The interdependent impact of clinical documentation on both ICD-10 and CPT coding is increasingly apparent in the complex behavioral health field, where attention to detail elevates the standard of care and ensures reimbursement.
As with many aspects of the practice of health care, getting it right is easier said than done.
Coding accuracy requires attention to a host of frequently shifting coding conventions and guidelines, a thorough understanding of the nuances of mental health and behavioral disorders and their various levels of severity, and how diagnosis codes and/or medical decision-making apply within that evolving framework.
To make things even more complicated, many diagnosis codes are not specific enough to be accepted by Medicare and other payers.
ICD-10 captures the why; CPT coding captures the what.
Although many mental health and behavioral health providers have relied on Current Procedural Terminology (CPT) coding developed and maintained by the American Medical Association to file claims for reimbursement, a specific reason is driving the use of ICD-10 coding. It’s the need for greater clarity.
Payers want to get a better picture of the why as well as the what they are being billed for. Health statisticians, researchers, and data analysts want to gain a better understanding of the reasons behind the need for health services and how those reasons drive the need for services.
Let’s review these two types of coding:
- ICD-10 is diagnostic coding. It provides the why behind the services rendered to the beneficiary. ICD- 10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, a medical classification by the World Health Organization (WHO). This classification set contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
- CPT is procedural coding. It provides the what, describing the services rendered. CPT codes describe the medical procedures performed by physicians and other qualified health care professionals, including psychiatric services.
CPT coding and ICD-10 coding are similar. ICD-10 does contain procedure codes, but those procedure codes are only used in inpatient settings. In outpatient settings, many providers use CPT codes to capture services provided.
Commercial insurance companies and the Centers for Medicare and Medicaid (CMS) use both CPT and ICD-10 codes to determine reimbursement rates. In most cases, commercial insurers follow the lead of CMS in determining reimbursement values.
Both ICD-10 and CPT coding must be supported by clinical documentation offering specific information about the beneficiary. Establishing diagnostic criteria and medical necessity for services provided is essential for ICD-10 coding. In the case of CPT codes, medical decision making may also play an integral role in accurate coding.
Coding specificity affects behavioral health in these important ways.
Mental health and behavioral health play a significant role in a person’s overall health. Accurate coding helps key in on specifics that drive quality of care and provide valuable information about individual treatment plans and overall public health data.
Coding accuracy affects the behavioral health field in these three important ways:
- Impacts patient care. Accurate coding ensures consistent documentation of diagnoses and procedures. Greater specificity through standardization leads to clearer communication among healthcare providers, in turn fostering stronger care coordination and collaboration.
- Improves reimbursement. Accurate coding is crucial for obtaining proper reimbursement from insurance companies. Reviews of the primary diagnosis, as well as diagnosis codes for conditions and comorbidities that may impact treatment, can lead to denied claims or reduced payments when there are errors or omissions.
- Informs research. Because mental health and behavioral disorders are major contributors to overall health, accurate coding helps collect information and aggregate data for research and public health purposes. This creates a greater overall understanding of mental health trends and treatment outcomes.
Complexity of behavioral health coding under ICD-10.
ICD-10, or diagnostic coding, is challenging because of its complexity. It demands specificity from all providers, but it can be particularly difficult for mental health and behavioral health providers.
Mental health and behavioral conditions often present with overlapping symptoms, and untangling the precise diagnosis can take time and effort. Co-occurring conditions are often seen. It isn’t unusual, for example, for depression or substance abuse to present with psychosis, or mania. Complications such as mood disorders, delusions, or delirium may occur.
Other issues at play include the severity level of the condition, which must be determined and provided with many mental health or behavioral health diagnoses. Supporting documentation must be provided for the diagnosis and the severity level.
Terminology is another important consideration, with new mental health and behavioral health diagnoses and treatments evolving all the time.
CPT coding brings challenges, too.
CPT coding brings its own challenges to mental health and behavioral health coding.
Medical decision-making, for example, and the level of complexity required, is an important part of Evaluation/Management coding. Accurate coding hinges on documentation that addresses the complexity of problems addressed during the encounter, the complexity of data reviews, and risk of complications.
6 Steps to Strengthen Your Behavioral Health Organization’s ICD-10 and CPT coding
Here are six best practices for behavioral health providers looking to strengthen their coding practices.
1. Stay on top of coding changes. Ongoing education is essential for successful coding. The beginning of each fiscal year brings hundreds of coding revisions and deletions to ICD-10. Guidelines and interpretations often change throughout the year at any time. CPT coding has its own changing requirements. Partnering with a reliable coding company like SimiTree ensures your organization will remain updated on current and best practices.
2. Optimize technology. It’s never been more important to have the right bells and whistles at your disposal. A behavioral health organization is only as accurate as its technology. Most electronic health record (EHR) systems can be easily updated with support tools and tracking assistance to reduce coding errors and improve efficiency. SimiTree’s independent IT consultants work with clients to make the right tweaks no matter the type of EHR.
3. Strengthen documentation. Does your supporting documentation provide a comprehensive picture of the patient’s condition? Be certain to include onset, duration, severity of symptoms, frequency, etc. Clinicians need training to clearly understand the relationship between documentation, coding, and accurate reimbursement.
4. Use specific codes. Use the most specific codes available to describe the patient’s condition. Precision is critical, because getting it wrong can put reimbursement at risk -- delaying payment, bogging down claims processing with additional documentation requests, or giving reason for payment denial.
5. Audit, audit, audit. Frequent internal spot-checks and audits are essential for identifying and correcting problem areas, but it’s also important to rely on independent, external audits for a fresh eye from time to time.
6. Choose the right outsourcing partner. SimiTree helps behavioral health clients navigate the complexities of coding and billing for optimal performance.
SimiTree can help.
When your behavioral health practice is targeted for an audit of any kind, SimiTree has the full resources and expertise to help with any part of the process, including appeals.
However, we recommend proactive action before an audit occurs. Our certified team of healthcare compliance experts is made up of former auditors and surveyors who fully understand Medicare’s review methodology and can help providers code for successfully processing commercial claims. We have experience across all healthcare settings and help clients implement safeguards to mitigate risk.
Our team of compliance experts carefully reviews clinical documentation and billing practices to identify any gaps in care or coding, and work with your organization to implement processes, procedures, and policies for full compliance.
With a full complement of outsourced coding, billing, revenue management, and compliance services, SimiTree offers the solutions your organization needs to ensure the highest level of accuracy and performance day in and day out.
Reach out to us today, and let’s work together to shore up compliance and improve performance at your organization.
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J’non Griffin serves as Senior Vice President/Principal for the Compliance as well as Coding divisions at SimiTree. Her healthcare career spans three decades of clinical and leadership experience, and she has a track record of helping many provider types implement effective compliance programs. She is a certified ACHC and CHAP consultant and holds additional certifications in diagnosis coding and other healthcare specialties. As an AHIMA ambassador, she was instrumental in the implementation of ICD-10.