Innerview Reimbursement in the Physician Office Setting * 2014

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OVERVIEW

This Guide is intended to assist with the process of billing and coding for Innerview®, a Mental Health Clinical Decision Support System used in the primary care setting. Billing, coding and payment options are reviewed below for private payers, Medicare and the Physician Quality Reporting System (PQRS).

BILLING PRIVATE PAYERS FOR INNERVIEW

The CPT codes most appropriate for billing private payers for administration of Innerview in the physician’s office setting include the following: 1

1. Evaluation and Management (E/M) codes based on the level of service offered during the office visit, and

2. CPT 99420 which is used to administer and interpret health risk assessment. E/M Codes

Perhaps the most commonly-used CPT codes in a physician office setting are those that apply to new and established patient visits (99201-99205; 99211-99215). These are timed codes – the more time a physician spends with a patient, the higher the reimbursement. The use of Innerview in the clinic will provide organized patient reports requiring time and effort on behalf of

physicians and other healthcare professionals to review these reports prior to the visit: The report includes:

• First person patient narrative

• Diagnostic & Statistical Manual of Mental Disorders (DSM)/ International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10; World Health Organization) driven diagnostic considerations

• Profile of symptoms and functioning and change in perceived severity or challenge with that symptom or function

Table 1 below describes the relevant E/M codes and shows how payment increases as the level of service and the time spent counseling and/or coordinating the care of the patient increases.

Documentation Requirements:

When incorporating Innerview, providers should select the appropriate level of E/M services based on the following criteria:

• For new or established patients, all the key components, i.e., history, examination, and medical decision making must meet or exceed the stated requirements to qualify for a particular level of service/CPT. 2

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1 This list may not be all inclusive; providers should check benefit policy requirements of individual payers to determine what procedure codes and coverage requirements apply.

2 Refer to CPT coding manual for more detailed description of coding requirements 3

AMA CPT Manual ¸ Introduction to E/M section, 2010

Table 1: List of CPT codes and payments (based on 100% of 2014 Medicare allowable) that may be used to bill private payers for administration of Innerview in physician office (Providers should

check individual payer benefit policies to determine actual coverage and payment amounts)

CPT Codes Descriptions Payments-Physician’s Office

Evaluation and Management-Office or Other Outpatient Services

New Patients

99201 Office visits new patient- 10 minutes f-to-f w/patient or family $43

99202 Office visits new patient- 20 minutes f-to-f w/patient or family $73

99203 Office visits new patient- 30 minutes f-to-f w/patient or family $105

99204 Office visits new patient- 45 minutes f-to-f w/patient or family $161

99205 Office visits new patient- 60 minutes f-to-f w/patient or family $200

Established Patients

99211 Office visits established patient- 5 minutes (may not require phys) $20

99212 Office visits established patient- 10 minutes f-to-f w/patient or family $43

99213 Office visits established patient- 15 minutes f-to-f w/patient or family $72

99214 Office visits established patient- 25 minutes f-to-f w/patient or family $105

99215 Office visits established patient- 40 minutes f-to-f w/patient or family $142

Prevention 99420 Admn and interpretation of health risk assessment instrument $11

CPT 99420

CPT 99420, described as “administration and interpretation of health risk assessment instrument” is a preventive medicine code listed in the chart above that is also appropriate to describe use of Innerview in the clinic. The AMA CPT Manuals states that “the actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT are available may be reported separately, in addition to the E/M code.”

Use of modifier 25

CPT modifier -25 is used when, on the day a procedure or service was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided. When billing CPT 99420 together with the E/M codes, providers should add modifier 25 to the appropriate level of E/M service. For example, for a 30 minute office visit with a new patient during which Innerview was administered and interpreted the physician would bill 99203-25 in addition to 99420.

BILLING MEDICARE FOR INNVERVIEW

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1. CPT E/M office visit codes described above (99201-99205; 99211-99215) based on the amount of time and level of service necessary. (Note: Medicare considers 99420 a

“non-covered” benefit and it should not be used to bill for services to beneficiaries)

4 As is the case with private payers, providers should check with local their local Medicare contractor to determine

whether these codes are eligible for reimbursement.

2. Medicare-specific HCPCS office visit codes (may be used in combination with E/M codes above if the physician provides a significant separately identifiable medically necessary E/M service):

• GO402 – Initial Preventive Physical Exam (once in a lifetime) • GO438 – Annual Wellness Visit (initial)

• G0439 – Annual Wellness Visit (subsequent)

3. G0444, G0442 and G0443- see descriptions below ( may be used in conjunction with E/M codes if modifier 25 is used appropriately as described above or with Medicare specific code G0439)

G0444: New Screening Code for Depression: In recognition of the need to provide preventive services and mental health screenings in the primary care setting, effective in 2011, Medicare added HCPCS code GO444 to cover annual depression screenings up to 15 minutes for Medicare beneficiaries in primary care settings. Medicare does not identify specific depression screening tools that can be billed using G0444. Rather, the decision to use a specific tool is at the discretion of the clinician in the primary care setting. Since Innerview can be used to identify depression criteria, it should be covered by Medicare.

