Coding for Mental Health Disorders in
Primary Care
Amy Heneghan, M.D.
Palo Alto Medical Foundation
[email protected]
Learning Objectives
Participants will be able to…
• Expand awareness of codes useful in describing
mental health and behavioral conditions
commonly seen in primary care
• Learn how to bill insurers appropriately for the
activities involved in caring for children with
mental health and behavioral problems
• Understand how the medical home model applies
to caring for children with mental health and
behavioral problems
Diagnoses: What is it?
• International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM)
– Arranges diseases and injuries into groups according to
established criteria
– Revised approx. q 10 years by WHO, annual updates by
Centers for Medicare and Medicaid Services (CMS)
– ICD-10-CM officially replaces ICD-9-CM on October 1, 2013,
• Diagnostic and Statistical Manual of Mental DisordersFourth Edition (DSM-IV):
– Published by the American Psychiatric Association (APA)
– Aim: to develop an official nomenclature of mental
– Subset of the ICD-9-CM: 290-319 series
Procedures: What did you do about it?
• Current Procedural Terminology (CPT)*:
‒Listing of descriptive terms and 5-digit numeric identifying
codes/modifiers for reporting medical services performed by
physicians and other qualified medical providers
‒Designated as the national procedural coding standard under
the Health Care Portability and Accountability Act
* CPT copyright 2011 American Medical Association. All rights reserved.
Payments: What is its financial value?
• AMA/Specialty Society Relative Value Update
Committee (RUC):
‒ Assigns appropriate relative value units for
practice expense, physician work and
malpractice expense
• 21% of U.S. children and adolescents meet diagnostic
criteria for mental health disorder with impaired
• 16% or more of U.S. children and adolescents have
impaired mental health functioning and do not meet
criteria for a disorder
• Despite “parity” legislation, ICD-9 and DSM-IV codes
are often treated differently when they are used by
primary care primary providers.
• Possible that 30% of your submitted claims rejected by
private payers because they refuse to pay you for
managing conditions in the ICD-9 290-319 series!
• ICD-9 selected must be most specific
• ICD-9 selected as primary diagnosis must
describe the condition necessitating the visit
• ICD-9 code does not determine the level of
the service (i.e. CPT or E/M code)
• V-codes can be used for diagnoses, but can be
problematic for some primary diagnoses
exceptions: V20.2, V60-V69
ICD-9 codes for mental health
• Organic Psychotic Conditions 290-294
• Other Psychoses 295-299
• Neurotic Disorders, Personality Disorders, And
Other Non-psychotic Mental Disorders 300-316
• Mental Retardation 317-319
• Symptoms, Signs, And Ill-Defined Conditions 780799
• Persons Encountering Health Services In Other
Circumstances V60-V69
2011 ICD-10-CM Diagnosis Codes
Mental and behavioral disorders F01-F99
F01-F09 Mental disorders due to known physiological conditions
F10-F19 Mental and behavioral disorders due to psychoactive substance use
F20-F29 Schizophrenia, schizotypal and delusional, and other non-mood psychotic
F30-F39 Mood [affective] disorders
F40-F48 Anxiety, dissociative, stress-related, somatoform and other nonpsychotic
mental disorders
F50-F59 Behavioral syndromes associated with physiological disturbances and
physical factors
F60-F69 Disorders of adult personality and behavior
F70-F79 Mental retardation
F80-F89 Pervasive and specific developmental disorders
F90-F98 Behavioral and emotional disorders with onset usually occurring in
childhood and adolescence
F99-F99 Unspecified mental disorder
Organic Psychotic Conditions 290-294
290 Dementias
291 Alcohol-induced mental disorders
292 Drug-induced mental disorders
293 Transient mental disorders due to
conditions classified elsewhere
• 294 Persistent mental disorders due to
conditions classified elsewhere
Other Psychoses 295-299
295 Schizophrenic disorders
296 Episodic mood disorders
297 Delusional disorders
298 Other non-organic psychoses
