Billing for Integrated Behavioral Health Primary Care Coding Guidelines Recording

– All right, so first of all, who are we? My name is Kate I work for HealthInsight We’re a nonprofit organization that works to improve health and healthcare We operate in four states in the western United States, Oregon, Utah, Nevada, and New Mexico One of our initiatives is to help providers care for older adults, specifically around screening for depression and alcohol misuse This initiative is one of ours to help look at different approaches to increase these screen rates, and so it was really fortuitous that we were connected locally to behavioral health leaders who have such an interest in this topic as well As we understand, billing and coding fee services is a key part of increasing these screenings and rates, and overall taking good care of people Our contact information’s available at the end We can provide individual assistance to clinics who want to learn more about this for Medicare So if that’s you and you think we might be able to help you, please be in touch because we would love to be able to do that A quick disclaimer: This information is through the very, very hard work of some wonderful people that you’re gonna meet today It was created by the Integrated Primary Care Leadership Collaborative, which is a self-convened group They got themselves together because they think this issue is so important They’re primary care behavioral health leaders in Oregon who have a mission to support clinicians and leaders in primary care practices in advancing integrated care And to that end, we have relied on the expertise of billing and coding experts, and behavioral health providers But this information is provided “as is” We’ve done a ton of work to vet it and to make sure that it’s as accurate as possible, but this is an evolving topic, and so we are presenting this info to you “as is” and we have done all we can to verify its accuracy, but please make sure that you’re verifying information with the health plans, with the coordinated care organizations and other payers that you might work with There’s a lot of information that we wanna cover today, and some great presenters, and I’m gonna introduce them in a minute, but I wanna say first, something about the technology We expected a large number of questions and we expect, we already have 225 people who joined us today and we may have more, so you are all on mute so we don’t have to worry about hearing your home music or your dog bark But we do wanna hear from you, so there’s a chat box that I mentioned already before, please type your questions into that We tried to save a lot of time at the end to answer those questions and we’ll get to as many of them as we can But we expect to get a lot of questions and so, if we aren’t able to follow up, know that we’re gonna take all of that and see what we can do for future sort of, education presentations, to get at what we know people are really asking us about I’ll share contact information too so that you can get in touch with us if you have some really specific follow-up pieces So, we’d love to know who’s here, and this is also your orientation for the chat box, so if you could find that chat box and type in where you are, and what your position is in your organization, are you a behavioral health provider, are you a biller, medical assistant, are you an office manager, or something totally different We’d love to start seeing some of those chats come in so we know who is here with us today and so you know who else is listening in While we hear from all of you, I’m gonna go ahead and introduce our presenters today So first, we welcome Dr. Joan Fleishman who completed graduate training at Pacific University’s School of Professional Psychology, and a fellowship in primary care psychology at the University of Massachusetts She’s the behavioral health clinical and research director for OHSU’s Department of Family Medicine, leading the extension of their behavioral health services across six primary care clinics She’s worked closely with other clinical leaders on strategy planning, program development, training of clinicians, and work-flow implementation She’s focused her work on practice transformation, population reach, alternative payment methodology and pain-based care, and she’s currently involved in projects in a program evaluation of primary care-based medication assisted treatment program and an implementation study of screening approach to intimate partner violence in primary care and implementing trauma and form-care standards in a family practice clinic So, very busy We’re gla to have her here And we also have Dr. Julie Oyemaja, who began her career in primary care in 2004 in a federally qualified health center in Portland, Oregon It was her experience there that really inspired her to go where the people are and serve them there And so, her passion is for supporting primary care patients, staff, and clinicians, and that’s really fueled her work as a clinician leader in two primary care organizations in Oregon

Her passion is to promote a new kind of primary care; one that’s empowered by psychological science and practice This results in sort of, an advanced primary care with intentional staffing for addressing the biopsychosocial needs of all patients who are served While her current focus is on primary care, her professional experience in psychology comes from a really diverse background from residential care for patients with substance use concerns, to community mental health, to private practice, to hospitals She served and supported in a variety of patients and clinical teams She’s currently an adjunct professor at George Fox and provides consulting and technical assistance to primary care clinics and health care organizations as a member of Mountainview Consulting Group These are impressive people, so I’m gonna take a breath there if you don’t mind We also have two billing and coding experts here with us today Our first is Jonique Dietzen She’s a certified professional coder and project manager for Multnomah Count Health Department She’s a college graduate with a bachelor’s of science in finance, an associates in science and math She has seven years of experience working with commercial health insurance payers and and additional four years of experience in medical office as a revenues cycle manager and project manager She’s been a certified coder since 2014, worked at Multnomah County for the past three years and that’s given her the opportunity to improve billing and reimbursement for the integrated behavioral health program there, working closely with providers to identify billing codes to improve fee-for-service reimbursement Denise Phillips is the revenue cycle manager for OHSU Family Medicine Seven years experience working in medical offices as a biller and an additional three as a revenue cycle manager In that role she’s had the opportunity to work with her fellow presenter Dr Fleishman and implement billing and coding reimbursement for their team of behavioral health clinicians And without further ado, I’m gonna turn the webinar over to Dr. Julie Oyemaja to get us started – Well, thank you so much, Kate, for that lovely introduction I’m just so happy to be here talking about this issue So what are we talking about today? Well, I thought we would start by talking about who we’re talking about today We’re talking about behavioral health clinicians And behavioral health clinicians, psychologist LCSWs who are working in primary care And more specifically than that, we’re talking about behavioral health clinicians working in primary care in the primary care behavioral health model I’m not gonna spend too much time talking about the primary care behavioral health model today, but I did wanna refer you to a special edition of the Journal of Clinical Psychology in Medical Settings that is coming it It goes through lots of nice literature on this new model, the PCBH model From the research in terms of its practice, how it works, what’s the definition, it’s a really great resource But I wanted to start us there because we’re talking about behavioral health clinicians who are working within this model in primary care teams for the goal of supporting the biopsychosocial needs of around three to six thousand patients, generally And their goal is to enhance the whole care of that population This unique way in which they’re practicing has some complications in terms of being able to be paid for the services that they’re delivering I would explain it has very specific billing and coding challenges for the BHCs who are working in this model I explain the billing and coding challenges in two ways The first way is that these behavioral health clinicians are working in primary care And primary care is a system that is not set up for the delivery of behavioral health services From check-in to receiving payment for billing, all operations in primary care are set to support primary care practices And so, the first level of complication for BHCs that are practicing in a primary care behavioral health model, is that they’re working in primary care, a system that’s not set up to bill for their services The second level of complication in BHCs working in this model of practice, is that they are doing work that is a little bit different than mental health practice historically So, mental health practice historically has been really, a practice that takes care of around 60 to 70 patients at a time, where a therapist will work with a patient weekly, bi-weekly, for months or years, took care of about 60 to 70 cases at a time The behavioral health clinician is doing something very, very different, in primary care Their goal is not necessarily, just to take care of 60 to 70 patients at a time Their goal is to take care of three to six thousand at a time, and team work with their primary care clinicians, their RNs, their MAs, that are all working together to promote the biopsychosocial health of many patients

