Thank you Kate and Heather for that lovely introduction. We’re going to review the new 2013 CPT code changes from the perspective of a biller, while focusing on the concerns of a provider who is doing their own billing. We’ll be spending an hour together today and going over about 20 slides. Please feel free to submit any questions you have during the presentation but we will answer all questions at the end. If we don’t have time to get to your question we will follow up with you via email later today. You can submit a question in the text entry box in the bottom right corner of your screen. Now, let’s begin!
It has been many years since the American Medical Association has made significant changes to the CPT codes used by behavioral health providers. Change is uncomfortable, but these new codes don’t need to be a cause for alarm. We’ll go over the biggest changes today, but there are many resources available to you. In fact, the first resource you want to take advantage of is the 2013 CPT code book. If you haven’t already ordered a copy please do so today. The book holds the entire CPT code set and includes instructions on how to use each code. Once you receive your book, read the introduction. It’s only four pages long and includes valuable information. Every practice should order the current CPT book every year. They are available directly through the AMA, and several other organizations. If you’re a member of an organization that sells the book you can usually get it at a great discount. This is your first and most important step in preparing for the 2013 procedure changes. The next step is to review, or learn, how to bill E/M codes. E/M stands for Evaluation and Management, and these codes are located in the red section at the beginning of the CPT book. While physicians and mid-level practitioners have always been eligible to bill E/M codes, the existence of procedure codes that capture both therapy and medication management, such as 90805 and 90862, have allowed behavioral health providers to effectively bill for their services without utilizing this code set. Prescribers who provide medication management will need to familiarize themselves with E/M billing before January 1 st . In conjunction with this, providers should reach out to their insurance payers and find out if the E/M codes they are likely to bill are already part of their contracts. We anticipate that all behavioral health payers will need to add E/M codes to their reimbursable procedure list, but if they are not currently part of your contract you will want to reach out to your provider services representative and confirm that they will be added, and ask about the reimbursement rates. You also want to ask about the reimbursement rates for the new medical CPT codes for 2013. They should be comparable to their 2012 predecessors.
Here we have a grid of all the behavioral health CPT codes that have been discontinued beginning January 1 st . Note that you will no longer use these codes for all services beginning in January – if after the first of the year you find that you need to bill for an appointment from December or November or earlier, then you will need to use the 2012 code set. A noteworthy feature in our current code set is that a different code is chosen based on outpatient versus inpatient therapy, and interactive psychotherapy has its own set of codes. We will review the replacements for each of these codes shortly.
Here we have a list of all the new behavioral health codes. You’ll notice it’s a much smaller chart! Billing for psychotherapy should be even simpler than before, with just one set of codes to choose from. However, medication management can now only be captured with the use of E/M codes. Before we cover medication management we are going to briefly review the new psychotherapy codes and go over changes in the definition of time.
We have a very straightforward crosswalk for the new psychotherapy codes in 2013 that do not involve medication management. Previous codes will be replaced with one of four new therapy codes, and up to one add on code demonstrating interactive complexity in the session. For example, 90801 (the initial psychiatric assessment) is now 90791, and 90802 (an interactive psychiatric assessment) is now 90791 and 90785. Add on codes are CPT codes that can never be billed on their own. They can only be bill in addition to a primary CPT code. A 90801 was considered a primary CPT code because it could be billed on its own, without any other codes on that day, and the new 90791 is also a primary code. The other primary therapy codes are 90832, 90834, and 90837. The time definitions for each therapy code have changed for 2013. Previously there was a range attached to each code; for example, a 90806 was 45-50 minutes of therapy. Now there is a defined time for each procedure. We’ll go over what this means next.
90832 is defined as 30 minutes of psychotherapy, 90834 is 45 minutes of therapy and 90837 is 60 minutes of therapy. I think we can all agree that sessions rarely, if ever, last exactly 30, 45 or 60 minutes. Because there is a set time defined for each code you will use the CPT time rule to determine what the most appropriate procedure code is for your session based on the time you actually spent face to face with the patient or their family. The time rule is covered in the introduction of the CPT book, but to summarize, it states that you should choose the procedure code closest to the actual length of the session. The AMA was kind enough to specify exactly what they meant, so we’ve listed the time ranges for each new procedure code. If your therapy session was between 16 and 37 minutes then you will bill 90832. If it was between 38 and 52 minutes you will bill 90834. If it was greater than 53 minutes you will bill 90837. The instructions specify that you should not report psychotherapy of 15 minutes or less. There is one more important definition change in the 2013 book. Starting in January, psychotherapy times are now for face-to-face services with the patient and/or their family members. Currently services are defined by time spent face-to-face with just the patient. In 2013 the patient must still be present for at least some of the service, otherwise you would continue to bill 90846 (family psychotherapy without the patient present).
