Why track billing data?

Behavioral Health Coding that
Works in Primary Care
Mary Jean Mork, LCSW
April 16 & 17, 2009
Workshop Outline
Our program background
Reimbursement big picture and problems
Your questions about reimbursement
Process for addressing problems
Products to organize our thinking
Your challenges and successes
Learning Objectives
Attendees will:
• Be able to identify who to involve in order to
better understand the regulatory and payment
situation for integrated care in your own setting
• Receive tools to help organize the facts around
payment and licensing at home
Mental Health Integration in Maine
Our Mental Health Integration Program:
Primary Care/Mental Health Teams
• Primary Care sites
– Rural Health Clinics (RHC)
– Federally Qualified Health Centers (FQHC)
– Hospital owned practices
– Private practices
• Local Mental Health Partners
– Specialty Mental Health agencies
– Hospital owned Behavioral Health organizations
– Community Mental Health Centers
The Goal:
Creating a sustainable model of
mental healthcare in primary care
The Problems with Integrated Care
• No one seems to know how to get paid
• Mental Health regulations and licensing expectations
don’t fit the primary care setting
• Confidentiality vs. “shared records”
• Lack of clarity and understanding about present
• Complicated licensing and reimbursement rules without
accessible experts
Examples from our Program
• A Psych NP working in a privately owned primary care practice is
unable to bill for Psychiatric services for 3 years due to lack of
Psychiatric Supervision “physically located on site.”
Is this correct?
• An LCSW is employed by a mental health center but working in a
primary care practice.
How should she bill?
• An LCPC wants to work for a primary care practice, but is not
employed by an agency.
Will this work?
Why is this so complicated?
Some Background Information
• AMA determines E&M and CPT codes
• CMS (Centers for Medicare & Medicaid
Services) determines if and how they will
reimburse the codes for Medicare
• Medicaid determines what should be
adopted on state level (as long as not in
violation of CMS rule)
Various Payers and Various Rules
Commercial Insurers
Mental Health vs Medical
• Licensing rules
• Variation exists in the interpretation and
application of the Federal program rules and
– Fiscal Intermediaries often have a more narrow
interpretation than Medicare law allows
– Creates misunderstanding of policies and confusion
at the practice level
– Denies reimbursement for allowable procedures
• Louisiana Regional Medicare Carrier – PBSI
Medicare Services
• www.lamedicare.com
• Search site for Local Coverage Determinations
(LCD’s) –
• Look for H&B codes
• Or – Find someone in your organization who
does this all the time and make them your friend!
• States have flexibility in defining covered mental
health services
• Can choose to contract with managed care
• Billing requires both a diagnosis and a
procedure code
– Some states limit procedures, providers and/or
practices that can use these codes
Commercial Insurance
• Inconsistencies among various
• Lack of clarity around covered
• Difficulty finding “experts” to answer
specific questions about
• Carve outs
• Other problems?
Coding that Works
Evaluation & Management (E&M)
• Use E&M codes 99201-99201 or 9921199215 whenever possible
• Services must be medically necessary
• Practitioner must be practicing within their
scope of practice
• Used in conjunction with a medical or
psychiatric diagnosis
Health and Behavior Codes:
Consider Their Use
Using Health & Behavior Codes
• Patients with underlying physical illness or
• Where biopsychosocial factor may be
affecting medical treatment
• Patients with cognitive capacity for the
• Physician documents need
• Assessment not duplicate of other
Documentation - Assessment
• Onset and History of physical illness
• Clear rationale for H&B
• Assessment outcome including:
– Mental status and
– Cognitive ability for treatment
• Goals and expected duration of
• Length of time for assessment
Documentation - Intervention
• Capacity
• Intervention
– Clearly defined
– How this will improve compliance
– Goals of intervention
– Response to intervention
• Rationale for frequency
• Length of time for intervention
Billing for the H&B
• Medical diagnosis
• Medical bill – not mental health
• Billed by practice with Mental Health
– Hospital license
– Primary care office
– Rural Health Clinic
– Federally Qualified Health Center
What have been your challenges in
billing and licensing?
How can you figure this out for your
• Make friends with your billers and coders
• Make connections at the state level for
Medicaid. Talk to the Provider Relations
• Find your Medicare site
(www.lamedicare.com) and see what is
available for you
• Talk with other providers doing this work
Consider a Work Group
• Representatives from all aspects of the reimbursement
Billers and coders
Audit specialists
Primary Care Practice Manager
Mental Health Program Manager
• Focus on all levels
• Information and ongoing learning are key
• Celebrate successes (and awareness) along the way
Work Group Strategies
Understand the current rules
Identify opportunities and barriers that affect
Use understanding of current rules to:
recommend most effective way to organize services
maximize reimbursement for integrated care
Target barriers with highest priority and/or are
most likely to be able to change
Organizing Information
“The Grid”
Components within “the Grid”
• Coding Category
• Coding number for service
• Discipline of Provider allowed to bill for
• Codes by insurer
• Psychiatric Services by type of license
• Practice site able to bill for code, funding
source, provider and license
Where to begin
• What is the discipline of your mental
health practitioner?
• What service will they deliver and what
code will be used?
• Under what license?
• Where will the service be delivered?
• Which insurance will be billed? What are
the rules for that insurer?
How have you addressed your
reimbursement challenges?
Share your good ideas and useful
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