implementing collaborative models of mental health for older
TRANSCRIPT
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Implementing Collaborative Models of Mental Health for Older Iowans
Models of Collaborative Care: Billing
______________________Des Moines, Iowa
Friday, May 18, 20073:30pm‐4:30pm
Phil Hurd, MHA, CPC, CCP‐Presenter
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Professional Fee Billing
• Independent Private Practice, collaborative agreement (NP’s), employee
• Licensed, Qualified Staff
• Credentialed with payers
• Billing and collection policies and procedures
• Documentation
• Reimbursement Compliance
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Private Practice or Employee?
• Eligibility depends on provider
– Psychologist and LCSW can be in private practice– Psychiatric Nurse‐employee billing “incident‐to” (may vary by payor)
• NPs – Collaborative Agreement
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Billing by Qualified Staff
Professional Fee Billing
– Licensed with respective agency in the state
– Credentialing process for:• NPI‐Medicare• PIN‐Medicaid and other
– NPI = National Provider Identifier• New requirement by CMS• NPI will replace the identifiers you currently use with Medicare and other
providers• You can apply online/free• NPI is an Administrative Simplification mandate of HIPPA• Process can take 3‐6 months
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Credentialing
• You must be credentialed with each payor to bill and receive payment on a fee‐for‐service basis
• Some commercial payers do not credential some non‐physician providers (e.g. PA’s, Psychiatric Nurses) and instruct billing under physician PIN– Get it in writing, or– Send a letter re: your understanding of how the payer wants you to bill
• Start the application process as soon as possible.
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Billing & Coding
Reporting of Codes
“Current Procedural Terminology (CPT®), Fourth Edition, is a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers. Each procedure or service is identified with a five‐digit code. The use of CPT® codes simplifies the reporting of services.”
“Inclusion of a descriptor and its associated five‐digit code number in the CPT® code book is based on whether the procedure is consistent with contemporary medical practice and is performed by many practitioners in clinical practice in multiple locations. Inclusion in the CPT® code book does not represent endorsement by the American Medical Association (AMA) of any particular diagnostic or therapeutic procedure. Inclusion or exclusion of a procedure does not imply any health insurance coverage or reimbursement policy.”
Source: CPT®, 2007, pg xiv, Introduction
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Reporting Services ‐ CPT® Codes
• 96101 (new code in 2005)‐ Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face‐to‐face time with the patient and time interpreting test results and preparing the report
• 90862‐Pharmacologic management, including prescritption, use, and review of medication with no more than minimal medical psychotherapy
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Reporting Services ‐ CPT® Codes
Evaluation and Management Services‐Established Patient Example
• 99213‐Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:
– An expanded problem focused history;– An expanded problem focused examination;– Medical decision making of low complexity.
Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs
Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face‐to‐face with the patient and/or family.
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Reporting Services ‐ CPT® Codes
Psychiatric Diagnostic or Evaluation Interview Procedures
• 90801 ‐ Psychiatric diagnostic interview examination
• 90806 ‐ Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face‐to‐face with the patient;
• →90807 ‐with medical evaluation and management services
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Billing and CollectionsPolicy and Procedures
• Develop and understand self pay collection policy
• Medicare has an annual deductible plus pays 80% of the Medicare Fee Schedule (MFS) amount
• Patient is responsible for paying the 20% and you are responsible for billing the patient this amount
• Medicaid Co‐pays
• $1‐$3 co‐pay for medications
• $2 for psychologist services
• Note: Some patients have both Medicare and Medicaid‐20% Medicare co‐pay is paid by Medicaid but patient still required to pay $1.00 co‐pay
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Documentation
• The biggest problem in Behavioral Health relates to medical necessity (determination by payers based on a review of services billed)
– Services performed by a non‐licensed provider particularly as “incident to” using the PIN of the licensed provider
– Music, game, instrument, pet interaction therapies, sing‐alongs, arts and crafts, and other similar activities should not be billed as group or individual activities.
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Documentation
• Complete records contain all pertinent and essential informationrelated to the patient’s current encounter.
• Each entry must be able to “stand‐alone”.
• Medical Records must indicate that the patient has a psychiatricillness or emotional behavioral symptoms.
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ReimbursementWho Gets Paid?
