It is possible to get paid for your work on the phone.

It takes the right coding for the right situations, the right
documentation and persistence.

Some research has indicated that 20% or more of the clinical services
provided in some specialties are done over the phone.

But most of the time spent on the phone with patients cannot be
reimbursed, because it is considered part of a face-to-face visit, the
call is short, or the insurer doesn’t cover it.

“These services have very specific guidelines in order to bill for
them,” said Betsy Nicoletti, author of The Field Guide to Physician Coding.

Insurers increasingly are willing to pay for e-mail consultations, but
physicians who deliver care by telephone say voice communication offers
better patient care.

For instance, a billable call can be initiated only by an established
patient or the patient’s guardian.

In addition, the conversation cannot be related to a face-to-face
appointment that occurred within the past week or will happen within the
next 24 hours or the next earliest available appointment.

In other words, the call has to substitute for in-office care.

The relevant codes are:

* 99441: Five to ten minutes of medical discussion.
* 99442: 11 to 20 minutes of medical discussion.
* 99443: 21 to 30 minutes of medical discussion.

* 98966, 98967 and 98968: The comparable codes for care provided by
other health professionals.

To increase the likelihood of payment, the call must be documented like
an in-person visit, with particular notation of the time spent.

In addition, experts advocate spelling out in contracts with insurers
that such services will be covered.

If an insurer does not cover phone calls, it may be possible to bill
patients separately.

Most insurers allow patients to be billed for medically necessary
noncovered services.

Most medical societies, including the American Medical Association,
support payment for medically necessary care provided by telephone.

The VADPRS has a 55 item rating scale and evaluates for ADHD and other co-morbid conditions. It takes 10 minutes or less to complete.

The VADPRS has two components: symptom assessment and impairment of performance at home, in school, and in social settings.

The automated feedback report provides instant scoring and item analysis.

The VADPRS is widely used by healthcare professionals to screen for symptoms of ADHD, oppositional defiant disorder, conduct disorder, and anxiety and depression in children.

It is endorsed by the American Academy of Pediatrics.

The legislation affects health insurance plans provided by employers with 51 or more employees and self-funded plans regulated under the Employee Retirement Income Security Act. The plans must ensure equality of out-of-network benefits for mental health and addiction treatment services and equality in treatment limitations and financial requirements. The parity provisions only apply to insurance plans that provide mental health coverage. Plans that experience a cost increase of more than 2% in the first year, or 1% in subsequent years, will be able to apply for an exemption.

What will the parity legislation mean for the field? It will be immense. Consider:

* Limited benefits for mental health and addiction treatment cause this niche of the health care field to be unattractive to health care provider organizations.
* People with addictions and mental illnesses leave their places of employment in order to become eligible for Medicaid and eligible for treatment benefits because they either do not have employer-sponsored health insurance or their insurance coverage for their behavioral disorders is inadequate.
* Health insurers create benefit plan designs with very limited mental health and addiction treatment benefits, which result in cost shifting to the consumer or state or county governments.
* Lack of availability of mental health and addiction treatment causes “miscoded” service delivery in many other systems — primary care, child welfare, juvenile corrections, and more.
* Inadequate addiction treatment and mental health benefits create overutilization of emergency rooms. (More clinical crises result from lack of timely, appropriate treatment — and emergency rooms are the only treatment site for most of those folks.)
* Our prisons are populated with untreated, undertreated, and ineffectively treated people with behavioral disorders.
* Limited benefits for mental health and addiction treatment make this niche of health care unattractive to investments dollars — in software and systems, in clinical technologies, and in facilities.

Overall, the major industry effect of the parity legislation is that mental health and addiction treatment spending in the health and human services system — currently distributed in miscoded general health care spending in primary care and emergency rooms and pushed to the social service system — will be correctly classified as spending on treatment for behavioral disorders. This will have a number of key market effects. First, the parity legislation will change how we account for health care spending resulting from behavioral disorders. A number of actuaries predict that the health insurance premiums will rise 1% to 2% in total as a result of the parity legislation. This translates into a 30% increase in mental health and addiction treatment spending within health plans affected by the legislation (assuming a national average premium for treatment of behavioral disorders of 6.2% of total health plan spending).

The increase in funding for treatment of mental illnesses and addictions brought about by parity will make the treatment of these disorders attractive to a wide range of provider organizations and health care systems. For consumers, this will be a boon — more choices from a wider range of treatment providers. Look for a reversal in the current trends for community hospitals to abandon psychiatric programs. However, for current specialty provider organizations, this change will mean more competition for consumers.

More people with mental illnesses and addictive disorders will stay in the workplace and employed — though these market effects will be limited by the bill’s provision exempting self-funded health plans (which includes most large employer plans). The combination of the newly-expanded Americans with Disabilities Act, better treatment tools, and equity in treatment benefits mean that more treatment will occur in the employer-sponsored health plans than ever before. This will take some of the pressure off of state and county mental health and substance abuse budgets, which have been the recipients of planned cost shifting from health insurance plans.

All of these changes to the delivery system resulting from the market effects of parity will likely increase the integration of the treatment of mental illnesses and addictions into the primary care system. As primary care provider organizations see the ability to provide treatment services that are reimbursed by insurers, their interest in integrating these services into their practices will increase.

The parity legislation should have positive effects–lower spending– on budgets for hospital emergency rooms, child welfare agencies, and the juvenile and adult corrections systems. It will take at least five years to see these shifts in service utilization due to lack of access to treatment — but they are likely to happen over time.

With these changes in the field, we should see an increase in investment dollars in areas focused on treatment of mental illness and addiction treatment. This area of health and human services has been capital deprived due to the very correct perception that the field had lots of demand but limited payment for treatment services. There should be increasing capital available for biotechnology, software, and facilities focused on behavioral health disorders.

For provider organizations with large portions of their budget dependent on “safety net” types of funding (state block grants, federal program grants, etc.), look for a reduction in “safety net” funding specific to mental health and addictions — with an increase in safety net funding for the uninsured in general.

As the parity provisions are phased into Medicare, there is a formula for calculating the decreased amount for patient copayments using a series of phase-in multipliers. The phase-in process will not apply to two outpatient mental health services which will both be covered at 2014 rates immediately. They are brief office visits for monitoring or changing drug prescriptions used to treat a mental health disorder (cpt codes 90862 and 90805) and partial hospitalization services billed by hospital outpatient departments and community mental health centers. However, since the professional services of providers to partial hospitalization are billed separately from the partial hospitalization program of services and their services are subject to the MIPPA changes in the limitation.

Diagnostic evaluations (cpt codes 90801 and 90802) and tests to establish or confirm a patient’s diagnosis are also not subject to the MIPPA. CMS instructed Medicare contractors to deem initial visits as diagnostic. In cases where a diagnosis takes more than one visit, the Medicare contractor may request documentation to justify the additional visit.

According to an October 30, 2009 CMS manual update to Medicare contractors, “Medicare Claims Processing Transmittal 1843: Outpatient Mental Health Treatment Limitation,” for outpatient mental health services provided before January 1, 2010, the pre-parity coverage rate will still be in effect. After meeting their deductibles, patients will pay 50% of the covered charges and Medicare will pay the other 50%. The phase-in process and percentages apply to claims for professional services provided by physicians, clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants. The phase-in process also applies to diagnostic psychological and neuropsychological testing to evaluate a patient’s progress during treatment.

To determine how much patients pay and how much Medicare pays, of the actual charges, the Medicare-approved amount will be multiplied by a limitation percentage to find the Medicare incurred expenses. The patient’s unmet deductible is subtracted, and the remainder multiplied by 80% to find the amount Medicare pays. The rest of the Medicare-approved amount is the patient’s responsibility. For the pre-parity coverage, the multiplier was 62.5%. The phase-in multipliers will be as follows:

* 68.75% as of January 1 (with an implementation date of January 4, 2010), through 2011; patients will pay 45% of covered charges; Medicare will pay 55% of the covered charges.
* 75% as of January 1, 2012; patients will pay 40% of covered charges; Medicare will pay 60%.
* 81.25% as of January 1, 2013; patients will pay 35% of covered charges; Medicare will pay 65%.
* 100% as of January 1, 2014; patients will pay 20% of covered charges; Medicare will pay 80%.

Two outpatient mental health services will be covered at the 2014 rate immediately. The phase-in process will not apply to brief office visits for monitoring or changing drug prescriptions used to treat a mental health disorder. These visits are reported using HCPCS code M0064. CMS instructed Medicare contractors that procedures identified as HCPCS code M0064 or any successor code will not be subject to the phase-in process. Diagnostic evaluations and tests to establish or confirm a patient’s diagnosis will also not be subject to the phase-in process. CMS instructed Medicare contractors to deem initial visits as diagnostic. In cases where a diagnosis takes more than one visit, the Medicare contractor may request documentation to justify the additional visit.

Key points are:

1) There is no CPT code for conducting psychotherapy over the telephone.

2) All the psychotherapy codes are described as face to face with the patient.

3) The only appropriate code to use would be 90899, “unlisted psychiatric
service or procedure.”

If you use this code, you should provide documentation describing that
it is for psychotherapy over the telephone. This could could also be used for other unlisted psychiatric services or procedures, e.g. outcomes assessment using a standard instrument.

There are timed codes for E/M services provided on the telephone (99441:5-10 minutes; 99442: 11-20 minutes; 99443: 21-30 minutes). These codes can be used for medical discussion with a patient for whom you have not provided an E/M service within the past seven days and whom you would not be seeing for the reason discussed in the call.

Features of the eRecord include:

Integration of Clinical Documentation, Patient Accounting and Claims
Every time a clinician writes a Progress note or completes an Intake, a charge is posted to the patient’s account and, if the patient has insurance, a claim is generated in X12 format for immediate submission to the insurance company.  Thus, duplicate data entry, filling out billing tickets and the like are eliminated, saving time and money. Built in rules validate data to ensure clean claims.

