Do You Know What You Don’t Know? Protect Yourself from Audits with Compliance Watch

by Nina Marshall on December 13, 2012

By Guest Columnist Nina Marshall, Director of Public Policy, National Council for Community Behavioral Healthcare

It’s always dangerous when you don’t know what you don’t know. Sitting beside me as I write this is a stack of questions that have been sent to me from around the country, all from people who are trying to understand the impact that the 2013 Current Procedural Terminology (CPT) code set will have on their organizations and how they deliver services.

Here are a few from the top of my stack:

  • “The CPT code book says that the new Interactive Complexity (+90785) code can be used when an interpreter or translator is used because the patient and health care professional don’t speak the same language, but CMS’ physician payment rule says that using that code for translation or interpretation services could result in discrimination because of higher beneficiary co-payments and it might be in violation of the ADA and Section 504 of the Rehabilitation Act of 1973. Now what? Is that only for Medicare, or for all payers?”
  • “If a patient is seen by a psychiatric nurse practitioner in the practice, and later seen by a psychiatrist, should the E/M code submitted by the psychiatrist be as a ‘new’ or ‘established’ patient? The CPT manual seems to be clear, but then we’ve also heard that references to ‘physician’ are sometimes shorthand for ‘physician or other qualified healthcare professional.’ Which way do auditors see it?”
  • “We’ve been told that billing Established clients on Time will create a red flag for audits because they only happen about 20% of the time… is this a reasonable prediction?”
  • “If doing a Medication Management assessment is there a particular way in which the Review of Systems is supposed to be addressed? We typically do 45-minute assessments (based on the Elements, not on Time) and in order to complete that level (99204) the Review of Systems needs to be “comprehensive” and at least ten systems need to be addressed. Is this as simple as asking them related questions or does it need it to be more thorough?”
  • “Should we be using rating scales and problem points to be establishing our level of complexity?”
  • “Is there any reliable data for the national averages on E/M codes for psychiatry services that we could compare ourselves against? I’m worried about both over-coding and under-coding.”

While these questions are daunting – and complex, and somewhat tedious to answer, and have so many caveats – at least these writers know what they don’t know. At least they are asking the questions!

This whole transition makes me nervous – it’s a steep learning curve , period – but what really stands out for me is how few people are asking questions at this level of detail. My hunch is that those who aren’t asking the questions don’t know what they don’t know.

Behavioral health providers have had the option to use Evaluation and Management codes for some time (cue my caveat: so long as payers permitted use of those codes and state scope of practice laws aligned with payer policy and the CPT code set). Now, though, we are being pushed full forward into a realm that requires far more documentation, nuanced code selection processes that we haven’t previously needed to pay attention to, and which has the potential to open us up to far more scrutiny by auditors. Sure, we can submit a claim and get paid today, but what risks are we incurring when we don’t know all that comes along with using a particular code?

Here at the National Council, we are continuously adding new resources to our CPT Resource page, we’re working with our partners at MTM Services to increase availability for trainings and consultation services, and we’re launching a new series in Compliance Watch on Evaluation and Management codes. With a Compliance Watch subscription, you can learn everything you need to know to protect yourself from an audit when using the new CPT codes. Post in the comments section below to let us know what else we can be doing to move behavioral health into a better position.



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