CPT Code Description MDCommunity Mental
Health Center Psychologist NP
90801PSYCH DIAG INTERV EXAM W/HIST,
MENT STAT 129.82 126.04 126.04 110.34
90804INDIVI PSYCHOTHERAPY INSIGHT,
20‐30 MIN 57.64 23.55 55.96 48.99
90805INDIVI PSYCHOTHERAPY W/ MED
EVALU; 20‐30 MIN 64.45 27.13 N/A 54.78
90806INDIVIDUAL PSYCHOTHERAPY; 45‐50
MINUTES 88.31 70.63 N/A 75.06
90847FAMILY MED PSYCHOTHERAPY; PER
15 MIN 18.70 22.38 11.37 15.89
96100PSYCHOLOGICAL TESTING
W/INTERP AND REPORT N/A 53.50 59.84 N/A
96110DEVELOPMENTAL TESTING,
LIMITED, W/INTERP N/A 64.68 59.84 N/A
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Iowa Medicaid Fee Schedule
Mental Health Modifiers for Community Mental Health Centers and Physician Billing
Modifiers
HP = Service by psychologist pay 90% of fee schedule
HO = Service by Social Worker pays 80% of fee schedule
HN = Service by Psychiatric Nurse pays 70% of fee schedule
U2 = Services by a Physician Assistant, pay 75%‐85% of physician fee schedule
Note: Effective 1/1/04
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Compliance / Fraud & AbuseMedicare Expenditures
Federal Government Expenditures for Health Service and Supplies2003
– Spending from General Revenues
Medicare Expenditures ‐ $93.4 BillionMedicaid Expenditures ‐ $160.9 Billion
Other Programs ‐ $66.9 Billion
(Other programs includes; Substance Abuse and Mental Health Services Administration, Maternal & Child Health, VA, Other)
Source: Health Care Financial Review/Web Exclusive/July 2005/Volumne 1, Number 2, pg 18
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Compliance / Fraud & Abuse
Medicare Leading Part B CPT Procedure Codes Based on Allowed Charges CY 2005
Rank Code Description Amount
1 99213 Established Office Visit $5,666 Million
27 90806 Psychotherapy 45‐50 Min $466 Million
55 90862 Medication Management $266 Million
83 90801 Initial Psychotherapy Visit $187 Million
Total for 110 Leading Procedures $53,581 Million
All Procedure Codes $107,061 Million
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Compliance / Fraud & Abuse
• Behavioral Health Services have been subject to fraud as have many other services.
• Services that have been billed inappropriately in the past include;
• Routine screening and periodic testing• Testing for other than diagnosing a suspected mental illness or to evaluate a change in mental illness
• Generic psychotherapy (group) not specific to patient’s condition
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Fraud Notice on 1500 Form
Professional Fee Billing – CMS 1500
**** Notice: Any person who knowingly files a statement of claimcontaining any misrepresentation or any FALSE, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.
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Fraud Notice on 1500 Form
Professional Fee Billing – CMS 1500
Medicaid Payments (Provider Certification)
• I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State’s Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept. of Health and Human Services may request.
• Notice: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws.
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White Plains Man Convicted of Medicaid FraudBaltimore Company Has Ties To Other Companies Convicted of Medicaid Fraud
• Dr. Angelo Reynolds, 39, was the owner of MYPO, Inc., a mental health clinic in Baltimore who billed Medicaid $496,000 for mental health therapy sessions.
• For 7 mos., 11/03‐6/04, MYPO, Inc.,– OIG Investigation discovered that;
• MYPO billed for multiple therapy sessions before anyone from the company had met with the patient
• MYPO billed for having treated patients during time periods when no therapist was even assigned to the individual seeking therapy
Outcome: Dr. Reynolds pled guilty for defrauding Medicaid of at least $175,000 to one count of felony Medicaid fraud. Sentencing for Reynolds was May 8, 2007. He was sentenced to five years incarceration with all but one year suspended, and to be served in home detention. The sentence comes after Reynolds pleaded guilty in Baltimore Circuit Court to one count of felony Medicaid fraud for his role in defrauding the Medicaid Program of at least $150,000. Reynolds was ordered to pay restitution of $150,000 over the course of five years of supervised probation.
Source: Maryland Attorney General‐News Release, March 22, 2007 and May 9, 2007
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Seattle Psychologist Sentenced to Prison for Falsely Billing Military Medical Insurance Program
Man Billed for Patients he Did Not Treat, Appointments that Never Occurred
“David Celio, 63, of Seattle, Washington was sentenced today in U.S. District Court in Seattle to twelve (12) months and one (1) day in prison for Health Care Fraud. CELIO pleaded guilty November 17, 2006 and on March 28, 2007 agreed to settle civil charges against him for the false bills by paying the United States $510,264”
– CELIO billed for therapy sessions with patients that never took place– For example, CELIO saw the brother of a patient, one time, as part of a family
counseling session then billed for twenty‐five sessions relating to therapy with the brother.
– Two months after the one time he saw the brother, CELIO submitted a written request to TRICARE for further treatments, noting symptoms and diagnoses for the brother and reporting on his progress in therapy.
– CELIO continued to submit claims to TRICARE for the brother after receiving approval. CELIO did not keep separate notes on each patient.
– When TRICARE asked for treatment notes for claims that had already been submitted, he made up new notes, including notes for sessions that in fact never occurred.
– Source: United States Attorney’s Office, April 6, 2007
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Professional Fee Billing
• NPI & PINs
• Documentation that supports services billed and medical necessity
• Understand what and how to bill
• Develop Compliance Plan and monitor documentation with periodic internal audits using Medicare and Medicaid guidelines
• Collect co‐pays
