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Mental Health Coding and Billing

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Dr. David E. Marcinko MBA

By Dr. David Marcinko MBA

http://www.CertifiedMedicalPlanner.org

Coding Classification

The classification and coding systems used by mental health insurers, both diagnosis-related groups (DRGs) through revenue codes for facility and program services and current procedural terminology (CPT) for in and out patient professional services and consultations, are still being defined through historical methodologies and are vague compared to the medical classification coding structure.

Example:

As an example, mental health insurers classify Tourette Syndrome (TS) as a “mental disorder.” In fact, TS is an inherited, neurobiological disorder, and both neurologists and psychiatrists treat TS with the same medications. If TS were reclassified under the medical coding structure, TS would not only receive potentially a better reimbursement but public perception of TS as a “mental disorder” would be changed.

DSM-IV-TR

The Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision), also known as the DSM-IV-TR, is a manual published by the American Psychiatric Association (APA) that includes all currently recognized mental health disorders. The coding system utilized by the DSM-IV is designed to correspond with codes from the International Classification of Diseases, commonly referred to as the ICD. Since early versions of the DSM did not correspond with ICD codes and updates of the publications for the ICD and the DSM are not simultaneous, some distinctions in the coding systems may still be present.

For this reason, it is recommended that users of these manuals consult the appropriate reference when accessing diagnostic codes. In addition, DSM5 was last updated in May 2013.  For more information, contact the APA at (800) 368-5777.

Assessment

Besides the above coding manual, the International Statistical Classification of Diseases and Related Health Problems” produced by the World Health Organization (WHO) is another commonly used manual which includes criteria for mental health disorders.

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NPI: More Than Just a Number

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Billing and Reimbursement are dependent on the taxonomy code designation and detail

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By Susan Theuns, PA-C, CPC, CHC

“Taxonomy codes and other elements of NPI registration directly affect a provider’s ability to submit claims, order services, and receive reimbursement.”

Back when the National Provider Identifier (NPI) was implemented in 2005 as part of the Health Insurance Portability and Accountability Act (HIPAA), a new identifier accompanied it: the taxonomy code. With that, the Centers for Medicare & Medicaid Services (CMS) developed the National Plan and Provider Enumeration System (NPPES) to officially assign these unique identifiers of the provider. These codes were created to improve the efficiencies and effectiveness of electronic medical claims submission and electronic health information.

What’s in a Name?

When registering for an NPI, one of the elements that also needs to be completed is the selection of a taxonomy code. Taxonomy codes are nationally standardized 10-character codes that are alphanumeric. The definitions range from prosthesis case managers to transplant surgeons. When healthcare providers initially applied for an NPI number, little importance was associated with selection of the taxonomy codes. However, now payers, including Medicare and Medicaid, are rejecting claims based on inconsistency of services provided and taxonomy codes. Now it matters.

The Healthcare Provider Taxonomy Code Set is available from the Washington Publishing Company (WPC) at wpc-edi.com. Taxonomy codes are maintained by the National Uniform Claim Committee, nucc.org, and update twice yearly with effective dates for changes April first and October first. Information included with the hierarchical classifications include descriptions and definitions as well as the codes themselves. The codes can be a primary (level I classification) or subclassifications (level II and III). The more detailed a classification, the more specialized the description. These are the codes that determine a provider’s area of concentration within their discipline, so being generic is not as effectual as drilling down to the most specific code. Think of this as an unspecified versus a specified code.

Depending on the underlying area of expertise, there may be more than one taxonomy code to choose from. For example, a “hand surgeon” may be subclassified under orthopaedics or plastic surgery – depending on the physician’s training. Sports Medicine is another example: there are 8 different taxonomy codes for this specialty under Emergency Medicine, Family Medicine, Internal Medicine, Orthopaedics, Pediatrics, Physical Medicine & Rehabilitation, Psychiatry & Neurology and even Chiropractic. By definition, selection of the code does not require board certification per se; but it does require special education, training, experience and knowledge in the selected area. Therefore, it is important to carefully select any subclassification from the correct and most accurate level I classification.