Clinical Documentation
The eRecord has an extensive library of clinical templates for Intakes, Progress Notes, Treatment Plans, Case management assessments, Outcomes assessments, etc. Also, the forms maker enables users to either edit our templates or create their own.

Intake Assessments
Intake assessments for children and adolescents, adults, geriatrics, substance abuser and other special populations are available in our library. Diagnoses entered at intake are pulled forward to subsequent clinical documents (progress notes) and can be modified as neeeded. A completed Intake automatically creates a patient charge and insurance claim if there is a coverage.

Progress Notes
Progress notes cover individuals and groups for the various mental health disciplines: social work, psychology, nursing, and psychiatry. Diagnoses are always pulled forward from note to note; in addition there is the option to allow notes to pre-populate forward so that an entire note from a previous session is displayed for easy editing. Group notes can be written rapidly. For example, a general comment can be applied to all the participants in the group and individual content applied for specific clients. This saves clinicians a great deal of time while insuring comprehensive documentation. As with Intakes, billing is integrated into progress notes so that each time a progress note is written a charge is posted in the patient’s account and a claim is automatically generated.

Treatment Planning
The e-Record enables clinicians to write treatment plans rapidly using templates that embody clinical pathways and best practices. Organizations and clinicians can use the e-Record’s standard pathways or they can create custom pathways tailored to the unique needs of their client populations. The treatment planning templates enables the creation of pathways that connect problems with symptoms, goals, objectives, and interventions. All templates allow clinicians to further customize elements in the pathway so that treatment plans never have a “canned” quality. CarePaths Treatment Planner has been approved by both CARF and JCAHO.

Outcomes Assessments
Built into the e-Record is a library of widely used client self-report, clinician-rated, and parent-significant other rated instruments. Real time reports are provided to clinicians and clients. Aggregate reporting at the clinician, program, clinic, and PRN level enable organizations to use outcomes measurement for quality improvement and benchmarking. The Patient portal and the Parent/Collateral portal expedites data collection. The automatic email reminder system allows for outcomes protocols to be automated.

Unlimited Electronic Claims Submission
Claims are submitted electronically to payers insuring rapid claims payment.  Users of the eRecord do not need to fill out billing tickets as claims are automatically generated from completed Intakes and Progress Notes. Electronic remittance advice posts automatically to the patient account.  Users who choose not to use the eRecord can use the separate claims submission module and can generate paper HCFA 1500’s if necessary.

Authorization Tracking
Authorization tracking gives the user a place to record authorizations. The system compares services provided with those authorized and alerts the user if there are additional units of service that haven’t been used. e-Claims allows a user to enter a scheduled service and determine if it is covered by an existing authorization.

Manage Receivables
Once claims are submitted, users can record receipts, write-offs and denials through the client ledger. Accounts receivable reports are available for receivables by payer or client.

Reporting
Reports analyze client demographics, claims history, accounts receivable, revenue statements, receipts history, utilization, outcomes and more.  There are hundreds of online reports available as well as an export utility which enables easy export of clinical data to standard formats such as Exel, Access, etc .

Patient Portal
The Patient portal enables clients to login online and fill out all required forms: consent for treatment, disclosure of information, HIPAA privacy notices, insurance and demographic information forms, clinical questionnaires, etc.  Information entered by the patient online populates the eRecord, saving staff time and enabling paperless practice.  Also, the upload function assures paperless practice by enabling paper documents to be scanned into the system.

E-Prescribing
The eRecord has a built in E-Prescriber that enables physicians and nurse practitioners to quickly write and electronically submit prescriptions. Features such as drug lookups, drug interaction alerts, etc are available as well.

Secure Messaging
Clinicians can communicate with each other securely, i.e. protected patient health information, can be sent between clinicians asynchronously.

Forms Maker
Users can create their own forms from scratch or edit CarePaths’ templates from it’s template library.  The eRecord works very much like a shell that allows end users the freedom to capture the information that fits their needs. Custom dictionaries, screens, and drop-down menus are easily created and modeling automatically maps to the database.

Alerts
For each staff, a To-Do list provide reminders of needed progress notes, treatment plan reviews, and other required documentation. Case managers and supervisors have access to staff To-Do lists.

System Access
The e-Record gives administrators granular control over access privileges enabling full compliance with the HIPAA “need to know” rule. Each staff member or group of staff–clerical, clinician, administrator, supervisor, or case manager–can be assigned the permission level privileges that are appropriate to their responsibilities insuring full control over who has access to the information.

Scalability
The e-Record is scalable and can be–and is–used by solo practitioners as well as by large multi-site psychiatric facilities. Features such as a call center (triage) module, user-definable access security, privileging, intra-organizational communications, multidisciplinary assessments, 24/7 access to records, etc. enable large-scale implementations. The core of the system–the intuitive clinical modules–serve the needs of any clinician, be he or she a solo practitioner, member of a small group practice, or staff member of a large treatment facility