Workshop coming your way!  For psychologists and billing professionals.

 

Go to http://www.wipsychology.org for online registration

Or submit registration form below

This workshop is for mental health providers and billers who wish to be successful at capturing the complexity of mental health interventions and reporting/billing services in a way that maximizes reimbursement while complying with Medicare’s ever-changing requirements. More than ever before, Medicare policy dictates requirements and implementation of all insurances. So, even if you are not primarily a Medicare provider/biller, the workshop will prepare you for upcoming changes in reimbursement. As we move away from fee-for-service payment to a tiered payment system, providers will need to demonstrate that their services meet certain quality, value and effectiveness criteria. Billers will play a major role in coding and reporting these criteria. The workshop will first review the basic Medicare requirements for mental health assessment, intervention and documentation. We will also review basic Medicare billing strategies. We will then explore the more complex aspects of Medicare including PQRS, secondary insurances, codes for special circumstances, and a variety of helpful strategies that have been learned via trial and error. Finally, we will introduce attendees to MIPS and the upcoming requirements proposed by Medicare. Plenty of time will be available for questions and exploration of your unique experiences with coding and billing mental health services. By the end of this workshop, you will be ready for the changes coming in 2017 and 2018.

 

OUTLINE

Review of Medicare requirements for mental health services

Medical necessity, documentation, physician definition, FFS vs Advantage plans, 

H&B codes/complexity & add-on codes

Detailed examination of PQRS

Available measures, reporting options, billing codes, MAV, Quality Net help desk

MIPS & other new Medicare requirements

Quality measurement, psychologist reporting requirements for next 2 years

Exploration of billing strategies

What both psychologists & billers need to know, strategies for special populations/place of service (acute care, LTACH, Rehab, SNF, hospice), unique billing differences among various insurers, appealing denials

Panel discussion with Q&A

Ask questions, explore coding & billing challenges, learn from other attendees, network

 
 

Learning Objectives

 At the conclusion of this workshop, participants will be able to:

 

Ø Recognize & define key Medicare requirements for mental health services

Ø Identify available measures and billing codes for PQRS along with appropriate reporting options, and help resources

Ø Describe MIPS and other new Medicare requirements

Ø Outline billing strategies both psychologists & billers should know for special populations/places of service and unique insurance requirements

Ø Give examples of coding and billing challenges

Presenters

 

Dori Bischmann, PhD

Dori Bischmann is a clinical psychologist with 25 years of Medicare experience both as an employee and in private practice. She has worked in a variety of settings including medical and psychiatric hospitals, long-term care and outpatient sites. Currently, she is employed half-time as a rehabilitation psychologist in a system with electronic health records (EHR) and introduced PQRS to that system. In her private practice, she has participated in the PQRS system since its inception. Dori is involved in many professional activities regarding PQRS. As the WPA liaison to Medicare, she is involved in trying to improve the Medicare system and educating Wisconsin psychologists about Medicare and PQRS. As the APA Federal Advocacy Coordinator (FAC) for Wisconsin, she advocates for Medicare issues at the national level along with FACs from every state and territory. She is the APA representative to the Physician’s Consortium of Provider Improvement, an AMA group that oversees the development of PQRS measures.

Diane Pedulla, JD

Diane Pedulla is the Director of Regulatory Affairs for the Practice Directorate of the American Psychological Association. She is responsible for monitoring federal policies that affect the independent practice of psychology, including coverage and reimbursement issues. Currently, her work focuses on performance measurement and quality reporting, including the development and marketing of the APAPO PQRSPRO registry for PQRS reporting in Medicare, the first registry designed specifically for psychologists and other mental health professionals. Diane holds a JD degree from the University of Wisconsin Law School, an MS in Higher Education from Syracuse University, and a BA in Psychology from the University of Massachusetts at Amherst. Prior to joining APA in 1999, she served as an attorney for the US Department of Labor in Washington, DC, and San Francisco, CA.

