CPT Changes in 2013 and Levels of Care –

Why it Matters and Why it doesn’t affect CMH

Medical Necessity:

Impact for Community Mental Health Psychiatrists

Donald Sharps, MD

Associate Medical Director HCA BHS AMHS & ADAS

Assistant Professor at University of California, Irvine

No relevant financial relationships with commercial interests

CPT Changes in 2013 and Levels of Care –

Why it Matters and Why it doesn’t affect CMH Medical Necessity

Impact for Community Mental Health Psychiatrists

CME Objectives

At the end of the presentation, the attendee will be able to:

1)Know how to use the new 2013 CPT Codes for Psychiatry – THREE OPTIONS

???

See Handout

CPT Changes 2013

– THREE OPTIONS

CPT Changes 2013

See Handout

Let’s Simplify

AMHS & CYS ARE ONLY OUTPATIENT

Let’s Further Simplify

Remove the Inpatient Codes

99212

NEW Pt E&M CODES ARE NOT USED IN THE BHS GROUP

(Pt MAY HAVE BEEN SEEN WITHIN THE SYSTEM IN THE LAST 3 YEARS)

AMHS & CYS ARE ONLY OUTPATIENT ESTABLISHED OUTPATIENTS

Let’s Further SimplifyRemove Initial Outpatient

E&M Codes

WITHOUT THE “PSYCHOTHERAPY ONLY”

THREE OPTIONS1)

2)

3)

WOULD THE CODE SELECTION AND DOCUMENTATION

ALGORITHM BE ANY SIMPLER WITHOUT THE

PSYCHOTHERAPY?

99212

99212

AMHS & CYS ARE ONLY ESTABLISHED OUTPATIENTS

WOULD THE CODE SELECTION AND DOCUMENTATION

ALGORITHM BE ANY SIMPLER WITHOUT THE

PSYCHOTHERAPY?

TWO OPTIONS, IF NO PSYCHOTHERAPY

99212

These Four CPT codes already exist for BHS Psychiatrists

“Time Method” OR “Key Component Method”

TWO OPTIONS

AMHS & CYS ARE ONLY ESTABLISHED OUTPATIENTS

IF > 50% of time spent ‘counseling’ or coordinating care with the pt or family (responsible party), you may continue to use the “Time Method”, not the “Key Component Method”

IF < 50% of time ‘counseling’ or coordinating care AND if note doesn’t include the extent of ‘counseling’ or coordinating care , then you must use the “Key Component Method”

Time Method RequiresCounseling or Coordinating Care

AMHS & CYS ARE ONLY ESTABLISHED OUTPATIENTSFIRST OPTION

1995 Documentation Guidelines for Evaluation and Management Services

1997 Documentation Guidelines for Evaluation and Management Services

OR

Counseling , as it relates to Time Method - defined:

Discussion with a pt and/or family concerning one or more of the following:

•Diagnostic results, impressions, &/or recommendations •Prognosis•Risks and benefits of treatment options•Side effects of tx (drug reactions, for example)•Importance of compliance with tx options•Client and family education

Counseling should not be confused with psychotherapy!

“Counseling” - FOR PURPOSES OF E/M CODECPT Elements of

'Counseling’ 

Corresponding Elements of Supportive Psychotherapy

 Elements of

Other Interventions

Diagnostic results, impressions, and/or recommended diagnostic studies

  Advice and Teaching  On line review of registry or labs with pt present

Prognosis   Reassurance & Encouragement    

Risks and benefits of management (treatment) options

 Advice and teaching,

Rationalizing and Reframing 

Eliciting sx’s and impairment, and connecting the two NEED eliciting sx’s and impairment, and connecting the two

Instructions for management (treatment) and/or follow-up

 

Anticipatory Guidance,

Reducing and Preventing Anxiety,

Naming the Problem,

Advice and Teaching

 Cognitive Behavioral Interventions

Importance of compliance with chosen management (treatment) options

  Expanding the Patient’s Awareness   Motivational Interviewing

Risk factor reduction  

Naming the Problem,

Expanding the Patient’s Awareness,

Advice and Teaching

 Monitoring for metabolic syndrome

Patient and family education  Praise, Encouragement,

Advice and Teaching   

Winston, A. Rosenthal, R & Pinsker, H., Introduction to Supportive Psychotherapy, American Psychiatric Press, Inc. 2004, p. 1 Winston, A. Rosenthal, R & Pinsker, H., Introduction to Supportive Psychotherapy, American Psychiatric Press, Inc. 2004, p. 1

“Counseling” - FOR PURPOSES OF E/M CODECPT Elements of

'Counseling’ 

Corresponding Elements of Supportive Psychotherapy

 Elements of

Other Interventions

Diagnostic results, impressions, and/or recommended diagnostic studies

  Advice and Teaching  On line review of registry or labs with pt present

Prognosis   Reassurance & Encouragement    

Risks and benefits of management (treatment) options

 Advice and teaching,

Rationalizing and Reframing 

Eliciting sx’s and impairment, and connecting the two

Instructions for management (treatment) and/or follow-up

 

Anticipatory Guidance,

Reducing and Preventing Anxiety,

Naming the Problem,

Advice and Teaching

 Cognitive Behavioral Interventions

Importance of compliance with chosen management (treatment) options

  Expanding the Patient’s Awareness   Motivational Interviewing

Risk factor reduction  

Naming the Problem,

Expanding the Patient’s Awareness,

Advice and Teaching

 Monitoring for metabolic syndrome

Patient and family education  Praise, Encouragement,

Advice and Teaching   

Winston, A. Rosenthal, R & Pinsker, H., Introduction to Supportive Psychotherapy, American Psychiatric Press, Inc. 2004, p. 1 Winston, A. Rosenthal, R & Pinsker, H., Introduction to Supportive Psychotherapy, American Psychiatric Press, Inc. 2004, p. 1

See Handout

COORDINATION OF CARE (C of C) FOR PURPOSES OF E/M CODES

1) No explicit definition / elaboration of C of C in CPT

2) In the office, C of C typically includes collaboration with• Social service agencies, case managers, family members,

assistance with SSI, SSDI benefit issues

3) Must be provided during face-to-face time in order to count towards the E/M time requirement

4) DOCUMENTATION BASED UPON COUNSELING AND/OR COORDINATION OF CARE

1) ED Face to Face time = ___ OR a statement, “Total time: 25 minutes”

2) Statement that “More than 50% of the visit included counseling and/or coordination of care”  

3) Specific nature of the counseling and/or coordination of care

4) Medical/medication management

See Handout

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R438PI.pdf

“Add-ons” 99354 & 99355 - Outpatient prolonged E&M codes

For the future – details on use in BHS to follow in 2013

What if it total face-to-face is more time than the E&M code?

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1490CP.pdf

Initial Psychiatrist Visit for 35 to 69 min Use 99354 add-on for 70 min to 114 min

Follow-up Psych Visit for 20 to 54 min Use 99354 add-on for 55 min to 99 min

Follow-up Psych Visit for 13 to 19 min When pt present (use instead of M0064)

Follow-up Psych Visit for 1 to 12 min When pt present (use instead of M0064)

99212 – 99215 Established Outpatient CPT Codes

No Interactive Add-on’s

Key Component MethodSECOND OPTION

See Handout

Key Component MethodSee

Handout

See Handout

See Handout

Selecting the correct E&M CPT code

• An E&M code for medication services is required – No More 90862’s

• Although any appropriately documented E&M code may be entered on BHS encounter document - there are cautions

– Services provided within CMH setting typically do not mirror the broad range of services provided within the general medical community

• One caution - Psychiatrists will be seeing "established" patients – (i.e. someone else in the HCA BHS group has already provided a clinical service)– In BHS, E&M codes will only be used by a psychiatrist

• E&M CPT code will be based on either of the following methods:– The presence of specified key components, OR – Time

99215 Com / Com / High / 40 (Typically a new pt for that MD)

• Face to face, office-based client visit typically 40 minutes. Unless the chart note documents that greater than 50% of an E&M visit is spent counseling the client and/or family or coordinating care, then there should be documentation of two of the three components.

