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The 'S of CSW Billing

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85 views2 pages

The 'S of CSW Billing

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mamatha mamta
Copyright
© © All Rights Reserved
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CODING & BILLING

The
’s of CSW Billing

BY CINDY PARMAN, CPC, CPC-H, RCC

A
clinical social worker (CSW) is a programs, and government programs and In addition, covered services include
practitioner trained, educated, can assist patients and their families in those that the CSW is legally authorized
and licensed at the graduate accessing this support. In many can- to perform under State law or regulation
level, with a master’s degree or higher in cer programs, the clinical social worker to diagnose and treat mental illnesses.
social work, to provide mental health ser- coordinates and/or facilitates patient and Services provided to beneficiaries that are
vices for individuals, families, and groups. caregiver support groups. inpatient or in a partial hospitalization
Some states have licensing requirements, The clinical social worker is generally program are considered to be Medicare Part
and these practitioners are referred to as part of a multidisciplinary team that works A expenses, while services performed in a
licensed clinical social workers (LCSWs). together to meet the needs of the cancer physician’s office, outpatient hospital, hos-
The profession of clinical social work patient and/or family. The CSW may be pice, or community mental health center
originated in the 1920s, and the role primarily responsible for managing practi- can be billed by the CSW to Medicare Part
of social workers shifted over time with cal issues, such as transportation, hous- B. Mental health services provided to a
increasing attention on individual social ing, financial assistance, and language or skilled nursing home patient may be Part A
adjustment. By the mid-20th Century, cultural barriers to treatment or ancillary or Part B, depending on the nature of the
psychiatric social work was an accepted services. While the primary assistance pro- patient’s admission to the SNF.
area of practice and laid the foundation vided by the social worker may be providing Covered therapeutic services are reim-
for what would be labeled “clinical social education related to the disease process, bursed as follows:
work” in the 1970s. discussion of treatment decisions, and sup- • The payment for CSW services is based
Of the four core mental health profes- port with coping skills, the CSW may also on 80 percent of the lesser of 1) the
sions, social workers comprise the largest provide and document individual and family actual charge, or 2) 75 percent of the
group of clinically trained practitioners in counseling sessions. physician fee schedule.
the United States. In addition, social work- • Professional services billed outpatient
ers are more likely than psychologists and Reimbursement in a Critical Access Hospital (CAH)
psychiatrists to work in rural communities.1 For purposes of Medicare reimbursement, are reimbursed at 115 percent of the
a clinical social worker is an individual allowed amount (75 percent of the
Cancer Center Social Work who possesses a master’s degree or physician fee schedule). The CAH is
A cancer center social worker typi- doctorate in social work, has performed required to append HCPCS Level II
cally provides psychosocial services to at least two years of supervised clinical modifier AJ (clinical social worker) to
patients, families, and caregivers facing social work, and either: the professional charges.
the impact of a cancer diagnosis. Social 1. Is licensed or certified as a clinical • The annual Medicare Part B deductible
workers are knowledgeable about the social worker by the State in which the and 20 percent coinsurance apply to
psychosocial, emotional, and financial services are performed, or CSW services.
issues that cancer patients may con- 2. If the State does not have a licensing or
front. Oncology social workers help fa- certification process, has completed at Covered clinical social worker services
cilitate the patient’s adjustment to can- least two years or 3,000 hours of post in the hospital outpatient setting are
cer and can help patients navigate the master’s degree supervised clinical social reimbursed by Medicare Part B, regard-
healthcare system. In addition, oncology work practice under the supervision of a less of whether the CSW is employed by
social workers are knowledgeable about master’s level social worker in an appro- the hospital or practices independently.
local resources, pharmaceutical and priate setting, such as a hospital, skilled However, clinical social workers cannot bill
non-pharmaceutical patient assistance nursing facility (SNF), or clinic. Medicare directly for outpatient services;

12 OI | March–April 2012 | www.accc-cancer.org


“Managing the costs of cancer treatment is difficult for many patients
and families coping with cancer, and may cause distress and worry and individual, group, or family therapy.
make it more challenging to follow their doctors’ prescribed treatment However, the CSW can be considered part
course,” said Carolyn Messner, president of the Association of Oncology of the hospital resources that contribute
Social Work (AOSW).2 AOSW was formed in 1984 and is dedicated to the to the level of the technical clinic visit
enhancement of psychosocial services to people with cancer and their service on the day the patient is evalu-
families to help them cope with the practical, financial, emotional, and ated by the physician in the hospital
social concerns of living with cancer. outpatient department.