 

Heather Hutchison, MHA

Heather Hutchison is Office Manager at Behavioral Solutions in Milwaukee. She holds a Masters degree in Health Care Administration from the University of St Francis – Joliet and a Bachelors in Health Care Administration/Business from UW Milwaukee. With 10 years of billing experience, Heather currently runs the life cycle of a claim from start to finish including insurance verification, billing, collections and appeals with mental health services in various place of services. She has extensive experience in billing Medicare for psychiatrists, psychiatric nurse practitioners and psychologists who provide services to SNF, LTACH, assistive living, rehabilitation, home and various outpatient locations. She is knowledgeable in PQRS and coding   

Location / Reservations 

The Hilton Garden Inn is located just off I-94 near Oconomowoc. There is no room block reserved for this workshop, but rates at this facility are very reasonable. Call 262-200-2222 or go online for reservations.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychology has a Hero!

Pro Photo of Amy Rosett (2)      

Our hero’s name is Dr. Amy Rosett, a California psychologist who challenged CMS and won!

This is her story:   In 2014, Amy participated in PQRS, reporting measures via claims. While CMS required providers to report 9 measures to receive a bonus, Amy was only able to report 8 measures because there were a limited number of measures pertinent to psychology and her geropsychology practice that can be reported via claims.   Her reporting rate was 100% for each of the 8 measures she reported. She went through the MAV (Measure applicability process: CMS computerized process which attempts to fairly evaluate providers who do not have 9 available measures to report) . The MAV indicated that Amy did not meet 2014 PQRS bonus requirements because she should have used measure # 46 and #317.     Measure #46 (Medication reconciliation post-discharge) requires the provider to review a recent inpatient medication list and correct any discrepancies between the inpatient and outpatient medication list  (To fully reconcile errors, the provider must have the capacity to prescribe, adjust dosages or discontinue a medication).  Measure #317 (screening for high blood pressure) requires providers to measure blood pressure during a session and counsel patients about abnormal blood pressure readings.  While our initial assessment and psychotherapy CPT codes are connected to these measures, most psychologists agree (informal survey, Bischmann 2016) that the quality actions (taking a blood pressure and reconciling medications) required by these measures are not within most psychologist’s scope of practice.

Amy reached out to Diane Pedulla, JD, APAPO (APA provider organization) who specializes in Medicare.  Amy wondered if other psychologists were denied by the MAV review because they hadn’t used  the blood pressure and medication reconciliation measure.  There was little information regarding the experiences psychologists were having with PQRS and the MAV. Mostly, we heard that many psychologists were frustrated with PQRS and had given up on it. Diane helped Amy write an “informal review and submit it to the quality net help desk (qnetsupport@hcqis.org).

Per CMS protocol, the “informal review”  is a formal way to appeal the MAV results.   In her review, Amy aptly pointed out that most psychologists are not trained to measure blood pressure and this is outside our scope of practice.  She also pointed out that the medication reconciliation measure states the measure is to be performed by “physician, prescribing practitioner, registered nurse, or clinical pharmacist.” Psychologists are not included in the list nor do we have the prescribing capacity to correct a medication list.

Unfortunately, Amy’s informal review supported the original MAV results: CMS expected Amy to have performed the blood pressure and medication reconciliation measure.   Amy wasn’t willing to accept this.  With Diane Pedulla’s assistance, a request was made via APA for CMS to review the outcome of Amy’s informal review.  CMS reviewed the outcome and agreed that Amy’s informal review came to the wrong conclusion.  Amy won!

CMS is a large governmental organization. Various departments administer different portions of the PQRS, MAV and provider feedback process.  Amy’s initial denial via the MAV was an unintended consequence.  The issue is that providers such as nurses and others use the CPT codes psychologist’s use.  While it is appropriate for psychiatric nurse practitioners to measure blood pressure and complete a medication reconciliation, it is not typical for psychologists to perform these actions.   Through Amy’s determination, CMS recognized a flaw in the MAV system and they are working on correcting it.

CMS is asking that psychologists send examples (e.g. screen shots, copies etc) of reports they get via MAV so that CMS  can continue to correct any errors and make PQRS work as it was intended.  You might wonder why CMS cannot review information internally to identify errors. Apparently, the people who approve the measures and set up the formula’s for the MAV do not have access to the reports that providers receive.

APA asks that you send examples to pracgovt@apa.org.  You can also send things to me and I will make sure it gets to APA.

