Medicare Billing for Behavioral Health Screenings: From Reimbursement Policies to Best Practices in Primary Care Collaboration between HealthInsight, HSAG and Noridian November 8, 2017

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Who is HealthInsight?

Our business is redesigning health care systems for the better

HealthInsight is a private, non-profit, community-based organization dedicated to improving health

and health care in the western United States.

www.healthinsight.org | Twitter: @HealthInsight_2

Arizona and California Providers:Where to Go for Help?

Debashish “Dave” Mittra, MBA, PMPExecutive Director, Physician Office Quality

Health Services Advisory Group (HSAG)November 8, 2017

Disclosure

I have nothing to report, nor are there any real or perceived conflicts of interest, implied or expressed, in the following presentation.

Debashish Mittra, Executive Director

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Agenda

• Introduce HSAG

• Resources available for depression and alcohol misuse screening

• Resources available for assistance with QPP and MIPS

• Questions

3QPP = Quality Payment ProgramMIPS = Merit-based Incentive Payment System

HSAG: Your Partner in Healthcare Quality

• HSAG is the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands.

• Committed to improving healthcare quality for more than 35 years.

• QIN-QIOs in every state/territory are united in a network under the Centers for Medicare & Medicaid Services (CMS).

• The Medicare QIO Program is the largest federal program dedicated to improving healthcare quality at the community level.

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HSAG’s QIN-QIO Territory

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HSAG is the Medicare QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands.

Nearly 25 percent of the nation’s Medicare beneficiaries

How Can HSAG Help?

Depression and Alcohol Misuse Screenings

• Tools and resources to support screenings

• Assistance to train staff in conducting screening and document in the electronic health record (EHR)

• Access to best practices and webinars

• Integrate screenings in your practice workflow

• Benefits

– Improve screening rates

– Increase reimbursements

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Participation in QPP and MIPS

• No-cost HSAG QPP Service Center

• Help to select quality measures and improvement activities

• Tools and resources to improve MIPS Quality Scores

• Access to exclusive on-demand live agents to answer your questions

• Invitations to webinars

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How to Get Help

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For questions related to screening and billing Medicare for depression and alcohol misuse screenings:• For Arizona, contact Padma Taggarse

602.801.6962 | ptaggarse@hsag.com

• For California, contact Debashish “Dave” Mittra818.265.4690 | dmittra@hsag.com

For questions and assistance related to QPP and MIPS, please contact our QPP Service Desk:

www.hsag.com/QPP

Questions

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Thank you!

Debashish Mittra, MBA, PMP

HSAG, Executive Director, Physician Office Quality

818.265.4690 | dmittra@hsag.com

This material was adapted by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin

Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, based on original content from CMS. The contents presented do not necessarily reflect CMS policy.

Publication No. QN-11SOW-G.1-10312017-01

Today’s Presenters

Christopher Wells assists clinics, hospitals, in-patient psychiatric facilities and other health care organizations in quality improvement around provider process and patient outcomes. He has worked as a research associate for a non-profit public health evaluation firm. He has experience working with behavioral health providers and served as a research coordinator in a busy Los Angeles medical practice. Christopher received his Master’s in Public Health from UCLA and his undergraduate degrees in psychology and sociology from Georgia State University. He is a regular contributor to Oregon-based Patient-Centered Primary Care Home Institute’s Technical Assistance Network Online Community for practice managers and facilitators.

Lori Weber is the current Idaho, Oregon and Utah Provider Outreach and Education (POE) representative with Noridian Healthcare Solutions, LLC. She joined Noridian, the current Medicare Part B fee-for-service contractor for 13 states and 3 islands, in 2006. She is a local chapter member of the American Academy of Professional Coders or AAPC, on the CMS/Noridian Carrier Advisory Committee (CAC), co-chairman of the Idaho HealthCare Conference (IHCC) and board advisor to Carrington College. She enjoys assisting and educating the provider community.