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Case Studies: Taxonomy Errors that Affect Reimbursement and Functionality

As healthcare becomes more technologically integrated, accuracy in electronic claims submission data becomes critical to reimbursement. In today’s world, a slight variation can make the difference between full payment and denial. Because a provider’s taxonomy code resides in the NPI registry, it has a direct relationship to payer credentialing. The taxonomy code identifies any specialty or sub-specialty that a provider has. Examples of taxonomy errors and necessary updates are (1) when a resident or fellow graduates and becomes a board-certified or state licensed physician, (2) a provider obtains specialty credentials i.e. orthopaedist becomes a trauma, hand or spine specialist, primary care provider becomes a geriatrics or palliative care specialist or hospitalist, and so forth. There are numerous sub-specialties available nowadays that impact when a physician can act in a consultant role from a billing perspective.

Here are some case scenarios that can result in non-payment or lack of services:

  1. A registered nurse (RN) completed advanced training and is now a licensed Certified Registered Nurse Practitioner (CRNP). She worked in this role for several years before being told by a patient that the prescription she had given her for diabetes supplies was denied by the pharmacy. Upon researching the root cause of the denial, it was discovered that the CRNP had never updated her taxonomy code from RN to CRNP in the NPPES database. Only a healthcare provider can order Durable Medical Equipment (DME) and supplies for a patient.
  2. A general orthopaedist saw a patient in the office and asked a colleague with more specialized training to see the patient with him when faced with a complex orthopaedic problem. Both physicians (they had the same employer and billed under the same group NPI), tried to bill an evaluation and management code for the services they rendered. One claim was paid and one claim was denied as a duplicate service. Research revealed that although one physician specialized in trauma and the other in foot and ankle, both used the generic taxonomy code of 207X00000X. Had they each selected a more detailed code, they both would have been eligible to receive reimbursement for the services they rendered on the same patient, same day.

See Figure: 1

A geriatrics specialist consulted on numerous hospital patients at the request of the admitting hospitalist, an internist. All of the Medicare Part B claims and some commercial claims were denied for these hospitalized patients and the geriatrician could not understand why. Investigation of the claims showed duplicate claims for internal medicine subsequent hospital care, no designation of attending of record, and care denied as non-participating under specialty contracts. All of these situations resulted from the provider never updating his taxonomy code from Internal Medicine to Geriatric Medicine when he passed his boards 7 years prior. Even the specialty contract recognized him as primary care and disallowed his consults. In addition, the hospitalist had never updated his taxonomy code from “internist” to “hospitalist”, which added another aspect of billing inaccuracy to his claims.

  • A new graduate took a job as a hospitalist and was fully credentialed upon hire, several months after completing her residency program. As a “student” in a residency program, she had applied for her NPI and correctly selected taxonomy code 390200000X.

See Figure: 2

However, she neglected to update her taxonomy code to “hospitalist” as the primary designation and “internal medicine” as the secondary when she graduated and took the new job. This resulted in rejections and denials deeming her as ineligible to provide billable services.

  • A physician received an inquiry from state Medicaid questioning whether or not he was a sole proprietor or not. They were holding claims awaiting his response. A quick check of his NPI profile showed that it had not been updated since 2007, at which time he had indicated that he was a sole proprietor. Since his initial NPI application, he had become employed by a medical group and was billing under his individual NPI and group NPI. Once he accessed the portal and changed the response to sole proprietor to “no”, the credentialing issue with Medicaid was resolved.
  • Working the rejection and denial billing reports, a director noted a pattern in the rejections from various payors for one physician stating that the provider was not eligible to provide that type of service. Careful inspection revealed an outdated and incorrect taxonomy code on the provider NPI profile that was inconsistent with the services being provided.

See Figure: 3

With all of these issues, the providers technically have 30 days to notify NPPES of any changes. Not adhering to this guideline is a self-imposed penalty that exceeds any potential fines from NPPES since reimbursement can be negatively affected. Most likely because of the reimbursement consequences, NPPES rarely imposes fines for delayed updates to a provider NPI, although they maintain the right under federal guidelines.

Figures: Figures 1 2 3

Assessment

This critical information should be carefully reviewed upon hire and annually to ensure accuracy in reporting and billing. New taxonomy codes are added bi-annually so new sub-specialties may become available that would allow a healthcare provider to be more specific than previously. In addition, providers of all levels should be encouraged to be part of the process.

An NPI is a provider’s for life and is not dependent upon employer so they need to be engaged and part of the process. Most of the information on the NPPES website is accessible by the public. This means that if a provider puts a home address or home phone/cell phone number for contact, their patients now have access to this information. It is a best practice to use only business contact addresses and phone numbers for your NPI for this reason.