 

Written by:  Dori Ann Bischmann, PhD

WPA liaison to Medicare

Advocacy Cabinet

References:

AMA (2015).  Measure #46 (NQF 0097): Medication Reconciliation Post-Discharge-National Quality Strategy Domain:  Communication and Care Coordination.

AMA (2015). Measure #317: Preventive Care and Screening:  Screening for High Blood Pressure and Follow-Up Documented-National Quality Strategy Domain: Community/Population Health.

APAPO (winter 2016).  Participating Successfully in the Medicare PQRS Program:  What to know and do for the 2015 and 2016 reporting years.  Good Practice:  Tools and information for Professional Psychologists, 12-15.

Rosett, A. (2015/2016) personal communications regarding PQRS.  California. http://www.dramyrosett.com.

QualityNet Help Desk (1-866-288-8912, qnetsupport@hcqis.org).

 

 

Pqrs Inquiry

I need your help.   I am trying to gather information regarding psychologist’s experiences with PQRS to share with APA.  I would appreciate any info you can provide about your own experiences and/or what you have heard from peers.

 

Here are some questions to guide you to the types of information I need.

 

  1.  Do you participate in PQRS?   If not, what factors contribute to your decision not to participate?

The following questions are for those who participate in PQRS:

  1. How do you report?   Claims, registry, EHR, GPRO?
  2. For 2014 data, how many measures did you report?
  3. Did you go through the MAV?
  4. Did you pass the MAV?
  5. Did you submit an informal review to CMS?
  6. If you submitted an informal review, what were the results?

7.  Are you aware that there are measures that include 90791 and the psychotherapy codes that require: taking a blood pressure and doing a “medication reconciliation?”

8.  Do you think that it is the scope of practice of most psychologists to measure blood pressure or do medication conciliation? Are these activities that you would feel appropriate doing in your practice?

9. Any other comments you would like to make are very welcome.

 

Thank you in advance for your help.  I will not be including any names in the summary information I provide to APA.  Although I haven’t written on this blog for a long time.  I continue to work on PQRS with others around the nation who work on PQRS issues for and on behalf of psychologists.  We are working to improve the process for psychologists and other providers. As you can imagine, working with CMS is a slow process.

Written by: Dori Ann Bischmann PHD

on behalf of the Advocacy Cabinet, Wisconsin Psychological Association.

 

 

PQRS Questions

Recently, A clinic in SouthEastern Wisconsin sent a variety of questions trying to understand PQRS.  I am addressing these questions here so everyone can benefit.

Question:  In PQRS, how many measures are required for each

patient?  This is technically difficult to answer.  I suppose the best answer is:  As many as possible, up to nine”      Medicare requires that providers complete nine measures (if available) on at least 50% of their fee for service patients.  However, depending on how you report (e.g. claims or registry) you may not have 9 available measures.  For psychologists reporting via claims, there are 7 available measures.  However, not all of these measures will be appropriate for your practice or for each of your patients.  For example, measure #317:  Screening for high blood pressure and follow-up plan is a measure that few psychologists will choose to use, although it is available to us.  Measure #181:  elder maltreatment screen and follow-up plan is available, but not appropriate for patients who are younger than 64 years.  

Question:  If a patient is being screened for depression (#134),

a Geriatric Depression Scale is used and indicates depression, is G8431 the

only billing code required?  You would report G8431 if you report via claims, you screened for clinical depression using a standardized tool, found depression and documented a follow-up plan.   If you report via claims and did not find depression and thus follow-up plan not appropriate you would report code G8510.  If you did not perform the measure because the patient was not appropriate (i.e. too medically ill to test) you would report G8433.  Don’t forget to also include the procedure code (i.e. 90791) and diagnosis code.   If you are reporting via registry, you don’t report any of the G-codes or CPTII codes. 

b.      Is this the only measure required for this patient?  No, this is not the only measure required for this patient.  You should complete as many measures as are available for each patient up to 9 measures.  Available measures will vary depending on:  how you report (claims vs registry), the age of the patient, the CPT code you are using and possibly the patient’s diagnosis.   If reporting via claims, the average older adult being screened for depression at the time of initial evaluation (CPT 90791 or 96150), would also be eligible for measure #128 (BMI screening), Measure #130 (verification of meds), measure #131 (pain assessment), Measure #181 (elder maltreatment screen), measure #226 (tobacco screening), measure #317 (blood pressure screen).  If you are reporting via registry, there are additional measures available.