New to the 2013 code set is the presence of therapy add on codes. The add on code available to all behavioral health providers is 90785, which indicates interactive complexity. Previously there were different CPT codes for interactive therapy based on time and the location of service. Starting in January interactive therapy will be reported using just 90785. The definition of interactive complexity has been expanded and the CPT book now includes broader descriptions of patients who are likely to have specific communication factors that complicate delivery of care. While the complex interaction therapy codes have most commonly been used for services with children, the new definitions make it more likely that services with adults will meet the billing requirements. For example, 90785 may be billed when at least one of the four following factors are present in the session: (1) the need to manage maladaptive communication among participants that complicates delivery of care (in other words, high anxiety, high reactivity, repeated questions or disagreement), (2) disclosure of a sentinel event to a third party (such as abuse or neglect being reported to a state agency) and discussion of the event with the patient, (3) caregiver emotions or behavior interfering with their understanding and ability to help implement the treatment plan, (4) the use of play equipment, physical devices, interpreters or translators to communicate with the patient. Three out of the four factors I just listed can describe services where the patient is not a child.
Another reason there are fewer therapy codes in 2013 than previously is the change in reporting location of services. Currently, the CPT book distinguishes between therapy performed in an outpatient setting and therapy performed in an inpatient setting. Starting in January, that distinction will disappear, and 30 minutes of therapy will be reported using the same code regardless of where the service was performed. The location will continue to be reported using the two digit POS code (or Place of Service code). Common POS codes are 11 (for office visits), 12 (for home visits), 21 (for inpatient hospital visits) and 22 (for outpatient hospital visits). A complete list of POS codes is available on the first two pages of your CPT book.
Now we’re ready to discuss the new codes for prescribers in 2013. Unfortunately, we don’t have an easy 1 to 1 replacement crosswalk for services that utilized your medical training. The only way to bill for services that include medication management is to choose the most appropriate E/M code. If the service also included therapy, a therapy add on code can be billed, too. Prescribers can bill up to three codes per session; the appropriate E/M code, an add on code indicating therapy was part of the service, and 90785 to report interactive complexity.
The new 2013 CPT code set represents many changes to billing for psychiatric services, but not everything has changed. The providers who are eligible to bill E/M codes have remained the same, as has the documentation requirements and instructions on how to choose an E/M code. CMS specifies that providers should choose the documentation guidelines that are most favorable to them. The 1997 guidelines are more favorable to specialties in general, including psychiatrists. They allow for examination of a single organ system, instead of the multi-system examination. If you are unfamiliar with billing E/M services I strongly advise you to sign up for a webinar, an online class, or to buy a book that goes over the documentation requirements in detail. I particularly like the book “Procedure Coding Handbook for Psychiatrists” by Schmidt, Yowell and Jaffe. Their latest edition does not include the new 2013 907xx and 908xx codes, of course, but there have been no changes to the documentation requirements for E/M codes. While instructions on how to meet these billing requirements are outside the scope of this presentation, we will briefly discuss the two different ways to document E/M services.
Remember, therapy can only be reported with medication management as an add on code. That means the new therapy slash med management codes can only be billed if the provider includes an E/M code for that service. 90833, 90836, and 90838 cannot be billed by themselves; payers will reject the claim if they are the only CPT code from the provider for that day. Further, if you are documenting that more than 50% of the session was spent on counseling or coordination of care, and you’re choosing the E/M code with time as your controlling factor, then you cannot include a therapy add on code. You can only bill 90833, 90836 or 90838 if you used the three key components of history, exam and medical decision making to determine the appropriate E/M code.
The time requirements for the therapy with med management codes are the same as the stand alone psychotherapy codes we discussed earlier. We have one code each for 30 minutes, 45 minutes and 60 minutes, and you will select the add on code closest to the amount of time spent on therapy in the session. It is very important to remember that the amount of time you spend on meeting your E/M requirements cannot be included in the amount of time you spent on therapy. Even though you are having one face-to-face session with your patient (and/or their family members), you are going to divide that time into two categories: the amount spent on evaluation and management, and the amount spent on therapy. Let’s look at some examples.
