Cheat Sheet for MHC and BHO Information Systems (IS)
SUBMITTING ENCOUNTERS/CLAIMS FOR NEW CODES, CURRENT STATUS
For 837s, the 5010 X12 standard already allows for multiple services to be reported within the same “claim loop”. For example, a hospital can (and typically does) bill multiple services for the same client, on the same day (but with different procedure codes) under the same claim number. It is possible that we can do the same for primary service codes + add-on codes using the same claim number, if the State desires it. However, it is also possible that the State can continue to receive services with distinct claim numbers. We should seek instructions/direction from the State, just as we would with any other payer.
For the Flat File, which is a HCPF-derived standard, we need to wait for directions/instructions from HCPF on how to proceed differently (if at all). It is possible that the current Flat File can accommodate the 2013 CPT code changes without any modification.
***The CBHC Coding Subcommittee has met with HCPF to sort out these processes. We will provide answers as soon as we receive them***
NEW CONCEPTS
Evaluation and Management codes (E&M): These are codes that specifically begin with 99.
The specific E&M code that a prescriber picks and will be billed depends on three major components:
- History
- Examination
- Medical Decision Making
In addition, the level of service also determines the correct E&M code to be picked.
Add on codes: Add on codes allow for showing additional work done on a primary service code. E.g., Psychotherapy done by a prescriber in addition to medication management.
- When billing a primary code with additional related (add-on) codes, the primary code and the additional add-on code(s) must appear on the same claim. The primary code MUST appear on the claim first preceding the add-on codes.
- Add-on codes are reimbursable services when reported in addition to the appropriate primary service by the same individual physician or other health care professional. Add-on codes reported as stand-alone codes are not reimbursable services in accordance with Current Procedural Services (CPT®) and the Centers for Medicare and Medicaid (CMS) guidelines.
- The primary code and add-on codes must be billed by the same individual physician or other health care professional reporting under the same Federal Tax Identification number.
- Add-on procedures must be reported with the primary procedure for the same date of service.
CODE CHANGES SUMMARY
Deleted Codes90801
90802
90804
90805
90806
90807
90808
90809 / 90810
90811
90812
90813
90814
90815
90816
90817
90818
90819 / 90821
90822
90823
90824
90825
90826
90827
90828
90829 / 90857
90862
New Codes
90791
90792
90832
90834
90837
90839
E&M Codes used for Medication Management or in conjunction with psychotherapy
Office or Other outpatient Visit/Consultations / Nursing Home / Hospital Services/Inpatient consultations / Rest Home, boarding home, Custodial Care
99201
99202
99203
99204
99205 / 99211
99212
99213
99214
99215
99241
99242
99243
99244
99245 / 99304
99305
99306
99307
99308
99309
99310
99315
99316
99318 / 99217
99218
99219
99220
99224
99225
99226
99231
99232
99233
99234
99235 / 99236
99238
99239
99251
99252
99253
99254
99255
99366
99367
99368
99441 / 99442
99443
99337
99341
99342
99343
99344
99345
99347
99348
99349
99350 / 99324
99325
99326
99327
99328
99334
99335
99336
99337
New Add-on codes
+90785, Interactive Complexity
+90833, 30-minute psychotherapy add-on code. Can be combined with any E&M code
+90836, 45-minute psychotherapy add-on code. Can be combined with any E&M code
+90838, 60-minute psychotherapy add-on code. Can be combined with any E&M code
+90840, 30-minute psychotherapy for crisis add-on code. To be used with crisis code 90839 as needed.
+99354 to +99357, Add on codes for prolonged services-DO NOT USE YET
Changes in two existing codes
90875, Duration changed to 30 minutes
90876, Duration changed to 45 minutes
Possible CPT Primary and Add On Code Combinations Allowed for Billing for Frequently Used Codes.
Follow similar logic for other E&M codes 999201-99255, 99304-99337, 99341-99350 when using Add on code 90785
Exceptions: Do not report 90875 in conjunction with 90839, 90840, or in conjunction with E/M services when no psychotherapy service is reported.