299 Pervasive developmental disorders
Neurotic Disorders, Personality Disorders, And
Other Nonpsychotic Mental Disorders 300-316
300 Anxiety, dissociative and somatoform disorders
301 Personality disorders
302 Sexual and gender identity disorders
303 Alcohol dependence syndrome
304 Drug dependence
305 Nondependent abuse of drugs
306 Physiological malfunction arising from mental factors
307 Special symptoms or syndromes not elsewhere classified
308 Acute reaction to stress
309 Adjustment reaction
310 Specific nonpsychotic mental disorders due to brain damage
311 Depressive disorder not elsewhere classified
312 Disturbance of conduct not elsewhere classified
313 Disturbance of emotions specific to childhood and adolescence
314 Hyperkinetic syndrome of childhood
315 Specific delays in development
316 Psychic factors associated with diseases classified elsewhere
Mental Retardation 317-319
• 317 Mild mental retardation
• 318 Other specified mental retardation
• 319 Unspecified mental retardation
Symptoms, Signs, And Ill-Defined
Conditions 780-799
• 780-789 Symptoms
• 790-796 Nonspecific Abnormal Findings
• 797-799 Ill-Defined And Unknown Causes Of
Morbidity And Mortality
Persons Encountering Health Services
In Other Circumstances V60-V69
V60 Housing household and economic circumstances
V61 Other family circumstances
V62 Other psychosocial circumstances
V63 Unavailability of other medical facilities for care
V64 Persons encountering health services for specific procedures
not carried out
V65 Other persons seeking consultation
V66 Convalescence and palliative care
V67 Follow-up examination
V68 Encounters for administrative purposes
V69 Problems related to lifestyle
E/M Complexity and MH Visits
Level of
99201 (10)
99202 (20)
99212 (10)
99242 (30)
99203 (30)
99213 (15)
99243 (40)
99204 (45)
99214 (25)
99244 (60)
99205 (60)
99215 (40)
99245 (80)
10 ROS
10 ROS
1 system or
area (brief)
2 systems
1 system
detailed and 1
area (brief)
8 systems
OR complete
exam of 1
8 systems
OR complete
exam of 1
99241 (15)
Meet level in all THREE components (History, Physical Exam, MDM)
Time: Total face to face time: “>50% of the visit spent in counseling and coordination of care”
Preventive, New
99381 – 99387
Preventive, Established 99391 – 99397
Documentation Requirements to
Bill Based on Time
• The 3 key components of history, PE, MDM may be ignored
– Only time is used to select the level of care
• Use when the time spent in ‘counseling and coordination of care’ > 50% of
the E&M visit
• May be used when the patient is present or when counseling a parent
when the patient is not physically present
• The total length of time of the encounter must be documented and the
record should describe the counseling and/or activities to coordinate care
• Time-based coding also may be used for follow-up appointments to
discuss management of common medication side-effects such as appetite
and/or sleep changes, behaviors requiring environmental changes rather
than medication adjustment
• Resident/NP/PA face to face time can not be included (except under
specialty specific Medicaid contracts)
Documentation Requirements to
Bill Based on Time
*** minutes spent, >50% in discussion and
counseling with the family about *** above.
The more detail the better!
National Correct Coding Initiative (NCCI)
• Developed by CMS to adjudicate Medicare claims
• Informed by CPT code descriptors, instructions and
coding guidelines developed by national societies
• Identify services that normally should not be billed
by the same physician for the same patient on the
same date of service
• Used to determine payment policies for physician
• Promote correct coding
• A means by which a physician can indicate a
service or procedure has been altered by
some specific circumstance but not changed in
the basic code definition
• 2 digit suffix appended to a CPT code
• The conditions of the modifier must be met
• Medical record must support the change
• Modifiers used for mental health care: -25; -59
• Modifier -25
– Used for a significant, separately identifiable service that is
performed during the same patient encounter
– Appended to the E/M code.