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9.13 NPI Logo and Business Card Gelling Ideas 24

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Summary

Taxonomy codes and other elements of NPI registration directly affect a provider’s ability to submit claims, order services, and receive reimbursement. This often overlooked and neglected piece of a provider’s NPI warrants regular review and updating when any changes occur, such as name change, office move, board certification, change in role, or shift in the specialty-focus of a practice, despite official certification. Last, but not least, the provider user name and password for NPPES and the NPI database are the same for the Provider Enrollment, Chain and Ownership System (PECOS), CMS Analysis & Information (A&I), and the EHR Incentives Program portal to report Meaningful Use and PQRS. As with all user names and passwords, they need to be maintained but carefully protected. It will save a lot of headaches for those who rely on these on-line service portals for their livelihood.

References

CMS Center for Program Integrity, Medicare Provider/Supplier to Healthcare Provider Taxonomy Crosswalk, November 2015.

National Plan and Provider Enumeration System, https://nppes.cms.hhs.gov/NPPES/Welcome.do

Washington Publishing Company, Health Care Provider Taxonomy Code Set, http://www.wpc-edi.com/reference/

ABOUT:

Susan Theuns, PA-C, CPC, CHC, is the administrative director of physician practices at MedStar Union Memorial Hospital in Baltimore, Maryland. In addition to her certifications, she holds degrees in Allied Health, Business Management and Leadership & Education. Theuns serves as a national advisor and is a contributing author for The Business of Medical Practice, 3rd edition. She is a member of the Baltimore, Maryland, local chapter.

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Compensation Trends for Allied Healthcare Professionals

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Beyond Physician Salary [Average by Position]

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  2. The 2015 Physician Pay Check-Up

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No More 10 and 90 Day Global Periods

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New Changes on the [CMS Payment Reform] Horizon
[By Dreama Sloan-Kelly MD CCS]

thDid you hear about the changes that are coming down the pike in regards to global services when billing for surgical procedures — be they in the office, in an ambulatory surgical center, or in the hospital?

CMS released their final 2015 Medicare Physician Fee Schedule (MPFS) ruling late last year. Embedded in this document was a proposal by CMS to get rid of both the 10 day and 90 day global periods! In fact, they want to do away with global period billing all together and have all procedures paid based on the work required to do the procedure itself — thereby billing for all post-surgical visits separately using E/M codes.

According to the final ruling, CMS proposes to transform all 10 day global services to ZERO global days starting in 2017. They will do the same in regards to 90 day global services starting in 2018. And, according to the U.S. Department of Health and Human Services (HHS) and the Office of Inspector General (OIG) they have “identified a number of surgical procedures that include more visits in the global period than are being furnished”. They go on to say that they are “also concerned that post-surgical visits are valued higher than visits that were furnished and billed separately by other physicians such as general internists or family physicians”. Based on the final ruling, they plan to begin the transition as previously stated in 2017 after they have considered all comments.

The ruling goes on to state, “as the agency begins revaluation of services as 0-day global periods, we will actively assess whether there is a better construction of a bundled payment for surgical services that incentivizes care coordination and care redesign across an episode of care”. So let’s talk reality and my take on this change.

Over the past few weeks I have read a lot of articles on this subject from various pundits in the industry — they are actually arguing that this change will mean increased reimbursement when you combine the separate payment for the procedure itself along with the visit by visit billing for the post-surgical follow up care when compared to the current reimbursement rate.

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Personally, I think they are all wrong for the following reasons:

Procedure Reimbursement Amount: This is the wild card. They are going to use the same RVU system that has always been used to calculate payment — but I guarantee you the payment for the procedure will not be anywhere near the reimbursement for the global package. I think the closest we could get to estimating the reimbursement rate of the procedure is to figure out what the current surgical care only rate would be (ie. as if you appended Modifier 54 to the procedure code). Beware that this rate would still encompass the pre-surgical evaluation — which I am assuming would be carved out since that is a part of the current global package they are trying to phase out.

Post Op Visits: Getting a patient to comply with medical visits is hard enough — now adding in the fact they would have to pay a copay each time — most often a specialty co-pay is going to make it even harder. Patient’s understand their follow up visits are currently covered in the cost for the surgery, and hence they tend to show up to these visits knowing they do not have any out of pocket expenses. If the proposed change comes to fruition many of the post-surgical visits may become cost prohibitive for a lot of patients and actually lead to a decrease in the number of follow up visits the patient actually schedules. Once the patient starts to feel better their motivation to return dwindles.

Lower Reimbursement Rate for Post-Surgical Visits: It is clearly stated in the CMS ruling that it is felt the post-surgical follow up care visits are paid at a higher rate than what a regular E/M visit would be paid for had the patient been seen by a primary care provider or an internist. That simple statement confirms to me that when the new procedure rate is combined with the individual visit payment rate, the overall reimbursement rate will be less than what is currently being paid.

So, how do you prepare?

First, stay on top of all bulletins coming from CMS in regards to this issue. Most of your medical societies and/or specialty societies have taken clear positions in regards to this matter — so be sure to stay in the loop and become a part of the process.

Run a report that allows you to pinpoint the average number of post-surgical follow up visits for your most billed procedures. This will give you an idea of the average number of follow up visits for particular procedures you know you will bill for if this transition does occur. Does this mean this number will be exact — NO — I would factor in a decrease of 15-20% for visits across the board based on the dynamics I previously described.

Lastly, begin creating a policy in regards to post-surgical follow up care that can act as an education tool for the patient, teaching them the important benefits of being compliant with their post-surgical care schedule and also warning them about the possible increase in out of pocket cost. Being transparent can go a long way into easing patient’s fear and encouraging their follow through.

As always I have included documentation for your library of information — you can find the CMS 2015 MPFS final ruling fact sheet HERE! I also created a brief video presentation on this hot topic HERE

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Thoughts on an Emerging Hybrid [Two-Tiered] Medical Payment Model

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The Changing Reimbursement Paradigm Shift

[By Dr. David Edward Marcinko MBA CMP™]

[By Prof. Hope Rachel Hetico RN MHA CPHQ CMP™]

David and HopeCurrent medical payment and reimbursement structures involve the submission and payment of medical CPT® coded claims.

So, some doctors feel they need to “up-code” to maximize revenue; or “down-code” for fear of having a claim denied.

Moreover, this pay-for-quantity model is slowly being relegated to the past in light of current P4P, ACO, and values based reimbursement models that favor modern payment-for-quality initiatives.

Tug-of-War System

Obviously, contradictory business goals bastardize the system into a payer versus provider tug-of-war, with patient care as a potential bargaining chip.

Instituting quality metrics should be included in this equation, and, a hybrid reimbursement model may be a viable option while integrating quality care metrics and reducing costs for all stakeholders.

A Two Tied System

This hybrid reimbursement system might use a two-tiered payment structure something like this:

  1. For the first payment, claims would be paid at hypothetical rate of 60% within one week of submission; partially decreasing office ARs, and favoring the time-value of money [TVM] equation.
  2. The second payment, consisting of the remaining zero to 40% of some total maximum allowable fee, is then paid quarterly. It would be based on scores like patient satisfaction, quality metrics, and stewardship of healthcare resources by analyzing a statistically valid sample of patient encounters taken from the electronic health record [EHR].

Green Dollars

Assessment

Such a hybrid payment system would remove unnecessary steps, like re-submitting claims and would lower the operational and administrative costs of healthcare claims processing.

These changes would decrease operational office costs and drive quality stewardship of the diminishing healthcare dollar.

Conclusion

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How Hospital Billing Impacts the Patient Experience

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It’s About … the Invoice

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Here, Connance visually shows how hospital billing process is directly correlated to the patient experience.

Assessment

Patients who encounter problems with their physician’s billing office are less likely to recommend that physician/clinician to others.

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Medical Office Fee Strategies for Disgruntled Patients

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Adroitly Handling a Tough but Common Office Situation

[By Dr. Gary L. Bode MSA CPA]

A common scenario, in medical practice, is patient disgruntlement over professional fees.

The Scenario

This scenario should not occur in front of other patients. Many receptionists find that genuine, cute little quips like, “I know it seems high, but (wink), I’m expensive to maintain,” defuse the situation by gentling pointing out the overhead factor.

The Balk

When a patient balks at fees, gently and politely imply that we could inquire if the local plumber was available to do the exam, procedure or surgery.

Assessment

This brings training and relative cost issues into play while making them smile.  Costs are high, but justifiable.

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