1. Wednesday, May 17, 2017
FLORIDA COUNCIL FOR COMMUNITY MENTAL HEALTH
Coding for Mental Health in
Today’s Environment
2. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 1
Objectives
Evaluation and management (E/M) overview
Psychiatric services
Diagnosis coding
Documentation patterns
DSM-IV vs. ICD-10-CM
Nurse practitioner (NP)/physician assistant (PA) scope
and supervision requirements
Payer guidelines regarding billing for NP and PA
Direct Billing
Incident-To Billing
Split/Shared Billing
Compensation/RVU methodology overview
3. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 2
Factors Influencing Provider Coding
• Education
Knowledge base of educator
Time allowance/attention span
Method of teaching
Shadowing, web-based, in-person, individual, group
Method of learning
Repetitive, personal
Incentives
wRVU-based compensation
Bonuses
5. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 4
E/M Correct Coding
Medical necessity of a service is the overarching
criterion for payment in addition to the individual
requirements of a Current Procedural Terminology
(CPT)1 E/M code
It would not be medically necessary or appropriate to bill
a higher level of E/M service when a lower level of
service is warranted
The volume of documentation should not be the primary
influence upon which a specific level of service is billed
1 Current Procedural Terminology (CPT® or CPT) is a registered trademark of the American Medical Association (AMA).
6. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 5
E/M Correct Coding (cont.)
Documentation should support the level of service
performed and reported
The service should be documented during its
performance, or as soon as practical after it is
provided, in order to maintain an accurate medical
record
The final E/M selection is not just about time
Source: Pub 100-04, Ch 12, 30.6.1 - Selection of Level of Evaluation and Management Service (A. Use of CPT Codes)
7. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 6
E/M Elements
Key Elements
History
Exam
Medical Decision Making
(MDM)
Contributory Elements
Counseling
Coordination of care
Nature of presenting
problem
Time
8. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 7
Documentation Requirements
History of Present Illness (HPI)
A chronological description of the development of the patient’s illness
from the first sign and/or symptom to present; often an area resulting in
coding errors
Brief (one to three elements) or expanded (four or more elements)
Review of Systems (ROS)
A list of questions, arranged by organ system, designed to uncover
dysfunction and disease
Problem pertinent (focused on issue only), expanded (two to nine
systems), or complete (10 or more systems)
Past, Family, Social, History
Questions asked and answered to discover contributory factors
Documentation Tip: Do not document “non-contributory” without
documenting what family history was obtained but not a factor
9. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 8
1995 Exam Guidelines
Body Areas
Head, including the face
Neck
Chest, including breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back, including spine
Each extremity
Organ Systems
Constitutional (vital signs, general
appearance)
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic
10. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 9
E&M: Psychiatric Exam (1997)
SYSTEM/
BODY AREA ELEMENTS OF EXAMINATION
Constitutional Measurement of any three of the following seven vital
signs: 1) sitting or standing blood pressure, 2) supine
blood pressure, 3) pulse rate and regularity, 4) respiration,
5) temperature, 6) height, 7) weight (may be measured and
recorded by ancillary staff)
General appearance of patient (eg, development,
nutrition, body habitus, deformities, attention to grooming)
Musculoskeletal Assessment of muscle strength and tone (eg, flaccid
cog wheel, spastic) with notation of any atrophy and
abnormal movements
Examination of gait and station
Psychiatric Description of speech including: rate; volume;
articulation; coherence; and spontaneity with notation
of abnormalities (eg, perseveration, paucity of
language)
Description of thought processes including: rate of
thoughts; content of thoughts (eg, logical vs. illogical,
tangential); abstract reasoning; and computation
Psychiatric Description of associations (eg, loose, tangential,
(Cont.) circumstantial, intact)
Description of abnormal or psychotic thoughts including:
hallucinations; delusions; preoccupation with violence;
homicidal or suicidal ideation; and obsessions
Description of the patient's judgment (eg, concerning
everyday activities and social situations) and insight
(eg, concerning psychiatric condition)
Orientation to time, place and person
Recent and remote memory
Attention span and concentration
Language (eg, naming objects, repeating phrases)
Fund of knowledge (eg, awareness of current events,
past history, vocabulary)
Mood and affect (eg, depression, anxiety, agitation,
hypomania, lability)
Complete mental status examination including:
Problem Focused: One to five elements identified by a bullet.
Expanded Problem Focused: At least six elements identified by a bullet.
Detailed: At least nine elements identified by a bullet.
