Integrated Primary Care and Behavioral Health

wgmarrs

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Parkersburg, WV
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We're a community BH center who has added integrated primary care in our agency. We're encountering two difficulties in billing primary care E/M and psychiatry E/M. The first problem involves clients who see both a psychiatric and primary care provider on the same day, with an E/M being provided by each. Our understanding is that multiple E/M's on the same day are acceptable when a) two different providers are involved and b) the focal problem is different. Nevertheless we cannot seem to get both of the services paid. Our second problem involves the New and Established patient distinction. From our point of view, even though a client may be established psychiatrically, when they see the primary care provider for the first evaluation we feel they should be regarded as a New patient - because a different provider specialization is involved. But payers are denying these efforts by insisting the client is already established, based upon the psychiatric history.

I was wondering if any other BH provider has sojourned into the integrated care arena and had encountered any similar problems - and if so, whether any suggestions in resolving them may be at hand? TIA.
 
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I can try to help but I need a bit more information. When a patient sees the PCP, is the CC completely unrelated to psychiatry? (eg, runny nose, leg pain). Does the documentation from the PCP "link" the service to the psychiatry visit on the same day (and vice versa)? What psychiatry services are being provided, what CPT codes are you billing? Are the DXs on the PCP claim completely different than those on the psych claim?

The patients that are being seen by a PCP, have they seen that PCP prior (past 3 years) just in a different location? Likewise for the psych providers, did they see the patient elsewhere? Regarding the new primary care providers, were they from a completely separate, outside group/Tax ID or were they just in a clinic under the same group and moved to your facility? For example, the facility I work for is a large teaching hospital with gobs of clinics all over the state. Everybody falls under the same group TIN even though they are hundreds of miles away from each other. If Dr. A is in a family care clinic in city 1 and moves to a specialty clinic in city 2, that relationship between city 1's clinic and city 2's clinic somewhat drives the new vs established situation, besides the specialty and some other odds and ends.

A lot of the questions you have really revolve around the relationship between your facility and where the primary care providers came from. Rather than running through the extensive list of possibilities, narrowing it down to your specific situation will greatly reduce the amount of information that I would have to post.
 
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