– Both the E/M service and the other service or procedure
require individual documentation, although this
documentation may be within the same written note
• Modifier -59
– Signifies that a procedure or service was distinct or
independent from other non-E/M services performed on
the same day.
– -59 is the “modifier of last resort”: only use -59 if it best
explains the circumstances of the visit and no other
Example: Procedures and Modifiers
• 96110: Developmental testing; limited
– Limited behavioral/emotional “testing”, with
interpretation and report
• e.g., Vanderbilt, MCHAT, Pediatric Symptom Checklist
– At this time, this is the only CPT code available for the noninteractive screening and rating scales used in mental
health care
• Use one unit for each individual rating scale administered,
scored and interpreted
• Append modifier -25 to E/M to show the E/M is a separate
and identifiable service by the same physician (on the same
day of the procedure) from the procedure performed
• 96111 and 99420 also used in some circumstances
Telephone Care (99441-99443)
Care Plan Oversight (99339-99340)
Medical Team Conferences (99367)
On-line services (99444)
Prolonged Services (99354-99359)
Telephone Care: MD
Telephone E/M service provided by a physician to
an established patient, parent or guardian not
originating from a related E/M service provided
within the previous 7 days nor leading to an E/M
service or procedure within the next 24 hours or
soonest available appt.
99441: 5-10 min. medical discussion
99442: 11-20 min. medical discussion
99443: 21-30 min. medical discussion
Care Plan Oversight
• Recurrent physician supervision of a complex
patient who requires multidisciplinary care and
ongoing physician involvement
• Non-face-to-face
• Reported separately from E/M services
• Reported by the MD who has the supervisory role
in the pt’s. care or is the sole provider
• Reported based on the amount of time
spent/calendar month
• 99339: 15-29 minutes/month
• 99340: greater than 30 minutes/month
Medical Team Conference: 99367
At least 3 physicians from 3 different subspecialties
Participation by physician
Patient and/or family NOT present
If patient/family present, report attendance w/ appropriate
E/M service based on time
≥ 30 minutes
Cannot be part of care plan oversight
Pre-service work: Review of chart
Post-meeting work: Clinician must document his/her
participation in the team
– Information he/she contributed
– Any treatment recommendations he/she made
– Review of the patient’s care plan
• Using the Internet or similar electronic
• Non-face-to-face E/M service for established
• Provided by a physician to a patient, guardian,
or healthcare provider
• Not originating from a related E/M service
provided within previous 7 days
• In response to a patients’ online inquiry
• Face to Face Prolonged Services
– 99354
– 99355
30 – 74 minutes = 1 unit
74 + minutes (each 30 min additional = 1 unit;
multiple units allowed)
– Must bill on same day as an E & M code, need not be
continuous time during that day
• Non Face to Face Prolonged Services
– 99358
– 99359
30 – 74 minutes
74 + minutes (1 unit = 30 min of time;
multiple units allowed)
– May be reported as stand alone encounter, need not be
during E/M encounter.
My Patient 1
• 24 month old girl at WCC
• Happy, healthy, PE normal
• MCHAT done to assess for autism
Routine infant or
child health check
99392-25 Preventive medicine
service, established
patient, age 1-4
(attach modifier 25)
Developmental testing
My Patient 2
• 7 year old girl for assessment of ADHD.
• Mother/teacher both completed Vanderbilt rating scales,
mailed to her when she called about her daughter’s symptoms
of distractedness, impulsivity, and poor school performance
• PE normal, forms scored by nurse show ADHD combined type
• Placed on medication with phone follow up in 2 weeks
314.01 ADHD combined type
99215-25 established
patient, 45 minutes spent
96110 Developmental testing
99442 telephone call 11-20 min
My Patient 3
• 14 year old male for WCC
• Tired, lack of focus, poor appetite, feels sad
• Beck Depression Inventory, Parent CBCL, CRAFT
Routine infant or
child health check
799.29* Other signs and symptoms
involving an emotional state
Preventive medicine
service, established
patient, age 12-18
99214-25 established patient, 25
Developmental testing
limited (Beck)
96110-59 Developmental testing
(parent CBCL)
* Also consider:
780.79 tiredness and/or
major depressive affective disorder single episode unspecified degree
My Patient 3
• Call mental health professional to discuss case and initiate
– could qualify as non face-to-face prolonged services (99358) if it exceeds
30 min and is documented.
