Behavioral Health Coding that
Works in Primary Care
Mary Jean Mork, LCSW
April 16 & 17, 2009
Workshop Outline
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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
practices
• 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
www.cms.hhs.gov
• Medicaid determines what should be
adopted on state level (as long as not in
violation of CMS rule)
Various Payers and Various Rules
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Medicare
Medicaid
Commercial Insurers
Mental Health vs Medical
codes
• Licensing rules
Medicare
• Variation exists in the interpretation and
application of the Federal program rules and
guidelines
– 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
Medicare
• Louisiana Regional Medicare Carrier – PBSI
Medicare Services
• www.lamedicare.com
• Search site for Local Coverage Determinations
(LCD’s) –
www.lamedicare.com/provider/medpolb/polmani
ndex1.asp
• Look for H&B codes
• Or – Find someone in your organization who
does this all the time and make them your friend!
Medicaid
• 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
insurers
• Lack of clarity around covered
services
• Difficulty finding “experts” to answer
specific questions about
reimbursement
• 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
injury
• Where biopsychosocial factor may be
affecting medical treatment
• Patients with cognitive capacity for the
approach
• Physician documents need
• Assessment not duplicate of other
assessment
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
intervention
• 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
Examples
Billing for the H&B
• Medical diagnosis
• Medical bill – not mental health
• Billed by practice with Mental Health
Provider:
– 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
setting?
• Make friends with your billers and coders
• Make connections at the state level for
Medicaid. Talk to the Provider Relations
folks
• 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
spectrum:
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Billers and coders
Audit specialists
Clinicians
Primary Care Practice Manager
Mental Health Program Manager
Physician/Psychiatrist
• Focus on all levels
• Information and ongoing learning are key
• Celebrate successes (and awareness) along the way
Work Group Strategies
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Understand the current rules
Identify opportunities and barriers that affect
sustainability
Use understanding of current rules to:
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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
service
• 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
information