Tag Archives: CPT codes

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).

 

 

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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

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

Teaser for New Information to Come Soon

There are so many changes in Healthcare that it has been difficult to keep up!   Starting in January, I will to go through the changes in more depth, but for now here is a summary:

1.  Wisconsin is expected to delay the cancellation of Badger care and HRSP (the WI high risk insurance sharing plan) to March so people can avoid coverage gaps while ACA (Affordable Care Act, e.g. Obamacare) website is fixed.

2.  As of January 1, 2014, Medicare payments for mental health services are on full parity with Medical services.  Medicare pays 80% for all services. Thus there is a 20% copay for all services.

3.  Most psychotherapy codes will have a small increase in Medicare reimbursement due to changes in the work value formula.  90832 does not increase and 90791 is expected to decrease by 15% (national average).

4.  SGR cut is delayed for three months to allow congress more time to figure out an alternative.

5.  No news yet on whether recent budget will impact the expected 2% sequestration cut to physician fees.

6.  The healthcare exchange website, Healthcare.gov, is working better and more people have been able to sign up for insurance policies through the website (including me, yippie!), but there are still technical problems to be worked out.

7.  Dean care insurance will be/is expanding its coverage area east into Waukesha County.  Dean does offer insurance plans on the Healthcare exchange for Waukesha Co residents, but in my opinion they don’t yet have enough providers east of Oconomowoc.

8.  Medicare is changing the rules regarding PQRS.  It is expected that completing 9 PQRS measures on 80% of your Medicare patients will be required for 2014 to avoid penalty in 2016.  Some PQRS claims based measures (what psychologists use) may be retired.  New ways to measure services, such as “value” are being proposed for the next couple of years.

9.  It appears that reporting PQRS measures via a registry is valued above reporting via claims based reporting.  APA is discussing the feasibility of developing a registry for psychologists.  It is my read that in the next couple of years psychologists will not be able to participate in PQRS (but will be able to incur penalties) if we are unable to report via Registry.

10.  The “Physician Compare” website is up and running.  This website will provide data on all physicians (including psychologists) and is available to the public (and insurance companies).  The website is put together by Medicare, but it is a requirement of the ACA.  The only interesting data I see on my listing so far is that I participate in PQRS.  Eventually, the ACA’s goal is to include ratings and other information that will allow the public to determine how an individual physician compares to others in his/her discipline.  Imagine what an insurance company might use this information for…..just saying.

11.  Healthcare changes are occurring rapidly.  These are changes you must know or you will potentially suffer penalties, be left out of insurance panels or other undesired things.  Please, please, please be a member of  your respective provider associations.  It is their job to sort through the volumes of government information and bring the must know info to you. It is impossible to keep up with the changes independently and you can’t afford to wait for pertinent info to trickle down through the grapevine. The changes are occurring too rapidly and they are often quite complex.

12.  While most of these changes start within the Medicare program, they will be applied to all programs in one way or another.  With the ACA, what was once restricted to Medicare, will eventually apply to all insurance plans.

13.  Details to come in January when written policies are available for review.

The WPA Advocacy Cabinet

(post author:  Dori Ann Bischmann, PhD)

PQRS (Physician Quality Reporting System)- Screening for Clinical Depression and follow up plan.Part 7

This is part 7 of a series of blog posts discussing PQRS.  In this post, I will review one measure:  Preventative Care and Screening:  Screening for Clinical Depression and Follow-UP Plan.

Note:  PQRS is mandatory for Medicare Providers.  These measures are subject to change without notice.  Continue to check the AMA (American Medical Association) and CMS (Centers for Medicare & Medicaid services) website to make sure the measures you are using have not expired.  CMS is the source document for all the measures and associated codes.  I found that AMA provides more detail and a worksheet for working on the measure.  I recommend the AMA information for new PQRS providers.

Medicare providers are required to participate in PQRS in 2013.  Unsuccessful participation will cause 1.5% and 2% penalties to be imposed in 2015 and 2016, respectfully.  For more information on the general aspects of PQRS, please consult  previous and subsequent blog posts.

All PQRS measures can be found on the CMS and AMA websites.

General Instructions for all Measures:

  1. Select measure(s) you will use.  If you are new to PQRS, you may choose to use only one measure.  If you are a continuing user of PQRS, you will continue to select 3 measures.
  2. Follow the instructions for completing the measure.  Most measures require one assessment point, utilizing a standard measurement tool and at times a follow-up plan.
  3. Complete the measure with the patient. Complete the measure with enough patients to meet criteria, currently 50% per year.  I complete the measure on all patients which creates a routine and allows for missed assessments and/or missed coding without risk of missing the 50% completion criteria.
  4. Document completion of the measure appropriately in the clinical record and send measure completion codes to your billing entity.  Medicare provides a Collection Sheet for each measure — or you can integrate the measure completion codes into your existing billing form.
  5. Billing entity sends in measure completion codes with billing.
  6. Keep all documents for your records.
  7. Periodically double-check that your billing entity is sending in the measure completion codes.

