ATT021_SurvivorCCE_TGD006_Billing_IHE_AME.pdf

Controlled Unclassified Information

TGD 006

July 2022

General Contractor Technical Guidance Document

TGD #006

Reimbursement for Services Included in Initial Health Evaluation and Initial and Annual/Follow-Up Monitoring Exam Roll-up Codes

ORIGINAL PUBLICATION: September 17, 2019

DATE LAST REVIEWED: July 01, 2022

Purpose This document provides clarification to the CCE/WSC on:

1. Reimbursement for time spent completing the WTC-3

2. Reimbursement for mental/behavioral health screening and monitoring on the same day as the initial health evaluation, initial monitoring exam, or annual/follow-up monitoring exams

Stakeholders Affected Clinical Centers of Excellence (CCE) Williams Street Clinic (WSC)

Background Roll-up codes Roll-up codes were developed by the WTC Health Program to permit fair reimbursement rates across the clinics for initial health evaluations for screening-eligible survivors (Appendix A), initial monitoring exam for responders (Appendix B), and annual/follow-up monitoring (Appendix B) exams for responders and certified-eligible survivors. Roll-up codes are Evaluation and Management (E/M)1 codes that are used to trigger a formula for payment of these types of services. The rate is recalculated each year based on the Federal Employees Compensation Act (FECA) fee schedule rates. Each initial health evaluation roll-up code and each initial monitoring exam and annual/follow-up monitoring exams roll-up code pay the same for each CCE and was calculated using the higher paid facility rates and the highest geographic location reimbursable rate to provide equal pay for the same work across the CCEs regardless of locale.

The codes within the formulas represent the different services to be performed in each visit.

These services include standardized evaluation and management of a member’s medical and psychiatric history; physical examination; counseling; education and training; health and behavior assessments; medical record review; exposure assessment (initial health evaluation and initial monitoring exam only); and, the certification process.

1 See https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Reimbursement for Services Included in Initial Health Evaluation and Initial and Annual/Follow- Up Monitoring Exam Roll-up Codes

Technical Guidance WTC-3 Completion and Administrative Work Covered by Roll-up Codes The roll-up codes for an initial health evaluation and initial monitoring exam include one (1) 60-minute unit of CPT code 993582 and one (1) unit of code 993593 (subsequent 30 minutes) totaling 90 minutes of record review and administrative activities. The roll-up codes for an annual/follow-up monitoring exams include one (1) 60-minute unit of CPT code 99358. The CCE is being reimbursed for this administrative non-face to face records review and administrative activities, for at least 60 minutes per exam, whether or not the member subsequently moves into the certification process. Therefore, the roll-up code for the initial health evaluation, initial monitoring exam, and annual/follow-up monitoring exams includes any and all of the following services:

1. Reviewing member records to assess World Trade Center relatedness

2. Preparation and/or completion of the WTC-3 form

3. Time spent on administrative work to process and submit the WTC-3 form

As of the date of this technical guidance document, the Program will no longer pay for preparation and completion of WTC-3 forms outside of the roll-up codes billed for the initial health evaluation, initial monitoring exam, and annual/follow-up monitoring exams. Codes 990804, 99358 and 99359 may not be used outside of the roll-up codes for reimbursement for administrative work for WTC-3 completion, administrative work during either the monitoring exams or treatment of members.

The codes 99358 and 99359 are approved for use by the billing physician or other practitioner (non-clinical staff) conducting extensive review of medical records for referrals and treatment but should be used sparingly given the CCEs are reimbursed for these services for every initial health evaluation, initial monitoring exam and annual/follow-up monitoring exam, through the administrative fees and staffing paid within each clinic contract.

Note: The Program will pay for administrative work related to the Victims Compensation Fund (VCF) disability exams using the codes 99455 and 99456.