Let’s say you have a 45 minute appointment with your patient. They showed up promptly at 9am and left at precisely 9:45am. You provided both medication management and therapy and want to bill two procedure codes to reflect this. If you spent 15 minutes on the E/M portion and 30 minutes providing therapy, you are not going to bill the 45 minute therapy add on code. You are going to use the three key components of history, exam and medical decision making to decide what the most appropriate E/M code is, and then you are going to bill 90833, the therapy add on code for 30 minutes. In our example, even though you saw your patient for 45 minutes you spent 30 minutes providing therapy. The 90836 add on code of 45 minute therapy and med management would be inaccurate. Let’s look at another example.
Let’s say you see another patient who is very good at arriving on time and leaving on time. If you have a 30 minute appointment and you spend 15 minutes on medication management and 15 minutes on therapy, what are you going to bill? If you said just the E/M code you were right! In this example you would NOT bill the 90833 30 minute therapy add on code because you provided less than 16 minutes of therapy.
CPT Webinar 11.19.12
2013 CPT Code Changes OverviewOur Webinar will start at 10:00 AM (PST)
Overview• 2012 vs. 2013 behavioral health codes – What’s new in 2013 – What’s been deleted in 2013• What’s changed about reporting location of services rendered• What’s changed about time – Determining what code to use when your time is somewhere in between the definitions – What does “face-to-face” mean now?• What remains the same – Evaluation and Management definitions and documentation requirements are the same – Prescribers have always been eligible to use E&M codes Please Note: This information is presented for educational purposes only, according to our understanding of available information, and is not meant as a directive to the viewer. 3
Contact information Vālant Medical Solutions #ValantCPT Carol Storch Heather GrubePractice Management Services Director of Billing (888) 774-0532 (888) 774-0532 www.valant.com www.valant.com 4
About VālantVālant’s EMR for Behavioral Health• Founded in 2005• Developed by Behavioral Heath Professionals• 1000+ Daily Behavioral Health Clinicians Using• Certified for Meaningful Use• Attestations & Payments Received From 2011! Sales: email@example.com 5
First steps• Order AMA 2013 CPT** book – AMA https://catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod1990006 – APA http://www.apa.org/ – AAPC http://www.aapc.com/• CMS Evaluation and Management Services Guide. This contains the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, two of three main parts of your E&M resource base – http:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_• Contact your payers*Current Procedural Terminology (CPT®) copyright 2012 American Medical Association. 7
New codes for 2013Diagnostic Psychotherapy Psychotherapy Other PharmacologicAssessment with E/M Psychotherapy Management90791 90832 90833 + E/M 90839 E/M code90792 90834 90836 + E/M 90840 90863** 90837 90838+ E/M 90785 **for therapists eligible to prescribe in LA and NM. 9
1:1 Crosswalk for Psychotherapy 2012 201390801 – initial psychiatric assessment 90791 – initial psychiatric assessment90802 – interactive initial assessment 90791 + 9078590804 – 20-30 min therapy session 90832 – 30 min90806 – 45-50 min therapy session 90834 – 45 min90808 – 75-80 min therapy session 90837 – 60 min These are the Psychotherapy CPT codes for non-prescribers 10
2013 Psychotherapy and Time Time values used to Code Defined Time determine code 90832 30 minutes 16-37 minutes 90834 45 minutes 38-52 minutes 90837 60 minutes 53+ minutesCPT Time Rule will be used to determine the appropriate CPT code for thesession. Think of the 15 minute time block between time definitions; anything 7minutes or less will be “rounded down” and anything 8 minutes or greater willbe “rounded up.”New definition of face-to-face time‘Psychotherapy times are for face-to-face services with patient and/or familymembers. Patients must be present for all or some of the service’.* 11
2013 Interactive Complexity ‘interactive complexity (list separately in 90785 addition to the primary procedure code)’*In 2012 there were designated CPT codes for interactive complexity asdetermined by timeIn 2013 interactive complexity is a single code which can be added onto any therapy code 12
Place of Service 2012 201390816 – 20-30 min inpatient therapy 90832 – 30 min therapy with POS 21 90832 + 90785 – 30 min interactive90823 – 20-30 min interactive IP therapy therapy with POS 21 In 2012 the therapy code definitions included Place Of Service (POS) In 2013 there is one list of therapy codes and location is reported using the POS code as it would correspond to box 24b on the CMS-1500 form 13