Evaluation and Management (Outpatient, New patient) / Evaluation and Management (Outpatient, Established) / Evaluation and Management (Inpatient) / Psychotherapy
Psychotherapy during crisis
Group Psychotherapy / Psychiatric Diagnostic Evaluation
99201...or…
99201 + 90833
99201 + 90836
99201 + 90838
99201 + 90833 + 90785
99201 + 90836 + 90785
99201 + 90838 + 90785
99202...or…
99202 + 90833
99202 + 90836
99202 + 90838
99202 + 90833 + 90785
99202 + 90836 + 90785
99202 + 90838 + 90785
99203...or…
99203 + 90833
99203 + 90836
99203 + 90838
99203 + 90833 + 90785
99203 + 90836 + 90785
99203 + 90838 + 90785
99204...or…
99204 + 90833
99204 + 90836
99204 + 90838
99204 + 90833 + 90785
99204 + 90836 + 90785
99204 + 90838 + 90785
99205…or…
99205 + 90833
99205 + 90836
99205 + 90838
99205 + 90833+90785
99205 + 90836+90785
99205 + 90838+90785 / 99211…or…
99211 +90833
99211+90836
99211+ 90838
99211 +90833+90785
99211+ 90836+90785
99211+ 90838+90785
99212…or…
99212 +90833
99212+90836
99212+ 90838
99212 +90833+90785
99212+ 90836+90785
99212+ 90838+90785
99213…or…
99213 +90833
99213+90836
99213+ 90838
99213 +90833+90785
99213+ 90836+90785
99213+ 90838+90785
99214…or…
99214+90833
99214+90836
99214+90838
99214+90833+90785
99214+90836+90785
99214+90838+90785
99215…or…
99215+90833
99215+90836
99215+90838
99215+90833+90785
99215+90836+90785
99215+90838+90785 / 99221…or…
99221+90833
99221+90836
99221+90838
99221+90833+90785
99221+90836+90785
99221+90838+90785
99222…or…
99222+90833
99222+90836
99222+90838
99222+90833+90785
99222+90836+90785
99222+90838+90785
99223…or…
99223+90833
99223+90836
99223+90838
99223+90833+90785
99223+90836+90785
99223+90838+90785
99231…or…
99231+90833
99231+90836
99231+90838
99231+90833+90785
99231+90836+90785
99231+90838+90785
99232…or---
99232+90833
99232+90836
99232+90838
99232+90833+90785
99232+90836+90785
99232+90838+90785
99233…or…
99233+90833
99233+90836
99233+90838
99233+90833+90785
99233+90836+90785
99233+90838+90785 / 90832…or…
90832+90785
90834…or…
90834+90785
90837…or
90837+90785
90839…or…
90839+90840
90839+90840+90840+…etc. (e.g., you can keep adding more ‘90840’s to cover the time you spent with
this session)
90853…or…
90853+90785 / 90791…or…
90791+90785
90792…or…
90792+90785
USING AND CODING E&M CODES
Choosing an appropriate E&M codes involves a variety of categories and levels of care. Prescribers are being trained on how to use these codes. To help IS code these combinations of categories and levels of care, we are proving you with cross tables. These tables are simple and only serve as a reference document. Clinicians and IS teams will need to work together to make the system configuration process meaningful.
Outpatient Office Visits E&M codes*Shows the number of the three key components: Exam, History, and Medical decision making needed to bill the code
Code / Type / History / Exam / Medical Decision-Making / Time
Problem Focused / Extended Problem Focused / Detailed / Comprehensive / Problem Focused / Extended Problem Focused / Detailed / Comprehensive / Straightforward / Low complexity / Moderate Complexity / High Complexity / Avg. Time
99201 / New Patient Office or other outpatient Visit *Requires 3 of 3 / X / X / X / 10 MIN
99202 / New Patient Office or other outpatient Visit *Requires 3 of 3 / X / X / X / 20 MIN
99203 / New Patient Office or other outpatient Visit *Requires 3 of 3 / X / X / X / 30 MIN
99204 / New Patient Office or other outpatient Visit *Requires 3 of 3 / X / X / X / 45 MIN
99205 / New Patient Office or other outpatient Visit *Requires 3 of 3 / X / X / X / 60 MIN
99212 / Established Patient Office or Outpatient Visit **Requires 2 of 3 / X / X / X / 10 MIN
99213 / Established Patient Office or Outpatient Visit **Requires 2 of 3 / X / X / X / 15 MIN
99214 / Established Patient Office or Outpatient Visit **Requires 2 of 3 / X / X / X / 25 MIN
99215 / Established Patient Office or Outpatient Visit **Requires 2 of 3 / X / X / X / 40 MIN
Inpatient, Nursing Home, Rest Home, Boarding Home, Custodial Care E&M codes
*Shows the number of the three key components: Exam, History, and Medical decision making needed to bill the code
Code / Type / History / Exam / Medical Decision-Making / Time