Comprehensive: Perform all elements identified by a bullet; document every element
in a shaded box and at least one element in an unshaded box.
CONTENT
and
DOCUMENTATION
REQUIREMENTS
1997 SINGLE ORGAN SYSTEM EXAM
LEVEL OFEXAM: Perform and Document
11. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 10
1995 vs. 1997 Exam Guidelines
1995 Requirements 1997 Requirements
Problem-Focused Examination:
• Limited to affected body area or organ system
Problem-Focused Examination:
• One to five element(s) identified by a bullet
Expanded Problem-Focused Examination:
• A limited examination of the affected body area or
organ system and other symptomatic or related
organ system(s)
• Two to seven body areas or organ systems
Expanded Problem-Focused Examination:
• At least six elements identified by a bullet
Detailed Examination:
• An extended examination of the affected body
area(s) and other symptomatic or related organ
system(s)
• Two to seven body areas or organ systems
Detailed Examination:
• At least twelve elements identified by a bullet
Comprehensive Examination :
• A general multi-system examination or a complete
examination of a single organ system
• Eight or more organ systems
Comprehensive Examination:
• Perform all elements identified by a bullet;
document every element in each box with a
shaded border and at least one element in
each box with an unshaded border
12. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 11
MDM
The complexity of establishing a diagnosis and/or
selecting a management option as measured by the:
Number of diagnoses and/or management options that must be
considered
Risk of complications and/or morbidity or mortality, as well as co-
morbidities, associated with the patient’s presenting problem(s),
the diagnostic procedure(s), and/or the possible management
options
Amount and/or complexity of data to be obtained, viewed, and
analyzed
13. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 12
MDM: Amount and/or Complexity of Data
Data Audit Points
Rev and/or order clinical tests 1
Rev and/or order tests in CPT medicine section 1
Rev and/or order tests in CPT radiology section 1
Discuss test results w/ performing physician 1
Independent rev of image, tracing or specimen
(This is where you get credit for non-billable 2nd
reads)
2
Decision to obtain old records and/or hx from
someone other than patient
1
Rev and summarization of old records and/or hx from
someone other than patient
2
Amount and/or Complexity of Data
14. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 13
MDM: Table of Risk
Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected
Minimal • One self-limited or minor problem (e.g., cold,
insect bite, tinea corporis)
• Laboratory tests requiring venipuncture
• Chest x-rays
• EKG/EEG
• Urinalysis
• Ultrasound (e.g., echocardiography)
• KOH prep
• Rest
• Gargles
• Elastic bandages
• Superficial dressings
Low • Two or more self-limited or minor problems
• One stable chronic illness (e.g., well-controlled
hypertension, non-insulin-dependent diabetes,
cataract, BPH)
• Acute uncomplicated illness or injury (e.g.,
cystitis, allergic rhinitis, simple sprain)
• Physiologic tests not under stress (e.g., pulmonary
function tests)
• Non-cardiovascular imaging studies with contrast
(e.g., barium enema)
• Superficial needle biopsies
• Clinical laboratory tests requiring arterial puncture
• Skin biopsies
• Over-the-counter drugs
• Minor surgery with no identified risk factors
• Physical therapy
• Occupational therapy
• IV fluids without additives
Moderate • One or more chronic illnesses with mild
exacerbation, progression, or side effects of
treatment
• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain
prognosis (e.g., lump in breast)
• Acute illness with systematic symptoms (e.g.,
pyelonephritis, pneumonitis, colitis)
• Acute complicated injury (e.g., head injury with
brief loss of consciousness)
• Physiologic test under stress (e.g., cardiac stress
test, fetal contraction stress test)
• Diagnostic endoscopies with no identified risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies with contrast and no
identified risk factors (e.g., arteriogram, cardiac
catheterization)
• Obtain fluid from body cavity (e.g., lumbar puncture,
thoracentesis, culdocentesis)
• Minor surgery with identified risk factors
• Elective major surgery (e.g., open,
percutaneous, endoscopic) with no identified
risk factors
• Prescription drug management
• Therapeutic nuclear medicine
• IV fluids with additives
• Closed treatment of fracture or dislocation
without manipulation
High • One or more chronic illnesses with severe
exacerbation, progression, or side effects of
treatment
• Acute or chronic illnesses or injuries that may
pose a threat to life or bodily function (e.g.,
multiple trauma, acute MI, pulmonary embolus,
severe respiratory distress, progressive severe
rheumatoid arthritis, psychiatric illness with
potential threat to self or others, peritonitis,
acute renal failure)
• An abrupt change in neurological status (e.g.,
seizure, TIA, weakness, or sensory loss)
• Cardiovascular imaging studies with contrast with
identified risk factors
• Cardio electrophysiological tests
• Diagnostic endoscopies with identified risk factors
• Discography
• Elective major surgery (e.g., open,
