Magellan of Virginia: Effective CPT Coding 2013 and Beyond January 10, Gary M. Henschen, MD Chief Medical Officer-Behavioral Health

Transcription

1 Magellan of Virginia: Effective CPT Coding 2013 and Beyond January 10, 2014 Gary M. Henschen, MD Chief Medical Officer-Behavioral Health

2 What are CPT Codes? Magellan must buy licenses from AMA to use CPT codes Current Procedural Terminology (CPT) codes are developed by the AMA, under contract with CMS to be the official coding system Describes medical, surgical, diagnostic services Under HIPAA, providers and insurers are required to use CPT codes to identify their services Identifies services rendered rather than diagnoses as in DSM and ICD-9 and 10 Communicates uniform information about medical services and procedures 2

3 CPT Code Changes for 2013 The AMA issued major changes to behavioral CPT codes impacting both payors and providers effective January 1, CPT codes changes affect 908x series therapy codes including the replacement of 90862, and require the use of 99 codes, specifically the 9920x and 9921x series, by psychiatrists, physicians assistants and advanced practice nurses. These changes apply to any services provided beginning January 1, Magellan conducted education across the country during late 2012 and early 2013 to educate practitioners about these changes. Professional societies also provided educational seminars and webinars to educate their memberships. 3

4 The Big Picture The new CPT codes are mandatory; non-compliance is a HIPAA violation. The switch to the new codes is based on the date of service, not the date the claim was submitted. For dates of service prior to Jan. 1, 2013, bill with the old codes and the claim will pay. CMS did not allow for a transition period. Providers had to bill with new CPT codes on Jan. 1 for dates of service on or after Jan. 1 or the claim will deny. This includes electronic claims. Code changes impact all provider types, not just psychiatrists. 4

5 The Changes 908xx xx and Most 908xx codes we are familiar with have been changed Medication management, has been eliminated Psychiatrists and other physicians must use E/M (Evaluation and Management) codes 992xx with an add-on code if psychotherapy is performed has been eliminated Now initial evaluation with medical services ; without medical services If initial evaluation code or is interactive, appropriate add-on code must be used Interactive code may be used with E&M only when add-on psychotherapy codes are used 5

6 The Changes Psychotherapy for patient in crisis-60minutes Crisis beyond 60 minutes, per each additional 30 minutes Add-on for medication management and psychotherapy by psychologist-applies to Louisiana and New Mexico 6

7 What s An Add-On Code? Used in conjunction with another primary code-indicated by a (+) Added to 99xxx codes to denote psychotherapy in addition to evaluation and management services (see next slide) Added to denote interactive psychotherapy use of device, interpreter or other circumstances (+90785) Initial evaluation codes (90791 or 90792) To evaluation and management codes (99xxx codes) if add-on psychotherapy code is used To psychotherapy codes To group psychotherapy codes Used with crisis therapy for each 30 minute session beyond the first hour

8 Psychotherapy Codes Codes simplified and expanded Includes time with patient and/or family member Only 3 timed codes, without medical services: minutes minutes minutes If E/M provided, timed add-on codes for psychotherapy-can be used only by medical providers-mds, ARNP s, PA s minutes minutes minutes 8

9 A Few Codes Remain the Same! Psychoanalysis Family therapypatient not present Family therapypatient present Multifamily group treatment Group therapy 9

10 Evaluation and Management (E/M) codes Psychiatrists must use E/M codes for services such as medication management These codes are the same ones all physicians use for similar services, and use the numbers 99xxx Documentation requirements are much more specific for these codes and require addressing various degrees of medical complexity APA has a training program online for psychiatrists in the use of these codes Physician extenders will also use these codes, but not other mental health professionals 10

11 Evaluation & Management Services Office/Outpatient services New Patient Office Visit Established Patient Office Visit 9924x Outpatient Consult Inpatient/Hospital Services Initial Hospital Care Subsequent Hospital Care Nursing facility care Home visit

12 Case Examples 1 John Smith, MD is providing brief medication check services of low complexity to Mr. Jones. He spent about 15 minutes with the patient. What code should he bill Magellan? After this patient, Dr. Smith evaluates a new patient who does not speak English, and an interpreter is used. What code should he bill Magellan? Dr. Smith has asked his LCSW, Ms. Brown, to lead a group therapy session with 8 patients. What code should she use to bill?

13 Case Examples Dr. Green is conducting a 60-minute psychotherapy session. During the session, the patient becomes agitated, psychotic and suicidal. Dr. Green must spend an extra 30 minutes to calm him down. Dr. Green is having a session with a 13-year-old patient for depression and alcohol abuse. The patient is on an antidepressant and an inhaler for her asthma. She presents with both of her parents, who are divorced and arguing over how to address the patient s recent alcohol binge. One parent wants to send her away to a boarding school. The other parent wants to follow the previously agreed upon course of treatment. Dr. Smith admits a patient to the hospital. He conducts a 45-minute psychotherapy session, and evaluates the patient s reaction to his medication. What code should he use to bill? What code should he use? What code should he use?

14 Case Examples 7 Dr. Smith and Ms. Brown, LCSW work in a CSB. Ms. Brown conducts a 45 minute psychotherapy session. After this, Dr. Smith sees the patient for a brief medication check of low complexity. What codes should they use to bill? Dr. Smith bills Ms. Brown bills Dr. Jones is a clinical psychologist working in New Mexico who is licensed to prescribe medications. He conducts a 45 minute psychotherapy session, and then prescribes medication for his patient. What code should he bill? Dr. Smith evaluates the efficacy of psychotropic medication with her patient, Mrs. Taylor. In the interview, she takes a family history, conducts a review of systems, reviews lab data, and performs elements of a physical examination. The patient s medical issues are of high complexity. She then conducts a 30 minute psychotherapy session to discuss family dynamics. What code should she bill?

15 Communicating Updates Resources to assist your use of the new CPT codes: A dedicated CPT Code page, which offers updated information and links, on under Getting Paid/HIPAA News Headlines and Provider Focus articles on the provider site A reminder notice when submitting claims online CPT Code messages on hardcopy EOBs Provider webinars And, additional local outreach as needed 15

16 Questions 16