Mental/Behavioral Health Services Covered by Monitoring Roll-up Codes The roll-up code for the initial health evaluation and initial monitoring exam includes 2 units (120 minutes) of CPT code 961565. The annual/follow-up monitoring exams include 1.5 units (105 minutes) of CPT code 96156. Therefore, the roll-up code for the initial health evaluation, initial monitoring exam, and annual/follow-up monitoring exams includes any and all of the following mental/behavioral health services, depending on patient need:

2 Prolonged evaluation and management service before and/or after direct patient care; first hour 3 Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (List separately in addition to code for prolonged service) 4 Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form 5 96156 is Health behavior assessment, or re-assessment (i.e., health-focused clinical interview, behavioral observations, clinical decision making)

1. Administration and interpretation of an alcohol misuse screen

2. Administration and interpretation of a depression screen

3. Administration and interpretation of a PTSD screen

4. Administration and interpretation of the Diagnostic Interview Schedule (DIS)

5. Any authorization of external mental health services

6. Routine oversight/review of appropriate mental health treatment

7. Routine assessment of patient compliance with their mental health treatment plan and/or encourage the patient to seek mental health treatment

8. Quality assessment of patient outcomes in alignment with provider reporting

The CCE shall not bill separately for the above listed services6 on the same day as the initial health evaluation, initial monitoring exam, or annual/follow-up monitoring exams effective date of this TGD. The CCE may bill separately for mental health crisis management7 in limited circumstances where the individual has been identified, during the exam, to present with mental health symptoms that require urgent evaluation. This should be clearly documented in the member record.

NOTE: This TGD is not meant to provide guidance on the use of the DIS tool in screening and does not limit the use of additional codes for mental health diagnostic or treatment provided on the same day of monitoring.

Quality Controls

The use of the codes mentioned above will be randomly audited by NIOSH to assure they have been used in alignment with this technical guidance and codebook guidelines.

Supplemental Material(s) Appendix A: Initial Health Evaluation/Initial Monitoring Roll-up code tables with descriptions8

Appendix B: Annual/Follow-up Monitoring Roll-up code tables with descriptions8

Revision History

Rev # Changes Made to Document Date

1 New Technical Guidance Document 09/17/2019

2 Roll-Up Codes and Pricing Updated in Appendices 01/01/2021

3 Updated to 2022 TGD Template 07/01/2022

6 Including but not limited to codes such as 96150, 90791, G0442, G0444, 90885 7 Mental health crisis management includes, but is not limited to, a patient who exhibits suicidal or homicidal ideation, severe substance abuse, or where there may be a need for further in-depth evaluation outside of the normal screening/DIS administration. The use of 96150 may also be appropriate if cognitive assessments are needed.

WTC Health Program Approval The undersigned acknowledges they have reviewed this WTC Health Program technical guidance document (TGD) and agree with the approach it presents. Changes to this TGD will be coordinated with and approved by the undersigned or their designated representative(s).

Signature: _____________________________________________________ Date: ____________

Controlled Unclassified Information

TGD 006

July 2022

Appendix A

Code Code Description Time Payment

99385 Initial comprehensive preventive medicine evaluation and management of an individual; new patient; 18-39 years

Time is not listed as a factor for this code.

$249.11

99386 Initial comprehensive preventive medicine evaluation and management of an individual; new patient; 40-64 years

Time is not listed as a factor for this code.

$249.11

99387 Initial comprehensive preventive medicine evaluation and management of an individual; new patient; 65 years and older

Time is not listed as a factor for this code.

$249.11

Code WTCHP Code Description for Roll-up Code Payment Formula Time Payment

98960

Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes;

individual patient

Billed for 30 minutes

$47.93

96156 Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)

Billed for 70 minutes per unit (The program allows 1.5 units total for this visit)

$227.04

99358 Prolonged evaluation and management service before and/or after direct patient care; first hour

Billed for 60 minutes $177.94

99359 Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes

Billed for 30 minutes $84.66

96156 An additional .5 units of this code is allowed only in the IHE for collecting the exposure history.

The program allows .5 units total for this visit $75.67

Initial Health Evaluation/Initial Monitoring Roll-up Codes

IHE/Initial Monitoring Payment Formula: (Applicable roll-up code ) + 98960 + (96156*1.5) + 99358 + 99359 + (96156*.5)