Problem Focused / Extended Problem Focused / Detailed / Comprehensive / Problem Focused / Extended Problem Focused / Detailed / Comprehensive / Straightforward / Low complexity / Moderate Complexity / High Complexity / Avg. Time
INITIAL INPATIENT CARE / 99221 / Initial Inpatient Hospital Care. New or established patient. * Requires 3 of 3 / X / X / X / X / 30
99222 / Initial Inpatient Hospital Care. New or established patient. * Requires 3 of 3 / X / X / X / 50
99223 / Initial Inpatient Hospital Care. New or established patient. * Requires 3 of 3 / X / X / X / 70
SUBSEQUENT INPATIENT CARE / 99231 / Subsequent Hospital Care. New or established patient. **Requires 2 of 3 / X / X / X / X / 15
99232 / Subsequent Hospital Care. New or established patient. **Requires 2 of 3 / X / X / X / 25
99233 / Subsequent Hospital Care. New or established patient. **Requires 2 of 3 / X / X / X / 35
INITIAL OBSERVATION CARE / 99218 / Initial Observation Care. New or established patient. * Requires 3 of 3 / X / X / X / X / X / X / 30
99219 / Initial Observation Care. New or established patient. * Requires 3 of 3 / X / X / X / 50
99220 / Initial Observation Care. New or established patient. * Requires 3 of 3 / X / X / X / 70
SUBSEQUENT OBSERVATION CARE / 99224 / Subsequent Observation Care. New or established patient. *Requires 2 of 3. / X / X / X / X / 15
99225 / Subsequent Observation Care. New or established patient. *Requires 2 of 3. / X / X / X / 25
99226 / Subsequent Observation Care. New or established patient. *Requires 2 of 3. / X / X / X / 35
OBSERVATION OR INPATIENT CARE ADMIT & DC SAME DAY / 99234 / Observation or Inpatient Care including admit and discharge on same day. New or established patient. *Requires 3 of 3 / X / X / X / X / NA
99235 / Observation or Inpatient Care including admit and discharge on same day. New or established patient. *Requires 3 of 3 / X / X / X / NA
99236 / Observation or Inpatient Care including admit and discharge on same day. New or established patient. *Requires 3 of 3 / X / X / X / NA
INITIAL NURSING HOME CARE / 99304 / Initial Nursing Facility Care. New or established patient. *Requires 3 of 3. / X / X / X / X / 25
99305 / Initial Nursing Facility Care. New or established patient. *Requires 3 of 3. / X / X / X / 35
99306 / Initial Nursing Facility Care. New or established patient. *Requires 3 of 3. / X / X / X / 45
SUBSEQUENT NURSING HOME CARE / 99307 / Subsequent Nursing Facility Care. New or established patient. *Requires 2 of 3. / X / X / X / 10
99308 / Subsequent Nursing Facility Care. New or established patient. *Requires 2 of 3. / X / X / X / 15
99309 / Subsequent Nursing Facility Care. New or established patient. *Requires 2 of 3. / X / X / X / 25
99310 / Subsequent Nursing Facility Care. New or established patient. *Requires 2 of 3. / X / X / X / 35
NURSING HOME DISCHARGE
OR ANNUAL REVIEW / 99315 / Nursing Facility Discharge 30 minutes or less / 30 or <30
99316 / Nursing Facility Discharge >30 minutes / >30
99318 / Annual Nursing Facility Assessment
*Requires 3 of 3 / X / X / X / X / 30
REST HOME, BOARDING HOME, CUSTODIAL CARE / 99324 / Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3. / X / X / X / 20
99325 / Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3. / X / X / X / 30
99326 / Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3. / X / X / X / 45
99327 / Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3. / X / X / X / 60
99328 / Rest Home, Boarding Home, Custodial Care. New patient. *Requires 3 of 3. / X / X / X / 75
99334 / Rest Home, Boarding Home, Custodial Care. Established patient. *Requires 3 of 3. / X / X / X / 15
99335 / Rest Home, Boarding Home, Custodial Care. Established patient. *Requires 3 of 3. / X / X / X / 25
99336 / Rest Home, Boarding Home, Custodial Care. Established patient. *Requires 3 of 3. / X / X / X / 40
99337 / Rest Home, Boarding Home, Custodial Care. Established patient. *Requires 3 of 3. / X / X / X / 60
EXAMPLE FROM MHCD, DRAFT CODING FOR E&M SERVICES
Please note: Some MHCs have requested an example of how to code E&M codes in their EMRs. MHCD is sharing their draft coding. Please make sure to check the 2013 CPT code book for accuracy.