Note that some measures can be used with all of the CPT codes psychologists use.  Other measures are only available to be used with assessment CPT codes.  The majority of measures are reporting once per reporting period (1 year), but some are required at every session (med review) and some are required to be completed every two years.  You must read each measure to determine the qualifications for that measure.  

c.       Are there any specific instruments required to screen for

depression?  Yes and no.  CMS requires that you use a standardized tool that has been “appropriately normalized and validated for the population in which it is used.”   Then they provide some examples such as Patient Health Questionnaire (PhQ9), Beck Depression Inventory (BDI or BDI-II) and Geriatric Depression Scale (GDS).  They give other examples as well.  Just use a scale that you know has been normed and validated for the particular population you work with and you will be fine.

2) Can you provide an example of  “nine measures across three domains?”  CMS has determined that measures cluster into national quality strategy domains (NQS).  These are just types of measures that CMS believes are important such as “Effective clinical care,” “Patient safety,” “community/population health.” CMS wants providers to choose measures across domains and not just use measures from one domain.  Psychologist’s don’t have to worry about this too much.  In claims reporting, we only have 7 measures we can use and these measures represent at least 3 of the various domains.  Use the measures available and you will automatically report measures over three domains.

What exactly does it mean and how does an individual provider comply?

2)               3)  How often must measures be reported for each patient?

Every session?  Once per month or year?  An individual provider complies by reporting as many measures as available for that provider up to 9 measures.  Reporting via claims, a psychologist has only 7 available measures.  One of the measures pertains to blood pressure which most psychologists will not use, effectively there are 6 measures available.  However, one of the 6 available measures is screening of elder abuse for patients 65 and older, so patients who are younger than 65 will only have 5 measures available.  

The best way to do this is to prepare a cover sheet listing all available measures that you will use in your practice.  Attach appropriate screening devices to your face sheet so you have everything you need to complete the measures.  

Plan to complete the measures at each initial evaluation and you have met the requirement for most of the measures for the year for most of your patients.  Some measures on your face sheet may not be applicable to your patient due to age, dx or other factor.  Simply cross that measure off.  You can only complete as many measures for that patient as are appropriate to that patient.  

Some measures such as #130 (medication review) must be reported at every session and both assessment (90791, 90792, 96150) and psychotherapy codes (90832 etc.) are eligible.  Some measures such as #131 (pain assessment) require reporting “at every session,”  but the only CPT codes available are assessment codes and thus you never report pain assessment with a psychotherapy session.  

Most of these measures, unless otherwise specified need to be reported only once a year so doing them during initial evaluation meets criteria for most of the measures and patients.  Note that if you are seeing a patient over more than one year, you should repeat the measures sometime during the second and each subsequent year that you see that particular patient.     

3)                4)  For what length of time are measures required to be

reported for each patient? Measures are generally required to be reported once per year per patient.   Each measure is different so you must read the requirements for each measure.  As stated above, the medication review measure requires reporting at each session.    Each eligible patient (only Medicare FFS, not Medicare Advantage, Medicaid or Commercial) should have measures repeated at least once per year (or more often if specified by the particular measure). 

4)               5) For what percentage of all Medicare patients are

measures required?  Is there a minimum of patients for which reporting is

required (what if I only see one or two Medicare patients)? You must report on at least 50% of your Medicare FFS patients.  If you only have one Medicare FFS patient, you would report on only that one.  While CMS presents reporting as mandatory, it is really only mandatory if you wish to avoid the 2% penalty to your Medicare reimbursements.  Some providers may make the financial decision not to report because it is less costly to not report for a few Medicare patients, than to learn the PQRS system and do the work required.  I can vouch that It is a very long and complex learning curve to figure out PQRS and do it correctly.  There are other benefits to reporting that may have an impact later on.  For example, the goal of the Affordable Care Act is to establish a score for each provider that is public (see physician compare website) and used to determine that providers quality as a provider.  PQRS reporting is one way to positively contribute to your score.

5)               6) Are there any specific assessment instruments that are

required to be completed for any measure?   CMS recommends that the instruments be normed and validated for the specific population you are working with and CMS gives some examples of appropriate instruments.  It is up to you to select the instrument you feel is best for your population.   You will have to read the requirements for each measure.  They all vary.

6)               7) As independent practitioners, but part of a clinic, does

each psychologist have to sign up, or can we just start reporting?   It depends on how you are reporting.  Most clinicians are still reporting via claims.  With claims reporting, each clinician reports independently via the normal billing claims.  There is no requirement that all clinicians participate in a given clinic (unless you report via GPRO).  With claims reporting, each provider is independent.  You must report the pqrs measure at the time you place a claim to be paid for your service.  If you are reporting via registry, you can collect the data all year and report at the end of the year (usually through February of the subsequent year).  If you are reporting via GPRO (also through a registry), info is extracted from the medical record and the group gets credit for meeting criteria and it doesn’t matter so much what an individual provider did or didn’t complete. 

Summary:   PQRS is complex.  One can report in a variety of ways.  Requirements vary depending on reporting method, patient age, CPT code used and in some cases the patient’s diagnosis.  Each measure has unique requirements, so a provider has to be familiar with the requirements of each measure that is used.  Available measures and requirements are likely to change every year. PQRS (or some form of quality measurement) is here to stay.  I recommend that providers learn the system now while everyone is going through the learning curve.  Errors are tolerated now more than they might be in the future.  Eventually, this data (and other data) will be used for establishing a “quality score” for each provider.   This score can be used to determined your payment rate for not only Medicare, but for all insurances.  Participating in PQRS will positively impact your score.  The Affordable Care Act requires payments to be based upon quality of services and not just the service per se.  Thus, we will all be paid somewhat differently for the same CPT code based upon our unique quality score.

Written by Dori Ann Bischmann, PhD

Advocacy Cabinet

Wisconsin Psychological Association

Measure #317: Preventive care and screeing: Screening for High blood pressure and follow-up

High blood pressure screen #317

2015 reporting options:  Claims and registry

Patient age:  18 and up

Diagnosis Code:  No specific diagnosis is associated with this measure.  Measure not appropriate for patients who already have an active diagnosis of hypertension.

CPT codes:  90791, 90832, 90834, 90837, 96118

Reporting requirements:  1. Report once per reporting period (calendar year). 2. Measure blood pressure during the qualifying session.  You can not obtain the measurement from an outside source (such as the medical record).  My interpretation of this is that you must do the blood pressure reading yourself or you could have an aid/nurse do the reading in your presence.    3. If BP falls in the pre-hypertensive or hypertensive range, document a follow-up plan (see CMS for recommendations on possible follow-up plans). 

Blood pressure parameters:

Prehypertensive:  greater than 120/80 but less than 139/89

Hypertensive:  greater than 140/90 

Please see CMS.GOV, 2015 measures list for additional details about this measure.

Resources:

CMS.GOV (12/23/14).  2015 measures list, Measure #317 Preventive Care and Screening:  Screening fo High Blood Pressure and Follow-up Documented_National Quality Strategy Domain: Community/Population Health   

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

PQRS Measure #128: preventive Care and Screening: Body Mass Index (BMI) screening and Follow-up Plan

BMI measure #128

2015 reporting options:  Claims and registry

Patient age:  18 and up

Diagnosis Code:  No specific diagnosis is associated with this measure.

CPT codes:  90791, 90832, 90834, 90837, 96150, 96151, 96152

Reporting requirements:  1. Report once per reporting period (calender year). 2. Measure height and weight (information can be gathered from outside source such as the physician’s office or via another provider in facility, i.e. dietician) and calculate the BMI.  Self-reported values, from the patient, cannot be used.  The BMI data used should be no older than 6 months.  Use a BMI chart to determine the BMI from height and weight data. Many different BMI charts are available, in the public domain, via the internet.  Normal BMI parameters are as follows: 

Age 65 years and older; BMI greater than 23 and less than 30 kg/m. 