So the complications of getting paid, in terms of billing and coding, I think are one, because they’re working in a context that’s not set up for behavioral health services and two, the behavioral health services that they’re delivering are a little bit different than the behavioral health services that are generally delivered And speaking to that, so mental health services, as I described, historically and traditionally the billing and codes that are set up to support those services, are set up with those specialty mental health services in mind, and not the services the BHC in primary care delivers So some ways in which these BHCs are different is, their goal is to take care of the biopsychosocial health of all patients, but also It looks like having difficulty advancing They’re doing things like having their schedule be 25 to 50% of the day, being available for same day access This is very different than specialty mental health or the traditional practice The work that they’re doing is focused They’re doing focused clinical assessment and intervention for many patients, and if identification of more severe concerns or facilitating patients to the specialty programs They may be identifying patients with (sound disappears) for higher level needs, like patients with a certain level A1C for diabetes and putting them on a registry to manage more rigorously And their work is, because they’re in these primary care teams and are working with their PCPs and other team members to take care of a subset of patients, they start to rework all primary care workflow So the BHC skills need to be used within the team So things like, if you’re doing universal screening, one could start to rework that universal depression screening workflow with a BHC to identify anybody who’s positive for depression screening, could, within 30 minutes, because of the same day access that a behavioral health clinician is allowing in this model, could come in within 30 minutes of being a positive screening in the clinic and do a more thorough assessment and developing a more thorough care plan with the BHC skills So these folks are also helping rework all these primary care workflows to take care of these three to six thousand patients So the billing and coding challenges, from my perspective, our challenges are that we are in a place where operations are not created for us and two, the way in which we’re delivering behavioral health services is just so different than what we have been historically trained to do We do have some good news to share in Oregon Actually, several bits of good news One, is that the primary care behavioral health model as a part of the patient-centered medical home is being widely adopted in Oregon Many practices in Oregon are adopting this BHC as a part of a primary care team to take care of a subset of patients In addition to that, because of all the adoption of this practice in Oregon, the BHC leaders that are implementing this work on the ground, are really active in convening each other to identify standard practices that could be implemented across organizations And actually, this tool that we’re gonna talk about today, is the product of a self-convening, as Kate mentioned, of a group of BHC leaders who are implementing in organizations with multi-clinics coming together and identifying that one of the top issues that they wanted to work on, was helping BHCs be able to bill and code in the current system Other things that are happening is that BHCs and in primary care, are actually defined in our Oregon law now Because of convening of BHC leaders and primary care leaders in our state, this definition, with all these different folks who are licensed practitioners, has been put into our state law and is, what we consider in our state as BHCs in primary care We’re not gonna talk a whole lot about why we need BHCs in primary care We’ve been around long enough where you know, in a situation where primary care has 70% of all primary care office visits are driven by psychosocial variables, they need for behavioral support in primary care is well understood, and so, we’re not gonna talk too much about why BHCs are in primary care, why they’re needed, which is a great thing to be able to say now that I’ve been in this work for some time that we really passed this step We’re really into the step of, okay, we know we need BHCs in primary care working to take care the whole health of patients, we’re past that to: “How do we do this?” And even past the implementation, because folks have been implementing this BHC model for some time in Oregon; even knowing that the payment for this model is a little bit shaky So we know we’re doing the right thing when we implement things we don’t know exactly if we’re gonna get paid for it So we’re well past the “why” BHCs are needed in primary care teams and well into the “how” And particularly, the “how” in regards to getting paid

Now, this slide is demonstrating something that I know is probably not too unfamiliar to this group You know, behavioral health practitioners and primary care practitioners, they have been trained in different places, they have practiced in different places, and even who pays them, are different people There’s a pot of money for physical health services that’s paid by certain parts of insurance, and then, there is a medical conceptus of this pot of money that’s maybe paid by a completely different insurance altogether Which just models the historical siloing of our training and of our practice But as integration has been understood as something we need move towards and away from this siloing, perhaps at some point integration, and in some places this is happening, integration of these pots of money may be what happened But in this point in time, there’s still a pot of money for physical health, a pot of money for mental health and substance use, and different insurers with different expectations for this money So that is where we are, which is another complication, because the primary care context is used to billing to the physical health plan and now, we have behavioral health practitioners who, most of their codes, or many of their codes for the services they would deliver in primary care, would need to go to mental health plans So those are some of the problems that we have in terms of being BHC as a part of primary care; primary care context and also, the services we’re delivering are so very different So we have many operations and implementation challenges, but when we pulled folks together, because we realized we needed to pull together, in Oregon, with the leaders who are implementing this work and doing it together because there’s so many challenges When we pulled together we asked this group, this integrated primary care leadership collaborative, “What are the top issues that we should work on to “standardize this work together?” And I’m sure it doesn’t come as very much surprise that the top issue was billing and coding Getting paid, in the current situation with the current billing codes that are available, and like I mentioned before, those codes, of course, were created in a system in which behavioral health and primary care practitioners were trained in different places, practiced in different places, and paid by different people So the code that is developed for mental health specialty practice, and not this particular practice in mind But saying al that, we have our code-set that’s available, and luckily, there are some codes changing that are very helpful for BHCs and primary care teams, particularly the collaborative care management codes There is some movement in that direction, but we do have a current CPT codes, and we do, BHCs do provide services that meet those billing codes, so the work of our IPCLC, and here’s a group of us here, it’s not all of us, but a good amount of us in our last meeting, let’s figure out what these codes are that we can bill and develop a tool for BHCs to help them provide the service, document the service, and bill the right codes for the services as they stand now There’s lots of good things happening in terms of alternate payment methodology and value-based care, and these kinds of things, which will help the BHC innovation in primary care But while we wait for all those things to happen, there are billing codes the BHCs can use and so, our work, our first work with this group of leaders on the ground, was to create a tool to ensure that the BHCs in our practices were able to document their work appropriately and bill for the codes that are available And so, I’m gonna give it over to Joan now and we’ll go ahead and pull up the actual billing and coding tool that we created with this group of leaders – So this is available, and HealthInsight just sent out the link on our chat But I just wanted to introduce and orient you to this tool that we created really for our systems that we wanted to really share with everyone, because we think this might, it is, translatable and can be more generalizable than our systems that we’ve used it in So here you can see that we broke it up into different code sets These are the preventative medicine counseling codes, and again, they’re by time and then there’s the group ones You can see the health and behavior codes here and again, there are the initial assessment and then the intervention, reassessment, you can see the group codes there The smoking and tobacco counseling codes are here And you can see we have the description of the service or the name of the code, the longer name in the code,

