Every year around this time, there’s a lot of anticipation around the changes to the CPT® codes. And the complexity increases when modifications are introduced in documentation to ensure that your billing captures the patient’s story correctly. That means you’ll have to sharpen your coding skills before mental and behavior health code updates kick in on January 1, 2019, so that you can avoid medical necessity denials in the new year.
Learn the nuances of coding mental and behavioral disorders in this information-packed webinar presented by coding and billing expert Dorothy Steed. Steed will walk you through the new codes for psychological testing, developmental testing, and behavior identification assessment in this informative webinar. She will explain the documentation changes that will keep your supplementing documentation in line with the new requirements, and tell the patient’s full story with your coding to receive proper reimbursement for your services.
After attending this webinar, you will emerge well-versed with the new mental and behavior health codes. You will be ready to begin correct reporting, and will also be able to implement any documentation requirements necessary to support the reporting. Plus, you’ll be better prepared to survive payer scrutiny of your reporting.
The webinar will cover the following topics in detail:
Who Should Attend
Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.
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Comment (C): I would like now to introduce your speaker for today, Dorothy D. Steed.
Dorothy D. Steed, CCS, CDIP, COC, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, is an independent healthcare consultant and educator in Atlanta. She was a Medicare specialist for a large hospital system and physician coding audit supervisor for another hospital system with 40 years of experience in healthcare.
Additionally, she is an instructor at a state technical college at – in Atlanta, provides auditing and
training in both facility and physician services and has been a speaker at several healthcare conferences.
Dorothy has written articles for several medical publishers and served as a contributing author for medical billing and coding training materials. She writes online courses and is an AHIMA certified ICD10 trainer both CM and PCS.
Dorothy is credentialed in medical coding, clinical documentation improvement, medical billing, medical auditing, utilization management, healthcare management, healthcare compliance and patient accounts.
Ms. Steed, welcome to the program. We are now ready to begin.
Comment (DS): Hello everyone and thank you for joining this webinar today with the 2019 CPT
Updates for Mental Health.
There have been a number of changes in the format for this year. The AMA has implemented into the new CPT book for 2019. So I will be going over the changes in that layout and we'll be looking at the criteria that is required for the reporting of each of those codes.
They have combined pretty much the psychology and neuropsychological components of the mental health section. So you will see some differences and how that is established.
There's 13 new codes that have been added for central nervous system assessments. And I will be going over with you the guidelines for reporting those as well as the definitions. Since they have combined those two disciplines in this one section, they have issued a lot of clarity about what you would be expected to do to support the reporting of that particular code.
We have some new information regarding health and behavior assessments, some revisions to those guidelines. And also in your cognitive assessment and care plan services, there are revisions to the codes that I wrote there, 99483.
The codes that you had previously used, 96101, 96103, 96111, 96118, 96119 and 96120, have been deleted from the book. They are replaced with 12 new codes. What you will need to know is that these new series of codes are not a one-on-one crosswalk from the deleted codes.
So, a lot of new definitions and some revisions that we'll be going over today, they are established to provide developmental and behavior screening and testing services and psychological and neuropsychological testing services.
The mental health arena has received a lot of attention in recent time. As we saw within the last year to introduce into the book was situations where you had a medical provider such as Premiere Care or Family Practice that had encountered a number of mental health related situations that needed to be addressed in order to move that patient forward to the most optimal goals.
There is a lot of collaboration that is out there today. In regards to that, how do you work with this patient looking at both of those disciplines in order to achieve some improvement of goal?
So, in the central nervous system assessments, there have been definitions and guidelines that had been added to address cognitive performance testing, interactive feedback, interpretation and report, neurobehavioral status examination, psychological testing evaluation services, standardized instruments and testing.
Now, in the 2019 CPT Manual, you will be given a couple of grids and how that is going to be helpful for you. They will be encompassed in this section of the book and it will give you some information if you are not real sure where to go, what this code would describe, who may perform that service and some additional information.
