Anthony Puente, Ph.D., President-Elect of the American Psychological Association and coding expert, provided an excellent webinar, “Getting Reimbursed for Treatment of Behavioral and Neurocognitive Disorders,” on Aug. 31, 2016. This webinar was offered to members of the APA Practice Organization, and will be posted on the APAPO website. (He had help for an APAPO staff member, whose name was not listed in the slides and I was unable to figure out her name from the sound track.)
It was a very informative presentation, and is highly recommended to APAPO members. Here is a summary of what I learned for those who are not APAPO members, who are not psychologists, or who may not want to take the time for view the hour-long presentation. I have quoted Dr. Puente as best I can, but some of the info may be paraphrased.
Dr. Puente views the ICD 10 as not really an international classification of disease. It is an international classification of symptoms.” He focused on the following ICD categories, mostly on the first and second:
F codes – Mental, Behavioral and Neurodevelopmental disorders
G codes – Diseases of the nervous system
R codes – symptoms, signs, and abnormal clinical findings, not elsewhere classified, in particular R40-46, Symptoms and signs involving cognition, perception, emotional state and behavior.
Tony aspires to have psychologists, and other mental health professionals, to be able to bill for all ICD categories – but currently we are limited to F, G and sometimes I, Q, R and S categories. Until then, “your job is to figure out if you can ethically” bill for your services using the payer’s “formulary,” or medical necessity criteria. In general, if you use an F code you should be OK, but if you add a G code you may be denied, depending on the formulary.
Many payers have formularies that are “buried very deep” on their website – or may not be there at all. This information will determine whether they allow payment for psychologists to use “medical” (non-F) CPT codes. You need to monitor your EOBs and “figure out what they are paying for, and what they are denying.” You also need to figure out which codes you can “ethically” use for billing that get will get you paid. You absolutely should not fudge your billing in order to manipulate the MCO’s billing formulary in order to be paid.
“Traditional” psychologists can “live in the F codes world,” but psychologists who are expanding the practice of psychology, such as health care psychologists, are “pushing the boundaries” into other codes. We need to educate payers that “we don’t just treat the mind, but also treat the body.”
The billing diagnosis should document the referral question that you are assessing. That is what is used on the HCFA form. Your “final” diagnosis determines what treatment is indicated, if any, and should be documented in your report. You need to code what is most important for what you are doing. If you have two diagnoses, and it seems to you that they are “50-50”, you still need to determine which one is most important – which one is “51%.)
For example, if the assessment question is, “is autism present?” and you find that the patient does not have this diagnosis, you bill for the diagnosis that you were evaluating, autism. If the outcome is not autism, but – for example – learning disability, you would still use autism as the billing code for the assessment, but subsequent billing would need to use the LD diagnosis – but this subsequent treatment may not be covered.
List the most important diagnosis, for the purposes of your assessment or treatment, first. When additional diagnoses are needed, list them in the order that they are listed in ICD 10. For billing on the HCFA form, he recommends using only the primary and secondary codes. Try to avoid use us “unspecified” codes, as much as possible. Use more specific codes, when possible. If you are providing “more complex” therapy, such as 90837 or using a billing modifier, then you may want to add more than two codes to support the need for “a higher level of service.”
If you do not find an F code in your initial assessment, it will be difficult to bill for therapy subsequent to the assessment. The initial dx assessment codes “must provide links” to subsequent treatment, if medically necessary.
Finally, your assessment diagnoses should be based on the current behavioral and testing data from your assessment. Information that the patient reports as their own perceived symptoms or diagnoses, or information about past symptoms and behaviors, would be documented in the “history” section. In other words, if a patient reports a history of symptoms but you do not see current evidence of them, it goes in the “history” section as reported info. Or, if the patient reports diagnoses provided by other professionals but not supported by current assessment data, this also will be documented in the “history” section and should not be listed in your diagnoses.
Tony and his APAPO college presented a lot of information, and if anyone thinks that I missed anything important, or got any of the above information wrong, please feel free to comment on this.