percutaneous, or endoscopic) with identified
risk factors
• Emergency major surgery (e.g., open,
percutaneous, or endoscopic)
• Parenteral controlled substances
• Drug therapy requiring intensive monitoring
for toxicity
• Decision not to resuscitate or to de-escalate
care because of poor prognosis
15. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 14
Time
Time may be the key or controlling factor to qualify the
use of a particular E/M service provided certain
conditions have been met:
Counseling and/or coordination of care (COC) dominates (more
than 50%) the patient encounter
Applies to E/M services only
Must be face-to-face time in office; floor time in the hospital or
nursing home setting
Documentation supports counseling/COC
Documentation of total visit time and time spent in
counseling/COC (i.e., include an example of what needs to be or
has been done)
16. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 15
Time: Risks
Using time as a work-around to
documenting history, exam, and MDM
Combining E/M time with the time spent
performing other procedures/services
Not documenting time:
Assuming time captured in EHR
Too difficult to keep up with – if the time is not
documented then the appropriate level is billed
based on components
18. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 17
New Patient vs. Established Patient Visits
New Patient
▪ A new patient is defined as
someone who has never been
seen by you or a physician in
the group OR who has not been
seen by you or a physician in
the group for at least three
years
▪ Applicable E/M codes are
99201-99205
▪ Require all three key
components
Established Patient
▪ An established patient is
defined as someone who has
been seen by you or a
physician in the same specialty
in your group within the
previous three years
▪ Applicable E/M codes are
99211-99215
▪ Requires two of the three key
components
▪ Many payer auditors require
MDM to be one of the two
19. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 18
Outpatient Consultations
▪ A consultation is a visit resulting from a request from
another medical provider
▪ Applicable E/M codes are 99241-99245
▪ Requires all three key components
▪ Remember the three Rs:
Request for opinion or advice from one provider to another
provider
Render and document consultation service
Complete a written report and forward to the requesting
physician
▪ Bill codes 99201-99215 if the requirements are not
met
21. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 20
Initial vs. Subsequent Hospital Care Days
Initial
Hospital Care Day
▪ Applicable E/M codes are 99221-
99223
▪ Requires all three key components
▪ Must have at least a detailed
history and examination in order to
bill even the lowest level E/M code
within the category (99221)
▪ All third-party payers will discount a
service to a subsequent patient visit
(99231-99233) if the history and
examination is not at least a
detailed level
Subsequent
Hospital Care Day
▪ Applicable E/M codes are 99231-
99233
▪ All third-party payers expect to see
lower E/M levels (99231 and
99232) closer to the discharge date
▪ Requires two of the three key
components
▪ Many payer auditors require MDM
to be one of the two
22. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 21
Inpatient Consultations
▪ An inpatient consultation is a visit resulting from a
request from another medical provider
▪ Applicable E/M codes are 99251-99255
▪ Requires all three key components
▪ Remember the two Rs:
Request for opinion or advice from one provider to another
provider
Render and document consultation service
Not necessary to do a separate report for services documented
within a “shared” record
23. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 22
Documenting an Inpatient Consult
The documentation within the shared record should support the
request:
Documented within physician orders
Documented within requesting provider’s notes
The reason should be clearly documented within the consulting
provider’s notes
The recommendations do not have to be separately documented
within a shared note
If the documentation does not meet the consultation requirements,
then the appropriate E/M service (e.g., subsequent or admission)
should be billed
If it is the first time the consulting provider is seeing a Medicare
patient and all three key components are documented, an inpatient
admission (99221-99223) can be reported
Admitting physician will have to append modifier -AI
24. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 23
Discharge Day Management
▪ Applicable E/M codes are 99238 (30 minutes or less) and 99239
(more than 30 minutes). They include:
Final examination of the patient (not required for Medicare but
documentation must support a face-to-face encounter)
Discussion of the hospital stay
Instructions for continuing care to relevant caregivers
Preparation of discharge records, prescriptions, and referral forms
Report per the date of the actual visit, regardless of the date the
patient is really discharged
Actual time spent must be documented in order to bill 99239
If admission and discharge services provided
on the same day, bill 99234-99236
25. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 24
Bottom-Line: Document
Why did you see the patient today?
