I thought it might be fun to talk about the birds and the bees this month. Let’s get dirty; let’s talk about conception and delivery and aftercare and check-ups. Except instead of a baby, let’s talk about the conception and birth of a primary behavioral health integrated care claim. Scrub in nurse, it’s fixin’ to messy up in here, and you might be surprised who all is involved in the process.
Meet Christy; she works at Redwall Community Health Center as a customer service representative (CSR). She sometimes snickers at the title because when asked what it means she says “I work the front desk at the doctor’s office and do patient intakes.” (Cue Marvin Gaye’s “Let’s Get It On”) Christy, you naughty devil – you’ve just kicked off the conception of our claim. She hands our new patient an intake form, and on that form is a few questions about depression and substance abuse, or more specifically the PHQ-2 and the CAGE-AID. “I know we ask about some things about depression and drugs,” Christy says, “because we have some people who can help with those things but I don’t really know much more than that.”
Next let’s meet Mandy, a medical assistant (MA). She has grabbed the completed intake form and will be escorting our patient back to the exam room after grabbing a couple of quick vitals. Before she does that though, Mandy will eyeball the questionnaire the patient filled out and notices that the one of the two depression questions was answered affirmatively. Instinctively she glances down the hall and sees Billie popping out of another room, but we’ll meet her later. Meanwhile the conception of our claim is in full order.
Nicole, a registered nurse, is next up. There’s not a lot she hasn’t seen or dealt with or wiped up in that time. As Mandy “rooms” our patient and walks back to the front of the office, she mentions to Nicole that one of the depression cues was checked. Nicole thanks her and on her way to the exam room grabs a PHQ-9 out of the hanging file folder in hallway. She completes the rest of the vitals, gets the patient disrobed and ready for the doctor, and before she steps out hands the patient a clipboard with the PHQ-9 on it and explains that we’d like to get a little more information about her current feelings. If we were to take an ultrasound on our claim, you could almost start to make out some of the features.
Dr. Dan, a family practitioner, is the next on the scene. Out in the hallway before entering the room, Dr. Dan and Nicole had a quick chat about the presenting complaint and the PHQ-9. Upon entering the exam room and after exchanging the normal pleasantries, the doc looks over the depression screen on the clipboard. As he’s completing his normal check-up, looking in the eyes, ears, nose and throat, he asks about a couple of the questions on the form. “It seems like you’ve been dealing with some sadness and lack of motivation lately,” he says. “Looks like it’s been going on for a couple of weeks, why don’t you tell me a little more about it,” he says as he checking the patient’s ears. After some discussion and a review of the other physical symptoms the patient was complaining about – headaches, poor sleep, poor appetite mainly – Dr. Dan asks if it would be OK if he stepped out for just a second to chat with a teammate.
Billie Hines is standing at the work station typing in a note from her last patient. She is a psychologist who works as a Behavioral Health Consultant (BHC) at Redwall. “Hey Dr. Hines, do you have a second to help me with a patient?” Dr. Dan asks. “There’s a pretty significant level of depression there and I’m not seeing a lot on exam that tells me there’s anything physical going on. Could you step in with me and we’ll chat with her?” Together, they enter the room. Our claim is born!
Dr. Dan introduces Dr. Hines as a teammate who is really well trained to help with depression. “I don’t know if you’re depressed or not,” Dr. Dan tells the patient, “and maybe Dr. Hines won’t know either right away, but before I just go cutting you a script for an antidepressant that may or may not work, let’s try something else.” After a few moments, Dr. Dan excuses himself and moves on to his next patient. Billie stays with the patient and talks some more about things that are going on her life and how she’s feeling. Billie suspects that there may be some depression at play, but gives her a few sleep hygiene exercises she can try and tells her she has a journal she will give her on her way out. “You don’t have to write every thought or anything, but you said you like to doodle and draw, so maybe once a day sketch something you like, or what you’d like to be doing. I think Dr. Dan is going to want to see you in a week or 10 days to follow-up, can I pop back in with you then?”
Out in the hall Drs. Hines and Dan catch back up as Billie is grabbing a journal from her resource cabinet. They talk about the possibility of starting an antidepressant if there isn’t any progress on her moods at the next visit. “She’s definitely not suicidal or anywhere near that point,” Billie says. “But I’m concerned that she’s stuck in some pessimism and some family stress that are keeping her up all night tossing and turning. I gave her some sleep and relaxation exercises and want her to journal and focus on herself a couple of times a day,” she said. “Let’s see if she is coping better and then decide if she’ll need a mood stabilizer or sleep agent at that point. I really think if she could just rest and get eight hours she’ll cope better and not feel so overwhelmed.”
And with that we have two claims. A medical check-up and a behavioral health intervention.
Next, Billie will type her note on a template developed by Tom in IT. Tom understands the complexity of an integrated approach and how those notes are really a part of the whole medical record and need to be easily accessed and read. No one has time to read traditional three-page narratives.
Flynn, Redwall’s CFO has been trying to negotiate with one of the new MCOs in the market to structure a global payment system instead of strictly a fee-for-service model. Flynn understands that the hallway conversations between Mandy and Nicole, and Drs. Dan and Hines are not captured in any code, yet they were essential to the patient’s care. He also is well aware of the weekly team meeting where all of the providers, MAs, and CSRs gather to talk about specific cases. Flynn calls it the most expensive hour of the week, but the team calls it the best hour of the week. Again, not captured by any code or billable. But under a global payment system such as a shared savings model or other pre-paid per-member-per-month model (PMPM), it could be. For now, though, Flynn has trained his billing and coding staff on the intricacies of an integrated model.
Carrie in coding looks closely at the claims from the superbill as they come in. She notices that Billie coded the patient visit described as a CPT 90791 which meant that it was a behavioral health intervention and not incident to a medical condition, and that it occurred in primary care and not in one of their outpatient mental health offices. There is a specific protocol on dealing with those codes that she follows. Periodically someone from their internal QA department will go through and audit the notes and codes to make sure they match and are accurate. Our claim is walking and talking now!
In a few weeks Audrey in Accounts Receivable will assure that the claim was paid by the payer. She is responsible only for claims filed with this particular payer so she is well aware of the service manual and claim mechanics. Audrey is all too familiar with how these specific interventions get tripped up from time to time and denied because they occurred in primary care and someone in the payer’s claims office doesn’t understand Redwall’s integrated care model. “I don’t know how many times I’ve had to call and dispute a rejection with them,” she says.
So you see in the conception, delivery and follow-up of a claim that there are many people, talents and skills involved. It is a process; a complicated process with many moving parts that all have to work in concert with each other. So as you consider moving to your integrated practice, think about all of the different levels of training that will be necessary. Think about the development of templates, of new processes, of new communications, of new flow, of new skills. It’s really a miracle of birth! Congratulations!