Transition from ICD9-ICD10

This was in a newsletter from ValueOptions and I believe it responds to an age old question I have received for many years as to why Clinicians are taught in school to diagnose with DSM when the standard for billing has always been ICD.

Both DSM and ICD codes are used for diagnosis, but per HIPAA, ICD must be used for billing purposes. DSM-5 utilizes ICD-9-CM and ICD-10-CM coding depending on the date of service. The move from ICD-9 to ICD-10 is a rather large change. Some highlights include:

  • · The number of characters are increasing from 3 to 5 characters to 7 characters
  • · Codes can be alpha or numeric on any character
  • · The number of codes is growing from approximately 14,000 to 69,000 codes
  • · The concept of one to many is introduced with the possibility of a single ICD-9 code now having multiple ICD-10 codes and descriptions
  • · Some concepts will be retired – an example is substance dependency where dependency is replaced by use and specific substances are documented vs. polysubstance

Overall, by using ICD-10, documentation should improve

Claims Implications

For purposes of claims payment, the correct ICD diagnosis coding should be utilized based on the date of service. For dates of service prior to October 1, 2015, the ICD-9 coding format should be utilized. For dates of service October 1, 2015 and later the ICD-10 diagnosis coding should be the format utilized. Claims will need to be split between these two dates if submitting for a range of dates.

This applies to all claims regardless of the method of submission.

In Addition, I found this little crosswalk that I thought might be useful.  For more information on this, contact our office at 877-891-9352

Co Pays Coinsurance and Deductibles

We are often asked this question about Co pays, Coinsurance and Deductibles.  We must talk on this topic at least 5-10 times a week to one customer or another.

1) Can you charge the client less than the co pay?

The answer is No you must charge the client the co pay on your ledger but what you accept is between you and the client.  If you are contracted with an insurance company the specific wording in your contract says that you may not charge your client more than the allowable or expect them to pay more than the allowable.  It does not say you cannot accept less than the allowable.  Be aware of what your allowable is for a specific service and do not shortchange yourself.  For instance many times I find that the co pay exceeds the allowable.  So your client comes to you and says I cannot afford 60 per visit so you slide it down to a more reasonable amount for this client and then the insurance comes along and applies all to the co pay and you get whatever you got from the client.  This is something I try to help our customers be aware of when we do the verification of benefits.

2) What is the fee for this client when the client has a coinsurance?

Co pays are a flat amount each service, but coinsurance is a percentage of the allowable for that service.  This amount will differ from service to service.  If you do 45 minutes or 60 minutes the coinsurance amount will change so you can’t set a flat amount for each service unless you intend to do the same service each time.   You must show on their ledger that you charged them the correct coinsurance and no more.  Again what you decide to accept as payment from your client is your business.  The accounting just needs to show that you did indeed charge them that amount.

3) How should I handle the deductible?

Here is the problem with deductibles,  other providers can meet that deductible it is not just your practice.  Be aware if your client is going to other types of providers because if I was to tell you that it will take 10 visits @60.00 per visit to meet that deductible it may take less because the client has seen another provider for a different service and it has been applied to their deductible.  Again if you are contracted with this insurance you do not want to charge the client more than the allowable until they meet that deductible.  If you are not contracted with the Insurance you may charge them your full fee.

These items tend to trip providers up a lot and we try to warn our customers against charging a customer a flat rate to meet the deductible it may be better to take a percentage of the allowed amount and advise them that once the claim has been processed by the insurance there may be a difference that they will be responsible for at a later date. Or you may choose to eat that it is entirely up to you.   Some of our customers use this method if the deductible is less than 1000.00 they will charge the client 50% each visit until deductible is met and if it is more that 1000 but less than 2500 they will charge the client 70-80% your choice until that deductible is met.  If more than 2500 then they charge the client 100%.  But of course it is your practice you can decide which way to do it.  Your billing person should advise you when the insurance starts paying and the client fee can be adjusted.