Codes Included in Annual/Follow-Up Monitoring Exam Payment Formula (Cannot be separately billed)

Reimbursement for Services Included in Initial Health Evaluation and Initial and Annual/Follow-Up Monitoring Exam Roll-up Codes

Appendix A

• Claim is billed with the most appropriate roll-up code based on the member’s age (99385, 99386 OR 99387)

• Claim is billed with ICD code:

o Survivors - Z13.9 as the primary diagnosis o Responders - Z04.9 as the primary diagnosis

• In the above example the roll-up code 99386 is the only code that should be reported on the claim o 98960, 96156, 99358 & 99359 is NOT separately billed

• Payment/reimbursement is based on the “IHE/Initial Monitoring Payment Formula” (see above)

Code Payment

99386 $249.11

98960 $47.93

96156 $227.04

99358 $177.94

99359 $84.66

96156 $75.67

Prolonged evaluation and management service before and/or after direct patient care; first hour

Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes

WTCHP Code Description for Roll-up Code Payment Formula Example: Billed age appropriate roll-up code for 50 year old is 99386

Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)

Initial comprehensive preventive medicine evaluation and management of an individual; new patient; 40-64 years

Total Time Allocated Total IHE/Initial Monitoring Payment

An additional .5 units of this code is allowed only in the IHE collecting the exposure history.

Approximately 4.5 hours $862.35

Reimbursement for Services Included in Initial Health Evaluation and Initial and Annual/Follow-Up Monitoring Exam Roll-up Codes

Appendix B

Code Code Description Time Payment

99395 Periodic comprehensive preventive medicine reevaluation and management of an individual; established patient; 18-39 years

Time is not listed as a factor for this code.

$206.68

99396 Periodic comprehensive preventive medicine reevaluation and management of an individual, established patient; 40-64 years

Time is not listed as a factor for this code.

$206.68

99397 Periodic comprehensive preventive medicine reevaluation and management of an individual; established patient; 65 years and older

Time is not listed as a factor for this code.

$206.68

Code WTCHP Code Description for Roll-up Code Payment Formula Time Payment

98960

Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes;

individual patient

Billed for 30 minutes

$47.93

96156 Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)

Billed for 70 minutes per unit (The program allows 1.5 units total for this visit)

$225.97

99358 Prolonged evaluation and management service before and/or after direct patient care; first hour

Billed for 60 minutes $177.94

Annual/Follow-Up Monitoring Roll-up Codes

Annual/Follow-Up Monitoring Payment Formula: ( Applicable roll-up code ) + 98960 + (96156*1.5) + 99358

Codes Included in Annual/Follow-Up Monitoring Payment Formula (Cannot be separately billed)

Reimbursement for Services Included in Initial Health Evaluation and Initial and Annual/Follow-Up Monitoring Exam Roll-up Codes

Appendix B

• Claim is billed with the most appropriate roll-up code based on the member’s age (99395, 99396 OR 99397)

• Claim is billed with ICD 10 code Z04.9 as the primary diagnosis for both Survivors and Responders

• In the above example the roll-up code 99396 is the only code that should be reported on the claim o 98960, 96156 & 99358 is NOT separately billed

• Payment/reimbursement is based on the “Annual/Follow-up Monitoring Payment Formula” (see above)

Code Payment

99396 $206.68

98960 $47.93

96156 $225.97

99358 $177.94

Example: Billed age appropriate roll-up code for 50 year old is 99396

Approximately 3.25 hours $658.52

WTCHP Code Description for Roll-up Code Payment Formula Periodic comprehensive preventive medicine reevaluation and management of an individual, established patient; 40-64 years

Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making) Prolonged evaluation and management service before and/or after direct patient care; first hour

Total Time Allocated Total Annual/Follow-Up Monitoring Exam Payment

Approval_Date_af_date: 7/15/2022