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For other articles and previous issues click here. January 12, 2004 Codes
Behaving Badly Medical coding is a complex issue. Changing laws and the seemingly constant addition of new codes require medical providers to stay on top of the issue to ensure that diagnoses are properly recorded and payment is fulfilled. This is especially true in the behavioral health services, where there seems to be more than the usual amount of confusion over proper coding techniques. Providers and staff around the country in this specific field are faced with enough challenges that there are indications that coding processes in the behavioral sciences will need a lot of attention in the coming years. Minor mistakes have the potential to cause problems for physician practices and patients alike, yet physician assistants and office managers are already so swamped with work that keeping up with these codes is a constant time challenge. There are coding and documentation challenges that are unique to behavioral health services. The nature of the field—where a diagnosis is being thoroughly scrutinized by insurance companies and government reimbursement programs—increases the importance of codes and the detailed documentation that accompanies them. “I believe that the behavioral health services field is greatly undervalued and misunderstood,” says Lisa Kanivetsky, charge master management consultant for Allina Hospitals and Clinics in Minneapolis. “Those who aren’t in the field don’t understand the types of services provided, so it makes it difficult to document.” One of the challenges faced by behavioral healthcare providers is that there are much fewer codes that determine certain types of documentation compared with other medical specialties. Yet, there are a large number of detailed regulations behind those codes that have been put in place partially because the system has been abused in the past. Kanivetsky maintains that more codes specific to the behavioral health services field would greatly benefit the billing process. Currently, the definitions and codes used are so complex that it inherently leads to confusion within the industry. “I believe that if we could add to the number of codes we can use, it will help to better identify documented information,” she says. “It would help us to speak on the same level as the payor and help process the speed of the claim.” According to a 2003 report on procedure code revisions in the industry, the more codes in behavioral health services, the better. Jointly released by Robert Glover, PhD, executive director of the National Association of State Alcohol & Drug Abuse Directors, Inc., and Lewis Gallant, PhD, executive director of the National Association of State Mental Health Program Directors, the report says that what might nominally be the same service would have vastly different characteristics when designed for children and adolescents than when designed for adults. It may require a different type of service—from more experienced technicians to a lower staff-to-patient ratio. Many healthcare fields acknowledge the age-specific features of clinical practice. This has become a particular feature of program and service design for behavioral health services. This distinction is essential for states to license and certify programs, place clients within those programs, and evaluate clinical oversight of the services in an effort to set accurate prices. “Without this modifier, a substantial number of additional service procedure codes would be required to retain the discrimination currently found in Medicaid local codes,” the report states. “For mental health services, the treatment population group is one of the most frequently made distinctions in these local codes. It may appear that this information is available elsewhere as client age, but it must be emphasized that the information to be coded in this modifier is a characteristic of a program or service and not an attribute of a client.” Kanivetsky agrees and adds that more codes would not necessarily complicate the process. “Our industry is about paperwork and details, and we have to ensure that we are getting the information right and using the same methods in coding to do just that,” she says. Medicare has completed thousands of audits over the past couple of years, the results of which led to stricter regulations being implemented into federal law. One of the laws many healthcare professionals might not be aware of was enacted in 1998 and states that if a patient comes to an organization and is not referred by his or her physician, the social worker and/or a psychologist must refer the patient to a physician for further evaluation. This is just one of the obscure regulations that are unique to behavioral healthcare, says Jaclynn Dean, CPC, a registered nurse who has helped Allina Health Systems get up to code in behavioral health. She also works as a treatment plan writer and consultant in behavioral healthcare. Dean recently spoke on some of these issues at the national American Health Information Management Association convention, saying that every healthcare worker in the behavioral health services field should have developed a plan of care and treatment plan to help ensure that they are following established processes. “You need to take each individual problem and have measurable goals and strategies to make sure you are following the law,” says Dean. “Right now, very few providers have a treatment plan in place that isn’t just a mess of paperwork. Given all of the other paper that healthcare providers deal with, it’s difficult for some to handle, but it doesn’t mean it shouldn’t be a priority.” For example, there is a code for a diagnostic assessment that is completed by a psychiatrist. Yet, Medicare can reject this diagnostic assessment if it is incorrectly coded without any attention being paid to the latest regulations that would allow