So I would encourage you to check out that grid. There's one that covers an entire page and then a couple of smaller ones that will guide you towards what you would want to report in order to justify that service.
So let's look at these new definitions. If you report cognitive performance test and you would be
expected to – in that area to assess the patient's ability to complete functional task that is applicable to the patient's environment with the goal to identify or quantify specific deficits.
Those results that are generated from that testing action would be used to determine exactly what impairments this patient has and develop some therapeutic goals and objectives.
After those tests have been done and you have the results of that, then reporting the interactive feedback code, that code then would cover the time when you convey the implications of the psychological or neuropsychological test findings to create your diagnostic formulation.
Within that reporting, you may include in there the patient's adherence to medical and/or psychosocial treatment plans addressing safety issues, facilitating psychosocial coping, coordination of that care, and engaging the patient in planning.
I noticed when I worked in this field that very frequently, these patients were lacking significantly in the coping skills. So, that would be an area certainly that you would want to address. What I do want to mention is, that you want to be sure that your documentation tells the complete story about this patient.
And it's becoming more and more difficult to justify medical necessity to your payer. That is what
they're looking for. They are looking for exactly what is the story with this patient and what are the methods you plan to use to try to move that patient forward.
Now, if you have a non-compliant patient, regardless of what that non-compliance may be
whether it is in regards to medication, in regards to avoidance of situations that would lead them to substance abuse. If the patient is non-compliant, you need to clearly document that in your chart.
Payers are looking for measurable words. The patient has not developed the skills due to this reason. And you have – you are addressing this deficiency in this manner.
So make sure that your documentation is very clear because that is going to be the deciding factor in regards to coverage or whether or not coverage would continue.
Now, the interpretation and report that would be done by a physician or other qualified healthcare professional. In some circumstances, those results may be generated through the use of a computer, tablet or other device.
So, it may be that the patient is using some technology resource in order to perform certain functions, but you would gather the results based upon that modality that the patient would be using.
In your neurobehavior status exam, that is when you would be doing an assessment of the cognitive functions and behavior. It may include a patient interview or other informants regarding the patient's prior history. What – how is that integrated into your plan for now and going forward. What other clinical data with critical decision making is available; you would assess your further treatment planning and/or report, your evaluation domains.
So what has the patient's acquired knowledge? Where is that at this time? Where have they come from to reach this status? Have they made improvements? Have they not made improvements? Are they kind of have reached the plateau where they are not really going any direction? What is their attention, their memory, their planning, ability and their problem solving ability, and what are their visual spatial abilities?
So, problem solving is typically a big hurdle to overcome with a lot of these patients. Clearly, make that, you know, and part of your documentation about the patient's problem solving abilities. And that might be something where you've used some technology platform to see how well they can problem solve whatever information you have established for them to do.
And your neuropsychosocial testing service, reporting this code would be an integration of the patient data with other sources -- your clinical decision making, your treatment planning and your report. You may include in that reporting of that code your inactive feedback to the patient, family members or caregivers if they had been brought in to that arena.
Your domains may include intellectual function, attention, their executive function, their language and communication abilities. Their memory abilities, is the memory strong? Remote memory, recent memory, both of those are okay, neither one is okay, one is better than the other. What is our visual-spatial function, sensorimotor function, the emotional and personality features and their adaptive behavior?
Now, I will not get into that in this presentation but there are changes in the adaptive behavior
section. If you are a practitioner in that arena, I would strongly recommend that you take a look at that section of the book. But it will not be a part of today's presentation.
In your psychological testing and evaluation services, now you see that they have this broken down code was into what is a neuropsychological evaluation and testing and what is psychological.
So, that is why I'm taking time to go over these definitions because you want to be sure that you
are selecting the right code for the service provided.
So, in the psychological testing evaluation services, in your evaluation, you would have an integration of patient data, your clinical decision making, your treatment planning, your report of those findings or plans, your interactive feedback when that's performed. Your domains may include emotional and interpersonal functioning, intellectual function, thought processes, personality and the psychopathology.