Age 18-64; BMI greater than 18.5 and less than 25 kg/m. 

 3. If the BMI is outside normal parameters, establish a follow-up plan.  The follow-up plan may include a referral to another provider (e.g. dietician, physician), education or specific psychological goals to address weight. 4. Document BMI and follow-up plan in medical record.   

SIDE NOTE: While we are not supposed to use self-reported values, it is my opinion that I will use self-reported values on occasion.  In my facilities, I can gather the information from the dietician’s notes.  In my outpatient office, I can weigh and measure the patient with the available scale.  However, in the office and when I do home visits I may have to rely on the patient’s report, if I am unable to get data from a physician’s office.  It is my opinion that it is better to complete the measure, using the patient’s self reported data, than to skip the measure or put the patient in danger (I work with disabled patients who may or may not be able to safely get on a scale.  I will not take that risk, even in the office where a scale is available.)  Furthermore, height information gathered from outside sources may be based upon the patient’s self report.  I have talked to dietician’s in hospitals where I work.  They typically ask the patient for their height.  They don’t measure the pt directly unless they are ambulatory (usually outpatients) or comatose (wherein the patient can not report a height. The dietician measures the patient from the sternum to the tip of his/her fingers and then doubles that for a measure of the patient’s height).    

Please see CMS.GOV, 2015 measures list for additional details about this measure.

Resources:

CMS.GOV (12/23/14).  2015 measures list, Measure #128 (NQF 0421):  Preventive care and screening:  body mass index (BMI) screening and follow-up plan-National Quality Strategy Domain:  Community/Population Health.   

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

Dori’s PQRS Picks for 2015

In 2015, I will again report via registry.  So my requirements for picking measures include:  measures that are appropriate for psychologists, measures that are appropriate for my client mix and measures that are available via registry.

All of the claims-based measures are available for registry reporting, so those of you who are reporting via claims can utilize the first section of my picks.  This year there are only 6 (there actually appear to be 7*) measures available for claims-based reporting that are appropriate for psychologists (APAPO, 1/25/15).  You must report on as many of these measures as are appropriate to your patient population to meet Medicare’s criteria for successful PQRS reporting.  Obviously, if you do not work with individual’s over age 65, you would not report on measure # 181, elder maltreatment screen and follow-up plan.  But if you have even one client over age 65 (who is a Medicare FFS recipient),  you must report on measure #181.  The remaining 5 measures are appropriate for every psychological practice. 

Recall that Medicare requires that providers report on 9 measures over the 3 NQS domains on 50% of eligible FFS Medicare recipients.  Since 9 measures aren’t available to psychologists via claims, you will need to report on all 6 available (or 5 if no patients over age 65) measures and will be reviewed via the MAV system (see previous post for description of MAV).  

The 7 measures available for claims based and registry reporting include:

#128 body mass index,

#130 documentation and verification of current medications in the medical record,

#131 pain assessment prior to initiation of patient treatment,

#134 screening for clinical depression, (note that the age for this measure is 12 yrs and up) 

#181 elder maltreatment screen and follow-up plan

#226 preventive care and screening:  tobacco use-screening and cessation intervention

#317 preventive care and screening: screening for high blood pressure and follow-up

Since I will be reporting via registry, I will also be using 3 additional measures to bring my total measures count to 9.   Note that there is an additional measure and measure group that could be used if reporting via registry.  I have chosen not to use those two options because they do not fit my patient population.

The three registry only measures I will be using are:

#173 unhealthy alcohol use

#325 adult major depressive disorder (MDD); coordination of care of patients with specific comorbid conditions

#383 adherence to antipsychotic medications for individuals with schizophrenia.

For additional details about PQRS and these measures, see previous posts.  I will be outlining some of the new measures in subsequent posts.

*Measure #317: Preventive care and screening:  screening for high blood pressure and follow-up appears to be appropriate for psychologists to report.  APA did not include this measure in it’s list, but it does include our CPT codes

Resources:

http://www.apapracticecentral.org

CMS.gov (12/23/14).  PQRS, 2015 measures list.

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet