Primary Care Coding Alert

Find out if your coding comprehension is correct.

Once you’ve answered the quiz questions on page 3, compare your answers with the ones below.

Answer 1: According to the AHA ICD-10-CM Coding Clinic (2021, Volume 8, Number 1), depression and anxiety are not automatically linked. This means you should assign separate codes to the two conditions unless your physician has documented that they are connected. So, the Coding Clinic recommends you use codes such as F32.9 (Major depressive disorder, single episode, unspecified) and F41.9 (Anxiety disorder, unspecified) “when the documentation has not established a linkage between the depression and the anxiety.”

However, the article goes on to tell you it would be appropriate to use F41.8 (Other specified anxiety disorders) when “the provider does indicate a relationship between the two conditions.” That’s because ICD-10 lists anxiety depression (mild or not persistent) and mixed anxiety and depressive disorder as synonyms for the code.

So, this would be a good time to query your physician concerning the specificity of both the relationship as well as type. If there is a note mentioning “a linkage in the documentation to indicate a single disorder” and that the linkage is “a distinct clinical diagnosis” such as mixed anxiety and depressive order, or MADD, per the Coding Clinic, it would be appropriate to use F41.8.

Answer 2: To answer this question, you need to understand the clinical similarities between the conditions. “Bipolar disorder is easily confused with depression because it can include depressive episodes. The main difference between them is that depression is unipolar, meaning that there is no ‘up’ period, but bipolar disorder includes symptoms of mania,” explains Donelle Holle, RN, president of Peds Coding Inc. and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Or, as the AHA ICD-10-CM Coding Clinic explains it, “bipolar disorder includes both depression and mania.” Because of that, the article goes on to say, “it is more important to capture the bipolar disorder,” so “a code for depression would not be reported separately” (Coding Clinic 2020, Vol 7, No. 1).

This is reinforced by the instructions for all the bipolar and major depressive episode codes, which state that the F32.- (Depressive episode) and F33.- (Major depressive disorder, recurrent) codes are Excludes1 codes for the F31.- (Bipolar disorder) codes, and that the F31.- codes are Excludes1 codes for the F32.- and F33.- codes.

So, in this situation, you would only report a bipolar disorder code. However, a definitive answer to this question becomes more complicated when you consider the numerous code choices in the F31.- category. The codes are divided into various subcategories depending on whether the patient is currently experiencing the condition (the F31.0 - F31.6- codes), whether the patient’s condition is in remission (the F31.7- codes), whether the patient is experiencing other forms of the condition (the F31.8- codes), or whether the condition is unspecified (F31.9).

Then, some of these subcategories are further subdivided by different characteristics such as severity (mild, moderate, severe, or unspecified); whether the current episode is hypomanic, manic, depressed, or mixed; and with or without psychotic features.

With so many code possibilities in play, then, the final answer to the question relies on you querying your physician “so that you can code to the highest level of specificity,” cautions Holle.

Answer 3: How to assign the correct codes for behavioral health care management comes down to understanding the differences between standard behavioral health integration (BHI) and a collaborative care model (CoCM). Be sure you fully understand which kind of program your practice uses.

CoCM: If your practice has a psychiatric CoCM program, the care team should have three distinct members: the behavioral health care manager, a psychiatric consultant, and the treating practitioner. This model is essentially an enhancement of the general BHI primary care model that provides additional support for patients receiving behavioral health treatment through their primary care practitioner (PCP).

CoCM coding: To bill for monthly services using the CoCM approach, use the following codes based on the behavioral health care manager’s time and whether the service is initial or subsequent:

• First 30 minutes, initial or subsequent month: G2214 (Initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional)
• First 70 minutes, initial month: 99492 (Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant …)
• First 60 minutes, subsequent month: 99493 (Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant …)
• Additional 30 minutes, initial or subsequent month: +99494 (Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month …)

BHI coding: If your practice has a general BHI model, the treating practitioner and other qualified clinical staff are the two  distinct member types involved. Note: The clinical staff might include contractors who also happen to meet the qualifications for CoCM.

You would report BHI code 99484 (Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month …) in situations that do not involve a psychiatric consultant or an appointed behavioral health care manager. Essentially, you may use this code for behavioral health care management services that aren’t part of a formal CoCM, if they include the appropriate service elements identified in the full code descriptor.

Documentation alert: Documentation is one of the biggest challenges with BHI programs because the codes are reported monthly and “each clinician must write his or her own note. Clinicians don’t always document in the same place around the same time for a service that is collaborative,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. It’s important that each member of the team, including coders, understands the elements required to report each code to ensure seamless reporting each month.

Note: For a complete list of service elements as well as the necessary documentation, check out our full BHI article in Primary Care Coding Alert volume 24 issue 10.