Coding for Mental Health in Today's Environment

Wednesday, May 17, 2017
FLORIDA COUNCIL FOR COMMUNITY MENTAL HEALTH
Coding for Mental Health in
Today’s Environment

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

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

Evaluation and Management (E/M) Overview
E/M Fundamentals

May 17, 2017
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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).

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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)

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E/M Elements
 Key Elements
 History
 Exam
 Medical Decision Making
(MDM)
 Contributory Elements
 Counseling
 Coordination of care
 Nature of presenting
problem
 Time

May 17, 2017
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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

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

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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

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

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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

May 17, 2017
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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

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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

May 17, 2017
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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)

May 17, 2017
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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

May 17, 2017
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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

May 17, 2017
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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

May 17, 2017
Page 20
Initial vs. Subsequent Hospital Care Days
Initial
Hospital Care Day
▪ Applicable E/M codes are 99221-
99223
▪ 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

May 17, 2017
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Inpatient Consultations
▪ An inpatient consultation is a visit resulting from a
request from another medical provider
▪ Applicable E/M codes are 99251-99255
▪ 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

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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

May 17, 2017
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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

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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?

May 17, 2017
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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

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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

May 17, 2017
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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

May 17, 2017
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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

May 17, 2017
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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)

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

May 17, 2017
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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

May 17, 2017
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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

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

NPP Scope and Supervision Requirements

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

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

May 17, 2017
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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

May 17, 2017
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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

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

Payer Guidelines
Direct Billing

May 17, 2017
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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

May 17, 2017
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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

Payer Guidelines
Incident-To Billing

May 17, 2017
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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

May 17, 2017
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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

May 17, 2017
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 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?

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

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

May 17, 2017
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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

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

May 17, 2017
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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

May 17, 2017
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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

Payer Guidelines
Split/Shared Billing

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

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

May 17, 2017
Page 58
Split/Shared Visit Locations
 Hospital inpatient or outpatient
 Emergency department
 Hospital observation
 Hospital discharge
 Office or clinic (uncommon)

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

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

Compensation/RVU Methodology Overview
Fundamentals of Provider Reimbursement

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

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

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

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

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

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

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

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

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

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)

What About Employed Physicians?

May 17, 2017
Page 73
Productivity or Work RVU Metrics

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)

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

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

May 17, 2017
Page 77
Determining Medicare
Reimbursement (MPFS)
Total RVU
Conversion
Factor
$35.8887
Medicare
Reimbursement
Rate
$$$

Examples

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

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?

May 17, 2017
Page 81
CPT Code wRVU Variance Analysis

Additional Validation of Productivity
Time Study

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

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
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

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.

May 17, 2017
Page 86
Questions?

PERSHING YOAKLEY & ASSOCIATES, P.C.
800.270.9629 | www.pyapc.com
Lori Baker, CPC, CHCA-F, RHIA
lbaker@pyapc.com
Thank you!
Denise Hall-Gaulin, RN
dgaulin@pyapc.com

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