Coding and Reimbursement for Dementia.Incorrect payment by Medicare carriers for treatment of Alzheimer's disease Alzheimer's disease (ăls`hī'mərz, ôls–), degenerative disease of nerve cells in the cerebral cortex that leads to atrophy of the brain and senile dementia. has been a significant problem throughout the country. Physicians and coders should be aware of the difficulties and complexities caused by the diagnostic sequencing differences of the ICD-9-CM ICD-9-CM International Classification of Disease, 9th edition, Clinical Modification
A standardized classification of disease, injuries, and causes of death, by etiology and anatomic localization and codified into a 6-digit number, which allows and DSM-IV DSM-IV
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States. coding process. The differences are evident with regard to identification of the principal diagnosis for inpatient services and reason for visit for outpatient services outpatient services Hospital-based services Managed care Medical and other services provided, to a nonadmitted Pt, by a hospital or other qualified facility–eg, mental health clinic, rural health clinic, mobile X-ray unit, free-standing dialysis unit Examples . In the DSM-IV coding assignments, the mental disorder diagnosis would usually be listed as the principal diagnosis or reason for visit with the general medical conditions that affect the treatment or management of the patient. In ICD-9-CM, whether the general medical or physical condition is sequenced before the psychiatric disorder depends on the instructional note for that particular diagnostic category or subcategory sub·cat·e·go·ry
n. pl. sub·cat·e·go·ries
A subdivision that has common differentiating characteristics within a larger category. .
MENTAL HEALTH CODING AND REIMBURSEMENT TIPS
The outpatient mental health treatment limitation does not apply to the diagnosis of Alzheimer's disease. Medical treatments provided to a person with Alzheimer's disease are considered medical management of the disease and are not subject to the limitation.
Medicare pays physicians in an outpatient setting based on a fee schedule. The actual payment of the claims depends on whether the purpose of the visit was for diagnosis or therapy. If the primary reason for the visit is to diagnose Alzheimer's disease, Medicare will pay 80 percent of the Medicare approved amount. If the primary service is for treatment of a mental illness, then Medicare payment is limited to 50 percent of the Medicare approved amount. While Medicare pays 80 percent of the allowed amount for most Part B services, the program pays only 50 percent of the cost for therapeutic mental health services provided in outpatient settings. Therefore, the patient is responsible for a much larger Medicare co-payment for therapeutic outpatient mental health services. For diagnostic services such as psychological testing, the patient is responsible for the standard 20 percent co-payment.
MEDICARE PROGRAM EVALUATIONS
Medicare and its beneficiaries paid an estimated $1.2 billion for Part B mental health services in 1998. Payments for mental health services provided in outpatient settings accounted for about 62 percent of this total ($718 million). On June 5, 2001 the Office of Inspector General Noun 1. Office of Inspector General - the investigative arm of the Federal Trade Commission
independent agency - an agency of the United States government that is created by an act of Congress and is independent of the executive departments (OIG Noun 1. OIG - the investigative arm of the Federal Trade Commission
Office of Inspector General
independent agency - an agency of the United States government that is created by an act of Congress and is independent of the executive departments ) of the Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS released an inspection report detailing the results of a review of 1998 Medicare Part B payments for mental health services. The report was based on a review of a stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers.
Arranged in the form of layers or strata. random sample of 526 mental health records from 1998. The purpose of the review was to assess the appropriateness of payments for mental health services provided to Medicare beneficiaries in practitioners' offices, community mental health centers, beneficiaries' homes, and custodial care facilities.
Medicare allowed $185 million in 1998 for inappropriate outpatient mental health services. Problems were found with all types of mental health services reviewed, but psychotherapy and psychological testing were the most problematic areas identified in the study. Fifty percent of group therapy and 34 percent of individual therapy services reviewed were inappropriate, along with 40 percent of psychological testing services. One-third of outpatient mental health services provided to Medicare beneficiaries were medically unnecessary, billed incorrectly, rendered by unqualified providers, and undocumented or poorly documented, according to this study.