What was planned vs. unplanned?
What did you do today?
Diagnoses assessed, history taken, exam performed, etc.
What MDM was required?
Lab results, values, etc.
What is the update from the previous visit?
What plan resulted?
Orders, prescriptions, other plan – and WHY?
27. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 26
Psychiatric Diagnostic Procedures
Unlike E/M codes, there are no bullets or “formula” to determine the
code
CPT code 90791 – Psychiatric diagnostic evaluation:
This is an integrated biopsychosocial assessment, including history,
mental status, and recommendations
The evaluation may include communication with family or other sources
and review and ordering of diagnostic studies
CPT code 90792 – Psychiatric diagnostic evaluation with medical
services:
This is an integrated biopsychosocial and medical assessment,
including history, mental status; it requires other physical examination
elements as indicated, and recommendations
The evaluation may include communication with family or other
sources, prescription of medications, and review and ordering of
laboratory or other diagnostic studies
28. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 27
Psychotherapy
CPT codes 90832 – 90838:
Time-based codes
Psychotherapy is the treatment of mental illness and behavioral
disturbances in which the physician or other qualified healthcare
professional attempts to alleviate emotional disturbances,
reverse or change maladaptive patterns of behavior, and
encourage personality growth and development
These are for face-to-face services with patient and/or family
member
Psychotherapy services can be reported with an E/M on the
same day by the same provider if it is significant and separate;
the E/M code is reported with modifier -25
The type and level of E/M service is selected first based upon
the key components of history, examination, and MDM
29. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 28
Psychotherapy (cont.)
Time associated with activities used to meet criteria for
the E/M service is not included in the time used for
reporting the psychotherapy service
If you see that your providers are frequently reporting
these codes together, it is recommended that an internal
review be conducted to verify that the documentation
supports the need for both services
30. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 29
Psychotherapy (cont.)
CPT codes 90839 and 90840 – Psychotherapy for crisis
is an urgent assessment and history of a crisis state, a
mental status exam, and a disposition
The treatment includes psychotherapy mobilization of
resources to defuse the crisis and restore safety, and
implementation of psychotherapeutic interventions to
minimize the potential for psychological trauma
The presenting problem is typically life threatening or
complex and requires immediate attention to a patient in
high distress
ICD-10 codes that reflect a risk diagnosis should be
expected
31. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 30
Other Psychotherapy CPT Codes
90845
• Psychoanalysis
90846
• Family
psychotherapy
(without patient
present)
90847
• Family
psychotherapy
(with patient
present)
90849
• Multiple-family
group
psychotherapy
90853
• Group
psychotherapy
(other than a
multiple-family
group)
32. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 31
Other Psychiatric Services
or Procedures CPT Codes
90863
Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services
90865
Narcosynthesis for psychiatric diagnostic and therapeutic purposes
90867-90869
Therapeutic repetitive TMS treatment
90870
Electroconvulsive therapy
90875-90876
Individual psychophysiological therapy incorporating biofeedback with psychotherapy (time-based codes)
90880
Hypnotherapy
33. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 32
Other Psychiatric Services
or Procedures CPT Codes (cont.)
90882
Environment intervention for medical management purposes on a psychiatric patient’s behalf with agencies, employers, or
institutions
90885
Psychiatric evaluation of hospital records, other psychiatric reports, psychometric and/or projective tests, and other
accumulated data for medical diagnostic purposes
90887
Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated
data, to family or other responsible persons, or advising them how to assist patient
90889
Preparation of report of patient’s psychiatric status; history; treatment; or progress for other individuals, agencies, or
insurance carriers
90899
Unlisted psychiatric service or procedure
34. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 33
E/M vs. Psychiatric Services
Why are psychiatrists billing inpatient admissions instead
of psychiatric diagnostic evaluations?