Medicare Deductible FAQ

Q: When is it acceptable to collect the deductible from the beneficiary?
A: When assignment is accepted, Medicare Part B recommends:
• Since it is difficult to predict when deductible/coinsurance amounts will be applicable – and over-collection is considered program abuse – do not collect these amounts until you receive Medicare Part B payment.
• If you believe you can accurately predict the coins…urance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. (We do not recommend that you collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse and can cause a portion of the provider’s check to be issued to beneficiaries on assigned claims.)
•This was posted under FAQ on Medicare Part B website. The deductible for 2014 will remain the same it will continue to be 147.00. Some folks have it covered with their supplements while others do not. Also to just give you the heads up the fees will change on January 1 and I do not have the fee schedule at this time but Medicare will be paying all Mental Health Services at 80% instead of the 65% they have been paying as of January 1, 2014.

Medicare Reimbursement Schedules 2013

Medicare has put out their reimbursement schedules for 2013.   DB Management configures these reimbursement schedules for the Behavioral Health Community and has them available for sale.  These schedules are calculated according to allowable, expectation of payment from Medicare and secondary or client responsibility.  The new CPT codes are included in these schedules along with Office EM codes that physicians and other prescribers will have to use.  These are available by sending us an email and requesting them.  If you would like one for your state and location, please contact our office via email at  Updates to these schedules for 2013 due to a rollback that will not occur until probably February will be provided at no extra cost.   Just an FYI the new Crisis Intervention codes are not covered by Medicare, however they are covered by some insurers.  Please feel free to leave a comment or a question in the comment section and we will get back to you.

More on CPT Coding Changes 2013

Many of my customers have been asking me about the new code changes and some of the answers are not quite clear.  You see most of the insurance industry has latched on to the idea that the former code of 90806 translates to 90834.  Well here is the problem with that 90834 is for 45 minutes.  Most of my customers will provide 55-60 minutes of therapy.   They more or less did away with the 90808 and they say they replaced it with 90837.  The other issue is that most of the insurance companies have latched on to this crosswalk and our fear is that they will not allow 90837 to be used routinely.  In fact the reimbursement for 90834 by Florida Medicare standard is about 43.00 for 2013.  This is extremely low.  So I would suggest using 90837 sparingly as we venture into 2013 and watch for indicators that your pay sources will pay for this code as opposed to using the 90834.   Just a suggestion and an experiment as we venture into these uncharted territories.

Medicare Reimbursement Changes 2013

There are a few things to be aware of for the coming year. The Medicare deductible goes up to $147.00 in 2013 and the Psychiatric deduction for reimbursement is now 81.25% instead of 75% as in recent years.  In addition the allowable for Medicare rates although the new published rates are down from last year will be reimbursed at 65% for service codes that begin with 908XX.  Hopefully Congress will intervene and correct this reduction of fees like they have every year since about 2003.  

The new evaluation code is 90791 for Initial Assessment w/o Medication Management and 90792 for Initial Assessment with Medication Management.   There are also some add on codes that become very confusing about when and where to use them.   This I would state will iron themselves out in the new year.  There are a number of places that are providing seminars etc… on the new coding and you would benefit your practice to read up and find out as much as you can.  

As always we are trying to stay ahead of the ever changing reimbursement environment.  We invite your comments and suggestions of information you would like to see discussed here.

CPT Coding Changes for 2013

During the past month or so we have received announcements from the Florida Federal Advocacy Coordinator for the APA and the National Council for Community Behavorial Health Care regarding changes for CPT Coding in 2013.   As we have reviewed this infomation it is noted that the most significant changes are for Psychiatrist and nurse practitioners.  A crosswalk regarding these coding changes is attached below.   It appears that beginning in 2013 those medication providers will be using a two code system.  The first code will be an evaluation and management code followed by an add on code.   For those providers who do not do medication management it is more of a simple change from 90804 to 90832.  For the Interactive codes you are permitted to use an add on code when complexity indicates the need for one but in general the crosswalk shows that the codes 90804, 90806 and 90808 will be deleted and replaced with 90833, 90836, and 90838.  