• 6 weeks later you call mental health professional to discuss
increasing dose of Prozac.
– Any additional time spent in discussion with the mental health
professional after the referral has been make could count towards care
plan oversight 99339 (for 15 – 29 minutes) or 99340 (for 30 minutes or
– Log of care plan oversight
Dates, service provided, action, amount of time
My Patient 3
• Initial Follow-up at 2 weeks
– 90 minute discussion of treatment plan (Discuss
risks and benefits of SSRI’s, other therapies)
ICD-9 296.2 or 799.29
CPT 99215 and 99354
• On-going follow-up monthly
– to assess progress with screening tool
ICD-9 296.2 or 799.29
CPT 99213-25 established patient, 15 minutes
96110 standardized screening forms
My Patient 3
• M.P. 3 improves steadily,
– follow-up visit intervals lengthen to every 3 months
– 99213-25, 96110; 296.5 or 799.29 to monitor progress via
standardized screening forms
– Send progress notes to Mental Health Professional (CPO log)
• M.P. recovers completely
– Longer visit to discuss wean and discontinuation of medication
– 99214, ICD-9 296.92 or 799.29
– Send progress notes to Mental Health Professional (CPO log)
Pediatric Councils
• Pediatricians and medical directors of insurance
companies meet regularly to discuss quality of
care issues for children
• Most states now have Pediatric Councils –
Chapter President has information
• If insurance companies not paying PCP’s for
mental health code, discuss value of doing this at
a Pediatric Council meeting (cost-effective,
insufficient supply of Mental Health
• Psychologists and social workers in community
should work with pediatricians to discuss their
issues at Pediatric Council meetings
Coding properly matters.
Documenting properly matters more!!
If in doubt, ASK!
Both screening tools and collaborating with mental
health professionals are good for patients and if
properly performed, can be good for your practice.
• Coding is a moving target with changes that require
and deserve your attention. (e.g., ICD-10)
• Advocate for your patients AND your practice
regarding identifying and treating mental health and
behavioral problems in primary care.
AAP Pediatric Coding
• AAP Coding Hotline:
[email protected]
• AAP Coding Fact Sheets for
Primary Care Clinicians
– Developmental Screening and
– Anxiety
– Bereavement
– Depression
– Inattention, Impulsivity,
Disruptive Behavior, and
– Post-traumatic Stress Disorder
– Substance Use/Abuse
– coding.aap.org
TeenScreen Website: www.teenscreen.org
TS Email: [email protected]
AAP Website: www.aap.org/mentalhealth
AAP Email: [email protected]
American Academy of Child/Adolescent Psychiatry:
AAP Section on Developmental and Behavioral Pediatrics
(SODBP): www.dbpeds.org
• http://www.cdc.gov/nchs/icd/icd10cm.htm#1
• http://www.icd9coding.com/
• http://www.icd9data.com/2011/Volume1/def
• http://www.medicalhomeinfo.org/downloads
• American Academy of Pediatrics. Coding for Pediatrics-2011:A
Manual for Pediatric Documentation and Payment. Elk Grove
Village, IL: American Academy of Pediatrics, 2010.
• American Academy of Pediatrics. Pediatric Coding Newsletter.
Elk Grove Village, IL: American Academy of Pediatrics.
• American Academy of Pediatrics Section on Developmental and
Behavioral Pediatrics. “Coding Conundrums”. Semi-annual
Newsletter. Elk Grove Village, IL: American Academy of
• AAP: Addressing Mental Health Issues in Primary Care: A Clinician’s

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