the description of the service and then, what we have identified is to be required in the documentation, and then some tips and guidelines So those are really to help clinicians figure out which code, and if there are anything that’s really not in the required documentation or the description that we have found helpful in guiding our clinicians in the use of these codes So just to keep going, we have our alcohol and substance use services, and then, the new BH care management that became available in January of 2018, as well as the screenings, both the developmental screening and brief emotional and behavioral screening for children And then we have our mental health codes that are at the diagnostic evaluation and the psychotherapy codes So, that’s essentially, what our tool goes over And some psychological testing, we know this isn’t happening everywhere, but it does occasionally take place in primary care, and then some group psychotherapy as well And at the bottom there are several paragraphs that coincide with the asterisk, that are kind of, notes for what the “yes” and the “no” in the different columns, means for the Medicare So it’s really important to actually read through those because they really help explain some of the points There’s a question in our chatroom if this is gonna be sent out It’s available online right now, with a link, and that link was about four chats back, four posts back on the chat sent by HealthInsight – [Kate] And we’ll also email it out to the folks on today, along with a link to a recording for the presentation – So, I don’t think I have control to continue to advance the slides, so – Kate, if you could give me control? There we are, great – So, I think one of the things that’s really important for us to think about is just the different ways that we have supported BHCs in the past Fee-for-service, this is kind of the idea of billing for a service and receiving payment for that specific service There’ve been alternative payment methodologies and models that have been rolled out the per-member, per-month payment that different states and different CCOs have rolled out And really this is, when we’re looking at the ideal model, we’re talking about one BHC FTE for every six FTE of primary care clinician And we’re looking at a BHC population penetration of about 20% for the primary care practice That is, touching or having contact with 20% of the primary care practice Those are the benchmarks that CCOs that we have worked with have chosen to reimburse at a higher rate for a PMPM model Then previously, this work really had been supported by grants There are still grants going on, opportunities for grants, but that seems to be kind of changing to the PMPM model So I wanted to really hit home on the benefits of billing for behavioral health clinicians work I think it’s important to capture the services that we’re actually providing There’s no other way, I mean, we have all found different ways to count what we’re doing, or kind of, contextualize what we’re doing, but this really, really hits home in terms of counting what we’re doing So I think there have been practices and there still may be many practices that are kinda piggybacking on primary care clinician visits where they’re using incident twos, or the primary care clinician up codes their visit, and what we found is that really, this hides the work that we’re doing; it doesn’t make it visible This is a way for us to really have visibility And it kind of downplays that we’re independently licensed practitioners who can do this work and have CPT codes that we can bill that can capture

the specific and valuable work that we’re doing It also helps us, oh, sorry, just to promote the primary care bottom line, and I think, in general, really show the value of our work – So, this is just one example of an insurance company and how these codes might break down, in terms of how the insurance company would pay for it So for the example of Medicare, Medicare credentialed psychologists and LCSWs, Medicare will reimburse for psychologists and LCSWs who are credentialed for mental health services Although Medicare credentialed licensed critical social workers, in terms of the health and behavior service codes, they will, even though LCSWs are credentialed with them, they will pay for a psychologist to do these codes And in terms of the preventive medicine codes that are listed, Medicare will pay for psychologists or LCSWs who may be providing services that are reflective of those codes – Okay so, how to succeed in the short term? So when you look at which BHCs you have, you need to also look at what your insurers pay the most For us, it’s psychologists and LCSWs We also have CSWAs working with us and students, which don’t typically get reimbursed And then, also do your research and talk to your payers Find out who your top payers are, talk to your provider representatives, figure out what types of services your BHCs are doing as you know which codes to use and talk to them about And when, it’s also important to get BH and your billing and coding team together, and train them together, so that way, questions that your BH staff may ask, knowing the answer and vice versa and really learn this process together and how to use these codes And we also engaged our clinic and senior leadership to let them know what the benefit was in using these codes in billing for BH services And then we also do billing and coding audits just to make sure that we are performing the services that we’re billing, and documenting correctly, and that we’re getting reimbursed for them And now we’ll move on to our billing options – I just wanted to address some of the questions that are coming in Some of them are very specific, in the chat, and we may not get to your specific questions before the Q and A section, but we’ll try to get to them in the Q and A section And also, some of them, we’ll be addressing as we go along So just hold tight We have a lot of information to share with you – So the first of the codes that we’ll go over is the health and behavior codes which are the 96150 to 96154, which are individual and there’s a couple for group health and behavior So these are for the prevention, treatments or management of physical health and medical problems You have to perform an assessment and some sort of treatment And then it address those things in psychological, behavioral, emotional, cognitive, and social factors of the physical health and medical problem These are not for assessing and treating for mental health disorders You can have a mental health disorder diagnosis, but it really needs to be listed as secondary, and not the primary code on the claim And for these codes you do report them as one unit for each 15 minutes then, so time needs to be documented So for each code-set that we talk about, we will give an example of a clinical situation that would match that code-set that a BHC might support So, here we are We have Jane, she’s 32 years old and she’s pregnant She received a diagnosis of gestational diabetes and she’s concerned about her health and the health of her baby She was referred to the behavioral health clinician to support with these concerns and to help her engage in a physical activity and plan, and a diet plan that will help to decrease this gestational diabetes concern The interventions that a psychologist or LCSW would perform in this kind of case, would often be motivational enhancement, you know,

identifying the pros and cons for Jane in making the changes And then doing some self-monitoring Just monitoring the food intake in a diary, and behavioral activation, just getting up and doing pleasant things, achievement oriented things, just getting activated So these are all psychological interventions that could be applied to this situation of a person with gestational diabetes concerns So, linking the medical condition that was referred and diagnosed by a medical provider, and then linking that with the interventions, really focusing interventions to help improve the gestational diabetes, and that’s what health and behavior are for – And so, the next set of codes are 99406-99407 These are the codes used to report tobacco cessation counseling So these codes can be used any time the provider counsels the patient on steps to stop using tobacco and tobacco products This could include a discussion to discover the specific barriers to quitting, or a discussion of practical methods for coping with those barriers The provider may end up writing a prescription to help the patient quit, or may refer the patient to a support group, if needed These are time-based codes and so, the amount of time spent counseling the patient on tobacco cessation would need to be documented But the good news is, it’s as little as three minutes So, if at least three minutes is spent counseling the patient in tobacco cessation, 99406 can be reported and then 99407 requires at least 10 minutes of tobacco cessation counseling Medicare will cover two cessation attempts per year And each attempt may include up to a maximum of four intermediate or intensive sessions So that means that Medicare will cover up to a maximum of eight times per year Just as a side note, taking a look at the diagnosis codes, Medicare does not consider tobacco use a covered diagnosis, but rather, the patient must be diagnosed with use, abuse, or dependence of nicotine, or a history of nicotine dependence And so, when choosing a diagnosis, you don’t want to just indicate that that patient is using tobacco, but rather, they have a dependence or use/abuse of nicotine And the FDA does consider vape products to be considered tobacco products So if the patient is working on solving vaping, as well as now, smoking tobacco, these codes can be used – So this is the example for our tobacco and smoking cessation counseling Jorge is 37 years old, he’s quitting smoking and he’s having a really hard time stopping, and he’s being seen for by the BHC and really focusing on tobacco cessation And I’m just talking a little bit about cravings and triggers, and validating his experience of how challenging this is And then doing some motivational inner building around going back to the PCC to consider the different options for nicotine replacement, and we would use tobacco use disorder for the diagnosis – The next codes 99408 to 99409 are for alcohol and substance use screening And so, it’s actually alcohol and substance use or abuse structured screening with a brief intervention service, so SBIRT, for short Usually, they must use a valid screening instrument, so typically, and AUDIT or DAST screening is completed The brief screening involves an intervention and same-day session for the intervention of alcohol or substance use At least 15 minutes needs to be documented as spent with the patient in order to bill for the first code So if it’s brief and less than 15 minutes is spent, then you can’t use these codes But the first code is used for at least 15 minutes of intervention, with a documented structured screening results, and then 99409, the second code, is used for at least 30 minutes met with the patient – So our example of the screening, brief intervention and

referral, is we have Jorge again who screened positive on an AUDIT when seeing his primary care clinician for nicotine-replacement options Luckily, there was a BHC in clinic and the BHC holds same-day appointments, so was able to review the alcohol use on the AUDIT with Jorge, in a timely fashion on the same day But this a focus for something like this that would work for these billing codes, will be education on where his alcohol use places him in comparison to other people who drink Interventions would again be, motivational enhancement would be used Support, that it’s challenging to make changes, it’s challenging when has been drinking for some time and to make a change in this area, as well as, any kind of behavior change, you know, really supportive and empathic support for that And if the issue was of a significance of a diagnosis for alcohol, a referral to a chemical dependency program And what’s really nice about having BHCs as a part of primary care, is that BHCs really know the mental health and substance abuse programs in the community They understand the services in great detail and so, they provide great value in the primary care team to understand the specialty services when they’re needed, and also, to fully facilitate a patient from the primary care level service to the specialty mental health, or addiction service and check in on that So those will be the kinds of interventions a BHC would do and very helpful for patients in primary care The visit diagnosis tied to this intervention would be alcohol use disorder – Okay so, 99484 is the behavioral health care management code This does need to be provided face-to-face and it’s to do initial assessment or follow-up monitoring, including any use of alcohol validated rating scales It’s to behavioral health are planning in relation to behavioral and psychiatric health problems, which includes revision of your care plan Maybe patient’s aren’t progressing or whose status have changed You can also use that to facilitate and coordinate treatments If they need psychotherapy, pharmacotherapy, counseling, or psychiatric consultation, and it’s used for continuity care with a designated member of the care team, so it can be behavioral health with the PCP as well And it does need to be at least 20 minutes per calendar month So what we do is, we just leave the encounter open for the month, until we reach that 20 minute mark, and then we close it and bill it out – So, I just wanted to address a question on the chat So all of the codes that we’re presenting right now are billed to the physical health plan If a payer has separated mental health billing or benefits from physical health benefits, then all these codes would be billed to the physical health side of that plan And we’ll denote when we are talking about codes that could be billed to a mental health side if the plan is split up So Jon is actually a patient of mine He’s 65, he comes in once a month for a “check in” We’re not really doing therapy, we’re not really doing prevention services, we’re not really doing health and behavior It’s really about care management And what we do is, we kinda just go, it’s really involved with lots of different agencies ADS is involved in his services He has Meals-on Wheels He just has a lot of different people who are helping care for him And so what we do is, just kinda go over how are things going We talk about his meds ’cause he has cognitive impairment and memory’s really hard We talk about upcoming appointments and making sure he has plans for transportation And we’re really kind of talking about any other changes that might be happening And it’s a supportive visit, but it’s also kind of a care coordination service, and we do use major depressive disorder as the diagnosis, because that’s really what is impairing his functioning and why he has all these services – So for the developmental screening code 96110, it’s for developmental screening for developmental milestones, speech, language delay, and it’s going with documentation per standardized instrument The provider uses a standardized form to analyze the presence of any developmental disorders

using measurable parameters These are things like the ASQ, the MCHATs, the Behavioral Health Assessment Scale for Children, and you see in the slide all the ones that apply to it Usually these are screenings done during infancy or adolescence to screen for any delays And then the provider may use the form to determine whether the patient requires any additional workup for the developmental disorder The provider can use various standardized screening instruments and as long as they score on documents, they can bill this code – There are several questions on the chat coming up about the additional collaborative care codes So, my understanding is, those codes, we talked about the care management code The additional codes, my understanding is that they’re for psychiatric services And our talk today is really specifically about the codes that psychologists, LCSWs, non-medication, nonmedical provider, behavioral health clinicians can bill for that That’s our focus today, but yes, there are some great codes that come in to support collaborative care models with psychiatrists, in addition to the care management code But of that said, the care management code is helpful to the work of LCWs and psychologists working on the psychosocial aspects of health as a part of primary care – And all the codes that we are talking about today, are anybody who is, to bill to Oregon Medicaid anybody who is listed in our slide about Senate Bill 832 and who is considered a BH clinician or BH provider So you can reference that slide when we send them out So this is just an example of maybe what you’d use a developmental mental screening code for Rose, she’s three, she came in BHC same-day visit We talked with her We interviewed her mom and we reviewed the ASQ and the MCHAT and we discussed what the developmental milestones that we’d expect for Rose would be And then we reviewed the concerns we had and we talked with mom a little bit about her concerns, as well And we talked with the primary care clinician, and mom, about referring the patient to an early intervention program – Alright, the next code is for brief emotional and behavioral assessment with scoring and documentation per a standardized instrument And so, this can be billed out whenever the provider administers a test to evaluate the patient for and emotional and/or behavioral problem And this includes various standardized instruments such as depression inventory, ADHD disorder, scales or symptom questionnaires The documentation should include the test score and the results You can actually report this code multiple times, 96127 It can be reported for each instrument that’s used for assessing the emotional state and behavior of the patient – So, example of brief emotional, behavioral health assessment via BHC Example would be Charlie, who’s 15 years old and luckily, his BHC can see him the same day ’cause they save same-day appointment slots, seen same day And luckily so because Charlie just came in for a well-adolescent exam and as a part of that exam, endorsed suicidal ideation, which is something we want to take care of right away and very well So BHC of course, a psychologist or an LCSW is well-equipped to review suicidal ideation with the teen, review the risk, develop a safety plan to meet that risk So it will be something like reviewing the Patient Health Questionnaire A, the suicidal ideation question, and then going further and using a robust risk assessment process to determine the level of risk for Charlie And then, once determined the level of risk, moving on to what kind of safety plan could be put in place to mitigate that risk to allow for continued being in the community, or if not, what kind of inpatient services might be necessary Formal diagnosis may, or may not be, made in a situation like this And if a formal diagnosis is not made, in this situation, using this code, and reviewing these screeners and then looking at it

more deeply, that is a diagnosis that would work for the situation, could be something like suicidal ideation – Alright, so the next set of codes are specific for preventative medicine for the state of Oregon Oregon Medicaid is expanding coverage to allow psychologists and LCSWs to bill for preventative medicine Currently, Medicare and most commercial insurance carriers will deny these codes, indicating that they’re not billable services by LCSWs And so, if you’re unable to bill these codes in your area, or you mainly bill Medicare or commercial insurance and you encounter problems, you can always consider billing these services as an “incident to” and submit the charges under the name of the supervising physician or provider That’s about all I’ll say about billing to “incident to” because that, in and of itself, would be an entire different presentation Alright so, Oregon Medicaid allows BHCs to bill for the preventative Medicare HCPC codes and therefore, is extending coverage to allow them to bill these preventative medicine codes as well They are classified as evaluation and management services, but they don’t require a physical exam Instead, these codes are used when the visit is focused on counseling to prevent illness or injury, promoting health or counseling to support a wide variety of symptoms So we’ll use these codes when the focus of the counseling is not for a specific, diagnosed medical condition But rather, the counseling is to prevent a condition, or the recurrence or worsening of an existing condition And so, this can include various mental health conditions or substance use, behavioral problems It could nutrition or diet and exercise counseling, or counseling on social issues including like, STI prevention or family problems – So this is just an example, a pediatric example of a preventative medicine counseling visit Jill, seven, she comes in, her mom actually brings her in ’cause she, mom is really concerned about some of her anxiety at home and some school avoidance that’s been happening lately, she’s missed a bunch of school So what we have done is, really spent some time talking with Jill, talking with mom We drew some pictures with Jill just to get a sense of where she’s at, what her thoughts are around school, and what’s going on at school Used some psychoed for mom and Jill about anxiety, talked to them a little bit about what anxiety is, and explored what Jill is actually, kind of worried about We used school avoidance, anxiety and worry; all of those would have been appropriate code to use for preventive medicine counseling purpose visit with Jill – I’ve just been following some of the chats There’s so much expertise coming in through the chats about different challenges with the different codes that we’re talking about We definitely don’t have all the answers, but we’ve been working on this and have found some success in billing, but I just wanted to say that one of the most successful things that we did was having people like me and Joan, clinician types, teaming up with our billing experts, like Denise and Jonique We really need to work closely with each other ’cause this is, as clinicians we try our best to understand all this code stuff, but we really need our billing experts to help us We really know what the clinical problems are, how to assess clinical problems, how to treat clinical problems, so we know what we’re talking about for those things and our billing and coding people help us find the codes that match the documentation and service that we just delivered So, I found so much, it’s just so relieving to have the support of these billing experts who really, team approach to this effort And then coming across organizations, multiple organizations in this integrative primary care leadership collaborative who are trying these things out, piloting them Leaders, the BHS leaders teaming up with their billing leaders and then multiple organizations doing this, we’re gonna find out a lot together And I think that this webinar today, you know, there’s people all across the country who are listening to this webinar, there’s a lot of good that can come out of this Clearly, this billing and coding thing (chuckles) is challenging for BHCs in primary care And there’s a lot of, how many people? Over 300 people signed up for this webinar, so there’s a lot of will to solve these issues We’re just here today to present the problems that

we have encountered and some of the solutions that we have, and solicit a conversation to keep this momentum going So we make sure to support BHC in primary care ’cause they’re doing such amazing work So now we’re moving into the mental health codes What we just talked about before were all codes that are technically physical health codes that bill, I mean, the services are separated and mental health is carved out; they bill to the physical health plan These codes are the traditional codes that us, as psychologists and LCWs are very used to using But our primary care colleagues, and our primary care contacts, may not be familiar with these codes And there may be great challenges to bill out for these codes by these practitioners who really do know these codes and these services well But these services are delivered every day by BHCs and primary care The problem is not the service delivery The problem is getting paid for the services delivered in this, for various different reasons – Alright, so the first psychiatric code that we’re gonna talk about is 90791 This is used for psychiatric diagnostic evaluation So in this service the provider performs a psychiatric evaluation of the patient with the aim of making a diagnosis Documentation should include a collection of information about the present and past behavioral concerns, as well as, a past family medical and social history And that should include all diagnostic tests that were performed to work up the diagnosis This code applies to new patients or any patient that’s undergoing a reevaluation – So an example of a diagnostic evaluation that would be done by a behavioral health clinician in primary care Here’s Jane again She’s had her baby, luckily she was able to come and see the BHC for the gestational diabetes, and that was helpful And she has come back of her own will because she realizes that perhaps something that the BHC said in regards to the gestational diabetes, maybe hit a little bit on anxiety that Jane was also having, and some marijuana use And you know, Jane as any good moms, it’s a good moment of life-change where people are really invested in making changes for their own health, but for their children’s health, as well, and this is the case for Jane She of he own accord, now that she has a relationship with the BHC, came in and said: “Hey, I have this anxiety and I need to deal with it, “and also, I’ve been using marijuana fairly consistently “as a way to try to manage this anxiety.” She filled out the PHQ9 and the GAD7, it’s the practice of the BHC to take these measures at regular basis to measure the outcome of the interventions that the BHC would do and to track it in the medical record for everyone to see objective outcomes over time in terms of the BHC support And the GAD7 did indicate some anxiety that needed further assessment So, further assessment was conducted, including a history of present illness of the anxiety and of the marijuana use The risk assessment was done in regards to an elevation on the suicide ideation question Observations of the patient occurred; a differential diagnostic process considering a history of trauma What was the history of this present illness? Is there other reasons? What is the diagnosis of anxiety for this particular case? A differential process occurred and was documented And a diagnostic formulation was arrived at, which included the generalized anxiety disorder was the best fit for what’s been going on with Jane, as well as this cannabis use that is an attempt to manage a longterm experience of generalized anxiety disorder And perhaps, the BHC being generalized anxiety, may start off with a course of four visits perhaps, of anxiety management training, teaching Jane about this anxiety and this disorder And teaching some coping skills that may be very helpful for her So that might be the place that BHC might start But the work of that visit was a diagnostic work that came to a diagnosis and it’s appropriately documented, and the code would work – So the next code is psychotherapy, which is probably the most common, that everyone is more familiar with You have your individual psychotherapy codes within this code-set There’s also family, with or without patient psychotherapy, and group psychotherapy, and multifamily group psychotherapy So for these codes, it’s insight-oriented, behavior modifying and/or supportive face-to-face with the patient, family, group And documentation should highlight the therapeutic communication, attempts to alleviate emotional disturbances, and change maladaptive patterns of behavior and encourage personality growth and development

Time does need to be documented for these For the lowest code, the 90832, it’s a minimum of 30 minutes – So an example of this is Jane Jane comes back, we’re talking a lot about Jane today, comes back to talk about her anxiety and how she’s gonna cut back on her marijuana use So really, this is a psychotherapy visit We’re doing psychoeducation, we’re exploring motivation, we’re talking about what skills and coping she has now How do we build upon those skills? Maybe even talking a little bit about where her anxiety comes from, how long she’s had it, when it started When she started using cannabis? And kind of, we probably reviewed some of the physiology around anxiety, how marijuana impacts emotions and mood, and probably, maybe even do some mindfulness training with Jane So I think that generalized anxiety disorder, cannabis use disorder as secondary, would be appropriate diagnoses for these visits And these are diagnoses, the psychiatric diagnostic evaluation that, and these psychotherapy codes, are being used by How do I say this? We’re, as mental health clinicians, we are making the diagnosis often And sometimes, the already have the diagnosis or the PCP has made the diagnosis – Okay, and there’s psychotherapy for crisis, which is 90839 to 90840 For these codes, crisis state is defined as a life-threatening or complex state requiring immediate attention to a patient in high distress The provider primarily aims the treatment at mobilization of resources to defuse the crisis and restore safety to the patient to minimize the potential for psychological trauma To use 90839, it needs to be, a treatment session typically lasts anywhere between 30 to 74 minutes, and then you bill 90840 each additional 30 minutes that you spend with a patient beyond 60 – There’s lots of good questions coming in about psychotherapy and some of these mental health codes So the way in which, so you hear us, the billing folks talk about what the CPT requires to be documented to be delivered in the service, and so what we are looking at is CPT guidelines and what they say psychotherapy is and what it needs to look like in the documentation in order to attach these particular billing codes So our reference is the CPT and what they think is required in order to use any particular code I hope that answers some of the questions that have been coming through In regards to a case that might work for psychotherapy for crisis, we have Felicity whose a 25 year old transgender patient, presenting in the lobby, stating she’s feeling suicidal You know, BHCs and primary care, typically, for the purposes of serving a great amount of patients, deploy population-based approaches like focused assessment and focused intervention But certainly, longer visits do occur and they occur based on the clinical need of the patient And this might be a really good example of that The patient in high distress and a lot of work needing to be done to establish the risk and to establish a safety planning that would mitigate that risk, hopefully to keep Felicity in the lowest level of care, but if not, escalating to a are that would keep Felicity safe in this period of distress So most of the time, the visits are 15 to 30 minutes in length, for BHC it’s a population-based approach to try to take care of many patients, identify patients for more significant, longer term services, and facilitating patients to those services, so to keep the door open for new patients But like this example brings about, this fits psychotherapy for crisis and the clinician would of course, do what is clinically necessary for the patient in front of them, first So the intervention might be some grounding, some identification and connecting to natural supports to deescalate this current crisis, safety planning of course, and rigorous follow-up schedule for a situation like this The visit diagnosis may be something like suicidal ideation Perhaps there would be something in this visit

in relation to gender dysphoria But those might be potential visit diagnosis, and the work would be to take care of the suicidal ideation and keep Felicity safe – Okay then, psychological testing, the 96101 code is billed per hour with psychologists or physicians time That’s both face-to-face time, administering tests to the patient, and time interpreting the test results and preparing the report This is not a code that LCSWs can bill, it’s for psychologists and physicians only And within this code, you would evaluate the individual’s mental functioning in terms of intelligence, cognition, personality, emotional quotient and behavioral traits The test scores are measured against norm, which is the standard averages score of the general population These test could include personality tests, attitude tests, IQ tests, achievements and direct observation tests And the tests use various stimuli, including verbal, visual, and computer media – An example of psychological testing that may be done by a psychologist who is working as a behavioral health clinician, I’ve definitely seen the use of tools like the Repeatable Battery for Neuropsychological Status for concerns around dementia This is an example of a patient who is 28 and the PCP is wondering if the psychologist behavioral health clinician could do a neuropsychological screening to identify a current neuropsychological functioning in the context of: Jackie just had a car accident a couple of weeks ago and has some symptoms of concussion, and PCP diagnosed concussion Patient didn’t recall the crash By report and looking in the record, that seems to be substantiated in the ER Coming-to within the emergency rooms, so significant impact And so, having these concerns and the PCP knows psychologist can do some neuropsychological testing in it, asked for some testing of functioning of which the BC has provided that testing and also done a clinical interview looking at the medical record, looking at what happened here, the past functioning, premorbid functioning of Jackie And after looking at these various things after a couple of weeks after a car accident and some testing, testing seemed to be within normal range and consistent with background history So that might be really helpful in the care for this patient and information for the PCP, but the psychologist might suggest further testing in the future But this might be a use of when psychological testing in primary care may be useful And the diagnosis would be made by the physician, which is a medical diagnosis, so concussion, and the testing would be of functional status at the current time – So, we’re moving into some tips for success Joan, are you reviewing this one? No, go ahead – Alright, so provide the service that is requested and clinically indicated So as a BHC, many issues come in for us to assess and treat And the most important thing to take away from a conversation about billing and coding as a clinician is that we just provide what’s necessary We get a referral for a particular problem and we’re gonna assess that appropriately based on our clinical backgrounds and experience, and we’re gonna provide the appropriate, make the appropriate, evidence-based recommendations We provide the service first that’s appropriate to the clinical need based on our training and then, there are these codes that may be usable, that may match that clinical service So first, as a clinician, provide the service that is necessary and then be knowledgeable about the billing codes and see what billing code matches the service that you provided This is as you can see, is fairly complicated for BHCs in primary care There are codes, which is good to know, but there’s many codes and how you apply them to any particular clinical service, that takes a little bit of effort Hoping that today gives some tools to support that work The tool in and of itself and then these talking through cases that match the different kinds of codes But you wanna do the service first, and then find the code that matches it Another point is that BHCs and primary care provide diagnostic evaluation and psychotherapy You know, there’s a lot of talk about the primary care behavioral health model being focused assessment and and focused intervention, and it certainly is And having same-day access and doing this

as a 15 to 30 minutes, and this is definitely what occurs in this model, but in that context there are many times in which the service that we are delivering looks a lot like diagnostic assessment Actually, I would say, a lot of what primary care providers want from you as a psychologist, they say: “What’s the diagnosis here?” Because I might have medications, or we might suggest treatments that may be helpful “Did you make that diagnosis?” And I would like to be able to say: “Yes, I’m a psychologist, I’m trained to diagnose.” So we did this work And then, you know, when it comes to psychotherapy outcomes, you know what our first, for psychotherapy visits people have the most outcome that they are going to obtain, and most people don’t stay for years of counseling They come for one to four visits and they get what they need and they may come back And that’s the capacity that the BHC does have, to provide brief, focused assessment and intervention And then, if things are good and progress is going alright, then providing an open door for future care, if necessary And if things are not getting better, facilitating that patient to more comprehensive treatments that may be helpful So we definitely, we’re (unintelligible) as psychologists we have skills in assessment and treatment of mental health concerns and we provide these services within this setting on a daily basis Alright and also, just to note, there is a psychotherapy for 30 minutes code So that is there and so, in our CPT code set there is allowance for a 30 minute psychotherapy code That’s been there before BHCs were around, so there is some understanding that psychotherapy could occur in 30 minutes because actually, there’s been a code there for some time for that purpose, even before BHCs – Julie, we’re just running a little bit behind schedule, and I think, maybe for the next couple of slides, we could just talk-through what we were thinking about and perhaps, just kind of go through them very quickly Is that okay? – Yeah, absolutely So, we had planned a talking-through of a case that may have many suggested billing pathways So maybe this just could be a take-home for folks to think about all the different ways in which one could bill for this service Would that work? – I think really, our point for the next two slides, this one and we also have a pediatric example, is that for both these visits you could, depending on the focus of the visit and what actually happens in the session with the patient, you could bill it a lot of different ways And that was really the take-home, is that both these patients have a lot going on, and depending on what you actually did and the intervention that you did, it might be billed, you might use a different diagnosis and a different billing code And this is just to illustrate that this is complex and it takes clinical acumen, and it takes BHCs who are using their clinical judgment around what needs to be addressed in that day’s visit, what was addressed, and then, what were they treating? What visit diagnosis are they gonna use? And then, what is the billing code that coincides with that? – Really good cases to review afterwords and see how you might select some of these billing codes – And if you have follow-up questions after the webinar, you can email HealthInsight and we’re gonna try to figure out how we can answer some of your questions So we’ve asked both Jonique and Denise to kind of, just go through these questions and maybe, quickly answer You guys have a lot of questions, the audience has a lot of questions about this information, so I’m gonna let Jonique and Denise take it away – [Jonique] I currently work for an F2HC and so, for us, it was mainly a matter of figuring out a way to capture the services that are being provided so that we can report it as part of our F2HC and indicate that we should get paid for these extra services We didn’t necessarily, do any additional communication with payers Denise, you would deal with a little bit more on the commercial side – [Denise] Yes, so we, within (unintelligible) family medicine, we have your regular practices, F2HC and an RHC, and so, before we started billing for behavioral health services, we talked to our top commercial payers and Medicaid, and then some of our Med-Advantage plans as well

Just as kind of, give them different scenarios and different codes that we would potentially be billing, to see how it would affect patients Whether or not our one hand-offs would create an additional copay for the patient, if we billed for those Or how they would really, start us handling billing these services So provider reps for different companies became my best friend in figuring out the different scenarios and how we would handle them And I know I saw it on the chat about one hand-offs and additional, the separate copayment That does happen, but we made it very clear with patients when we do the one hand-off, that it is a separate visit, and our behavioral health clinicians do have a script that they follow, just so patients are aware that we are billing and there may be some out-of-pocket involved And then we also talked to our senior leadership, practice managers, just to make sure and get everyone on board with what we were doing – Great, thanks Denise I wanna talk about some specific challenges Some of your audience, some of the questions are asking about these challenges These are challenges that we faced in our department Denise and I have been working through the problems One of the things we noticed, and this happened right in January, that patients in the beginning of the year had large deductibles If they had separate plans, mental health and physical health, they had possibly, two deductibles And some people who didn’t have separate plans, they just have a large deductible for their entire physical health plan, or their entire health plan So we learned the hard way, and so next year, I think we will be talking with patients at the end of the year, probably starting in October, talking with patients about: “We’re nearing the end of the year, “you probably wanna check what your deductible is “and be knowledgeable about your plan, “so you’re not surprised if you get a bill.” So we had some patients who got really, really big bills, and that was really just because their deductible wasn’t maxed, it was January Another thing that has happened is, we’ve had patients who cannot afford their copay They have a high copay, or really, anything is a, any copay would be a financial burden So our systems has allowed us to, we work in a very large system and the system had, already in place, a payment plan for what a patient owes Also, our system has a discount program depending on where they fall with the federal poverty level Again, we work in a very large system, but these might be Can you go back to the other slide? Or is that your way of telling me to hurry up? – No – Okay so, I just wanted to So if the patient can’t afford the copay, you may think about implementing a discount program depending on their income, or implementing a payment plan for patients We also have trainees in our practices and we’re not billing for trainee services at this time, and so that’s another option for a lower cost service Another thing that’s happened, we had patients who were very, very concerned They would receive a notice from their primary payer that the services will not be covered and they will be receiving out-of-pocket costs But they have a secondary payer, and the secondary payer will be covering the service, but they’re not aware of that So it’s again, really helpful to encourage your patients to understand what their primary care and secondary payer cover, and then also, to understand that sometimes they get an explanation of benefits that has numbers attached to it, but that’s not a bill And so, patients often need a lot of education So, lessons learned So consider who you have in your clinic When you’re hiring, you really want to consider who your payer mix is and who will be able to bill We, in our system, have decided to hire LCSWs and clinical psychologists because we know that is who we can, who Medicare pays for these services for

So we’ve made a decision to hire those two credentials We know that is a luxury, we’re in a large metro area with a large number of licensed clinical psychologists and LCSWs so we know that’s not always an option for rural clinics, or clinics that don’t have a large workforce to choose from Really consider your payer mix At our system, we have many clinics and each payer mix is a little bit different Some of our clinics have mostly Medicare patients Some of our clinics have mostly commercial payers Some of our clinics have mostly Oregon Medicaid So also consider your payer mix We, as a department, really went back to our core values, and we went back to that we provide services regardless of ability to pay and we’ll work with patients on an individual basis if this becomes a barrier to care We started with just billing two BHCs in two different clinics that had very different payer mixes, to just see how this would affect our patients And we learned from that, we one, learned that we didn’t actually have that many problems and and we also learned what the problems were And Julie, do you wanna speak to the last point? – It was so helpful when BHC when getting to know Joan and some of our integrated primary care leadership collaborative colleagues, coming together saying: “Hey, we need support, let’s all get together.” It was lovely that one of our very innovative payers in our area, decided to provide mutual facilitation for this group of BHC leaders that are getting this work done on the ground and supporting BHCs and practices There’s real power across the board in terms of the difficulties with implementing behavioral health practice in primary care, bringing together BHC leaders and their supporters There are many people that are championing and cheering us on and want us to be successful BHC leaders and BHCs And you know, building a collaborative, if you’re in a state that doesn’t have this pulling together, I could not recommend it more You know, to be with folks who know the difficulties, the challenges of trying to implement this work in this new context There’s so much vision, so much good will towards this work There are just some challenges to overcome It’s so much easier to do that with being closely connected with wonderful people who are doing this work So we started with billing ’cause that’s often, what is most concerning to folks, but there are many things that we will be working on in terms of standardizing this work for the benefits of patients across organizations within our state – [Kate] Hi, everybody So hi, this is Kate, again I’m gonna kind of go through some wrap up pieces, but also, we could do a couple of questions I am going in no order, but again, the benefit of using the chat was, we captured all of those And we knew that this content was gonna be way more than we could cover in this time So we’ll do follow up to let you know how we might be able to get at some of those specific questions But one that really stood out was: “You know, you mention this partnership between billers and “coders and behavioral health providers, “but how are they getting their competency and “knowledge in these areas?” And what suggestions, maybe Jonique and Denise, would you have about how billers and coders can get this education? – [Jonique] Um, I think it really starts with just reading the code books And the codes are there, it’s just they’re not used as frequently So if the coding and billing team just take the time to really familiarize themselves with the different codes, they can then take the information back to the providers And I know someone in chat had mentioned doing provider audits And I think it starts with just being really familiar with what the billing options are Which was the point of this, to let you know that we’ve got lots of different codes that could be billing options And then just taking a look at services provided, matching them up with the best billing code and hopefully, being able to get reimbursed for those services – [Kate] Great, Denise would you add anything to that? – [Denise] No, I think she put it great – [Kate] Awesome, so one other question that was just (unintelligible) to me Some primary care practices are just reluctant to bill

for behavioral health codes, if not all insurances allow billing for the same services And we’ve seen very clearly today that it’s just more complex than that So what recommendations would you have for primary care practices that are reluctant to bill under our current circumstances? – Well, I could say that was us, that we were real concerned about: “Oh gosh, Medicare doesn’t pay for this and “Medicaid doesn’t pay for this.” And what we sat down with, we actually sat down with our CFO and Denise, and we said: “What’s our goal here?” And I think, our biggest goal was to capture what we’re doing I think it’s really a philosophical way of thinking about implementing billing is that, you’re gonna bill for the services you’re providing And the clinician will do what is in their scope and bill the correct code for the service that’s provided that’s clinically indicated And then, from there you can look at: “Okay, who are the payers that pay which codes?” And that’s why I really suggest a pilot with one behavioral health provider, just to see who is paying what And what Denise did, and she can speak to this, she actually called up our payers that we work with frequently, and talked with them “Out of these codes, what do you pay?” “who can bill these codes?” And they were, we collaborated with our payers We’ve had Oregon Medicaid, our CCOs, come into our clinics and observe the work we’re doing to understand Our colleague Brian Sandoval, at Yakima Valley Farm Worker’s Clinic, will always tell people: “Invite your payers into your clinic to see “the work you’re doing, it’s very powerful.” So I totally understand the reluctance I totally get it I think it’s important to understand what your payers reimburse and understand who your payer mix is And then, to set up systems and maybe Denise could speak to the systems that we have set up, where the patients are not being hit with large bills if a payer does not pay that code So for example, if we bill a commercial insurance, Denise, preventative medicine counseling, and they don’t reimburse preventative medicine counseling codes, what happens with that charge? – [Denise] We end up writing the charge off just because they’ll deny it as no authorization You can’t bill the patient, provider responsibility Or just, this provider credentialed can’t bill this code and we know we can’t bill the patient at that point And so, for us, it’s just really that simple It’s that we have, if it’s a true denial, we don’t bill the patient for it – And that’s a system we’ve set up – [Kate] Denise, could you, I just, this is kind of related to another question Are some or many commercial insurers in Oregon adopting these codes? We’ve kind of talked about it briefly, but can you just talk about what your experience has been with that? – [Denise] So, for the preventative counseling codes, it seems to be about a 50-50 split with our commercial payers Some will pay for them, and some, follow Medicare guidelines and they’ll deny them For the health and behavior ones that are also typically, the physical health, it’s about the same – [Kate] Great, thank you That’s really helpful So we can do another question, but I’m gonna move forward and just say a couple of things first, and then maybe will do one last question So you can find the Coding and Guidelines document, the link has been provided in chat, here’s the link again Again, we’re gonna send out a recording of this presentation with a link to this document, so anyone who is registered for the email, you will get that and you should forward this to colleagues who might want this information We captured all the questions in the chat today We have them, we know who you are And if we can do a specific follow up, we will If not, this was very helpful to let us know how to structure for future learning opportunities around this So please, keep them coming You can continue even after today by emailing ORBH@HealthInsight.org and getting in touch with us And again, HealthInsight’s work is really around Medicare And so, for those of you who have Medicare-specific questions in the chat, we will follow up with you individually and share what we know and let you know where you can get more resources on that, for that in particular So maybe, you’ve talked about this a lot, but maybe we could just finish on, there are lots of comments about getting denials for lots of reasons And can you just talk about how you, you’ve talked about it a little, but say it more about

how you’ve pursued the process of looking at what gets denied and incorporating that into your workflow? – [Jonique] So for us, when we receive denials, especially surrounding the health and behavioral codes, because the health and behavioral codes require that the focus be on a physical health condition, not necessarily, a mental health condition, so a lot of it is then, going back and taking a look at the chart, to see if it supports a re-bill using a more physical health diagnosis, rather than mental health And coding is all about making sure that the code matches the services provided And so, it’s not always necessarily, about changing the code just so that we can get paid, but rather, making sure that the codes are the best representation of the services that were provided And so, for health and behavioral assessment intervention services, those really are focused on supporting the patient in improving on their physical health conditions And so, if that isn’t actually captured in the coding, we can often go back to the providers to add more information about the physical health, more so than behavioral health, and sometimes we can go back to the payers and receive reimbursement – [Denise] Yeah, and we do the same thing when we get denials We look at the coding again, just to make sure we got it correct the first time And we do try and re-bill anything that is possible to be re-billed And we follow the same process that Jonique mentioned – It’s been so helpful, when providing clinical services, doing the service and documenting it, to have folks like Jonique, I’ve experienced that, have Jonique review the documentation to make sure that the documentation matches the code selected That support is really empowering to BHCs in primary care, having that support lets us move forward in things that we may be nervous with too, in terms of trying new codes Having the billing folks do a double-check is really helpful – [Kate] Great, and then, I think we put a link to a survey in the chat Please, if you’re hopping off in our last couple of minutes here, please complete that survey As we’ve said, this is journey not a destination, and so, all of the comments are really helpful The other thing we heard is, the chat transcript would actually be a helpful resource to people So we’ll clean that up and we’ll include that in the materials that we send out because there were some helpful tidbits thrown in there I guess, I would invite any of our panelists to share a parting thought in 30 seconds or less, and then we’ll be done today – It’s worth it, to go on the path of billing for these services Insurance companies and other folks in our system need to know what BHCs are doing in primary care We are adopting the primary care behavioral health model significantly, and we are providing tons of behavioral health services in primary care If don’t bill for these codes, people will not know what we’re doing and that puts us at risk and it puts our ability to provide the care and primary care at risk So it can be scary, both for the clinician and for the organization, to move forward with billing this work, but being invisible in a system, doesn’t tend to promote the model So, it’s worth it – I would add, Julie, that this is a way to bee seen by the payers It truly is a way to bee seen by the payers and we have not been seen really, since we started So yes, to that I would also say, don’t be afraid to try things We all started by experimenting And again, very small scale One clinician, or one practice in a system So, really not being afraid to try something and revise and learn from that I think there’s a lot of chatter in the chat about different codes, and you can’t do this, and you can’t do that Yes, there’s a lot of rules We’ve tried to kind of boil it down to what we’ve learned, and this is a tool we are using in our system And the four of us put it together and it’s not, it’s a prototype, exactly like what we said, it’s a prototype So use it, use it to make your own, or use it the way it is, or take some and leave the rest at the door, it’s up to you But don’t be afraid to try something – [Kate] Great Alright, we’re right at the hour and I know folks have to hop off to their next thing, but thank you very much to our presenters today

And thank you to the attendees for all the thoughtful questions We look forward to following up and potentially, hosting future learning opportunities for you Thank you