99221 – wRVU 3.00
99222 – wRVU 3.25
99223 – wRVU 1.92
90791 – wRVU 3.00
90792 – wRVU 3.25
To bill the higher E/M levels, the provider must document
a complete ROS and HPI, which is often difficult or
unnecessary to the patient’s condition
35. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 34
Common Diagnosis Coding
and Documentation Issues
Psychiatric diagnoses are very specific, and often providers do not
document to the highest level of specificity
In the inpatient setting, the rounding providers often document
different diagnoses
DSM-IV vs. ICD-10-CM variances
Not documenting time for psychotherapy services
Lack of documentation to support the continued need for inpatient
stay
Limited documentation for follow-up visits in the hospital setting
Psychotherapy service notes often do not thoroughly reflect the
discussion of therapy
Many providers document their services based on time, and often
the total amount of time exceeds a normal working day
37. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 36
NPP Scope of Practice
CMS Guidelines:
Services allowed are such as those traditionally
reserved for physician
The supervising physician/substitute should have
experience and/or expertise in the same area of
medicine as the NP/PA
39. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 38
Three Different Billing Scenarios
Direct Billing: 85% of Physician Fee Schedule
Certain NPPs (NPs, PAs, Certified Nurse Specialists, Clinical
Psychologists) can be credentialed and can bill under their own
provider number
Medicare reimburses on a percentage of the Physician Fee
Schedule
Other payers may not recognize NPPs and services would be billed
and reimbursed under the physician’s National Provider Identifier
(NPI)
Incident-To Billing: 100% of Physician Fee Schedule
This is a physician-directed services/team
Service is billed under physician’s NPI
Shared/Split Billing: 85% or 100% of Physician Fee
Schedule
NPPs and physicians “share/split” a patient visit
Service can be billed under NPP’s or physician’s NPI
40. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 39
Medicare and Medicaid
NPP Reimbursement
Medicare and Medicaid have the most specific guidance
for NPP billing:
85% of the Physician Fee Schedule for services which include
independent MDM by NP/PA
100% of the Physician Fee Schedule under the supervising
physician on-site for incident-to services
Medicaid requires the provider of service to bill for the
service rendered under his or her own NPI
41. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 40
Incident-To and Split/Shared Visits
Incident-to and split/shared services are both
documentation and billing concepts that can be
used to report services performed by a NP/PA
42. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 41
Clinic Visit Types
▪ New Patient Visits
▪ The service must be billed under the NPP’s NPI
▪ Established Patient Visits
▪ An established problem can be billed under physician’s NPI
▪ A new problem must be billed under the NPP’s NPI
▪ Consultations
▪ The service must be billed under the NPP’s NPI
44. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 43
NPP Direct Billing Criteria
for Medicare and Medicaid
NPP bills services directly to Medicare/Medicaid
Must meet Medicare/Medicaid’s credentialing
requirements
Can bill in any setting allowable under scope of practice
(office, inpatient and outpatient hospital, etc.)
Can provide any services allowed under their scope of
practice, but will only be reimbursed for covered services
Should have a collaborative agreement with physician or
group of physicians
45. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 44
NPP Medicare Direct Billing Services
Office:
New patient
Established patient with new problem/condition
Consultation
Hospital:
NPP-only service, no physician E/M, same date
Critical care
47. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 46
Incident-To Service Definitions
What is an incident-to service?
When services are provided by auxiliary personnel under direct
physician supervision, they may be covered as incident-to services
Services performed by the NPP are billed under the physician's NPI
What are auxiliary personnel?
Auxiliary personnel means any individual who is acting under the
supervision of a physician, regardless of whether the individual is
an employee, leased employee, or independent contractor of the
physician, or of the legal entity that employs or contracts with the
physician
The supervising physician may also be an employee, leased
employee, or independent contractor of the legal entity billing
and receiving payment for the services or supplies
48. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 47
Incident-To Requirements
It must be an integral, though incidental, part of a
physician’s professional service
It is commonly rendered without charge, or included in
the physician's bill
It is of a type commonly furnished in an office/clinic
It is furnished under direct supervision of the physician
49. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 48
Is the payer private, Medicare, or
Medicaid?
Is the patient new or established?
Is the patient presenting with only
established problems, or are there new
problems that need to be addressed?
Is this a consultation?
Was the service incident-to?
Where were the services provided?
Which provider do I bill under?
When Can an NPP Bill Incident-To?
50. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 49
Medicare Incident-To Guidelines
Office only, incident-to is not recognized in a facility
setting (e.g., hospital, nursing facility, etc.)
