Transcript E-M Medical Training April 2015x

E/M coding for
Mental Health
Pamela Pully CPC, CPMA
Professional Insurance
Consultants.
Presenter
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Pamela Pully
30+ years billing/coding/auditing all
specialties.
CPC - Certified Professional Coder
CPMA – Certified Professional Medical Auditor
Member of American Academy of
Professional Coders (AAPC), Past officer of
local chapter. National Alliance of Medical
Auditing Specialist (NAMAS) member, and
current officer of Michigan Association of
Reimbursement Officers (MARO)
Disclaimer
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This information is accurate as of April 1, 2015
and is designed to offer basic information for
coding and billing. All information is based on
experience, training and has been
researched, interpreted and carefully
reviewed by this trainer. Medical
compliance/coding and billing information
changes quickly. This can become outdated
quickly. This is intended to be an educational
guide and should not be considered as legal
or consulting opinion.
Disclaimer cont.
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CPT, HCPCS and ICD-9 books were used for
coding information.
Rules used come from AMA, ICD-9,CMS, final
rule and others.
HIPAA and PPACA laws.
Any questions on information I am presenting,
please ask. I will give you the source
document I used.
It is important to me to give the best and most
up to date information I can.
Goals for Training
 Have
a better understand of things you
should and should not do when
documenting for Evaluation and
Management (E/M) codes.
 Be aware of what is needed and/or
required for each level of E/M.
 Learn what is required for the new
Diagnostic Evaluation.
 Understand when to use add on codes
What we are going to talk
about today.
1)
2)
3)
4)
5)
6)
7)
8)
9)
Evaluation and Management (E/M) codes. The
replacement for Medication Review 90862.
7 Elements of E/M
1997 Exam Rules
What are differences between New patient and
established patients.
Diagnostic evaluation.
Add on code 90785
Documentation requirements.
This is an aggressive schedule, we can do it.
Ask questions as we go.
What we should not do
 Cross
Walk codes-90862 to any one E/M.
 Use only time as factor for coding.
 Use of unspecified diagnostic codes for
services. Just minimal training in this area.
Getting correct diagnosis especially ICD10 is a different training.
 Treat all carriers the same.
 Only use one carriers set of rules. This is
especially important for Medicaid.
Different codes different rules
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If you cross walk , the old medication review
to one E/M code you run the risk for not
meeting the documentation requirements.
Using the same code for easy and difficult
cases can lead to rejections and flag for
audit.
Documentation ( sometimes carrier utilization
rules) decides the code.
Keep in mind 1% errors is100% wrong.
Review of documentation
requirements
90862
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Must include the
condition for which
the medication is
needed, type of
medication, dosage,
directions for use, any
frequent side effects
and the effect the
medication is having
on the patients
symptoms/condition
99213
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2 of 3 for established
patient
Expanded problem
focus history
Expanded problem
focus exam
Low Medical Decision
Making (MDM)
Evaluation and Management
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1.
2.
3.
4.
5.
6.
7.
There are 7 components to E/M 3 key elements
and 3 contributory factors and time.
History
Exam
Medical Decision Making
Counseling
Coordination of care
Nature of Presenting Problem
Time
E/M rules for time
 Time
factor: You can only use time if
more than 50% of the visit is spent
counseling and it is documented.
More on this later.
 You can have a higher level of E/M
codes with less time.
 Chief Complaint (CC) and Medical
Decision Making (MDM) are the most
important part of an E/M code.
Chief Complaint
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The Chief Complaint also known as CC, is
part of the medical history taking, and is a
concise statement describing the symptom,
problem, condition, diagnosis, physician
recommended return, or other factors that
are the reason for a medical encounter.
The patient's initial comments to a physician,
nurse, or other health care professional help
form the differential diagnosis.
Understanding History Element of
E/M
]
CMS required history elements
Type of
history
CC
HPI
ROS
Past, family, and/or social
Problem
focused
Required
Brief
N/A
N/A
Expanded
problem
focused
Required
Brief
Problem
pertinent
N/A
Detailed
Required
Extended
Extended
Pertinent
Comprehensive
Required
Extended
Complete
Complete
1995/1997 Exam rules
 Best
advise decide what works best for
your practiced and use it.
