AUDIT? NO PROBLEM!PROACTIVE DOCUMENTATION GUIDELINES, PART 2MINNESOTA PSYCHOLOGICAL ASSOCIATION ANNUAL CONFERENCE, 2015

RICHARD SETHRE, PSY.D., L.P. WWW.MHCONCIERGE.COM

OVERVIEW

Overview – the importance/power of Medicare guidelines

CPT codesDiagnostic AssessmentsTreatment planProgress and psychotherapy notesHow to be proactive about audits

ANTONIO PUENTE, PH.D - ROCK STAR OF CODING GUIDELINES

http://psychologycoding.com/

http://psychologycoding.com/wp-content/uploads/2014/07/CPT-Webinar-06.19.14.pdf

http://psychologycoding.com/wp-content/uploads/2015/02/CPT-01.31.15-1.pdf (2-2-15)

Puente

Medicare sets the standardThe Standard for Universal Health Care: – Coding (what can be done)– Value (how much it will be paid)– Documentation (what needs to be

said)– Auditing (determination of whether it

occurred)

Puente

• Possible Codes for Psychology = Approximately 60

• Sections = Five Primary Separate Sections – Psychiatry (e.g., mental health) – Biofeedback – Central Nervous System Assessment (testing) – Physical Medicine & Rehabilitation – Health & Behavior Assessment & Management

– Team Conference – Evaluation and Management

PuenteCodes 90832-90838 describe time-

based face-to-face services with the family and/or patient, with times of 30, 45, and 60 minutes.

Time refers to “face-to-face” unless otherwise stated.

• Unit of time = “when the midpoint has been passed”

Puente

Time: Defining 60 Minutes “The Rounding Rule” • 1 unit > or equal to 31 minutes to < 91 minutes • 2 units > or equal to 91 minutes to < 151 mns. • 3 units > or equal to 151 minutes to < 211s mns. • 4 units > or equal to 271 minutes to < 331 mns.

The choice of code is based on the one that is closest to the actual time. In the case of the 30 minute codes, the actual time must have at least crossed the midpoint (16 minutes). (never less than 16 minutes)

Puente90832 (30 minutes) for actual

psychotherapy time of 16-37 minutes 90834 (45 minutes) for actual time of

38-52 minutes 90837 (60 minutes) for actual time of

53 minutes or more. 90 minutes = – to be determined for

code and time – For now, use 60 minute code plus 22 modifier

Puente 60 Minutes – Pre-authorization required by some

companies – Does not equal previous 45’ code 90 Minutes – In E & M section, hence CMS is not covering

– Other carriers may Use 90837 in Conjunction with the Appropriate Prolonged

Service Code (99354-99357) for face-to-face Psychotherapy Services with the Patient of 90 minutes or longer) (tip = current prolonged services codes are E & M and thus not typically reimbursable for non-physicians)

• Interactive complexity, reported with add-on code 90785, refers to specific communication factors that complicate the delivery of certain psychiatric procedures (90791, 90792, 90832 - 90838, 90853).

Puente Psychotherapy provided to a patient in a crisis state is reported

using codes 90839 and 90840 The presenting problem is typically life threatening or complex

and requires immediate attention. Codes 90839 and 90840 are used to report the total duration of

time spent face-to-face with the patient and/ or family by the physician or other qualified healthcare professional providing psychotherapy related to crisis.

Code 90839 is reported only once for the first 30-74 minutes of psychotherapy for crisis on a given date, even if the time spent by the physician or other health care professional is not continuous. • Add-on code 90840 is used to report additional block(s) of time of up to 30 minutes each beyond the first 74 minutes reported by 90839 (i.e., total of 75-104 minutes, 105-134 minutes, etc.).

Puente

Each CPT Code Should Generate a Separate Report (or at least a separate section) • If Separate Sections Within One Report, Clearly Label/Title Sections of the Report to Match Code Used (e.g., Interview)

Health and Behavioral Codes (H & B) - from APAPO

Typically, health and behavior assessemnt and intervention services address an assortment of physical health issues – including patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors and overall adjustment to physical illness.

APAPO, H & B Codes

Only an ICD-9 physical diagnosis may be used in connection with these services. The psychologist may not make a medical diagnosis, as our scope of practice does not include making medical diagnoses. Clinicians may not bill psychiatric and H & B codes on the same day. The clinician must bill for the principle service being provided. H & B codes are billed in 15 minute units, rounded up, face-to-face time only.

APAPO, H & B codes

96150, initial assessment 96151, reassessment 96152, interventoin service 96153, intervention provided to a group 96154 – intervention provided to a family

with patient presenting 96155 – intervention provided to family w/o

patient present

DIAGNOSTIC ASSESSMENT (D.A.)Puente, again

• History obtained, includes:- Past psychiatric history– Chemical dependency history– Family history– Social history– Treatment history– Medical history

D.A., Puente Additional Information

Obtained– Review of systems– Safety– Lethality– Aggression– Competency

D.A., Puente• Specialty Specific Examination – Mental status• Diagnosi(e)s; – Psychiatric diagnosi(e)s – Personality considerations– Contributing medical factors– Psychosocial stressors– Current level of functioning

D.A., Puente• Treatment Plan – Consideration of medications– Psychotherapy– Tests– Level of Care/Supervision• Informed Consent for Treatment Plan • Disposition of Patient (e.g., testing)

D.A., MN DHS

Brief Diagnostic AssessmentStandard Diagnostic AssessmentExtended Diagnostic AssessmentAdult Diagnostic Assessment

Update

TREATMENT PLAN DOCUMENTATIONDonald Wiger Ph.D., L.P Wiger, DE (2010). The clinical

documentation sourcebook (4th ed.). New York: WileyWiger, DE (2007). The well-managed mental health practice your guide to building and managing a successful practice, group, or clinic. New York, Wiley.