MEDICARE MEDICAL REVIEW POLICY
To date, the Health Care Financing Administration Health Care Financing Administration,
n.pr department in the U.S. agency of Health and Human Services responsible for the oversight of the Medicaid and Medicare benefit programs, including guidelines, payment, and coverage policies. (HCFA HCFA
Health Care Financing Administration
n.pr See Health Care Financing Administration. ) has not established a national medical review policy for all carriers to follow in assessing the appropriateness of claims for mental heath services. While carriers' policies do not contain comprehensive lists of psychological tests that are correctly billed under psychological testing code 96100, most state that this code should not be billed for self-administered or self-scored instruments, or for screening tests of cognitive function. Testing services specifically listed as inappropriate include the Beck Depression Inventory Beck Depression Inventory
A trademark for a standardized questionnaire used to diagnose depression.
Beck Depression Inventory , the Geriatric Depression Scale The Geriatric Depression Scale (GDS) is a 30-item self-report assessment used to identify depression in the elderly. Description
The GDS questions are answered "yes" or "no", instead of a five-category response set. , the McGill Overall Pain Scale, and the Folstein Mini-Mental Status Exam Mini-Mental Status Exam MMSE of Folstein Psychometric testing A screening mental status tests; a perfect score on the Folstein is 30; a score < 17 corresponds to probable dementia. . These types of assessments are considered to be part of a clinical interview or evaluation and management service, and are not reimbursed separately.
DOCUMENTATION OF MEDICAL NECESSITY
Mental health services reimbursed by Medicare include psychiatric diagnostic or evaluative interview procedures, individual psychotherapy, group psychotherapy; family psychotherapy; psychoanalysis, psychological testing, and pharmacologic management. Generally, a patient must have a psychiatric illness and/or emotional or behavioral symptoms for psychiatric therapeutic procedures such as individual and group psychotherapy to be covered. Symptoms, goals of therapy, and the patient's capacity to participate in and benefit from psychotherapy must be documented in the patient's medical record. Psychotherapy should improve or maintain a patient's health status and functioning.
Psychological testing is covered when it aids in determining a patient's diagnosis and therapeutic planning. The patient's medical record must indicate the presence of symptoms of mental illness, and document specific psychological tests performed, number of hours of testing, scoring, and interpretation of test results. The patient's medical record should include a written report interpreting the patient's test results and the treatment recommendations.
Pharmacologic management is covered for in-depth management of a patient who is taking psychotropic medications. Evidence of mental illness should be documented in the patient's medical record, along with patient's response to medication, side effects, medication or dosage changes, and compliance with the medication regimen.
COMMONLY REPORTED CODING ERRORS
The most common code reported erroneously is 96115 (neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning] with interpretation and report, per hour). A mini-mental check usually takes about 10 to 20 minutes. Code 96115 should be used when the physician performs special neurological testing that is reported "per hour."
Another code commonly reported erroneously is 90802. This procedure code is used principally by child psychiatrists, psychologists, and clinical social workers performing an initial evaluation of children who do not have the ability to interact with ordinary verbal communication. This code may also be used to report the initial evaluation of adult patients who have organic mental deficits or who are catatonic (jargon) catatonic - A description of a system that gives no indication that it is still working. This might be because it has crashed without being able to give any error message or because it is busy but not designed to give any feedback.
Compare buzz. or mute.
See: Carriage Paid To codes 90804 through 90899 should be viewed as psychiatric CPT codes. Technically, any physician can use any CPT code. Most managed care companies have reserved the psychiatric CPT codes for mental health specialists and only pay those codes to those specialists.
Code changes that are new for 2001 ICD-9-CM are seen in 294.1 "Dementia in conditions classified elsewhere." In addition to the severe cognitive impairment that is the hallmark of dementia, many individuals develop behavioral disturbances that require the clinical attention of a mental health professional. ICD-9-CM has added a fifth digit to designate whether the dementia is without behavioral disturbance (294.10) or with a behavioral disturbance (294.11). Behavioral disturbances are defined as aggressive behavior, combative behavior, violent behavior, and wandering off.
with behavioral disturbance 331.0 [294.11]
without behavioral disturbance 331.0 [294.10]
Senility senility (sənil`ətē), deterioration of body and mind associated with old age. Indications of old age vary in the time of their appearance. without mention of psychosis 797
Old age Senile:
Senescence senescence /se·nes·cence/ (se-nes´ens) the process of growing old, especially the condition resulting from the transitions and accumulations of the deleterious aging processes.
n. debility debility /de·bil·i·ty/ (de-bil´i-te) asthenia.