—Cindy Parman, CPC, CPC-H, RCC, is a


the hospital must file the Medicare claim for assigning the different levels of principal at Coding Strategies, Inc., in
and identify the social worker with a clinic visit codes. As long as the services Powder Springs, Ga.
specific provider number. The CSW can- furnished are documented and medically
not generally charge for evaluation and necessary and the facility is following References
management (E/M) services, psycho- its own system, which reasonably relates 1. National Association of Social Workers.
logical testing, or procedure codes that the intensity of hospital resources to the Clinical Social Work Medicare Facts. Social
include medical management. Therapeutic different code levels, Medicare assumes Work Reinvestment Initiative. National
services that can generally be billed by that the hospital is in compliance with Association of Social Workers. Available
a CSW include individual psychotherapy, these reporting requirements.3 Therefore, online at www.socialworkreinvestment.
group therapy, and family therapy (proce- Medicare has only two requirements: org/Content/cswmedicarefacts.pdf
dure codes 90804–90899). • The services must be documented and Last accessed Jan. 31, 2012.
Remember that payers other than Medi- medically necessary, and 2. Association of Oncology Social Work
care may have different limitations on the • The mapping should reasonably reflect Survey Shows More than Half of Cancer
number of sessions or hours reimbursed per the intensity of the hospital’s techni- Patients Say Cancer Costs Negatively
patient per calendar year or fiscal year. cal resources. Impact Their Focus on Recovery [press
release]. Association of Oncology Social
Component of Hospital While the CSW cannot bill for clinic Work; December 2, 2009. Available online
Clinic Visit visits, management services, or non- at www.disabilityrightslegalcenter.org/
There are two parts to every outpatient psychotherapy procedures, all resources about/documents/AOSWSurveyShows_
hospital visit 1) the professional compo- expended by the hospital in an outpa- StreetInsider_120209.pdf. Last accessed
nent that reports the physician’s service tient department can be used to report Jan. 31, 2012.
and 2) the technical and facility component a facility clinic visit (technical service). 3. Federal Register. April 7, 2000.
used to report the services of hospital This visit includes social worker services
ancillary staff, room, and overhead costs, relating to patient education, naviga-
collectively called the hospital resources. tion, or other services that include direct
Since the implementation of the face-to-face patient contact. For example, Additional Resources
Medicare Hospital Outpatient Prospec- if the hospital employs a point system • CPT® Manual, 2012 Edition
tive Payment System (HOPPS) in August or other methodology to track resource • Medicare Benefit Policy Manual.
2000, hospitals have been coding clinic utilization for purposes of billing the clinic Available online at: www.cms.gov/
visits using the same E/M procedure codes visit, appropriate credit can be given for manuals/Downloads/bp102c06.pdf.
as those reported by physician offices. the services of the CSW on the date of a Last accessed Feb. 6, 2012.
When assigned by the hospital, however, technical clinic visit. Remember that the • Medicare Claims Processing Manual,
these codes have entirely different defini- clinic visit is the technical component of a Chapter 4 – Part B Hospital. Avail-
tions. Physician reporting relates to CPT® face-to-face physician evaluation and man- able online at: www.cms.gov/manu-
definitions based on complexity of history, agement service in the outpatient depart- als/downloads/clm104c04.pdf. Last
examination, and medical decision-making. ment. Hospital clinic visit codes include: accessed Feb. 6, 2012.
In contrast, hospital reporting of a • New patient visits (99201–99205) • Medicare Claims Processing Manual,
technical visit service takes into account • Established patient visits (99211– Chapter 12 – Physicians/Nonphysi-
the intensity of facility resources used 99215). cian Practitioners. Available online
by hospital staff on the day of a patient at: www.cms.gov/manuals/down-
encounter with the physician. To recap: clinical social workers cannot loads/clm104c12.pdf. Last accessed
Medicare holds each facility ac- bill separately for services provided to an Feb. 6, 2012.
countable for following its own system individual patient that are not considered

www.accc-cancer.org | March–April 2012 | OI 13

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