Author Topic: IOP Billing - 180 minutes not reached.  (Read 4728 times)

Yesi

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IOP Billing - 180 minutes not reached.
« on: March 20, 2014, 04:49:47 PM »
It takes 180 minutes to complete an IOP. Sometimes client's walk out and don't complete 180 minutes. Can I bill for the service we did provide? Example: 90837- Psychotherapy 60 mintues? In PPO cases, an authorization is not always required (we are a facility) making the service payable.   Will the insurance question why we have an authorization for IOP and are billing OP services in between IOP's? Are providers expected to not bill for these services because they are incomplete IOP's?

Michele

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Re: IOP Billing - 180 minutes not reached.
« Reply #1 on: March 21, 2014, 09:04:13 AM »
I am not a certified coder, but what you are basically asking is 'can you bill for services that were provided'.  Even though the appointment did not go the way it was intended the patient did come, the provider was there, and a service was performed.  Of course you can't bill the IOP (which you didn't intend to) since the whole service was not provided, but if another cpt code more accurately describes the service that was performed (90837) then I believe it would be appropriate to bill that code.  I would relate it to a provider who planned on doing a total hysterectomy but during the surgery ended up only removing the ovaries (for whatever reason).  They intended to do and bill for a total hysterectomy but would only bill for the removal of the ovaries since that is what was done.  (Just to make it clear, I'm also not a doctor so I don't know if that scenario would ever happen!)

Hoping Heidi will weigh in here!
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rdmoore2003

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Re: IOP Billing - 180 minutes not reached.
« Reply #2 on: March 21, 2014, 09:21:12 AM »
The 90837 can be billed.  As long as your documentation shows that this is the service that was done.   if the insurance does ask why this service was done and not the IOP, your documentation should show this and should not be an issue.
Regina

HeidiK

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Re: IOP Billing - 180 minutes not reached.
« Reply #3 on: March 21, 2014, 11:23:08 AM »
Good Morning!

I'll do my best to "weigh in" as Michelle put it - this is a complicated issue!  :)  Basically, Regina is correct - documentation is always key to any service billed.  Having an authorization however, poses a potential problem.  If you request prior auth for one service and perform something else, you must call and revise that auth in order to guarantee payment (I use the word "guarantee" loosely - no authorization or verification of benefits is a "guarantee".  Insurance companies cover themselves by saying "this is not a guarantee of coverage, payment will be decided based on claim submission).  Bottom line, the service you did not authorize can potentially be denied for not having "prior auth".

My first question would be to ask if you are providing coding services for this client?  If not, how do you know the required time was not provided?  Is it your responsibility to offer guidance and instruction on proper coding or are you only responsible to submit claims based on the source document provided?

If you are coding, review the documentation and verify all components for the service are included based on the carrier guidelines you are submitting the claim to.  You didn't state which IOP was performed - was it S9480 for Mental Health or H0015 for Chemical Dependency?  H0015 is described as IOP for at least 3 hours per day, at least 3 times per week.  Medicare will not cover either of these codes and many carriers will not recognize them either.  The authorization issue comes up here as well, coding and billing instruction should be verified with the carrier when requesting authorization.

As far as psychiatric codes for this situation, they are basically split into three groups:

90791-90792 - Psychiatric Diagnostic Evaluation - For assessment or reassessment
90832-90838 - Psychotherapy - Includes ongoing assessment and adjustment of interventions
90839-90853 - Psychotherapy for Crisis - Urgent assessment and history of crisis state

CPT Coding guidelines offer many more details such as which require patient to be present, when an E/M can be billed in addition to etc.  The guidelines also state times required for certain codes which is what I believe you are trying to verify:

90832 & 90833 - 16-37 min    90834 & 90836 - 38-52 min    90837 & 90838 - 53 min or more

The time specific codes listed above can be billed with a different "add-on code" 90785 for Interactive complexity which refers to "specific communication factors that complicate the delivery of a psychiatric procedure".  This code is typically used when the patient is impaired, young or verbally undeveloped and have family members and/or other caregivers present for the session.  It is not a time-based code.

The only code I could verify for extra time is 90840 which is an "add-on code" (meaning it cannot be billed by itself) for each additional 30 minutes when 90839 is billed.  90839 is defined as Psychotherapy for crisis; first 60 minutes.  CPT codes for Psychotherapy for Crisis also state "even if the time spent on that date is not continuous" meaning the provider must calculate the total face-to-face time with the patient and/or family within a 24 hour calendar date.  An example would be initial encounter with a suicidal patient for 90 minutes, then four hours later the provider returns for additional psychotherapy for 30 additional minutes - Coding on the bill would be 90839 and 90840 x2.

Clearly, this really is complicated!  My interpretation is based on CPT guidelines and are not carrier or state specific so I would suggest a discussion with the provider or a certified coder experienced with the CPT Psychiatry Section.  I also found a couple of links which might further help as well:

Medicare Coverage of Psychiatry
http://www.medicareadvocacy.org/medicare-info/medicare-coverage-of-mental-health-services/

CPT Coding changes for Psychiatry - 2013
http://www.psych.org/cptcodingchanges

Hope this helps - at least a little!

Heidi Kollmorgen, CCS-P



Heidi Kollmorgen, CCS-P
AHIMA Approved ICD-10 Trainer
hdmedicalcoding.com

Merry

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Re: IOP Billing - 180 minutes not reached.
« Reply #4 on: March 21, 2014, 11:58:01 AM »
Wow Heidi.  You are a wealth of information. And so generous, to share.

Yesi

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Re: IOP Billing - 180 minutes not reached.
« Reply #5 on: March 24, 2014, 06:34:01 PM »
Thank you so much everyone!! Heidi, you have so much info to share! You've opened up some thoughts and new questions for me to think about. By the way the HCPC is H0015 for chemical dependency. I had billed some codes for services that were done and documented and we were paid, but I was not sure if there was a correct way of billing - for example could I use Mod 52?? I hope another IOP provider (chemical dependency) can chime in and give a little input - What are other providers doing in these cases?

Michele

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Re: IOP Billing - 180 minutes not reached.
« Reply #6 on: March 25, 2014, 11:35:02 AM »
What are other providers doing in these cases?

Are you still referring to someone leaving early for the IOP?

52 modifier is indicating reduced services.  Why are you saying the H0015 is a reduced service? 

I'm just not sure I understand completely what you are asking so I don't want to respond wrong.   :)
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Yesi

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Re: IOP Billing - 180 minutes not reached.
« Reply #7 on: March 25, 2014, 11:57:59 AM »
Hi, someone suggested using 52 w/ H0015 as a possibility but they were not sure.
Yes, I'm trying to figure out billing for someone leaving before finishing a 180 minute session. Thank you.
« Last Edit: March 25, 2014, 11:59:47 AM by Yesi »

Michele

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Re: IOP Billing - 180 minutes not reached.
« Reply #8 on: March 26, 2014, 10:46:11 AM »
Oh, ok.  I can see where that might be a possibility.  Since I am not a coder though, I really don't know the answer.  I'm hoping Heidi might be able to clear this up. 

Which is better?

1.  Bill for the service that was actually performed but not the service that was authorized?  90837

2.  Bill for the service that was authorized and was supposed to be performed and use the 52 modifier?  H0015

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HeidiK

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Re: IOP Billing - 180 minutes not reached.
« Reply #9 on: March 26, 2014, 12:16:07 PM »
Hello!

In my opinion, there are still a couple of unanswered questions in order to give specific advice. 

1. Are you billing on a CMS1500 or UB?  Provider based coding differs greatly from out-pt facilities just as it would differ from in-pt or acute care facilities.

2. If the facility is out-patient, what revenue code is being used?  Review of the carriers revenue code definitions would be necessary to be sure of accuracy.

I don't believe Modifier -52 would be appropriate.  Most carriers, including Medicare, will not recognize -52 on time based codes or E/M services.  This modifier is typically used for surgical procedures, such as a surgery which is stated in CPT to be bilateral and only one side is operated on or when the primary surgeon calls in another surgeon to manage another part of the procedure.  The second surgeon would use -52 to show he/she did not open or close the patient thus, his/her services were reduced for that procedure.

A conversation with the doctor or coder at your client's office or even a call to the specific carrier is the best way to clear this up.  The carrier will be able to review the patient's own policy guidelines and determine if a new authorization is needed or if the existing one can be modified. 

They will also be able to answer any questions about how they require coding and/or modifiers to be used.  Remember, proper billing and coding is not only determined by individual carriers but also by individual or group policy contracts the provider has agreed to.

Hope this helps lead to an answer for you!  :)



Heidi Kollmorgen, CCS-P
AHIMA Approved ICD-10 Trainer
hdmedicalcoding.com