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Welcome and Introductions

Please type in the chat:• Your geographical location• Position within your

organization (e.g., provider, biller, MA, office manager)

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Alcohol and Depression in Older Adults: The Numbers

Percentage of older adults who die from alcohol-related deaths

each year

Number of older adults who suffer from

depression

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Depression Screening

PHQ-2 PHQ-9

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Alcohol Screening

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Poll

How often do you screen Medicare patients for depression and alcohol use?- Not at all- Less than 25%- 25-50%- 51-74%- 75% or more

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Poll

How often do you bill for depression and alcohol use screening?- Not at all- Less than 25%- 25-50%- 51-74%- 75% or more

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Revenue Potential

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Behavioral Health ScreeningPresented by:

Medicare Part B Provider Outreach and Education November 2017

DISCLAIMER

This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at https://med.noridianmedicare.com/ and the CMS website at http://www.cms.gov

The identification of an organization or product in this information does not imply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2017 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

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Helpful AcronymsAcronym DescriptionCCI Correct Coding InitiativeCR Change RequestE/M Evaluation and Management F2F Face to FaceIOM Internet Only Manual POS Place of Service

USPSTF United States Preventive Services Task Force

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Agenda

• Behavioral Health Screening– Overview– Alcohol Misuse– Depression– Screening, Brief Intervention and Referral to

Treatment (SBIRT) • Annual Wellness Visit (AWV) with above• Resources

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Behavioral Health Screening

Screening Services

• Services detecting undiagnosed disease• Early detection may prevent harm where

and when patient has no – Signs– Symptoms– Laboratory evidence– Radiological evidence– Personal history of disease

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USPSTF• U.S. Preventive Services Task Force (USPSTF)

makes recommendations to guide medical practices, patients and payers to determine– Preventive or screening services recommended for

individual Medicare patients

• Affordable Care Act (ACA), otherwise known as the health care reform bill, requires Medicare – Cover services with A or B rating at 100%, without co-

pay or deductible for Medicare patients

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Alcohol Misuse Screening• G0442 – Annual screening

– Up to 15 minutes• If screening is positive, may have up to 4

counseling sessions in 12-month period • G0443 – Brief F2F counsel – once/day

– Up to 15 minutes• All Medicare beneficiaries eligible• Coinsurance and deductible waived• Allowed in POS 11, 22, 49, 71

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Alcohol Misuse Screening 2

• Medicare beneficiary counseling eligibility:– Alcohol misuse where levels/patterns of

consumption do not meet alcohol dependence and desire to quit

– Competent/alert at time of counseling and furnished by qualified primary care physician or practitioner in primary care setting

• Noridian’s Portal contains eligibility– G0442/G0443 (updated 11/8/17)

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Alcohol Misuse Screening 3

Counseling completed with Five A’s Approach:1. Assess: Ask about or assess behavioral

health risks and factors affecting choice of behavior change goals/methods.

2. Advise: Give clear, specific and personalized behavior change advice, including personal health harms and benefits.

3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

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Alcohol Misuse Screening 4

Counseling continued:4. Assist: Using behavior change techniques (self-help and/or counseling), aid patient in achieving agreed upon goals by acquiring the skills, confidence and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.5. Arrange: Schedule follow-up contacts (in person/telephone) to provide ongoing assistance/support and adjust treatment plan as needed, include referral to more intensive or specialized treatment.

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Eligible ProvidersMay submit claims for G0442 & G0443:• 01-General Practice • 08-Family Practice • 11-Internal Medicine • 16-Obstetrics/Gynecology • 38-Geriatric Medicine • 42-Certified Nurse Midwife (CNM)• 50-Nurse Practitioner (NP)• 89-Certified Clinical Nurse Specialist (CNS)• 97-Physician Assistant (PA)

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Depression Screening – NCD 210.9• G0444 – Annual depression screening

– Up to 15 minutes with all elements met– No specific screening tools

• POS 11,19, 22, 71• Deductible/coinsurance waived• AWV same day per CCI?

– Initial (G0438) no; Established (G0439) yes• Noridian Portal contains eligibility

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Depression Screening 2

• Estimate 1 in 6 (over 65) suffer depression• Does not include treatment options,

therapeutic interventions such as:– Counseling, pharmacotherapy, phone calls, self-

help or medications are non covered• Primary care setting with clinical staff-

assisted support (e.g., RN)– Assures accurate diagnoses, effective treatment,

coordinate referrals and follow up• Not considered primary care: ED, IP hospital,

IP rehab facility, ASC, IDTF, SNF or hospice

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SBIRT Services

• Screening, Brief Intervention and Referral to Treatment (SBIRT)

• G0396 (alcohol/other substance abuse assessment/intervention 15-30 mins.)