G0442: New Screening Code for Alcohol Misuse: Effective in 2011, Medicare added HCPCS code GO442 to cover annual screenings for alcohol misuse up to 15 minutes for Medicare beneficiaries in primary care settings. Medicare does not recommend specific screening tests for alcohol misuse but rather indicated clinicians can choose screening strategies that are appropriate for their clinical population and setting. Since Innerview can be used to identify alcohol misuse criteria, it should be covered by Medicare.

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Table 2: Guidelines for billing Medicare-specific codes for Innerview and payments (based on 100% of 2014 Medicare allowable)

Medicare Preventive Services – Coding Guidelines

Services HCPCS/CPT Codes/ Payment

ICD-9 Codes

Who is covered Frequency Beneficiary Pays

Initial Preventive Physical Examination (IPPE) For services on or after 1/1/05 G0402- IPPE $163 No specific code

Medicare beneficiaries enrolled under Part B and who obtain IPPE no later than 12 months after date of first Part B coverage

Once in a lifetime Copayment, coinsurance, deductible waived Annual Wellness Visit (AWV) For services on or after 1/1/11 G0438- Initial G0439-Subsequent $168 $113 No specific code

Medicare beneficiaries who are no longer within 12 months of IPPE

Medicare beneficiaries with no AWV within last 12 months

Once for G0438 Annually for G0439 Copayment, coinsurance, deductible waived Screening for Depression For service on or after 10/14/11 G0444 – Annual depression screening. 15 minutes $18 No specific code Medicare beneficiaries in a primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, treatment and follow up Annually Copayment, coinsurance, deductible waived Screening for Alcohol Misuse For service on or after 10/17/11 GO442- Annual alcohol misuse screening, 15 minutes $18 No specific code

Medicare beneficiaries enrolled under Part B Annually Copayment, coinsurance, deductible waived Behavioral Counseling for Alcohol Misuse For service on or after 10/17/11 GO443 –brief face-to-face behavioral counseling for alcohol misuse, 15 minutes $25 No specific code

Medicare beneficiaries enrolled under Part B who screen positive for alcohol misuse

Up to 4 brief face- to-face behavioral counseling interventions per year Copayment, co-insurance, deductible waived CODING SCENARIOS

Billing and coding for mental health services can be confusing for primary care providers. While it is not possible to provide coding guidelines for every patient encounter, the following case scenarios are examples of situations that may be appropriate for billing Innerview.

Scenario #1 – Private pay patient, initial office visit

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Coding/Payment

CPT/HCPCS Code(s)

Modifier Medicare allowable (private payments vary)

ICD-9 Code/description (other examples may apply)

99203 25 $105 300.2-Generalized anxiety disorder

99420 $11 V79.0-Screening exam, depression

Scenario #2 – Private pay patient, established office visit

A 29 year patient with private health insurance making follow-up office visit, presents with stomach aches, chronic generalized pain and mood swings. A comprehensive history and examination is conducted involving medical decision making of high intensity, and Innerview is administered. Approximately 40 minutes spent in face to face meeting with patient and/or family.

Coding/Payment

CPT/HCPCS Code(s)

Modifier Medicare allowable (private payments vary)

ICD-9 Code/description (other examples may apply)

99215 25 $140 296.90-Episodic mood disorder

99420 $11 V79.0-Screening exam, depression

Scenario #3 – Medicare patient, subsequent annual wellness visit

A 68 year Medicare beneficiary patient making follow up visit, showing weight loss, demonstrating less interest in daily activities and less ability to concentrate. A comprehensive history and examination is conducted and Innerview is administered. Practitioner reviews Innerview results with patient/family and decides on follow up plan.

Coding/Payment

CPT/HCPCS Code(s)

Modifier 2013 Medicare allowable ICD-9 Code/description (other examples may apply)

G0439 $112 300.0-Depression disorder, not

otherwise specified

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PHYISICIAN QUALITY REPORTING SYSTEM (PQRS)

PQRS is a program where an incentive payment is made to professionals including primary care physicians who report data on various measures. Innerview may be used to meet data collection requirements in the following scenarios:

CPT Code(s) PQRS # Measure Title Reporting Options

99201 99202 99203 99204 99205 99212 99213 99214 99215

9 Anti-depressant Medication Management Registry, EHR 106 Adult Major Depressive Disorder (MDD): Comprehensive

Depression Evaluation: Diagnosis and Severity

Claim, Registry

107 Adult MDD: Suicide Risk Assessment Claim, Registry, EHR 134 Preventive Care and Screening: Screening for Clinical Depression

and Follow-Up Plan

Claim, Registry, EHR, GPRO l

173 Community/Preventive Care and Screening: Unhealthy Alcohol Use-Screening

Registry, Group

247 Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence

Claim, Registry

248 Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence

Claim, Registry

325 Adult MDD: Coordination of Care of Patients with Specific Comorbid Conditions

Registry

G0402 G0438 G0444

134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Claim, Registry, EHR, GPRO l

G0439 134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Claim, Registry, EHR, GPRO l

173 Community/Preventive Care and Screening: Unhealthy Alcohol Use-Screening

Registry, Group

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