E/M Codes: New Issue Brief Outlines Advocacy Strategies for Adoption
A new National Council issue brief, Coding for Behavioral Health Services: Evaluation and Management CPT Code Adoption, outlines advocacy strategies for improving reimbursement and adoption of the Evaluation and Management (E/M) code set for behavioral health services provided by certain medical professionals.
Two years ago, the behavioral health field had to implement new code sets for psychiatric services. Medical professionals were encouraged to begin using E/M codes, which are complicated but also pay more for more complex work (as opposed to one code for all evaluations). E/M codes leave room to address physical health issues and encourage integration. And, because of their use by medical professionals outside of our field, they have the potential to bring behavioral health closer to parity with other specialty services.
And yet, as a survey completed by the National Council has found:
- Adoption of the E/M codes has been variable;
- Medicaid programs may not require that the same codes be used by managed care providers, creating the potential for coding compliance errors; and
- Rate setting for E/M services typically varies between fee-for-service (FFS) and managed care providers.
Two states have taken action around E/M code adoption, both of which are profiled in the National Council’s new issue brief. In Massachusetts, the Association for Behavioral Healthcare advocated for the universal adoption of E/M codes by all publically-funded payers and for an increase in rates. As a result:
- All payer entities under MassHealth are required to adopt all CPT E/M codes;
- There is a rate floor—behavioral health providers are paid at the same rate as medical surgical services in non-facility settings AND any Medicaid integrated care organization, managed care entity or behavioral health carve-out entity must pay, at a minimum, the MassHealth rates for all CPT E/M codes.
- Managed care capitation rates will be adjusted to reflect changes to behavioral health services payments.
In Maryland, the Community Behavioral Health Association of Maryland was able to align itself with the medical community and saw an increase in reimbursement rates.
The two states each had different political dynamics to navigate, but were able to agree on a few advocacy tenets in this area:
- Focus on the compelling argument – frame your advocacy in terms of access to services
- Keep it simple – stay away from coding jargon
- Weight the benefits of E/M adoption – training and compliance concerns are significant
- Link to a Bigger Health Care Reform Goal – consider what issue areas are already top of mind for policymakers in your state.