Established patient with established problem =
established plan of care
Cannot bill incident-to for an established patient with a
new problem
Physician is on-site/direct supervision provided
Physician sees patient at a frequency showing
involvement in the patient’s care plan; this means that
the physician is required to periodically evaluate the
patient and update the plan of care accordingly
51. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 50
Direct Personal Supervision
Each visit/occasion of service by auxiliary personnel does not
need to be at the actual rendition of a personal professional
service by the physician
Direct supervision in the office setting does not mean that the
physician must be present in the same room with his or her
aide
The physician must be present in the office suite and
immediately available to provide assistance and direction
throughout the time the aide is performing services
If auxiliary personnel perform services outside the office
setting (e.g., in a patient's home or in an institution other than
a hospital or skilled nursing facility [SNF]), their services are
covered incident-to a physician's service only if there is direct
supervision by the physician
52. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 51
Supervising vs. Ordering Physician
Regardless of the ordering physician, the service should
be billed under the supervising physician’s NPI and
name
The billing physician on the claim form should be
consistent with the on-site physician who is providing
direct supervision
53. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 52
Private Payers
Private payers have different rules regarding NPP billing
PYA recommends that the top three to five payers be contacted
to confirm whether the NPP service can be billed incident-to
under a physician’s NPI
If the payer allows incident-to billing under the physician and
provides no further guidance:
Recommend: Bill under the supervising physician on-site or
designated for supervision that day
Follow state supervision and collaboration rules
54. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 53
Incident-To Vs. Direct NPP Billing
Incident-To
No new patients
No new problems
Physician in suite
Not at hospital or SNF
Physician directs patient
care
Full payment
Code at any level
Direct Billing
Any patient
Any problem
Location of physician is not
an issue
Any point of service
NPP in control
85% of fee
Code at any level
55. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 54
Documentation Requirements
For incident-to services, the medical record must
document:
Services provided by office personnel whom the physician
directly supervises and who represent a direct financial expense
Physician review of the qualified provider’s chart notes in order
to monitor treatment progress
Physician signature indicating the physician is actively involved
in the patient’s course of treatment
Physician must be immediately available (present in the office
suite)
Solo providers must directly supervise the care
In group practices, if the ordering physician is not available, any
physician of the group may provide direct supervision
57. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 56
Split/Shared Simply Stated
A split/shared E/M visit is defined by Medicare Part B
payment policy as a medically necessary encounter with
a patient where the physician and a qualified NPP each
personally performs a substantive portion of an E/M visit
face-to-face with the same patient on the same date of
service
A substantive portion of an E/M visit involves all or some
portion of the history, exam, or MDM key components of
an E/M service
Both providers (NPP and physician) must have a
documented face-to-face encounter with the patient
The physician and NPP must be employed by the same
employer
58. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 57
Split/Shared Simply Stated (cont.)
The level of service is based on the combined
documentation of both providers, and the documentation
must clearly identify what was personally performed by
each provider
The physician cannot merely co-sign or complete an
attestation similar to a teaching physician statement
If the documentation meets the requirements, the visit
can be billed under the physician’s NPI, as opposed to
the NPP’s NPI
59. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 58
Split/Shared Visit Locations
Hospital inpatient or outpatient
Emergency department
Hospital observation
Hospital discharge
Office or clinic (uncommon)
60. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 59
Split/Shared Visits Are Not Allowed…
In an SNF or nursing facility setting
For procedures
In a patient’s home or domiciliary site
For critical care services and other time-based CPT
codes
61. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 60
Payer Notes Regarding Split/Shared Visit
NPP and physician document a portion of the E/M
service (same patient, same date of service)
Bill under physician
Note: Co-signature does not count
Must include some E/M elements
For example: “Saw patient and agree with above, heart and
lungs clear”
Medicaid and some third-party payers require that the
service be billed under the NPP’s NPI, and do not
recognize the split/shared billing methodology
63. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 62
Physician Practice (Non-Facility)
A physician’s private practice location, office, clinic; a freestanding
entity for reimbursement purposes
Provider-Based Clinic (Facility)
An outpatient department of the hospital; paid differently than a
freestanding clinic
Recent law has impacted the prior popularity of acquiring and
establishing provider-based clinic locations
Hospital (Facility)
Could include services that are ancillary in nature (lab test, x-ray),
inpatient services (patient kept overnight for a series of days),
and/or outpatient or observation services (patient may stay
overnight but discharge is anticipated within a shorter timeline
than inpatient care)
These terms represent location, setting, or place of service
Important Terms
64. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 63
Important Terms
Fee-for-Service
A schedule that pays a provider based on the volume of services
rendered; generally relates to Physician Services
Example: If Medicare pays $50 for an office visit and Dr.
