Coding and Reimbursement for Dementia.

Incorrect payment by Medicare carriers for treatment of Alzheimer's disease 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 and DSM-IV coding process. The differences are evident with regard to identification of the principal diagnosis for inpatient services and reason for visit for outpatient services. 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.

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 (OIG) of the Department of Health and Human Services 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 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 (HCFA) 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, the Geriatric Depression Scale, the McGill Overall Pain Scale, and the Folstein Mini-Mental Status Exam. 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 or mute.

CPT 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.

ALZHEIMER'S DEMENTIA

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.

Alzheimer's

Dementia (senile)

with behavioral disturbance 331.0 [294.11]

without behavioral disturbance 331.0 [294.10]

Senility without mention of psychosis 797

Old age Senile:

Senescence debility 

Senile asthenia exhaustion

VASCULAR DEMENTIAS

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) dementia or psychosis, also referred to as arteriosclerotic 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 

290.42 Arteriosclerotic dementia with delusional features

290.43 Arteriosclerotic dementia with depressive features

Acute confusional states

State

confusional 298.9

acute 293.0

with

arteriosclerotic dementia 290.41

presenile brain disease 290.11

senility 290.3

Delirium 780.09

acute (psychotic) 293.0

Delirium

in

presenile dementia 290.11

senile dementia 290.3

Dementia

presenile 290.10

with

acute confusional state 290.11

delirium 290.11

delusional features 290.12

depressive features 290.13

senile 290.0

with

acute confusional state 290.3

delirium 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 (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.

References

(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 Web site, www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm