Billing for Integrated Behavioral Health: Primary Care Coding Guidelines. Integrated Primary Care Leadership Collaborative June 6, 2018

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1 Billing for Integrated Behavioral Health: Primary Care Coding Guidelines Integrated Primary Care Leadership Collaborative June 6,

2 Who Is HealthInsight? Our business is redesigning health care systems for the better HealthInsight is a private, non-profit, community-based organization dedicated to improving health and health care in the western United States. healthinsight.org 2

3 Disclaimer This information may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies, and guidelines are undergoing continuous improvement. The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors and other data only are copyright 2018 American Medical Association. All rights reserved. 3

4 We expect a large number of questions. Please submit your questions through the Chat feature during the presentation and we will do our best to answer them! 4

5 Welcome and Introductions Please type in the chat: Your geographical location Position within your organization (e.g., provider, biller, MA, office manager) 5

Julie Oyemaja, PsyD Adjunct Professor at George Fox University &

6 Webinar Presenters Joan Fleishman, PsyD Behavioral Health Clinical and Research Director for Oregon Health & Science University (OHSU) Julie Oyemaja, PsyD Adjunct Professor at George Fox University & Healthcare Organization Consultant for Mountainview Consulting Group 6

County Health Department Denise Phillips Revenue Cycle

7 Webinar Presenters Jonique Dietzen Certified Professional Coder & Project Manager for Multnomah County Health Department Denise Phillips Revenue Cycle Manager for Oregon Health & Science University (OHSU) Family Medicine 7

8 What are we talking about? Behavioral health clinician (BHC) as a primary care team member assigned to generally 3 6 FTE primary care clinicians. BHC enhances biopsychosocial care for all For our billing conversations, psychologists and LCSWs practicing in Oregon 8

9 What are we talking about? 25% 50% of day available for same-day visits Focused clinical assessment and intervention to patients of all ages and severity levels Registry management of higher-needs patients Team-based workflows support quality incentive metric success Depression screening and follow-up SBIRT Well-child visits A1C etc. 9

10 BHCs are licensed independent practitioners OR Senate Bill 832 outlines who is considered a behavioral health clinician in primary care and whom CCOs may pay: A licensed psychiatrist; A licensed psychologist; A certified nurse practitioner with a specialty in psychiatric mental health; (d) A licensed clinical social worker; A licensed professional counselor or licensed marriage and family therapist; A certified clinical social work associate; An intern or resident who is working under a board-approved supervisory contract in a clinical mental health field; or Any other clinician whose authorized scope of practice includes mental health diagnosis and treatment. 10

11 We re not talking about... Why BHCs are needed for primary care teams Photo by rawpixel on Unsplash 11

Insurance Reimbursement Streams Physical Health and Mental Health/Substance Use funding streams MH/SUD: Focus is more on severe conditions Limited funding to

12 Insurance Reimbursement Streams Physical Health and Mental Health/Substance Use funding streams MH/SUD: Focus is more on severe conditions Limited funding to support full range of behavioral health concerns Many patients do not follow up on external referrals for MH/SUD Making primary care the de facto mental health system 12

13 Trailblazing Together 13

14 Integrated Primary Care Leadership Collaborative Engaging & empowering on-the-ground leaders Joan Fleishman, PsyD; Lexy Kliewer, LCSW; Andrew Huff, LPC; Julie Oyemaja, PsyD 14

15 BHC Billing/Coding Tool: Prototype 15

16 Fiscal Sustainability: BHCs Fee-for-Service Business operations for Medicaid MH billing Alternative Payment Models Per-Member/Per-Month (PMPM) for practices that... Grants Care for all primary care patients better (QIMs) Staff team-based BHCs at least 1FTE/6FTE BHC/PCC BHC population penetration >20% Fewer of these now as BHC is more mainstream 16

17 Benefits of billing for BHCs Capturing the services provided to patients Promotes visibility to payers Some BHCs will piggyback on PCC visits (PCC upcodes/incident to) Hides unique work of the BHC to payers and policy makers BHCs are independently licensed practitioners Recognizing the fiscal value of the services Promoting primary care bottom-line Maintain and grow BHC jobs and services 17

18 Provider Credentials and Scope of Practice Example Payer: Medicare Mental health services = psychologists and licensed clinical social workers Health & behavior services = psychologists Prevention = neither 18

19 Succeeding in the Short Term Which BHCs get paid by insurers most? Do your research: Who are your top payers? What kinds of services are your BHCs doing? BH and billing/coding leaders team up! Train BH/billing staff together Engage clinic and senior leadership Billing/coding random chart audits 19

20 Billing Code Options 20

21 Coding Guidelines: BHCs in Primary Care in Oregon Health & Behavior Codes Prevention, treatment, or management of physical health/medical problems Assessment and treatment Psychological, behavioral, emotional, cognitive, and social factors Not for assessing/treating MH disorders Report 1 unit for each 15 minutes 21

22 Health & Behavior Intervention Jane is 32 yrs and worried about gestational diabetes. She is at the borderline. Visit focus: Increasing physical activity/decreasing carbs Intervention: Motivational, food diary & behavioral activation Visit diagnosis: Gestational Diabetes 22

23 Coding Guidelines: BHCS in Primary Care in Oregon Smoking & Tobacco Counseling Smoking and tobacco use cessation counseling 2 cessation attempts per 12-month period Maximum of 4 intermediate or intensive sessions per attempt 3-minute minimum 23

24 Smoking & Tobacco Counseling Jorge, 37 yrs, who is quitting smoking. He is struggling to stop completely. Visit focus: Reducing tobacco use Intervention: Psychoeducation on craving and avoiding triggers, validating experience of challenge & referring to PCC to discuss nicotine replacement Visit diagnosis: Tobacco Use Disorder 24

25 Coding Guidelines: BHCs in Primary Care in Oregon Alcohol & Substance Use (SBIRT) Alcohol and/or substance use structured screening and brief intervention services Must use a validated screening instrument (AUDIT/DAST) 15-minute minimum 25

26 Screening, Brief Intervention, & Referral (SBIRT) Jorge screened positive on AUDIT when seeing PCC for nicotine-replacement options. BHC same-day to review alcohol use. Visit focus: Education on where his alcohol places him among other people who drink Intervention: Motivation, support for challenge, referral to CD Visit diagnosis: Alcohol Use Disorder 26

27 Coding Guidelines: BHCs in Primary Care in Oregon Behavioral Health Care Management Initial assessment or follow-up monitoring, including the use of applicable validated rating scales Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision of plan for patients who are not progressing or whose status changes Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation Continuity care with a designated member of the care team One at least 20-min session every calendar month 27

28 Behavioral Health Care Management Jon, 65 yrs, sees BHC 1x month for a check in. Jon has MDD and cognitive decline. Visit focus: Reviewing care plan and patient goals, risk assessment, & reviewing how he is taking his meds Intervention: Managing his care, ensuring safety, and providing support Visit diagnosis: Major Depressive Disorder 28

29 Coding Guidelines: BHCs in Primary Care in Oregon Developmental screening Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument The provider uses a standardized form to analyze the presence of any developmental disorder using the measurable parameters of the standardized instrument Ages and Stages Questionnaire: Social Emotional, ASQ SE Australian Scale for Asperger's Syndrome, ASAS Behavior Assessment Scale for Children, BASC Behavioral Rating Inventory of Executive Functioning, BRIEF, for Psychological Assessment Child Development Review Communication and Symbolic Scales Developmental Profile, CSBS DP Kaufman Brief Intelligence Test Parents' Evaluation of Developmental Status, PEDS Pediatric Symptom Checklist, PSC Vanderbilt Rating Scales. 29

30 Developmental Screening Rose, 3 yrs, seen in BHC same-day visit. PCP requested BHC screening today and PCP visit tomorrow. Visit focus: Interview mother and review ASQ and MCHAT Intervention: Discuss development milestones, review concerns, allay fears, and recommend PCP refer patient to early intervention Visit diagnosis: Developmental screening 30

31 Coding Guidelines: BHCs in Primary Care in Oregon Brief emotional/behavioral assessment Use of a valid screening instrument for a brief assessment for ADHD Depression Suicidal risk Anxiety Substance abuse Eating disorders etc. 31

32 Brief Emotional/Behavioral Assessment Charlie, 15 yrs, seen in BHC same-day visit. He endorsed suicidal ideation in his well-teen paperwork. Visit focus: Reviewing PHQ-A, assessing risk, developing a safety plan with mom, and beginning to formulate mental health diagnosis Visit diagnosis: Suicidal ideation 32

33 Preventive Medicine Codes in Oregon Unique to Oregon Medicaid Billable by psychologists and LCSWs Medicare and most commercial insurance carriers do not cover psychologists and LCSWs billing for preventive CPT codes Consider billing as an incident to service 33

34 Coding Guidelines: BHCs in Primary Care in Oregon Preventive Medicine Counseling , Promoting health and/or preventing illness or injury Symptoms identified; diagnoses not yet determined Counseling to support a wide variety of symptoms and concerns, including family problems diet and exercise substance abuse sexual practices injury prevention behavior problems diagnostic and laboratory test results 34

35 Preventive Medicine Counseling Jill, 7-yr-old female whose mother is concerned about her worries at home and school avoidance. Visit focus: Info gathering Drawing pictures (playground, classroom) Intervention: Psychoeducation for mom and Jill about anxiety Exploring what is worrying Jill at home/school Visit diagnosis: School avoidance, anxiety, and worry 35