• G0397 (additional 30 mins) – Need start/stop times with time-based codes

• Eligible MD, NP, PA, CNM, CNS, CP, CSW • POS 11 (office) or 22 (outpatient hospital)

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SBIRT Services 2

• Identifies, reduces & prevents problematic substance use disorders with early intervention; 3 major components:

1. Screening: risky substance use behaviors using standardized assessment tools

2. Brief Intervention: short conversation providing feedback, motivation and advice up to 5 counseling sessions

3. Treatment Referral: provide to brief therapy/additional treatment if show need

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SBIRT Services 3

• March 2017 - 11 pages– https://www.cms.gov/Outreach

-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/SBIRT_Factsheet_ICN904084.pdf

• Documentation requirements and billing dual eligible

• May perform Telehealth– https://www.cms.gov/Outreach

-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf

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Annual Wellness Visit (AWV)

AWV• G0438 – Once in a lifetime (initial)• G0439 – Annually (subsequent)• No specific diagnosis code required• Coinsurance/deductible waived• Performed by health professional:

– MD, PA, NP, CNS – Other medical professional (health educator,

registered dietitian, nutrition professional or other licensed practitioner)

– Team of such medical professionals, working under direct supervision of physician (e.g. RN)

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Initial AWV Components • Health risk assessment• Establish current providers• Establish medical/family history• Potential depression risk review factors• Review of functional ability/level of safety

Acquire Beneficiary

History

• Obtain measurements• Detection of cognitive impairmentAssessment

• Establish of written screening schedule• Establish list of risk factors and

conditions for intervention• Personalized health advice

Counsel Beneficiary

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Subsequent AWV Components• Update health risk assessment• Update current provider list• Update medical and family history

Update Beneficiary History

• Obtain measurements• Detect cognitive impairmentAssessment

• Update written screening schedule• Update intervention risk

factors/conditions• Personalized health advice

Counsel Beneficiary

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Prepare for AWV Visit

Suggested Information Needed From Patient• Medical records, including immunization• Family health history, as much detail possible• Full list of medications and supplements

Include calcium and vitamins How often/how much of each taken

• Full list of current providers and suppliers involved in providing care

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Preventive Services Checklist

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https://www.medicare.gov/Pubs/pdf/11420.pdf

Miscellaneous TipsCheck CCI if screening allows same day AWV• G0396/G0397 (SBIRT) =

allowed (no CCI)• G0442/G0443 (Alcohol

Misuse) = allowed • G0444 (Depression)

cannot bill same day as IPPE or initial AWV

• Subsequent AWV allowed (G0439)

• Noridian Portal has eligibility searches:– Alcohol Misuse

G0442/G0443 – Depression (G0444)

• Cannot search portal:– AWV (G0438/G0439)– SBIRT G0396/G0397

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In Conclusion……….

• Today, we spoke to Behavioral Health Screenings for Alcohol Misuse, Depression, SBIRT and the AWV

• More Noridian Preventive/Screening PDFs: • JF https://med.noridianmedicare.com/web/jfb/

education/event-materials• JE

https://med.noridianmedicare.com/web/jeb/ education/event-materials

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RESOURCES

IOM References

Medicare Internet Only Manual (IOM)• 100-02, Chapter 15, Section 280.5• 100-03, Chapter 1, Part 4, Section 210 • National Coverage Determination (NCD)

210.8 and 210.9• 100-04, Chapter 18, Sections 140,180, 190

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National Coverage Determination (NCD) 210.8

CMS Preventive Services Chart

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-

QuickReferenceChart-1.html

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Paper Billing with High Return

From Electronic Tracking back to Paper Tracking

Prov

ider

Med

ical

Assis

tant

Billi

ng

Behavioral Health Billing Best Practice 1 of 2

Clips billing document to front of physical paper

chart

Reviews completed screenings, ensures

documentation within EMR prior to

closing chart

Physically checks depression or

alcohol screening on the billing document

Add relevant encounter and

service codes that were checked on the

billing document

Closes chart and returns physical chart to biller for

review

Using traditional pre-EMR billing

checklist document, weekly/bi-weekly meetings are used to indicate which

measures should be looked at closely by individual providers

or the group as a whole

Physically highlights the necessary lines (services) on billing

Using an EMR’s Fullest Potential

Keeping Everyone Accountable

Prov

ider

Med

ical

Assis

tant

Billi

ng

Behavioral Health Billing Best Practice 2 of 2

Morning chart scrubbing – to

include whether annual screenings were conducted

Collects completed screening and enters

into EMRIf high score on

depression/alcohol screen(s) then

verbally mentions to provider and leaves completed form on

front of chart

Closes encounter and ensures

documentation that screening occurred

has been delineated

After chart close, biller reviews the electronic chart to

ensure documentation of

service provided and proper coding

If does not contain both documentation

or coding – biller contacts provider to

close loop

Questions?

Questions and More Information

HealthInsight SupportCall: 503.382.3962

Email: cwells@healthinsight.org Web:

https://healthinsight.org/improving-behavioral-health

This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-G1-17-24 11/8/17

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