The standardized instruments that you will see mentioned in these codes, in that regard they typically mean some validated task that is administered and scored in a consistent standard manner that is applicable to the validation of that task.
So, you will notice is some things will be performed by a physician or other qualified healthcare professional. Some will be performed by a technician and some will be a joint effort between the QHP and the technician.
So, that is what they mean as far as that term in your code book in regards to standardized instruments. Something that is familiar in this field that would have some valid results applicable to managing the patient and identifying the deficits.
Your testing for psychological testing will be administered by a physician or other qualified healthcare professional and a technician or completed by the patient. The mode can be manual or automated.
So in your assessment of aphasia and cognitive performance testing, your interpretation and report, that is in regards to the codes 96105 and 96125. If you do a developmental screening, that new code is 96110. Development and behavior testing, interpretation and report is identified by codes 96112 and 96113.
Now, in your examination testing and scoring, your neurobehavior status exam is going to include
your interpretation and report. Now, make sure that that is available and that it is complete because payers are increasingly inclined to ask to review records, they are having a lot of reviews that have been engaged with some external source. I myself do a lot of those types of reviews on behalf of different entities and we are looking for your interpretation and report. That would be described by codes 96116, 96121 and 96127. So those are your new codes for your behavior status exam.
The new codes for your test and evaluation services are 96130, 96131, 96132 and 96133. The
testing and scoring services that will be done by a physician or other qualified healthcare professional are going to be described by your new codes 96136 and 96137.
These codes do not include evaluation time, that's your integration of the patient data and
interpretation of test results. This time is included with your test evaluation services. So you've got two different issues here. You've got your testing and scoring services where you're actually looking at the data and interpreting that to create a plan of action and then your time evaluating different sources is going to be with the 96130, 96132 and 96133.
Now, services that are provided by the technician make sure that you select the right code. Is it the physician or QHP or is it a technician or are they working in conjunction?
So, the 96138 and 96139 are your new codes that are to be performed by a technician. That is an automated testing and results – and your code 96146 will describe a single automated instrument with an automated result.
So, look at those three codes carefully and their descriptive before you make a selection as of what you should report.
These new codes, in regards to testing services, these are your requirements. We are speaking now about the codes related to testing services 96105, 96125, 96112, 96130, 96131, 96132, 96133 and 96146. You must include an interpretation and report when performed by a physician or other QHP or a result generated by automation.
The AMA has also, in this year’s book for 2019, have reiterated the fact that these are term-based codes and most of your payers operate on the 50% + 1 concept, meaning that you must document if you got a 30-minute service, that you must document a minimum of 16 minutes for that to be a reimbursable service.
Now, if you do not document any time, and we see this quite often, that the payer has no supporting evidence that you met the 50% + 1 requirement and that service may well be denied because they don’t find that statement of time. So always document your time.
You can just jot a quick note that the end or you may have something in your EHR system that allows you to put the minutes. But do put the minutes. Don’t rely on documentation where you have a time in and a time out. That is not usually what payers are looking for. When you do that, they don’t have any evidence that you were with that patient the entire time. What they are looking for is a documentation of the minutes by the provider of that service. So, 16 minutes would be required for a 30-minute service and if it is a one hour service, 31 minutes would be required.
And they are speaking in regards to these codes 96116, 96121, 96130, 96131, 96132, 96133, and 96125, that is face-to-face time with the patient and time spent integrating and interpreting data. So, that is why a time in and time out is not effective to a payer because they do not have supporting evidence that the provider was face-to-face with that patient that are the requirements, otherwise it may say patient and/or family, but the requirement is imbedded in the code and so, minutes of what they are looking for.
So these codes for the testing service, you will report your total time at the completion of the entire episode of evaluation. So, it is common for these services to go into more than one calendar day. If that is the way you’re managing your testing service, then you will need to keep some type of a time grid in order to be able to capture your total time at the end of the episode for your billing purposes.