36 Mental Health Codes 36

37 Coding Guidelines: BHCs in Primary Care in Oregon Diagnostic Evaluation A psychiatric evaluation of the patient with the aim of making a diagnosis Assessment identifies factors of mental illness, functional capacity Determination of a person s need for mental health services Applies to new patients or to patients undergoing re-evaluation 37

38 Diagnostic Evaluation Jane is a new mom. She returns to BHC to address anxiety and MJ use. She comes to visit with PHQ9/GAD7 filled out at postpartum visit. Visit focus: HPI, risk assessment, observations, differential diagnosis, and diagnostic formulation Intervention: Praise her desire to improve her health Visit diagnosis: Generalized Anxiety Disorder & Cannabis Use 38

39 Coding Guidelines: BHCs in Primary Care in Oregon Psychotherapy , 90846, 90847, 90849, Individual psychotherapy, insight oriented, behavior modifying and/or supportive, face-to-face with the patient Documentation should highlight... therapeutic communication attempts to alleviate the emotional disturbances change maladaptive patterns of behavior encourage personality growth and development 39

40 Psychotherapy Jane returns to discuss anxiety and her plans to cut down on 3-year habit of daily cannabis use. Visit focus: Psychoeducation, motivation, and skill acquisition Intervention: Review the physiology of anxiety, cannabis impacts on emotions, and teaching ways to calm the sympathetic nervous system Visit diagnoses: Generalized Anxiety Dx & Cannabis Use Dx 40

41 Coding Guidelines: BHCs in Primary Care in Oregon Psychotherapy for Crisis Psychotherapy services provided to a patient who presents with circumstances that require urgent or immediate attention Patient in high distress Patient with complex problems Patient with life-threatening circumstances 41

42 Psychotherapy for Crisis Felicity, 25-yr-old transgender pt, presents in the lobby stating she is feeling suicidal. Visit focus: 90-min visit, risk assessment & safety planning Intervention: Grounding, identifying/connecting with natural supports, safety planning, and follow-up scheduled Visit diagnosis: Suicidal ideation & Gender dysphoria 42

43 Coding Guidelines: BHCs in Primary Care in Oregon Psychological Testing Psychodiagnostic assessment of emotionality, intellect, personality and psychopathology Document tests performed, scoring and interpretation as well as time involved Establish need for testing and what the results suggest, as well as, implications for treatment Psychologists only 43

44 Psychological Testing PCP referred 28-yr-old Jackie for neuropsychological screening. She was in a car accident. She reportedly does not recall the crash. Records indicate she lost consciousness which was regained in the emergency room. She saw a psychologist BHC. Visit focus: Clinical interview, neuropsychological screening, and behavioral observations Visit diagnosis: Concussion (diagnosed by PCP and active) 44

45 Tips for Success 45

46 Quick Tips: BHCs in Primary Care Provide service that is requested and clinically indicated. Then find the billing code that matches the service. BHCs in primary care provide diagnostic evaluation and psychotherapy. BHC visits generally range from 15 to 90 min. Most often 30-min visit blocks. Bill the 30-min psychotherapy code, when appropriate. 46

47 Which code to use? Sarah, 23 yrs, is having a miscarriage. She is tearful, anxious, and says, I want to die. Visit focus: 45-min visit focused on support and crisis management Intervention: Review medical plan, activate support system, instill hope, risk assessment & safety planning Visit diagnosis?? Billing code?? 47

48 Which code to use? Hannah, 12 yrs, is experiencing bullying at school. She is tearful, anxious, and says, I want to die. Visit focus: 45-min visit focused on support and crisis management Intervention: Review medical plan, activate support system, instill hope, risk assessment & safety planning Visit diagnosis?? Billing code?? 48

49 Billing/Coding Experts Did you communicate with payers? Why and how? What issues have you encountered? What research was required? What other stakeholders did you contact? What should practices who are just starting consider? Is there anything you would have done differently? 49

50 Challenges Large deductibles for MH at beginning of year Encourage patients to be familiar with plan Remind patients at the end of the year Patient cannot afford copay Set up a payment plan, or discount program Utilize supervised practicum, interns, and postdoc Primary payer does not cover, secondary does Encourage patient to bring insurance bills & letters Provide patient education 50

51 Lessons Learned Consider your BHC credentials when hiring Consider your payer mix Clarify your values We provide services regardless of ability to pay... Do a billing/coding PDSA One BHC Sub-group Build a BHC leadership collaborative to standardize practices (including billing) and together begin to have conversations with payers about BHC billing challenges 51

52 Q & A 52

53 Wrap-Up 53

54 Contact Information You can find the Coding Guidelines document with our Oregon-specific resources at If you have further questions, you can contact us at any time at This material was prepared by HealthInsight, the Medicare Quality Innovation Network - Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), and agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-G OR 4/23/18 54

Specialty Behavioral Health and Integrated Services

Specialty Behavioral Health and Integrated Services Introduction Behavioral health services that are provided within primary care clinics are important to meeting our members needs. Health Share of Oregon supports the integration of behavioral health and