The Medicare rate schedule should be out by the end of November and perhaps at that time we will see some mention of this but at this time none of the Medicare MAC’s have mentioned this change nor have we seen anything coming from the different insurance carriers.  All this information is coming from the various associations and has not been implemented or addressed by insurance companies at this time.  We will have to wait an see how they intend to handle the transition.  More on this as things come up.

October 30, 2012     Update we have just received notification from New Directions who is the Managed Care for BCBS of Florida that these codes will be changing effective 01/01/2013.  We have yet to see anything posted for Medicare at this time.  More as these changes are recognized by the different insurors.

Medicare Fraud

Today in the news there was a flash across the screen concerning  the arrest of providers for Medicare Fraud.  Be aware of what constitutes fraud and what you can do to keep your practice ethical and legal.  Fraud is when services are either not considered necessary because the diagnosis and patient’s condition do not require the type of treatment that you are billing for or services that are billed were not provided.  The Medicare Population may not always have the best memory about the visits, so you need to protect yourself.  One of the ways I would suggest is that you maintain your records accurately and obtain a signature each and every time you see a client.  You can use a sign in sheet with removable labels so as not to compromise confidentiality.   I would also recommend that you make sure  clinical documentation backs up each and every visit.  The documentation should include a note that confirms your diagnosis and prognosis on each and every visit.  If Medicare comes knocking on your door you will be asked to produce this and because you are a Medicare participating provider you must comply.     Some of the things these providers that were arrested are clearly fraudulent and make it really bad for the rest of providers that are merely trying to make a living.  So my advice to you is keep good records.  Make sure that if you are billing for a service it was indeed provided and you have the documentation to support it.


Great West Health Information

Behavioral health benefits for your patients with a GWH-Cigna ID card are now being managed by Cigna. This change was effective May 1, 2012. Benefits for these patients had previously been managed by Value Options.

Contact Information
If you need to verify eligibility and benefits for your patients with a GWH-Cigna ID card, please contact us at 1.877.299.0656.
If you have questions regarding a claim, please contact us at 1.877.299.0658.

If you need an authorization, need to determine authorization requirements, or need to find a list of health care professionals for a referral, please contact us at 1.866.912.3339.
The claim address for your patients with a GWH-Cigna ID card is:
1000 Great West Dr
Kennett, MO 63857
If you submit claims electronically, the payer ID is 80705.
If you have contracting or credentialing questions, please contact your provider services department at 1.800.926.2273.

The Difference between Medicare and Medicaid

There are two programs that are often confused by the general population.  Most people do not know or understand the differences including most politicians.  Medicare is administered by the Federal Government .  I should qualify that statement by saying that all the rules on Medicare are dictated by the Federal Government and are the same from state to state.    They use what is called MAC’s to administer the claims process strategically located across the United States.

For Medicaid each state administers it’s own Medicaid and every state will have different benefits.  The Federal Government funds a portion of Medicaid to each and every state and mandates a specific amount of requirements that each state has to adhere to but each state sets the policy guidelines.   That is why when a patient who is on Medicaid in one state will have to reapply when moving to another state.   Medicaid is a state to state program.  Eligibility criteria will differ from one state to another as do the benefits.  In addition, provider eligibility will differ from state to state as well.

In simple terms, eligibility for Medicare depends on age or disability while Medicaid is determined by a financial criteria.  Each state sets those limits.  In one state an eligible recipient has to have income less than 11,700 while another state might say 7,000.  Those numbers are purely examples and not linked to any state criteria known.

My point is that although both programs come under the CMS umbrella, they are very different in the way they are managed.  Medicare is funded by the Social Security Trust Fund and member participation while Medicaid is funded partially by the Federal government and the rest being the responsibility of the State.   Medicare benefits are the same all over the country while Medicaid is different from State to State.

In Florida there is no provider status for licensed master level providers while in other states licensed master level providers are recognized by Medicaid.  For Medicare licensed clinical social workers are recognized in all states.  Next time a little thought process on the problem with the Social Security Trust Fund.