Now, I know when we use paper records, we keep a little time sheet in the front of that chart, as
we would jot down the time for the testing, and this is the day and this is the time, now with the electronic record, depending on how your software is set up, whether that gives you that option but you would need to develop some type of means to keep track of those times that is span more than one calendar day. Remember you will be reporting at the completion of the entire episode.
All right. Now your assessment of aphasia and cognitive performance testing. The new code 96105 is your assessment of aphasia, expressive and receptive speech/language function, language comprehension, speech production ability, reading, spelling writing by the Boston Diagnostic Aphasia Examination. And this would be your interpretation and report to be included and that will be reported per hour. So you must document a minimum of 31 minutes in order for that to be a reimbursable service.
The new code 96125 is your standardized cognitive performance testing such as the Ross
Information Processing Assessment, and that is per hour of your qualified healthcare professional’s time, both face-to-face time administering tests to the patient and time interpreting test results and preparing a report.
So, there have been two new codes that have been added that will cover your developmental/behavior screening and testing. The first one is 96112, and that is your developmental test and administration. That will include your fine motor and/or gross motor skills, your language, cognitive level, your social, memory and/or executive function by standardized developmental instrument when performed. This will be done by a physician or other qualified healthcare professional with an interpretation and report and that will be for the first hour.
Should this service go beyond an hour, then the code 96113 will describe each additional 30 minutes beyond that. So again, documentation of number of minutes is going to be a key piece of your documentation that is going to show the payer whether or not your service being reported meets the reimbursement criteria.
So here is an example of 96112. This would be an extended development testing for a child with autism, in the presence of the parents, to determine appropriate school placement. There would be observed behaviors and any difficulty in performing functions and tasks are noted and scored.
So in this particular one, your documentation of total encounter time of 85 minutes would be reported with 96113. So, you’ve got your first hour and the 60 minutes and then you have gone an additional 25 minutes so you’ve met the criteria for the each additional 30 minutes. So you would report this service with 96113 if it exceeds the first hour plus the required time for the additional 30 minutes. So this would be an example of reporting either of those codes.
Now, your neurobehavioral status exam, those will be reported with the two new codes 96116 and 96121. Now, there has been a revision in the terminology of 96116 and it has been changed from per hour to the first hour. And it may be reported by a physician or other qualified health care professional.
And so, should this go into an additional hour or hours, you would use your add-on code 96121.
So this is different from the previous screen that we looked at that had an additional – each additional 30 minutes. This is for each additional hour. So for that one, for the 96121, you would need to have a minimum of 91 minutes documented in your record to support that.
So, here is an example. The family reports that a 75 year old patient with increasing difficulty in attention span, recent memory problems, and ability to problem solve. A neurobehavioral status examination is performed.
So for this service, you would observe the behavior and record the responses to that. Your clinical impression will be developed and discussed and your total encounter time of 85 minutes. So again, be mindful of the 50% + 1 standard that most payers do follow and the AMA has reiterated that in the 2019 book.
So you would have your first hour and the 60 minutes and then an additional 25 minutes. You wouldn’t be able then to report 96121 because you have to document at least 31 minutes of that additional hour. So, it would have to be a minimum of 91 minutes documented. And I see payers frequently reject services because they don’t have the adequate time documented in the record.
So your testing evaluation services reported with these two codes 96130 and 96131. They may be non-face-to-face. So, notice in your code descriptive whether the time must be face-to-face or non-faceto-face.
This would be psychological testing evaluation by a physician or other qualified healthcare
professional. It would include integration of patient data, interpretation of standardized test results, your clinical data and decision making, your treatment planning and your report and your interactive feedback to the patient, family or caregiver, when performed the first hour, with the 96131 for each additional hour.
Now, when you’ve got other parties present other than the patient, the family and caregiver, I would strongly recommend that you document who those parties are and what is their relationship to this patient. I have seen, when I worked in this field, often some impaired family dynamics was part of the entire problem. So, who are these parties that are participating? What is their relationship to the patient, and also what appear to be the dynamics between those two parties?
So, here is an example of 96130. This patient has an autoimmune disorder and they have a recent episode of emotional trauma and they display symptoms of depression, fatigue and social withdrawal. The services would include interpretation of tests, your clinical decision making, you would determine your diagnosis in regards to that interpretation process, developmental treatment plan, and create your report based upon those findings.
Testing evaluation services. 96132 and 96133 are your codes regarding this service, the new codes. 96132 is your neuropsychological testing evaluation that would be done by a physician or other qualified healthcare professional and that will include the integration of data, your interpretation of standardized test results, your clinical data and decision making, your treatment planning and report, and interactive feedback to the patient, family or caregiver when performed the first hour.
Now, if you do not include the family or caregiver (it will still) – but you do include the patient, this would still be the code because it says, when performed. So, it means that they either can be present or can not be present but you would be given interactive feedback to one of those parties. And that would be your first hour with 96113 for each additional hour.
Here is an example, now of reporting 96132. This patient has a family history of dementia and personal history of hypertension and diabetes and has displayed changes in behavior, personality and cognitive skills. There would be neuropsychological testing that would include integration of patient data, clinical decision making diagnosis, treatment interactive feedback and creation of report.
Now, here is an example that we mentioned earlier that often medical professionals are encountering this mental health related issues that must be addressed along with the medical problems to try to move that patient forward towards some goals.
So, if the patient does have a personal history of hypertension and diabetes, but they have also displayed changes in behavior, personality and cognitive skills, so both of those disciplines would become involved in managing this patient to move them towards some optimal goal. They also have a family history of dementia, so that is another factor to be considered.
So, we are seeing very blurred lines today and expect that going forward where mental health and
medical are going to need to collaborate to improve this patient. A lot of attention has been given to posttraumatic stress, to substance abuse; we have new codes in regards to human trafficking that has been some studies have indicated that many of those human trafficking victims will at some point be
seen by a medical professional. So, we are seeing the inclusion of a lot of mental health related issues and medical issues that must be worked in tandem in order to move this patient forward.
Now, test administration and scoring. Be sure that you pick the right code depending upon who will provide this service. 96136 is your psychological or neuropsychological test administration and scoring by a physician or other qualified healthcare professional, two or more tests given by any method for the first 30 minutes.
So, you must do at least two tests, but they can be by any method and it is to be done by a
physician or other qualified healthcare professional. So that is your first 30 minutes. Notice that these – these new codes tend to switch back and forth between 30 minutes and 1 hour.
So, whatever the code descriptor has as far as the time base, you have to make sure that your documentation supports that.
Each additional 30 minutes would be done – reported using 96137. So, that – those two codes must be – there must be a physician or other QHP that performs that service and there must be a minimum of two tests that they can be given by any method. So your documentation is going to have to be clear that at least two tests were performed to meet the requirement of this code.
Now, the new codes, 96138 and 96139 will be done by a technician. That will be your psychological or neuropsychological test administration and score ran by a technician. But there must at least two tests, they can be administered by any method and it is the first 30 minutes, with each additional 30 minutes reported with 96139.
Now, these two – these sets of codes do not include your time for evaluation services. Now, it may be or will be that you fulfill the requirements of both of these sets of codes. You may have certain testing that is administered and scored by a physician or QHP, at least two tests by that person, and then you may have services performed by a technician that you may be able to report both of those groups. But make sure that you have fulfilled the requirements of both of those groups and that your documentation reflects that as well as documenting your appropriate time for each group.
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- Dorothy D. Steed
Dorothy D. Steed, CCS, CDIP, COC, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, is an independent healthcare consultant and educator in Atlanta. She was a Medicare specialist for a large hospital system and a physician coding audit supervisor for another hospital system, with 40 years of experience in healthcare. Additionally, she is an instructor at a state technical college in...
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