CPT Code Training Module

[Pages:41]CPT Code Training Module

Last Updated: March 1, 2018

Maintained by the CPT Coding and Reimbursement Committee

Benjamin Shain, MD, PhD, CPT Advisor Sherry Barron-Seabrook, MD, RUC Advisor Jason Chang, MD, CPT Alternate Advisor Kai-ping Wang, MD, RUC Alternate Advisor

David I. Berland, MD Dorothy O'Keefe, MD

AACAP STAFF Karen Ferguson, Deputy Director of Clinical Practice

For More Assistance with CPT codes and reimbursement, call the AACAP Clinical Practice Department at 202.587.9670 or kferguson@

CPT? is a registered trademark of the American Medical Association (AMA).

Disclaimer The American Academy of Child and Adolescent Psychiatry (AACAP) has consulted authors believed to be knowledgeable in their field. However, neither AACAP nor the authors warrant that the information is in every respect accurate and/or complete. AACAP assumes no responsibility for use of the information provided. Neither AACAP nor the authors shall be responsible for, and expressly disclaim liability for, damages of any kind arising out of the use of, reference to, or reliance on, the content of these educational materials. These materials are for informational purposes only. AACAP does not provide medical, legal, financial, or other professional advice and

readers are encouraged to consult a professional advisor for such advice.

Copyright ? 2018 by the American Academy of Child and Adolescent Psychiatry. CPT is a registered trademark of the American Medical Association.

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CPT Training Module

Table of Contents

Introduction ..........................................................................................................................3 Three Components of Relative Value Units (RVUs) ..........................................................3 Fraud and Abuse ..................................................................................................................4 CPT Codes for Child and Adolescent Psychiatrists.............................................................6

? Evaluation and Management Services (99xxx) .................................................6 ? Psychiatric Diagnostic Codes ............................................................................9 ? Psychotherapy Codes .......................................................................................10 ? Interactive Complexity.....................................................................................12 ? Other Psychotherapy........................................................................................13 ? Other Psychiatric Services ...............................................................................14 ? Care Coordination / Collaborative Care Codes ...............................................16 ? Other Codes .....................................................................................................22

o Screening Codes...................................................................................23 o Prolonged Services...............................................................................25 o Telephone Services ..............................................................................27 ? Modifiers..........................................................................................................29 Common Psychiatric Code Summary ................................................................................30 Appendices A. Partial Glossary .................................................................................................31 B. E/M Coding Summary Guide............................................................................32 C. Sustainable Growth Rate and Congress ............................................................33 D. Code Categories ................................................................................................34 E. Social History of American Medicine ...............................................................35 References ..........................................................................................................................40

Copyright ? 2018 by the American Academy of Child and Adolescent Psychiatry. CPT is a registered trademark of the American Medical Association.

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CPT TRAINING MODULE FOR CHILD AND ADOLESCENT PSYCHIATRISTS

INTRODUCTION

Current Procedural Terminology (CPT) codes describe medical procedures and services provided by physicians and other qualified healthcare professionals (QHP). The American Medical Association (AMA) owns and maintains CPT codes. The Healthcare Insurance Portability and Accountability Act (HIPAA) of 1996 included electronic billing standards requiring CPT codes to report physician services.

The Center for Medicare and Medicaid Services (CMS) uses a physician payment system known as the Resource Based Relative Value Scale (RBRVS) to assign each CPT code a Relative Value Unit (RVU). The Relative Value Scale Update Committee (RUC) - sponsored and maintained by the AMA - recommends RVU values to CMS. CMS publishes the RVU value in the Final Rule of the Federal Register every November. Congress mandates reviewing these values every five years.

This module explains: ? The RVU determination process for CPT codes, ? consequences of failing to utilize correct coding (fraud and abuse), ? CPT codes from the psychiatry section of the current CPT manual, and ? Evaluation and Management codes.

Appendix A is a glossary of commonly used terms; Appendix B discusses the Conversion Factor and Sustainable Growth in Healthcare; Appendix C discusses CPT code categories: Category 2 (tracking) and Category 3 (emerging technology/services) codes. Appendix D presents the Meritbased Incentive Payment System (MIPS) from the Patient Protection and Affordable Care Act (ACA) 2010.

Relative-Value Scale Update Committee (RUC)

Relative Value Units (see next section) are assigned to CPT codes by CMS after receiving recommendations from the RUC. The RUC consists of 31 voting members representing the largest medical societies in the AMA House of Delegates. Advisers serve from the remainder of the medical societies in the House of Delegates. The American Psychiatric Association has a voting member and the American Academy of Child & Adolescent Psychiatry has an advisor, currently Dr. Sherry Barron-Seabrook.

THREE COMPONENTS OF RELATIVE VALUE UNITS (RVUs)

Three components determine the resource cost of providing a service: ? physician work ? practice expense ? professional liability insurance expense

Copyright ? 2018 by the American Academy of Child and Adolescent Psychiatry. CPT is a registered trademark of the American Medical Association.

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Physician Work (Relative Value Work or RVW) The physician work component accounts for an average of 51% of the total relative value for each service. The factors used to determine physician work include:

? amount of time to perform the service/procedure plus pre- and post-service time ? technical skill and physical effort involved in performing the service/procedure ? mental effort and judgment required ? stress due to potential risk to the patient from the underlying illness or procedure

Practice Expense (PE) Practice expense RVUs account for an average of 45% of the total value for each service. These PE values reflect office costs like play equipment, rent, utilities, billing expenses, etc. Since 2004, all new or revised codes presented to the RUC must include both work and PE values.

Professional Liability Insurance (PLI) The professional liability insurance component accounts for an average of 4% of the total; relative value for each service.

Conversion Factor The sum of these 3 components (work units + practice expense units + professional liability expense units) yields the RVU. The RVU is then multiplied by a conversion factor (a monetary figure determined by CMS) and adjusted for geographical variability to arrive at the payment. For example: for 99213, RVW is 0.97, PE for non-facility is 1.02, PLI is .07; therefore, 0.97 + 1.02 +.07 = 2.06 (Total RVU). That number is multiplied by 35.99 (the Conversion Factor for 2018) to arrive at the Medicare payment of $74.14 (before the geographic factor is applied) for 99213. (Go to for the complete list of CPT codes and their RVUs.)

Scope of CPT And RUC While the Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that private payers use current CPT codes, CPT code reimbursement values are applicable only to services billed to Medicare through any of its regional carriers. Private payers may set their own reimbursement values.

FRAUD AND ABUSE

The only legal way to be paid for a service is to bill using the correct CPT code. You must document that the level of service claimed was medically necessary and delivered.

Kennedy-Kassebaum (Title II of HIPAA, 1996):

? Added "knowingly and willingly" standard to false claims legislation. Before 1996, physicians could be accused of violating the law if they simply made a mistake. Now, the standard is "knowingly and willingly," BUT ignorance of coding rules is NOT an acceptable explanation for repeated coding errors.

? Made "falsifying" a private claim a federal offense like falsifying a Medicare/Medicaid claim.

? Added 700 investigators to the Inspector General's office at CMS.

Copyright ? 2018 by the American Academy of Child and Adolescent Psychiatry. CPT is a registered trademark of the American Medical Association.

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? The physician is responsible (and liable) for all coding done in that physician's name. The physician is responsible for appropriate documentation of services even if the patient or physician's employer submits the bill to an insurance company.

False Claims

Billing for services not provided (False Claims Act (FCA) 1986).

Up coding

Reporting a higher-level service or procedure than one that is performed or is medically necessary (eg, Reporting the psychotherapy add on code for less than 16 minutes of psychotherapy. Coding 99214 while documentation and medical necessity support a lower level of service).

Code edits

Billing codes that do not belong together (Correct Coding Initiative ? CCI) (eg, Violating AdminiStar software program ? most edits involve surgical procedures like separate billing for amputation of digits and foot when performing a below the knee amputation). Edits for the current psychiatry codes are being developed. ()).

Medically Unlikely Edits (MUE) Codes that are unlikely to be billed together. These edits may be appealed on a case-by-case basis. (eg, multiple psychotherapy sessions for the same patient on the same day). Originally, the edits were called "medically unbelievable," but because of physician objection, the term "unlikely" was substituted for "unbelievable," maintaining the acronym MUE. MUEs for the current psychiatry code set continue to be developed.

Consequences: ? Damages up to 3 times the amount of the claim. ? Mandatory penalties of $5,000 to $10,000 per claim, regardless of the size of the claim. ? The Return-on-Investment (ROI) is about $8 for every $1 spent in the investigation. Funds are transferred to the Medicare Trust Funds ($2.5 B in FY 2012). Some of these monies are used to support the salary of the investigators. See (HCFAC = Healthcare Fraud and Abuse Control). ? Whistle-blowers act in the name of the government and may seek the same damages. The Department of Justice may intercede, and the whistle-blower could still receive 15% to 25% of the claim. The whistle-blower may proceed alone and keep up to 30% of the final recovery. Such cases are also called "qui tam" cases.

Code Categories

The Health Insurance Portability and Accountability Act (HIPAA) required CMS to request proposals for alternative coding systems. The AMA initiated the CPT 5 project to develop necessary modifications. In August 2000, CMS announced that it would continue to use CPT as the coding system for medical procedures for Medicare patients. Two additional code categories (II and III) debuted in CPT 2002 and are discussed in Appendix C.

Copyright ? 2018 by the American Academy of Child and Adolescent Psychiatry. CPT is a registered trademark of the American Medical Association.

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CPT CODES FOR CHILD AND ADOLESCENT PSYCHIATRISTS

CPT 2013 redesigned the structure of the commonly used psychiatric codes. From 1997 through 2012, psychiatric CPT codes were divided into "diagnostic or evaluation interview procedures" and "psychiatric therapeutic procedures" (and further sub-divided into office vs facility psychotherapy; other psychotherapy and other psychiatric procedures). HIPAA (1996) and Mental Health Parity and Addiction Equality Act of 2008 (MPHAEA) require providers to use CPT in all electronic claims for psychiatric services to all insurance companies, both private and government sponsored. Psychiatrists use CPT Codes to report these services:

? Evaluation and Management (E/M) Services ? Psychiatric diagnostic evaluation ? Psychotherapy ? Interactive complexity ? Other psychotherapy ? Other psychiatric services ? Collaborative care services ? Other codes ? Modifiers

Evaluation and Management (E/M) Codes

History

CPT (2013) deleted 90862 (pharmacologic management) with instructions to use E/M codes to report these services. The availability of E/M codes to psychiatrists allows psychiatric services to be reported with the same range of complexity and physician work as all other medical specialties.

While Medicare always allowed psychiatrists to use E/M codes, until 2010 few private payers reimbursed psychiatrists for E/M codes for outpatient services. Psychiatrists were essentially restricted to the use of the basic "one size fits all" 90862 code for pharmacologic management. Code 90862 poorly described the complexity of current psychiatric practice and accounted for 60% of psychiatrist billing. This code, written when the standard for pharmacologic management was prescribing one or occasionally two psychotropic medications at a time had become outdated. Revisions were needed to address the increased complexities of psychopharmacologic management in current practice. E/M codes best describe the work and medical decision making now required.

E/M codes may report evaluation and management services either alone (pharmacological/ medical management and no other service reported that day) or with the addition of psychotherapy. Psychotherapy is reported as an "add-on" code to the primary procedure, the E/M service. This change effectively reverses "psychotherapy with or without E/M" to "E/M with or without psychotherapy." The parameters of psychotherapy, such as time, presence of interactive complexity, and site of service, are discussed below. For additional information, go to the AACAP website, and click on CPT and Reimbursement under Member Resources at the top of the homepage. There are webinars for specific, detailed information on the 2013 codes as well as selecting and documenting E/M codes.

Copyright ? 2018 by the American Academy of Child and Adolescent Psychiatry. CPT is a registered trademark of the American Medical Association.

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Common Evaluation and Management Code Families Used by Psychiatrists

E/M Description

Office or Other Outpatient Services, new patient Office or Other Outpatient Services, established patient Office or Other Outpatient Consultations, new or established patient Initial Hospital Care, new or established patient Subsequent Hospital Care, new or established patient Inpatient Consultations

Codes

99201 to 99205 99211 to 99215 99241 to 99245 99221 to 99223 99231 to 99233 99251 to 99255

Other E/M code families include observation care (99218 to 99220, 99224 to 99226), observation or inpatient care services (99234 to 99236), nursing facility care (99304 to 99306, 99307 to 99310), emergency department services (99281 to 99285), domiciliary, rest home, or custodial care services (99324 to 99328, 99334 to 99337), home services (99341 to 99345, 99347 to 99350), and neonatal and pediatric critical/intensive care (99468, 99469, 99471, 99472, 99475, 99476, 99291, 99292, 99477 to 99480). As most psychiatrists will be using Office or Other Outpatient Services, Established Patient (99211 to 99215), this section will use this code family as examples. First, however, one must distinguish a "new" from "established" patient to use CPT correctly.

What is a "new" patient?

Using new patient E/M codes (99201 to 99205) is more restrictive than using psychiatric diagnostic evaluation codes (90791, 90792; described in the following section.). New patients must not have received any professional services in the past three years by the physician OR another physician in the same group practice of the exact same specialty and sub-specialty. Advanced practice nurses, physician assistants and covering professionals working with physicians are considered as working in the exact same specialty and exact same subspecialties as the physician.

Determining Evaluation and Management Levels by Time

Time or key components determines the level of E/M codes in both outpatient or inpatient settings. Time is a simpler criterion and requires that counseling and/or coordination of care accounts for more than 50% of the encounter. Time for office and outpatient visits is only the face-to-face time with the patient and/or family members. Inpatient or hospital consultation time is unit floor time and consists of patient and/or family contact, chart review, orders, writing notes, telephone calls, and meeting with the treatment team while on the "floor."

Copyright ? 2018 by the American Academy of Child and Adolescent Psychiatry. CPT is a registered trademark of the American Medical Association.

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Counseling is discussion with patient and/or family about diagnostic results, prognosis, treatment risks and benefits, risk factor reduction, treatment compliance, and/or education. Coordination of care is discussion of patient care with other providers or agencies.

Description

Office or Other Outpatient Services, new patient

Office or Other Outpatient Services, established patient

Office or Other Outpatient Consultations, new or established patient

Inpatient Consultations

99201 10 min 99211 5 min

99241 15 min

99251 20 min

Codes and "Typical" Time

99202 20 min

99203 30 min

99204 45 min

99212 10 min

99213 15 min

99214 25 min

99242 30 min

99243 40 min

99244 60 min

99252 40 min

99253 55 min

99254 80 min

99205 60 min 99215 40 min

99245 80 min

99255 110 min

Determining Evaluation and Management Levels by Key Components

Rather than using time to select the level of E/M code, physicians may use key components. Please see the video webinars under the dropdown Menu (CPT) on the Member Resource tab on the AACAP homepage as well as carefully review the AMA's CPT Manual for a full understanding.

The three key components are history, examination, and complexity of medical decision making. Established patients for office or other outpatient services (99211 to 99215) only require 2 out of 3 key components. "New" patients (as defined above) require 3 out of 3 key components (99201 to 99205). Each key component has four levels.

See Appendix A with E/M Coding Summary Guide v2. ( /cpt/EM_Coding_Summary_Guide_v2.pdf)

History consists of four levels ? problem focused, expanded problem focused, detailed, and comprehensive depending on the amount of information from the history of present illness (HPI), past, family, social history (PFSH), and review of systems (RoS).

Examination consists of four levels - problem focused, expanded problem focused, detailed, and comprehensive depending on the number of elements. In 1997, for CPT purposes, HCFA (now CMS) recognized 10 single organ systems whose examination could be documented in place of the general multi-system examination to meet standards for the levels of E/M codes. Psychiatry is recognized as having a single organ system examination and includes mental status, constitutional and musculoskeletal elements.

Medical decision making consists of four levels ? straightforward, low complexity, moderate complexity and high complexity. The calculation of complexity depends on diagnosis, management options, data reviewed (eg, records, labs, test results), and level of risk (eg,

Copyright ? 2018 by the American Academy of Child and Adolescent Psychiatry. CPT is a registered trademark of the American Medical Association.

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