Smith does two of them, he would get $100
This is a type of reimbursement schedule
Providers are financially incentivized to see more patients
65. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 64
Charges, Payments, and Cost
Charges are the amount the hospital lists as the price
for services; very few pay this “sticker price”
Payment or Reimbursement is the amount the hospital
actually receives in cash for its services
Private insurers, public insurers, self-pay patients, and the
uninsured all pay different amounts for the same services;
payment can be either more or less than what it costs the
hospital to provide a given service
Cost is what it actually costs the hospital to provide the
services
66. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 65
Reimbursement Methodologies
Hospitals
Percent of Charge
Per Diems
Case Rate Payment
Diagnosis-Related
Groups (DRGs)
Medical Severity DRGs
Global
Ambulatory Patient
Groupings
Ambulatory Payment
Classifications
Other
Carve-Outs
Professional Services
Fee-For-Service
Discounts
Fee Schedules
Payment Based on
Resource-Based Relative
Value Scale (RBRVS)
Capitation
Withholds
Pools
Case Rates
67. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 66
RBRVS
RBRVS developed to better align physician payments
with costs
Payments for services are determined by the resource
costs to provide them
Relative Value Units (RVUs) are used to rank the costs
Work RVUs (wRVUs) are updated annually
Entire system is reviewed every five years by law
68. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 67
RBRVS (cont.)
Conversion factor (CF) is used to determine
payment when multiplied by total RVU; CF is updated
annually
Adjustments to the fee schedule:
Geographic adjustment
Budget neutrality factor (BNF), also known as budget neutrality
adjustment
If changes in schedule, change outlays in excess of $20
million
69. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 68
Work RVU Analyses
Physician wRVU – The relative level of time, skill,
training, and intensity to provide a given service; a code
with a higher wRVU takes more time, intensity, or some
combination of these two
Analysis Considerations
Personally performed services
Modifier use
Date of service vs. posting date
Location (does it matter?)
Global surgical period
70. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 69
Medicare Part A
Hospital insurance plan
for the elderly
Financed through social
security taxes
At age 65 years, patients who
have paid >10 years into SSI
are automatically enrolled
Those <65 years of age who
are totally and permanently
disabled may enroll after 24
months of disability
Those with ESRD on HD usually
enrolled without wait period
Medicare Part B
Insures the elderly for
physicians’ services
Financed by federal taxes and
monthly premiums from
beneficiaries
Available to those eligible for
Medicare Part A who elect to
pay the Medicare Part B
premium of $147/month
(2015), adjusted upward
according to income
Medicare
Government-Financed Insurance
71. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 70
Why Is Medicare So Important?
Medicare is typically a significant payer for most
physicians (and hospitals); in some cases, it could be
the largest payer in a physician’s or hospital’s payer mix
Medicare’s fee schedules are publicly available and
published annually (with updates), so they are a reliable
and available source of information
72. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 71
Medicaid:
Government-Financed Insurance
Medicaid (varies by state)
Federal program administered by the states
Federal financing for low-income patients
Federal government
Pays between 50% and 76% of total Medicaid costs
Requires that a broad set of services be covered, including
hospital, physician, laboratory, x-ray, prenatal, preventive,
nursing home, and home health services
EACH STATE has its own Medicaid program and fee
schedule(s)
Medicaid is generally an undesirable payer for physicians
because the reimbursement is typically pretty low (less
than Medicare, sometimes 70-80% of Medicare)
74. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 73
Productivity or Work RVU Metrics
75. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 74
What Is a Work RVU?
A wRVU is a numerical value intended to reflect the
physician’s:
Time
Effort/Skill
Intensity
Associated with a specific service (as represented by a
CPT code)
Examples:
An office visit for a new patient (CPT code 99203) has 1.42 work
RVUs
An office visit for an established patient (CPT code 99213) has
0.97 work RVUs
wRVU values are published annually (with quarterly
updates) by the Centers for Medicare & Medicaid
Services (CMS)
76. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 75
Total Relative Value Unit
Components (tRVU)WorkRVU
• wRVU
• Physician’s
(Provider)
time, effort,
technical skill,
judgement,
stress, and
amortization
of education
PracticeExpenseRVU
• peRVU
• Direct
expenses
related to
supplies, non-
MD labor, the
pro-rata cost
of equipment
used, and an
amount for
indirect
expenses
MalpracticeRVU
• mpRVU
• The cost of
malpractice
risk for the
procedure
77. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 76
Relative Value Units
Relative Value Units (RVUs) are established by CMS
within the RBRVS to establish:
Relative difficulty associated with each procedure; accounts for
time, skill, and intensity (Physician Work)
Costs associated with each procedure, which includes
equipment, supplies, and staff (Practice Expense “PE”)
Costs associated with malpractice/liability for each procedure
(Malpractice Expense)
The Physician Work portion is reflected in a wRVU
78. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 77
Determining Medicare
Reimbursement (MPFS)
Total RVU
Conversion
Factor
$35.8887
Medicare
Reimbursement
Rate
$$$
80. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 79
tRVU Example: 99213
wRVU
• 0.97 work RVUs
• Always the
same value,
regardless of
setting (facility
or non-facility)
PracticeExpenseRVU*
• Non-Facility
• 1.01 PE RVU
• Facility
• 0.4 PE RVU
MalpracticeRVU*
• Non-Facility
• 0.07 MP RVU
• Facility
• 0.07 MP RVU
*PE and Malpractice RVUs represent national, unadjusted amounts;
specific, locality-adjusted amounts will vary
81. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 80
tRVU Example: 99213 (cont.)