 You can use 1995 for one claim and 1997
for another.
 Eliminate the potential risk from an audit.
Make decision to use 1995 or 1997.
 Write in policies and procedures. “We use
1997 exam rules for E/M” or “1995 rules”.
Understanding Exam Element
of E/M
1995
rules are easy but usually
for specialty physicians this is
not the best rule to use.
1997 rules has bullet points
within one area exam allowing
you to get a better level.
1995/1997
 Lets
look at the 1997 exam for psych
 https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/eval_mgm
t_serv_guide-ICN006764.pdf
Understanding MDM Element
of E/M
 A-number
of diagnosis or treatment
options
 B-Risk of Complications and/or Morbidity
or Mortality
 C-amount and/or complexity of data
reviewed
 Remove the lowest next lowest rules.
A. number of diagnosis or
treatment options
A
Number of Diagnoses or Treatment Options
A
Problem(s) Status
B
xC=
Number
Points
Max = 2
1
Self-limited or minor (stable, improved, or
worsening)
1
Est. problem (to examiner); stable, improved
2
Est. problem (to examiner); worsening
New problem (to examiner); no additional
Max = 1
3
workup planned
New problem (to examiner); add. Workup
planned
4
D
Result
B. Risk of complications and/or
morbidity or mortality
 There
is much information in this
area.
 It is found on the paper passed out
with this power point.
 Let review
 Important factor in using the high
level of toxic medicine.
Amount and/or complexity
data reviewed
C
Amount and/or Complexity of Data Reviewed
Reviewed Data
Points
Review and/or order of clinical lab tests
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
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from someone other than patient
1
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.
Independent visualization of image, tracing or specimen itself (not simply review of
report)
1
2
AIMS test adds to E/M
 Aims
tests are not individually billable.
Usually done by non-physician provider.
 If you review test positive or negative and
document you reviewed this is, an
additional point is added to review of test
data. This is in the MDM section of the E/M
code. Test data reviewed, one point.
Time for counseling/coordination
of care
 You
must spend more than 50% of the visit
on counseling or coordinating care.
 It must be documented: Total time and
the amount of time spent on counseling
or coordinating care.
 You do not have to use start stop time of
counseling. You can think of time spent
as part of the entire visit. Just make sure
you document.
N.A.M.A.S. 5/9/2014
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Documentation of Time with Evaluation and
Management Services:
Time is built into the E/M codes so physicians are told to
base their E/M selection on the 3 components: History,
Exam and Medical Decision Making. Times are listed in
the CPT manual with each level of service as a
guideline only.
If a provider spends more than 50% of a face-to-face
visit counseling and/or coordinating patient's care, the
provider can code the visit based on time spent even
if the History, Exam and MDM elements are lacking.
N.A.M.A.S. 5/9/2014
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Time must be documented as well as the
detailed description of the circumstance
(counseling patient or coordinating care). For
example: 55 minutes spent with patient, 30
minutes was spent in discussion with patient
and family regarding care.
Prolonged service codes can be reported in
addition to an E/M code when the length of
time a provider spends with a patient in an
outpatient setting exceeds greater than 30
minutes beyond the typical for the level of
service selected.
Difference in New patient and
Established patient
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A new patient for a group practice is one that
has not been seen by anyone in the group
with the same discipline in the last 3 years.
CMS and AMA have different rules for “new”
A new patient E/M code must meet 3 of 3 to
be coded at that level.
An established patient only requires 2 of 3 to
be coded at that level.
E/M codes for different place
of service
 AFC/Group
home.
 There are two groups of codes. New and
Established.
 New 99324-99328
 Established 99334-99337
 Residential home POS 12
 New 99341-99345
 Established 99347-99350
90785 add on code for
complicated cases
90785-This code can be used to add on to
diagnostic evaluation and therapy codes
not E/M when the follow is present.
Factors typically present
1. Have other individuals legally responsible
for their care, such as minors or adults
with guardians, or
New 90785 add on code for
complicated cases
2.
3.
Factors typically present
Request others to be involved in their
care during the visit, such as adults
accompanied by one or more
participating family member or
interpreter or language translator or
Require the involvement of another third
parties, such as child welfare agencies,
parole or probation officers or schools.
90785 maybe reported when
at least one is present:
1.
2.