Measure Options

Preventative Care and Screening:  Screening for Clinical Depression and Follow-Up Plan. (AMA, PQRS 2011 measure 134).

This measure is used for persons aged 12 years and older.  The provider screens for clinical depression using an age appropriate standardized depression screening tool AND, if there is depression, a follow-up plan is documented.  Screen for clinical depression at least once per reporting period (reporting period is 24 months).  Use with CPT codes:  90791, 96150, 96151, 90832, 90834, 90837, 90839 and others.  Recommended clinical depression screening tests:  Patient Health Questionnaire, Beck Depression Inventory, Center for Epidemiological Studies Depression Scale, Duke Anxiety-depression Scale, Geriatric Depression Scale, Mood feeling questionnaire and others.  Be sure to select a scale that is appropriate to the age of the person you are evaluating.  If the screening measure indicates the presence of clinical depression, a follow-up plan must be documented including at least one of the following:  additional evaluation, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions, other interventions or follow-up for diagnosis or treatment of depression.  A patient is not eligible for this screen if he/she refuses to participate, is in an urgent or emergent situation, has a functional capacity or poor motivation level that impacts the accuracy of screen or ALREADY HAS AN ACTIVE DIAGNOSIS OF DEPRESSION OR BIPOLAR DISORDER. Note that this screening measure can be used by a variety of professionals and not just mental health professionals.  One follow-up plan for nonmental health professionals would be to refer to an appropriate mental health professional.

Codes for reporting measure completion (Preventive Care and Screening:  Screening for Clinical Depression and Follow-Up Plan)

G8431:  Positive screen for clinical depression and follow-up plan documented.   Clinician gets credit for completion.

G8510: Negative screen for clinical depression, follow-up plan not needed.  Clinician gets credit for completion.

G8433:  Screening not documented because patient isn’t eligible (see above list above). Clinician gets credit for completion.

G8940:  Depression screen documented, follow-up plan not documented because patient isn’t eligible for screening. Clinician gets credit for completion.

G8432:  Depression screen and follow-up plan not documented, no reason given.  Clinician gets credit for completion.

Clinical Vignette

I assess a 65 y.o. man in my outpatient clinic.  I screen for depression using the Geriatric Depression Scale.  The patient scores 20/30 which places his score in the mild/moderately depressed range.  He denies feeling suicidal.   I document that I completed the GDS and that the patient scored in the depressed range.  I also document my follow plan which will likely include:  follow-up psychotherapy, discussion of possible referral to psychiatry for medication.     When I send in my billing, I send the following:   90791 for initial assessment,  G8431 (this code indicates that I screened for clinical depression and documented a positive screen with a follow-up plan.  At this point, I use the diagnosis code of 311 for depression NOS.

Keep following this blog for more information on PQRS and specific measures.

The Advocacy Cabinet

(Post by Dori Bischmann, PhD)

Resources:

CMS (2012).  2013 Physician Quality Reporting System (PQRS) measures list.  Available from CMS website.

www.ama-assn.org:  Physician Quality Measure Reporting

www.apapracticecentral

PQRS (Physician Quality Reporting System)- Part 6

This is part 6 of a series of blog posts discussing PQRS.  In this post, I will review one measure:  Preventative Care and Screening:  Tobacco Use: Screening and Cessation Intervention.

Note:  PQRS is mandatory for Medicare Providers.  These measures are subject to change without notice.  Continue to check the AMA (American Medical Association) and CMS (Centers for Medicare & Medicaid services) website to make sure the measures you are using have not expired.  CMS is the source document for all the measures and associated codes.  I found that AMA provides more detail and a worksheet for working on the measure.  I recommend the AMA information for new PQRS providers.

Medicare providers are required to participate in PQRS in 2013.  Unsuccessful participation will cause 1.5% and 2% penalties to be imposed in 2015 and 2016, respectfully.  For more information on the general aspects of PQRS, please consult  previous and subsequent blog posts.

All PQRS measures can be found on the CMS and AMA websites.

General Instructions for all Measures:

  1. Select measure(s) you will use.  If you are new to PQRS, you may choose to use only one measure.  If you are a continuing user of PQRS, you will continue to select 3 measures.
  2. Follow the instructions for completing the measure.  Most measures require one assessment point, utilizing a standard measurement tool and at times a follow-up plan.
  3. Complete the measure with the patient. Complete the measure with enough patients to meet criteria, currently 50% per year.  I complete the measure on all patients which creates a routine and allows for missed assessments and/or missed coding without risk of missing the 50% completion criteria.
  4. Document completion of the measure appropriately in the clinical record and send measure completion codes to your billing entity.  Medicare provides a Collection Sheet for each measure — or you can integrate the measure completion codes into your existing billing form.
  5. Billing entity sends in measure completion codes with billing.
  6. Keep all documents for your records.
  7. Periodically double-check that your billing entity is sending in the measure completion codes.

Measure Options

Preventative Care and Screening:  Tobacco Use: Screening and Cessation Intervention. (AMA, PQRS 2011 measure 226).

This measure is used for persons aged 18 years and older.  The provider screens for tobacco use and provides cessation counseling intervention if the person is a tobacco user.  Screen for tobacco use at least once per reporting period (reporting period is 24 months). there is no specified assessment tool.  It appears that you simply ask your client if they are using tobacco products.  Cessation counseling intervention includes counseling and/or pharmacotherapy.  “Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates.” (AMA, 2011),

Codes for reporting measure completion (Tobacco Use:  Screening and Cessation Intervention)

4004F:  Patient screened for tobacco use AND received tobacco cessation counseling, if identified as a tobacco user.   Clinician gets credit for completion.

1036F:  Patient screened for tobacco use and not a current tobacco user.  Clinician gets credit for completion.

4004F-1P:  Documentation of medical reasons for not screening for tobacco use, e.g. limited life expectancy. Clinician gets credit for completion.

4004F-8P:  Tobacco Screening not performed, reason not specified. Clinician gets credit for completion.

Clinical Vignette

I assess a 65 y.o. man in the hospital who is status/post hip replacement. He reports surgical pain, but denies any psychiatric symptoms. I screen for use of tobacco products.  The patient tells me that he quit smoking.  I follow-up with the question, “when did you quit smoking?”  He states that he quit when he came into the hospital.  I ask if he is interested in quitting permanently.  He indicates that he would like to, but doesn’t want to make any promises.  We briefly discuss the benefits of quitting which includes decreasing stroke and cancer risk, saving money, smelling better, improved sense of taste/smell and improved healing.  We discuss options such as counseling and/or nicotine patch.  The patient indicates that he would like to try the nicotine patch.  I tell him that I will mention this to his physician and the physician will talk with him further.  In subsequent sessions, I can talk more about the physical vs psychological aspects of quitting and provide written information on the benefits of tobacco cessation, if appropriate.  I document the patient’s report of tobacco use and the discussion we had about cessation.  I make sure to notify the physician about the patient’s desire for nicotine patch.     When I send in my billing, I send the following:   90791 for initial assessment,  4004F (this code indicates that I assessed for tobacco use and provided counseling on smoking cessation), dx codes:  i could use 305.10 (nicotine dependence) or 292.9 (nicotine withdrawal).  Besides the smoking related issues, this patient did not appear to have any psychiatric disorder so I might use a Health and Behavior code for initial assessment and include a medical diagnosis that corresponds to his hip replacement.

Keep following this blog for more information on PQRS and specific measures.

The Advocacy Cabinet

(Post by Dori Bischmann, PhD)

Resources:

CMS (2012).  2013 Physician Quality Reporting System (PQRS) measures list.  Available from CMS website.

www.ama-assn.org:  Physician Quality Measure Reporting

www.apapracticecentral

There is Hope: Psychtherapy Codes

It has been very exciting here at the APAPO State Leadership Conference in Washington D.C. We have lots of information to bring back home. There has been positive news despite the fact that we have many battles related to Medicare cuts. Let me share just a few of the positive things.

-the work values tied to our new psychotherapy codes are just interim values.
-since all new codes were not yet valued, Medicare chose to use the work values for the old codes while remaining codes went through valuation.
– the work values for the new codes are higher than the values for old codes. Thus after the interim period the work values of codes will be higher and thus rates may increase.
-three sets of codes are going through survey now and then will be valued for work rating: complexity add-on, crisis and 90 minute psychotherapy code
– yes there will be a 90 minute psychotherapy code.
-during this transition period we have the opportunity to shape our own world
-use the 60 minute psychotherapy code (90837) if you spent more than 53 minutes with your client. Don’t down code to 90834 because an insurance company might deny and you have to resubmit. Don’t let the insurance companies dictate the appropriate services to provide your client.
-Medicare says 90837 is a legal code, our provider association says its ethical to provide 60 minute sessions and with some types of client groups, it might be the most appropriate service to provide
-the system is in transition. The new norm is being established. Advocate for your profession, your livelihood and your clients by having conversations with insurance companies about the appropriateness of 60 minute sessions. We won’t win all the battles, but we will win some. Winning some is better than never trying at all.
-this is the time that we all have to speak up and advocate for what is right one case at a time
– our future is up to us. There is power in numbers. Join me and do your part in shaping your own future!

Tomorrow we go to the hill to advocate for change via our legislators. More than 300 psychologists representing every state and territory will descend upon the Capitol to tell our respective legislators that things need to change. We can’t continue to sustain these payment cuts, psychologists need to be allowed at the table for incentives to become part of the electronic healthcare records so that we don’t become obsolete by not having the required tools to participate in an integrated healthcare system, let us be included in the group that includes doctoral level, independently licensed professionals. Psychology is the only doctoral level profession to be left out of this group and this automatically leaves us out in the cold on many issues related to Medicare. As with all Governmental things, change doesn’t happen over night. But we will continue to advocate for what is right.

Much more to come.

Advocacy Cabinet
(Post author: Dori Bischmann, PhD)

Reference: 2013 APAPO State Leadership Conference. Washington D.C.