the assessment to go through. This can lead to billing problems down the line that hurt the healthcare provider. “Just prescribing medication doesn’t pay the doctor enough money, so they conduct assessments but may not be up-to-date on how best to record the information,” Dean says. Julia Olson, CPC, president of Austin-Webster Group, Ltd., a Minnesota consulting firm that provides healthcare coding and documentation training and auditing services, says that behavioral health providers who are not documenting their services accurately may have their payments denied by Medicare, Medicaid, or other payors. Another difference between behavioral health and other medical disciplines is that the medical necessity of mental health treatment must be proved in more detail. In recent years, new rules and regulations have made it easier for Medicare to deny payment if sufficient proof of necessity has not been supplied. Why? Because unlike clearly defined diseases such as cancer and heart ailments, behavioral health problems are heavily based on doctors’ opinions. With no set parameters, it is more difficult to “prove” that treatment was necessary. “It is very important to have a good system of capturing documentation, such as a medical necessity document,” Olson says. “We’ve seen an increase in the number of cases where managed care plans aren’t covering behavioral health for as many services as they previously did.” There are information systems that can help organize and manage these coding processes specifically for behavioral healthcare providers. Research should be conducted on all facets that are coded—from crisis intervention and acute long-term care hospitalization to short-term episodic outpatient treatment services and crisis intervention. The problem is clearly widespread. According to Outsource Management Group, a medical billing and coding consultant and solution company in Bloomington, Ind., one-fourth of all medical practice income is lost as a result of underpricing, undercoding, missed charges, or unreimbursed claims. The statistics for behavioral health may be even higher because of the complexity of physician diagnoses. Because of the confusion surrounding the coding of behavioral health services, Kanivetsky says that behavioral healthcare physician providers should collect any information they can. In fact, the more, the merrier. This is one of the lessons learned from her involvement with the Minnesota Behavioral Support Group, a collection of peers from behavioral health providers that has met on a regular basis to discuss the difficulties involved with billing. Kanivetsky says that the group, comprised of behavioral health professionals from Minnesota and Wisconsin, has discussed industry definitions, how to deal with discrepancies, ways to improve billing processes, and methods to ensure that all members are consistent in how they code and document. “We have even had representatives from Medicaid or Medicare in attendance or on a conference call where they were involved in the discussion,” she adds. “We’re all very open in the group and it has been helpful to show that all of us are dealing with the same issues, but now we can do it together.” Dean says that within a behavioral health organization, there should be a point person who is educated about the required coding and documentation rules and regulations. That person should be responsible for putting the processes in place while simultaneously taking the confusion out of the equation. “Again, I get back to the fact that mental healthcare providers need to be accountable for changing their thought processes,” she explains. Dean adds that behavioral healthcare physicians should pay closer attention to when a patient may no longer need treatment. “Providers themselves need to become more accountable, but they also need to have someone on their staff who can help because the laws are changing all the time,” she notes. One of the laws that changed in Minnesota had previously allowed the state to pay for types of therapeutic recreation that even included entrance fees and food and drink costs to county fairs. “That’s just one reason why these regulations are required,” Dean says. Olson believes that behavioral healthcare providers should send someone from their office to national seminars or training sessions at least once per year to ensure that the latest rules and regulations are met when specifically discussing coding issues. Even though there have been few new codes added to the behavioral health industry in the last two years, some new codes may be added to the Current Procedural Terminology book in the coming years. “The coding should be straightforward if the rules are followed,” she says. “A billing sheet should be internally developed, and there should be a review for all codes and procedures. We are likely to have some Level 2 code changes on the horizon.” Kanivetsky says that there were a “large handful” of H codes developed in 2003 that thus far have not been widely accepted. One of her goals for the new year is to work with industry peers in an attempt to make these codes more widely accepted. “We just need to get everyone on the same page because, unfortunately, not everyone in the field has the same training at the same time,” she says. “That’s actually one of the biggest challenges, and we’re doing what we can to try to streamline the process.” Olson recommends developing a template coding form that will help with the documentation process. “If a logical form is developed, it should streamline the entire coding process,” she explains. Streamlining the entire process? Now wouldn’t that be met with open arms by behavioral health professionals. — Mike Scott is a freelance writer who has contributed to more than 70 magazines, newspapers, and Web sites on numerous topics—from business to healthcare to technology. He lives in Waterford, Mich. |
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