CPT Coding Update And Other Issues
Robert E. Smith, M.D.
Alison Lynch, M.D.
November 13, 2013
1
Disclaimer
• This information is for educational and informational purposes only, and represents the understanding of the presenters regarding the material involved. The presenters assumes no liability or responsibility for behavior based on this presentation.
Reminder for Medicare Documentation
Individual Psychotherapy - Documentation Reminder
WPS Medicare has noted recent Comprehensive Error Rate Testing (CERT) denials for individual psychotherapy services because the documentation
requirements for the services were not met. In these cases, the CERT reviewer found the clinical record submitted was missing one or more of
these required elements:
Target symptoms Goals of therapy Methods of monitoring outcomes
Frequency of treatments
Clinical records to support beneficiary's relevant medical history Results of diagnostic tests or procedures
Prognosis and progress to date Estimated duration of treatment
It is important for providers who bill these services to be aware of the documentation requirements. Upon a Medicare request for a review, all documentation to support the billed service(s) must be submitted or
services may be denied.
Behavioral Health CPT RVUs
Values for 2013 were interim values
Crisis Code values set by the third party payer (carrier pricing)
Values for 2014 have been submitted to CMS
2014 RVU Values
Changes with DSM-5
Multi-axial System GONE!
WHY:
GAF Questionable psychometrics in routine practice
Axis IV ICD-9-CM and ICD-10-CM have their own V and Z codes for psychosocial and environmental problems
Changes with DSM-5
Axis I, II and III now are combined to reflect the relationships between physical and mental illness
Meaningful use now comes in play with the requirement for a problem list
How can this be good?
Loss of Axis I - III
Loss of Axis I - III
Diagnoses becomes:
Schizophrenia (Principle Dx), Metabolic Syndrome, Hypertension, Tobacco Use Disorder
Medical Decision Making clearly more complex
ICD-10-CM Coming
ICD-9-CM diagnostic codes are the ones we are currently using
ICD-10-CM codes are referenced in DSM-5
(i.e.) Major Depressive D/O, single episode-moderate
296.22 (F32.1) ICD-9-CM ICD-10-CM
:
Upgrading billing, claims processing and electronic health record software
Revising forms and coding support tools Training staff
Updating payer contracts and fee schedules Identifying coverage changes
Testing updated systems
Stockpiling cash reserves to preserve cash flow Experts say physicians who have not begun
preparations for ICD-10 should begin now.
Among the many changes that may be required are such comprehensive measures as:
CMS Quality Improvement and Incentive Programs
Medicaid EHR Incentive Program
Medicare EHR Incentive Program
Physician Quality Reporting System (PQRS)
Medicare Improvements for Patients and Providers Act
(MIPPA) e-Prescribing Incentive Program
MEDICARE’S PHYSICIAN QUALITY REPORTING SYSTEM (PQRS)
A CMS incentive program to improve quality of care for individuals covered under Medicare Part B.
But has a potential for penalties
Details for fulfilling Changes annually
Eligible and Able to Participate in PQRS
MEDICARE’S PHYSICIAN QUALITY REPORTING SYSTEM (PQRS)
WHAT YOU NEED TO KNOW RIGHT NOW
To avoid the 2015 penalty an eligible provider has only to report on one appropriate measure for one Medicare patient by the end of 2013
Penalty for those Participating in Medicare PQRS
in 2015 providers who failed to participate in the PQRS as of this year, 2013, will be hit with a 1.5% penalty for all their Medicare reimbursements beginning on January 1, 2015.
This penalty increases to 2% on all Medicare payments in 2016.
PQRS
In 2013 – 269 measures
measures pertinent to mental health providers, including five measures on depressive disorder, four measures on screening for unhealthy substance use, and one measure on medication reconciliation
EXAMPLE OF HOW INFORMATION WOULD BE ENTERED ON THE 1500
Measure #9--Major Depressive Disorder (MDD):
Antidepressant Medication During Acute Phase for Patients with MDD
Description: Patients aged 18 years and older diagnosed with new episode of major depressive disorder (MDD) and documented as treated with antidepressant medication during the entire 84-day (12 week) acute treatment phase. *
Applicable Procedure Codes
90791, 90792, 90832, 90834, 90837, 90839, 90845, 90849, 90853, 99078, 99201, 99202-99205, 99212- 99215, 99341- 99345, 99347- 99350
Action Taken
Acute treatment with antidepressant medication G-Code
G8126 – Patient w/ new episode of MDD documented as being treated w/ antidepressant medication during entire 12-wk acute treatment phase
Measure #107 (NQF 0104): Adult Major Depressive Disorder (MDD): Suicide Risk
Assessment
Measure #107 (NQF 0104): Adult Major Depressive Disorder (MDD): Suicide Risk
Assessment
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes, and the appropriate CPT Category II code OR G-code. All measure-specific coding should be reported on the claim(s) representing the eligible encounter
Numerator Quality-Data Coding Options for Reporting Satisfactorily: Suicide Risk Assessed G8932: Suicide risk assessed at the initial evaluation
MEDICARE’S PHYSICIAN QUALITY REPORTING SYSTEM (PQRS)
Link for list of 2013 measures:
http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-
Instruments/PQRS/MeasuresCodes.html .
CMS Quality Improvement and Incentive Programs
Medicaid EHR Incentive Program
Medicare EHR Incentive Program
Physician Quality Reporting System (PQRS)
Medicare Improvements for Patients and Providers Act: (MIPPA) e- Prescribing Incentive Program