The need to manage maladaptive
communication (related to, e.g.; high
anxiety, high reactivity, repeated
questions or disagreements ) among
participants that complicates delivery of
care.
Caregiver emotions or behavior that
interferes with the caregivers understand
and ability to assist in the
implementation of the treatment plan.
90785 maybe reported when
at least one is present:
3.
Evidence or disclosure of a sentinel
event and mandated report to
third party (e.g., abuse neglect
with report to state agency) with
initiation of discussion of the
sentinel event and/or report with
patient and other visit participants.
90785 maybe reported when
at least one is present:
4.
Use of play equipment, other physical
devices, interpreter, or translator to
communicate with the patient to
overcome barriers to therapeutic or
diagnostic interaction between the
physician or other qualified health care
professional and a patient who…….next
slide
90785 maybe reported when
at least one is present:
a)
b)
Is not fluent in the same language as the
physician or healthcare professional.
Has not developed or has lost, either the
expressive language communication
skills to explain his/her symptoms and
response to treatment, or the receptive
communication skills to understand the
physician or healthcare professional.
99211
 This
is the most basic service done in the
office.
 Usually done by nurse when patients is not
being seen by doctor.
 You must document 2 elements, Example
vitals and what you did. This must be
billed under the provider.
99211
 This
code is for the office setting only.
 If there is a nurse visit done in the home
you have to follow the rule: CPT code first
HCPCS codes second.
 There is no CPT code for nurse visit in the
home so you look to HCPCS.
 The best HCPCS code for a nurse visit in
the home is T1002.
 Do not use T1002 for in office visits.
Documentation
Documentation Guidelines
a) They are in place and you need to
familiarize yourself with them.
b) Medical necessity is the most weighted
elements in a E/M. There needs to be a
reason for the visit. Chief Complaint.
c) There are different guidelines for
different carriers when it come to billing.
Documentation rules for E/M
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We now know the parts of E/M. We need to
be reminded that documentation must be
complete in these areas.
You can lose money or increase revenue with
your documentation.
You must put down what you are doing and
the calculations in your head must be
documented.
One doctor I worked with put it like this.
“Document what you did do and why did
you do it. Explain your thought process.”
Timeliness requirement
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3.3.2.5 - Late Entries in Medical Documentation
(Rev. 377, Issued: 05-27-11, Effective: 06-28-11,
Implementation: 06-28-11)
The MACs, CERT, Recovery Auditors, and ZPICs shall give
less weight when making review determinations to
documentation, including a provider’s internal query
responses, created more than 30 calendar days
following the date of service. If the MACs, CERT, or
Recovery Auditors identify providers with patterns of
making late (more than 30 calendar days past the date
of service) entries in the medical documentation,
including the query responses, the reviewers shall refer
the cases to ZPIC and may consider referring to the
RO(regional office) and State Agency.
Diagnostic Evaluation CPT
90791 and 90792
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Local Coverage Determination (LCD):
Psychiatry and Psychology Services (L30489)
90791: A psychiatric diagnostic evaluation (90791 is an integrated
assessment that includes history, mental status and
recommendations. It may include communicating with the family
and ordering further diagnostic studies. Use add-on code 90785 in
conjunction with 90791 when the diagnostic evaluation includes
interactive complexity services.
90792: A psychiatric diagnostic evaluation with medical services
(90792) includes 90791 and a medical assessment. It may require a
physical exam, communication with the family, prescription
medications and ordering laboratory or other diagnostic studies.
Use add-on code 90785 in conjunction with 90792 when the
diagnostic evaluation includes Interactive Complexity services
Diagnoses
 The
rule is to code to the highest
specificity .
 Should not use unspecified codes.
 Make sure to include all diagnoses that
you considered before setting the plan or
prescribing medication.
 ICD-9 has ordering rules.
 Final rule ICD-10 effective 10-01-2015
Medicaid provider
qualifications requirements
 90791--ok
for N .P. or psychiatrist
 90792 require a psychiatrist.
 There was much discussion in Lansing with
the state and changing this requirement. I
finally happened 1/1/2015
 The current mental health qualification
chart has been changed.
Any questions?
Thank you
 Pamela
Pully CPC, CPMA
 P.I.C. 810-964-1987
 [email protected]