o “Remainder of ROS and PFSH unchanged since

9/2/2014”

• ROS and/or PFSH may be recorded by ancillary staff or patient as long as the provider documents confirmation of the information (NOT HPI)

• If unable to obtain a history from the patient or other source,

document the patient’s condition that precludes getting it and you can be credited for a comprehensive level of history.

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Determining the Level of History

*start in the highest level

*element located in the lowest level will

determine overall level of history

Problem

Expanded

Detailed

Comprehensive

‘95 - Body Areas ‘97 -Elements

1 1 - 5

2 - 7

2– 7 * with 1

detailed

8 + organ

systems

6 - 11

12 - 17

18 / 9

Multi - Sys Psychiatric

1 - 5

6 +

9 +

Perform ALL

Document ALL Shaded +

Document at least 1 Unshaded

Determining Level of Physical Exam

Body Areas / Organ Systems

Be aware of Carrier specifics

Constitutional:

o 3 vital signs

Height, weight, BP, pulse rate, respiration,

temperature

o General appearance statement

Psychiatric:

o Description of speech including: rate; volume;

articulation; coherence; and spontaneity with

notation of abnormalities (eg, perseveration,

paucity of language)

o Description of thought processes including: rate

of thoughts; content of thoughts (eg, logical vs.

illogical, tangential); abstract reasoning; and

computation

o Description of associations (eg, loose, tangential,

circumstantial, intact)

o Description of abnormal or psychotic thoughts

including: hallucinations; delusions;

preoccupation with violence; homicidal or

suicidal ideation; and obsessions

o Description of the patient’s judgment (eg,

concerning everyday activities and social

situations) and insight (eg, concerning

psychiatric condition)

Psychiatric (cont’d)

o Complete mental status examination

including:

o Orientation to time, place and person

o Recent and remote memory

o Attention span and concentration

o Language (eg, naming objects,

repeating phrases)

o Fund of knowledge (eg, awareness of

current events, past history,

vocabulary)

o Mood and affect (eg, depression,

anxiety, agitation, hypomania, lability)

Musculoskeletal: (only 1 from below required)

o Assessment of muscle strength and tone

(eg, flaccid, cog wheel, spastic) with

notation of any atrophy and abnormal

movements

o Examination of gait and station

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Bullet Page #1

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MEDICAL DECISION MAKING

BOX A: Number Of Diagnosis or Management Options (N x P = R)

Problems Number Points Results

Self-limited or minor (stable, improved or worsening) Max = 2 1

Est. problem: stable or improved 1

Est problem: worsening, failing to change 2

New problem: no additional work-up planned Max = 1 3

New problem: additional work-up planned 4

Bring to line A in Final Result for MDM Total

Bullet Page #1

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MEDICAL DECISION MAKING

BOX B: Amount and/or Complexity of Data to be reviewed Points

Review and/or order of clinical lab test 1

Review and/or order of tests in the radiology section of CPT 1

Review and/or order of tests in the medicine section of CPT 1

Discussion of test results with performing physician 1

Decision to obtain old records and/or obtaining history from

someone other than patient 1

Review and summarization of old records and/or obtaining history

from someone other than patient and/or discussion of case with

another health care provider 2

Independent visualization, tracing or specimen itself (not simply

review of report) 2

Bring to line B in Final Result for MDM Total

Bullet Page #1

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BOX C: Risk of Complication and/or Morbidity or Mortality

Presenting Problems Diagnostic Procedures ordered Management Options Selected

Min

imal

Lab tests requiring venipuncture

EKG/EEG

Urinalysis

Rest

Lo

w

1 stable chronic illness

Acute uncomplicated illness or

injury

Clinical lab test requiring arterial puncture

Over-the-counter drugs

Mo

der

ate

1 or more chronic illnesses

w/mild exacerbation, progression or side effects of treatment

Undiagnosed new problem w/ uncertain prognosis

Prescription drug management

Hig

h

1 or more chronic illnesses w/ severe exacerbation, progression, side effects of treatment

Injury/condition that pose a threat to life or bodily function (self or others)

Abrupt change in neurologic status

Drug therapy requiring intensive monitoring for toxicity

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Bullet Page #1

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MEDICAL DECISION MAKING

BOX D: Final Result for Complexity of Medical Decision Making: 2 of 3 required

A Number of diagnoses or

management options

≤ 1

Minimal

2

Limited

3

Multiple

≥ 4

Extensive

B Amount and complexity of

data to be reviewed

≤ 1

Minimal

2

Limited

3

Multiple

≥ 4

Extensive

C Risk of complications and/or

morbidity or mortality Minimal Low Moderate High

TYPE OF DECISION MAKING Straight

Forward

Low

Complexity

Moderate

Complexity

High

Complexity

2 out of 3 required

** MDM should serve as a guide to the correct level of E&M service

Pulling It All Together (Outpatient, Established)

Established patients require 2/3 (one “key” being MDM)

99211 99212 99213 99214 99215

N/A Problem Focused EPF Detailed Comprehensive

N/A Problem Focused EPF Detailed Comprehensive

N/A Straightforward Low Moderate High

Start in highest level…established patients require 2/3 key components

Pulling It All Together (New Patients/Consults) Due to the EPF examination, 99202, 99242 or 99252 is supported

99201 99241 99251

99202 99242 99252

99203 99243 99253

99204 99244 99254

99205 99245 99255

Problem Focused Expanded

Problem Focused Detailed comprehensive comprehensive

Problem Focused Expanded

Problem Focused Detailed comprehensive comprehensive

Straightforward

Straightforward

Low

Moderate High

Start in highest level…new patients and consults need all 3 key components

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Pulling It All Together (Inpatient, Initial)

Initial Inpatients (Admits) require all 3 “KEY” Components 99221 99222 99223

Detailed Comprehensive Comprehensive

Detailed Comprehensive

Comprehensive

Straightforward / Low Moderate High

Start in highest Admits require all 3 key components 99221 is supported in this case due to DETAILED HISTORY

Pulling It All Together (Inpatient, Subsequent)

Initial Inpatients (Admits) require all 3 “KEY” Components 99231 99232 99233

Problem Focused Expanded Problem

Focused Detailed

Problem Focused Expanded Problem

Focused

Detailed

Straightforward / Low Moderate High

Start in highest: “Rounds” require 2/3 key components 99232 is supported here

Thanks For Attending

John F. Burns, CPC, CPMA, CPC-I, CEMC

CEU Index# 38866HVL

jburns@drsmgmt.com