START EMCodingQuestions(parmfile, option, client, retcode)parmfile is x, option is x, client is x, retcode is x
$allowupdate(retcode)
sCPT is x
bNewPatient is b
sPctCounseling is x
sPctCoordination is x
tDuration is t
iHistory is i'1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensive
iExam is i'1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensive
iComplexity is i'1 = straightforward, 2 = low, 3 = moderate, 4 = high
iPresentingPx is i'1 = minimal, 2 = minor, 3 = low, 4 = moderate, 5 = high
%define kTitle "E/M Supplemental Questions"
%define true 1
%define false 0
rc is i
EnterData(client, bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx)
sCPT = ComputeEM(bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx)
'Note, in order to be useful, this program should then do something with the CPT code that is calculated.
END EMCodingQuestions
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
dynamic function EnterData(sConsumer, bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx) is null
sConsumer is x
bDone is b
bNewPatient is b
sPctCounseling is x
sPctCoordination is x
tDuration is t
iHistory is i'1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensive
iExam is i'1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensive
iComplexity is i'1 = straightforward, 2 = low, 3 = moderate, 4 = high
iPresentingPx is i'1 = minimal, 2 = minor, 3 = low, 4 = moderate, 5 = high
sErrorMsg is x
$allowupdate(bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx)
bDone = false
do until bDone = true
$form()
$tag("<center>")
$text(kTitle, "H1")
$br(2)
if sErrorMsgdp then
$text(sErrorMsg, "error")
endif
$table(1)
$row()
$col()
$text("Consumer status*", "datatag") $br()
$radio(bNewPatient, "New", true) $br()
$radio(bNewPatient, "Established", false)
$col()
$text("Duration of E/M encounter*", "datatag") $br()
$textbox(tDuration, "DUR", 5, 5)
$row()
$col()
$text("Percent of encounter devoted to counseling*", "datatag") $br()
$textbox(sPctCounseling,,3,3) 'note, it would be really nice if there were a numeric edit available for textboxes...
$col()
$text("Percent of encounter devoted to coordination of care*", "datatag") $br()
$textbox(sPctCoordination,,3,3)
$row()
$col()
$text("Extent of history obtained*")
$dropbox(iHistory, "Problem-focused", 1)
$dropbox(iHistory, "Expanded problem-focused", 2)
$dropbox(iHistory, "Detailed", 3)
$dropbox(iHistory, "Comprehensive", 4)
$col()
$text("Extent of examination performed*")
$dropbox(iExam, "Problem-focused", 1)
$dropbox(iExam, "Expanded problem-focused", 2)
$dropbox(iExam, "Detailed", 3)
$dropbox(iExam, "Comprehensive", 4)
$row()
$col()
$text("Complexity of medical decision making*")
$dropbox(iComplexity, "Straightforward", 1)
$dropbox(iComplexity, "Low", 2)
$dropbox(iComplexity, "Moderate", 3)
$dropbox(iComplexity, "High", 4)
$col()
$text("Nature of the presenting problem*")
$dropbox(iPresentingPx, "Minimal", 1)
$dropbox(iPresentingPx, "Self-limited or minor", 2)
$dropbox(iPresentingPx, "Low severity", 3)
$dropbox(iPresentingPx, "Moderate severity", 4)
$dropbox(iPresentingPx, "High serverity", 4)
$endtable(1)
$tag("</center>")
$sendform()
$clear(sErrorMsg)
bDone = "libNTExtra":ValidateEM(sConsumer, bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx, sErrorMsg)
enddo
end EnterData
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