• CPT examples –

• Office visit for a 29-year-old female, established patient, who is abstinent from previous cocaine dependence but reports progressive panic attacks and chest pains;

• Office visit for an established adolescent patient with history of bipolar disorder treated with lithium; seen on urgent basis at family’s request because of severe depressive symptoms;

• Office visit for a 27-year-old female, established patient, with bipolar disorder who was stable on lithium carbonate and monthly supportive psychotherapy but now has developed sx’s of hypomania;

• Office visit for a 25-year-old male, established patient with a history of schizophrenia who has been seen bi-monthly but is complaining of auditory hallucinations

Example from BHS Coding Manual:

• 40 minute appointment for a psychotic-depressed client, (perhaps with care coordinator or community support person present), OR

• Established client (maybe new to this provider) office appointment for a comprehensive evaluation of the need for a psychotropic medication for a client who has been assessed or evaluated by any HCA care coordinator

• Two of the following three:

99215 Com / Com / High / 40 (Typically a new pt for that MD)

• Two of the following three:

• Comprehensive history - Chief complaint and HPI 4 elements (severity, frequency, duration, modifying factors), PFSH 2, ROS 10 - 14

• Comprehensive exam (All bullets) – 3 vitals, appearance, muscle strength, gait, full MSE

• High-complexity medical decision-making (4 Prob pts) (4 Data pts) (High risk – chronic illness progressing)

99214 Det / Det / Mod / 25 (Typically for an established pt for that MD)

• Face-to face, office-based client visit typically 15 minutes. Unless the chart note documents that greater than 50% of an E&M visit is spent counseling the client and/or family or coordinating care, then there should be documentation of two of the three components.

• CPT example - Office visit for a 52-year-old male, established patient, with a 12-year history of bipolar disorder responding to lithium carbonate and brief psychotherapy. Psychotherapy and prescription provided

Example from BHS Coding Manual:

• 25 minute follow-up (or urgent initial to provider) appointment for an anxious client who is having difficulty with physical symptoms that are probably anxiety, but could be a physical disorder. Two of the following three:

• Detailed history - HPI 4 elements (severity, frequency, duration, modifying factors), PFSH 1, ROS 2 - 9

• Detailed Problem-focused exam (> 9 bullets) – 3 vitals & 6 MSE items• Moderate-Complexity medical decision-making (3 Prob pts) (3 Data

pts) (Moderate low – chronic illness) “Illness is not yet consistently stable”

99213 EPF / EPF / Low / 15 (Typically an abbreviated follow up or covering)

• Face-to face, office-based client visit typically 15 minutes. Unless the chart note documents that greater than 50% of an E&M visit is spent counseling the client and/or family or coordinating care, then there should be documentation of two of the three components.

Example from BHS Coding Manual:

• 15 minute follow-up appt for client with mild psychotic symptoms with whom it was difficult to establish rapport in previous evaluations. Client wanted to think about the treatment options including medication and the plan was to have him/her return in a few days if he/she was willing to start the medication that had been offered. Two of the following three:

• Expanded Problem-focused history - Chief complaint and brief "interval" history (symptoms OR impairments OR events OR side-effects), No PFSH, ROS - 1

• Expanded Problem-focused exam (> bullets) – 6 MSE items• Low-Complexity medical decision-making (2 Prob pts) (2 Data pts)

(Risk low – chronic illness)- Diagnosis of a psychotic disorder continues and the plan to start the medication and a signed consent obtained

• No CPT example but 99211 CPT example - Office visit for prescription refill for a established patient, with schizophrenia, who is stable but has run out of medication and is scheduled to be seen in a wk

99212 PF / PF / SF / 10 (Typically an abbreviated follow up or covering)

• Face to face, office-based client visit typically 10 minutes. Unless the chart note documents that greater than 50% of an E&M visit is spent counseling the client and/or family or coordinating care, then there should be documentation of two of the three key components (history, exam and medical decision making).

Example from BHS Coding Manual:

• 10 minute very brief follow-up appointment for a depressed client with partial response to treatment to high dose of SSRI but is now going to have adjuvant medication added that may have significantly different side effects. Two of the following three:

• Problem-focused history - Chief complaint and brief "interval" history (symptoms OR impairments OR events OR side-effects), No PFSH, No ROS

• Problem-focused exam (1 – 5 bullets) - Today's symptom(s) • Straightforward medical decision-making (0-1 Prob pts) (0-1 Data pts)

(Risk minimal – chronic illness)- Affirming that the diagnosis of depression continues, the side-effects are the same or better, and a plan to continue with added medication or titration

• No CPT example but 99211 CPT example - Office visit for prescription refill for a established patient, with schizophrenia, who is stable but has run out of medication and is scheduled to be seen in a wk

IF, you do CHOOSE the Psychotherapy with E&M,

Then Key Components ARE required!

Cannot use the “Time Method”

AMHS & CYS ARE ONLY ESTABLISHED OUTPATIENTSTHIRD OPTION