TX PLAN, WigerOFAID system

OnsetFrequencyAntecedents (triggers)Intensity (rating scales)Duration

TX PLAN, Wiger, OFAID example

Child with tantrums - Onset one year ago - Frequency 3 times per week- Antecedents – when not permitted to get her way- Intensity- 7 on a scale of 10-Duration – 15-30 minutesGoal: specific and measurable treatment goals

PROGRESS NOTESWiger

SOAP Subjective Objective Assessments PlanDAP Data Assessment Plan

PROGRESS NOTES, MH DHSProgress notes include:

• Type of service

• Date of service

• Session start and stop times

• Scope of service (nature of interventions or contacts including treatment modalities, phone contacts, etc.)

• Recipient’s progress (or lack of) to overall treatment plan goals and objectives

• Recipient’s response or reaction to treatment intervention(s)

• Formal or informal assessment of the recipient’s mental health status

• Name and title of person who gave the service

• Date documentation was made in the client record

PROGRESS NOTES, MH DHSOther elements that may(emphasis added) be included: • current risk factors the recipient may be

experiencing • emergency interventions

• consultations with or referrals to other professionals

• summary of effectiveness of treatment, prognosis, discharge planning, etc.

• test results and medications

• symptoms

“Psychotherapy notes” vs. “Progress notes”, MN Law

Acknowledgments include “special advisers” - includes Trisha Stark, MPA

PSYCHOTHERAPY NOTES, MN LAW

Psychotherapy Notes Defined. Notes recorded by a health care provider who is a mental health professional that: 1) Document or analyze the contents of conversations during a counseling session; and 2) Are separated from the rest of the patient’s medical records . (45 C.F.R. § 164.501)

PSYCHOTHERAPY NOTES, MN LAW

Federal law (HIPAA Privacy Rule) allows a mental health professional to share psychotherapy notes, at the provider’s discretion, with patient consent . In recognition of the sensitivity of this information, HIPAA requires that this consent be captured on a form only documenting the consent to release psychotherapy notes .

PSYCHOTHERAPY NOTES, MN LAW

Minnesota law is more stringent than HIPAA with respect to the rights of individuals .2 In Minnesota, patients have the right to view or release all parts of their medical record and psychotherapy notes are part of that medical record that can be viewed or released . The added protection of the notes inclusion in the medical record is to assure greater access for patients to all of their protected health information .

PSYCHOTHERAPY NOTES, MN LAW

What’s in a medical record? Much of the confusion stems from the differences in definition of what constitutes a medical record . Even if psychotherapy notes are kept in a separate file, in Minnesota, they are considered to be part of the medical record. This is to ensure that patients have full access to complete information about their health.

PSYCHOTHERAPY NOTES, MN LAWHIPAA standard. Psychotherapy notes are specifically excluded from a patient’s general right to access or inspect their own medical records under HIPAA’s Privacy Rule . If mental health professionals wish to disclose the psychotherapy notes, they are generally permitted to do so, but must receive the patient’s authorization .

PSYCHOTHERAPY NOTES, MN LAW

Minnesota standard. Minnesota’s Health Records Act gives patients access to “complete and current information possessed by that provider concerning any diagnosis, treatment, and prognosis” and does not distinguish psychotherapy notes from other medical records.

PSYCHOTHERAPY NOTES, MN LAWMinnesota law requires that a provider give a patient “complete and current” information concerning any diagnosis, treatment or prognosis that relates to the patient upon request . (Minn. Stat. § 144.292, subd. 2) . A client also has the right to access and consent to release records related to psychological services under administrative rules governing psychologists (Minn. R. 7200.4710) .

PSYCHOTHERAPY NOTES, MN LAW

Minnesota has created an exception, however, that gives providers the discretion to withhold health records (including psychotherapy notes) if the provider believes that “the information is detrimental to the physical or mental health of the patient, or is likely to cause the patient to inflict self harm, or to harm another .” (Minn. Stat. § 144.292, subd. 7) .

AUDITS, PROACTIVE DOCUMENTATION, Wiger

“The best preparation for an audit is to be prepared, with or without notice.”

“Charts should be up to date as a matter of standard procedure.”

“Charts should be written in a standardized format.”

Do not modify charts when preparing for an audit.

Be courteous and professional when interacting with the auditor.

AUDITS, PROACTIVE PREPARATIONS, Wills and Sethre

Be knowledgeable about the policies and procedures for all MCO's with which you are contracted.

You, or someone on your behalf, signed a contract with each MCO that includes a clause stating that you will read and comply with the MCO's policies and procedures guidelines.

ONLINE RESOURCES

APAPO Billing and Coding page:http://www.apapracticecentral.org/reimbursement/billing/

For a text copy of this presentation, including long urls:www.mhconcierge.com

QUESTIONS, DISCUSSION, COMMENTS