Total RVUs (non-facility) = 2.05
Total RVUs (facility) = 1.44
Total RVUs are higher in the non-facility setting
Why?
82. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 81
CPT Code wRVU Variance Analysis
84. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 83
Physician Time Study Analysis
Used to understand the amount of time required, on
average, to perform a single service (or a series of
services)
Can be used to test the reasonableness of highly
productive physician utilization data
85. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 84
Psychiatric Time Study Trending Data
CPT Code CPT Description
2016 Medicare
Time Study Pre-
Service Time
(minutes)
2016 Medicare
Time Study
IntraService Time
(minutes)
2016 Medicare
Time Study Post-
Operative/Service
Time (minutes)
2016 Medicare Time
Study Total Time
(minutes)
+90785 Psytx complex interactive 0 0 11 11
90791 Psych diagnostic evaluation 10 60 20 90
90792 Psych diag eval w/med srvcs 10 60 20 90
90832 Psytx pt&/family 30 minutes 5 30 10 45
+90833 Psytx pt&/fam w/e&m 30 min 0 30 3 33
90834 Psytx pt&/family 45 minutes 5 45 10 60
+90836 Psytx pt&/fam w/e&m 45 min 0 45 3 48
90837 Psytx pt&/family 60 minutes 5 60 10 75
+90838 Psytx pt&/fam w/e&m 60 min 0 60 3 63
90839 Psytx crisis initial 60 min 10 60 20 90
+90840 Psytx crisis ea addl 30 min 0 30 0 30
90845 Psychoanalysis 5 45 11 61
90846 Family psytx w/o patient 0 50 0 50
90847 Family psytx w/patient 5 50 21 76
90849 Multiple family group psytx 11 84 14 109
90853 Group psychotherapy 2 14 8 24
90865 Narcosynthesis 0 90 0 90
90870 Electroconvulsive therapy 10 20 5 36
90875 Psychophysiological therapy 10 25 10 45
90876 Psychophysiological therapy 10 50 10 70
90880 Hypnotherapy 8 50 40 98
90882 Environmental manipulation 0 0 0 0
90885 Psy evaluation of records 0 0 0 60
90887 Consultation with family 10 50 28 88
90889 Preparation of report 0 0 0 0
90899 Psychiatric service/therapy 0 0 0 0
Psychiatry CPT Codes
86. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 85
Benchmark Time Analysis Results
September 2014 to August 2015
Provider
Total
Pre-Service Time
(in Hours)
Total
Intra-Service Time
(in Hours)
Total
Post-Service Time
(in Hours)
Total
Professional
Service Time
(in Hours)
FTE-Equivalent
(Based upon 2,000
Annual Hours)
Dashboard
>2.0
>1.5
>1.25
Provider A, MD 580 1,925 1,049 3,554 1.78
Provider B, MD 464 2,020 658 3,142 1.57
September 2015 to February 2016 (Annualized)
Provider
Total
Pre-Service Time
(in Hours)
Total
Intra-Service Time
(in Hours)
Total
Post-Service Time
(in Hours)
Total
Professional
Service Time
(in Hours)
FTE-Equivalent
(Based upon 2,000
Annual Hours)
Dashboard
>2.0
>1.5
>1.25
Provider A, MD 530 2,453 1,072 4,054 2.03
Provider B, MD 409 2,005 607 3,021 1.51
Note: FY16 data has been annualized based on a six-month period.
87. Prepared for Florida Council for Community Mental Health
May 17, 2017
Page 86
Questions?