1:1 Crosswalk Psychotherapy with E/M 2012 2013 Interactive (E/M code) Any of the following Complexity9080590807 Appropriate E/M code 9083390809 (99201-99215) 30 min therapyPOS 11, 22, etc.9081190813 Appropriate E/M code 90836 9078590815 (99201-99215) 45 min therapyPOS 11, 22, etc.9081790819 Appropriate E/M code 9083890822 (99218-99239) 60 min therapyPOS 219082490827 Appropriate E/M code 9078590829 (99218-99239)POS 21 14
E/M codesAll duly, appropriately licensed providers of any specialty have alwaysbeen eligible to use E/M codesMost typical E/M codes used are 99201-99205 and 99211-99215The 1997 Evaluation and Management Services Guidelines outline therequirements for a psychiatric examination with clearly defined bulletpoints that can be easily counted to determine the level of examination.One of the bullet points is the mental status exam, already usedregularly by psychiatrists. – https:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGu 15
Choosing the Appropriate E/ME/M documentation requirements are unchangedTwo ways to choose the level of E/M 1. Counseling and coordination of care consideration where >50% of total time in session is devoted to counseling and coordination of care with patient/ caregivers (in this description, counseling does not mean therapy) • Time is considered the key factor ~i.e. you must note the start and end time of the entire session and carefully note how much time is devoted to counseling and/or coordination of care. Documentation should explicitly describe the plan of care. 2. Based on 3 key components (history, exam, and medical decision making) of 7 elements. Many educational resources exist for E/M coding. Your 2013 CPT guidebook and the 1997 CMS publication are the place to start. 16
Outpatient Therapy with E/M 2012 2013 (E/M code) Any of the following90805 90833 – 30 min therapy Appropriate E/M code90807 90836 – 45 min therapy (99201-99215)90809 90838 – 60 min therapyIn 2012 therapy with medical evaluation and management services wasreported by a single code based on face-to-face timeIn 2013 therapy with medical evaluation and management services canonly be reported as an add-on code to the appropriate E/M codeIf time is your controlling factor for determining E/M code (counselingand coordination of care consideration) you may not bill a therapy add-on code 17
2013 Psychotherapy with E/M and Time Time values used to Code Defined Time determine therapy code90833 30 minutes 16-37 minutes90836 45 minutes 38-52 minutes90838 60 minutes 53+ minutes All therapy codes on this page are add-on codes that must be use with the appropriate E/M code Time spent on E/M is separate from time spent in therapy E/M codes billed with therapy add-on codes must be chosen according to medical complexity, history and the exam. They are not based on the amount of time spent on the E/M portion of service. 18
E/M and Therapy example9:00AM 9:45AM Appropriate E/M code 90833 – 30 min 90836 – 45 min 19
E/M and Therapy example11:00AM 11:30AM Appropriate E/M code 90833 – 30 min Do not report psychotherapy of <16 minutes 20
Psychotherapy for Crisis 90839 first 60 minutes +90840 each additional 30 minutesNew category in 2013Do not report psychotherapy for crisis of less than 30 minutes totalduration 21
Pharmacologic Management 90862 is no more !!To report pharmacologic management, you must use the appropriate E/Mcode based on medical complexity or timeYou might find the E/M code falls in the middle of 99211-99215 when choosingthe appropriate code for medication management only (no therapy timecalculated) 99212 - need 2 of 3 99213 – need 2 of 3 Problem focused history Expanded problem-focused history Problem focused exam Expanded problem-focused examination Straightforward medical Medical decision making of decision making low complexity 22
3 things to do now!1. Order 2013 CPT book2. Review or learn how to use E/M coding and the documentation requirements3. Contact your payers and ask if the E/M codes you are likely to bill are included in your contract, and ask for fee schedules for the new 2013 codes 23
Resources• Order AMA 2013 CPT** book – AMA https://catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod1990006 – APA http://www.apa.org/ – AAPC http://www.aapc.com/• CMS Evaluation and Management Services Guide. This contains the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, two of three main parts of your E&M resource base – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf – https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf• Your local, state, and national associations• CMS.gov – Medicare Learning Network: http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNGenInfo/index.html **Current Procedural Terminology (CPT®) copyright 2012 American Medical Association. 24
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