dynamic function ComputeEM(bNewPatient, tDuration, sPctCounseling, sPctCoordiation, iHistory, iExam, iComplexity, iPresentingPx) is x
bNewPatient is b
sPctCounseling is x
sPctCoordination is x
tDuration is t
iHistory is i'1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensive
iExam is i'1 = Problem-focused, 2 = Expanded Px focused, 3 = detailed, 4 = comprehensive
iComplexity is i'1 = straightforward, 2 = low, 3 = moderate, 4 = high
iPresentingPx is i'1 = minimal, 2 = minor, 3 = low, 4 = moderate, 5 = high
iPctCounseling is i
iPctCoordination is i
iPctBoth is i
iPctCounseling = $casti(sPctCounseling)
iPctCoordination = $casti(sPctCoordination)
iPctBoth = iPctCounseling + iPctCoordination
select bNewPatient
case true
if iPctBoth > 50 then 'when Counseling and Coordination > 50% of session, E/M is time-based
select tDuration
case >= 53
ComputeEM = "99205"
case >= 38
ComputeEM = "99204"
case >= 25
ComputeEM = "99203"
case >= 15
ComputeEM = "99202"
case other
ComputeEM = "99201"
endselect
else
select iHistory
case 4
select iExam
case 4
select iComplexity
case 4
ComputeEM = "99205" 'History 4, Exam 4, Complexity 4
case 3
ComputeEM = "99204" 'History 4, Exam 4, Complexity 3
case 2
ComputeEM = "99203" 'History 4, Exam 4, Complexity 2
case 1
ComputeEM = "99202" 'History 4, Exam 4, Complexity 1
endselect
case 3
select iComplexity
case >= 2
ComputeEM = "99203" 'History 4, Exam 3, Complexity >= 2
case 1
ComputeEM = "99202" 'History 4, Exam 3, Complexity = 1
endselect
case 2
ComputeEM = "99202" 'History 4, Exam 2, Complexity any
case 1
ComputeEM = "99201"'History 4, Exam 1, Complexity any
endselect
case 3
select iExam
case >= 3
select iComplexity
case >= 2
ComputeEM = "99203" 'History 3, Exam >= 3, Complexity >= 2
case 1
ComputeEM = "99202" 'History 3, Exam >= 3, Complexity 1
endselect
case 2
ComputeEM = "99202" 'History 3, Exam 2, Complexity any
case 1
ComputeEM = "99201"'History 3, Exam 1, Complexity any
endselect
case 2
if iExam >= 2 then
ComputeEM = "99202" 'History 2, Exam >= 2, Complexity any
else
ComputeEM = "99201" 'History 2, Exam 1, Complexity any
endif
case 1
ComputeEM = "99201" 'History 1, Exam any, Complexity any
endselect
endif
'Existing Patient Logic
case false
if iPctBoth > 50 then 'when Counseling and Coordination > 50% of session, E/M is time-based
select tDuration
case >= 33
ComputeEM = "99215"
case >= 20
ComputeEM = "99214"
case >= 13
ComputeEM = "99213"
case >= 8
ComputeEM = "99212"
case other
ComputeEM = "99211"
endselect
else
select iHistory
case 4
if iExam = 4 or iComplexity = 4 then
ComputeEM = "99215"
elseifiExam = 3 or iComplexity = 3 then
ComputeEM = "99214"
elseifiExam = 2 or iComplexity = 2 then
ComputeEM = "99213"
else
ComputeEM = "99212"
endif
case 3
if iComplexity = 4 and iExam = 4 then
ComputeEM = "99215"
elseifiComplexity >= 3 or iExam >= 3 then
ComputeEM = "99214"
elseifiComplexity = 2 or iExam = 2 then
ComputeEM = "99213"
else
ComputeEM = "99212"
endif
case 2
if iComplexity = 4 and iExam = 4 then
ComputeEM = "99215"
elseifiComplexity >= 3 and iExam >= 3 then
ComputeEM = "99214"
elseifiComplexity >= 2 or iExam >= 2 then
ComputeEM = "99213"
else
ComputeEM = "99212"
endif
case 1
if iComplexity = 4 and iExam = 4 then
ComputeEM = "99215"
elseifiComplexity >= 3 and iExam >= 3 then
ComputeEM = "99214"
elseifiComplexity >= 2 and iExam >= 2 then
ComputeEM = "99213"
else
ComputeEM = "99212"
endselect
endif
endselect
end ComputeEM
1