The state of being weak or feeble; infirmity.
Senile asthenia asthenia /as·the·nia/ (as-the´ne-ah) lack or loss of strength and energy; weakness.
neurocirculatory asthenia exhaustion
Vascular dementia is becoming more prevalent as a diagnosis in our aging population. This has caused a change in the 2001 ICD-9-CM codes. Vascular dementia has been classified as a subterm under Dementia, in the Alphabetical Index of the 2001 ICD-9-CM. Multi-infarct (cerebrovascular cer·e·bro·vas·cu·lar
Relating to the blood supply to the brain, particularly with reference to pathological changes.
pertaining to the blood vessels of the cerebrum or brain. ) dementia or psychosis, also referred to as arteriosclerotic ar·te·ri·o·scle·ro·sis
A chronic disease in which thickening, hardening, and loss of elasticity of the arterial walls result in impaired blood circulation. It develops with aging, and in hypertension, diabetes, hyperlipidemia, and other conditions. dementia, requires the use of an additional code to identify cerebral atherosclerosis (437.0).
290.4 Arteriosclerotic dementia
290.40 Arteriosclerotic dementia, uncomplicated
290.41 Arteriosclerotic dementia with delirium delirium
Condition of disorientation, confused thinking, and rapid alternation between mental states. The patient is restless, cannot concentrate, and undergoes emotional changes (e.g., anxiety, apathy, euphoria), sometimes with hallucinations.
290.42 Arteriosclerotic dementia with delusional features
290.43 Arteriosclerotic dementia with depressive features
Acute confusional states
arteriosclerotic dementia 290.41
presenile presenile /pre·se·nile/ (pre-se´nil) pertaining to a condition resembling senility, but occurring in early or middle life.
1. brain disease 290.11
acute (psychotic) 293.0
presenile dementia 290.11
senile dementia 290.3
acute confusional state 290.11
delusional features 290.12
depressive features 290.13
acute confusional state 290.3
delusional features 290.20
depressive features 290.21
CHANGES TO EXPECT
The Health Care Financing Administration (HCFA) is expanding Medicare coverage of positron emission tomography positron emission tomography: see PET scan.
positron emission tomography (PET)
Imaging technique used in diagnosis and biomedical research. (PET). The use of PET may allow some Medicare beneficiaries to avoid undergoing invasive procedures and may also give beneficiaries and their physicians information that will increase confidence in the management of their care. Consideration of requests for coverage of dementia has been referred to the Medicare Coverage Advisory Committee a panel of top private sector experts created to advise HCFA on important coverage issues.
Recommendations were made to HCFA by the OIG as a result of the recent inspection report concerning inappropriate payments in 1998 for outpatient mental health services.
The recommendations are:
* HCFA should target problematic mental services for prepayment edits or post-payment medical review
* HCFA should promote physician awareness of documentation and medical necessity requirements for Part B mental health services
* HCFA should work with both carriers and mental health professionals to develop a specific and comprehensive listing of psychological assessments that can be correctly billed under CPT code 96100
* HCFA should require Medicare carriers to initiate recovery of payments for the inappropriate outpatient mental health services identified in the OIG report.
(1.) Office of Inspector General (OIG) Draft Report: Medicare Part B Payments for Mental Health Services (OEI-03-99-00130). Available at the Office of Inspector General Web site, www.hhs.gov/oig/oei/whatsnew.html
(2.) Official ICD-9-CM Guidelines for Coding and Reporting. Available at the National Center for Health Statistics National Center for Health Statistics (NCHS) is part of the Centers for Disease Control and Prevention (CDC), which is part of the United States Department of Health and Human Services.
NCHS is the United States' principal health statistics agency. Web site, www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm