Management of a Psychiatric Consultation Service

Overview

The purpose of this chapter is to give psychiatric providers of consultation-liaison (C-L) services an understanding of the complex business aspects of their work. Understanding that appropriately adhering to the often-confusing guidelines for reimbursement can be stressful to clinicians and expose them to time-consuming and stressful audits and substantial penalties, both personally and for their institutions. In this atmosphere, providing ethical, legal, and clinically astute services can be a daunting task. A fuller understanding of coding and billing will also help psychiatrists, C-L hospital-based programs, and hospital administrators to collect the appropriate reimbursement for services rendered. In this chapter, we will address principles of coding, billing, and documentation that will improve medical documentation by C-L clinicians, as well as address improvements in clinical outcomes and economic benefits accrued by the general hospital due to a smoothly run C-L service. Assessment, assurance, and improvement of the C-L service's quality will also be discussed.

Documentation Should Reflect the Service Performed

Successful C-L services rely on the establishment of cooperative and collaborative relationships with medical colleagues. Hospital-based physicians are exposed to psychiatric co-morbidity on a daily basis. Consultations may be requested for guidance regarding the creation of a differential diagnosis, recommendations for evaluation and treatment, as well as assistance with their approach to inpatient care. The needs of a physician do not always mirror the severity of the patient's medical condition. Billing, however, is always geared to the patient's illness . Although a medical service may purchase a psychiatrist's time and involvement due to their expertise or to guarantee a readily available psychiatrist, the insurance company or other third-party payer is paying solely for a service for an individual patient (rather than purchasing the expertise of a clinician).

Bill Only for Services Documented in the Medical Record

The overriding principle for third-party reimbursement is to bill only for those services documented in the medical record. The charge for service and the reimbursement available for the service are guided by definitions established by Current Procedure Terminology (CPT) codes. A brilliant, life-saving consultation that goes undocumented is not billable. The effectiveness and expertise of the consultant is not an issue for the collection of a reasonable fee. Moreover, significant pressure may be placed on clinicians to “maximize revenue” for the services they provide. Efforts to “game” the system, by “up-coding” (i.e., charging for a more intensive service than delivered) are illegal and unethical. On the other hand, inadvertent “down-coding” on account of the sometimes Kafkaesque documentation and billing rules is also unfair and ultimately damages the ability of hospitals and providers to care for patients.

Follow the Medicare Guidelines for All Entries in the Medical Record

Medicare is the predominant insurance coverage in the general hospital. This is especially true for a psychiatric consultation on an elderly or disabled patient. CPT codes were developed by the American Medical Association (AMA) and adopted by the Health Care Financing Administration (HFCA) in the early 1990s. Current guidelines dictate that Evaluation and Management (E&M) CPT codes, which are not specific to psychiatry but cover all psychiatric hospital-based and outpatient encounters, along with the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), are to be used for billing. These guidelines, established as mandatory for Medicare and Medicaid billing, are essentially universal, in that they apply to most insurance plans. More important, Medicare guidelines for reimbursement are the strictest among insurance plans. Adhering to the Medicare guidelines ensures that the provider will be in compliance with all insurance plans for appropriate coding and reimbursement purposes .

Documentation requirements for inpatient psychiatric and consultation services are different in form and content from the documentation that might be employed in outpatient practices. Codes for billing inpatients reflect the need for the consultant to be aware of the physical status of the patient as well as the patient's psychiatric state. A premium is paid for thoroughness and attention to “process of care.” Thus documentation for inpatient consultative psychiatric services requires documentation of co-morbid medical problems, laboratory studies, and imaging . An extensive psychiatric examination, including recommendations for treatment and medication without the inclusion of elements of the review of systems, for example, can be billed only for the lowest consultation service code. The critical ingredients of an appropriate note congruent with an appropriate billing code will be addressed in the section on documentation and coding.

Obtain Preauthorization for Services Whenever Necessary

Although mental health parity was mandated in the 2010 Patient Protection and Affordable Care Act, mental health coverage largely remains governed by insurance carve-outs and frequently requires prior authorization. Health insurance companies vary in their requirements for precertification (i.e., permission for providing a consultation before the delivery of the service to enable payment for that service). Medicare does not require precertification, while most carve-out behavioral health organizations do. A patient may be authorized by the primary insurance carrier for the medical admission, authorizing payment for all physicians performing medical consultations save for the psychiatrist who requires specific and separate authorization from the carve-out company for payment for the psychiatric consultation. Critical to the financial viability of C-L services is the management and monitoring of the billing and collection of third-party claims, and the understanding that the billing and authorization process for each payer is essential to receive payment for services rendered.