There are several major national changes affecting the clinical practice of clinical social workers in 2014. Clinical social workers should prepare for these changes to avoid reimbursement denials and overpayment requests. Changes are in the areas of claims, coding, diagnosing and quality measures, and include the following:
Revised CSM-1500 Form
Clinical social workers submit claims for reimbursement on the CMS-1500 Form. The National Uniform Claim Committee (NUCC) has updated the form and approved a transition timeline for the version 02/12 of the 1500 Health Insurance Claim Form. From January 6 through March 31, 2014, clinical social workers may use either the current or revised form. Beginning April 1, 2014, clinical social workers must submit claims only on the revised CMS-1500 Claim Form, version 02/12. Claims will be rejected if they are not submitted on the revised form by April 1, 2014.
The International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) will be implemented on October 1, 2014.
It is a classification system of diagnoses used to identify diseases and will replace the ICD-9-CM codes. The changes in ICD-10-CM will not affect the Current Procedural Terminology (CPT) codes used by clinical social workers to perform psychotherapy services. The ICD-10-CM code sets are available free of charge at www.cms.gov/ICD10. Clinical social workers should begin preparing for this transition by:
- Enrolling in training to become familiar with the new changes and how to implement them in practice;
- Communicating with third-party payers about their specific requirements regarding these changes;
- Updating electronic systems, billing statements, and other forms; and
- Establishing an emergency fund to cover unexpected reimbursement delays during the early months of implementation.
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) coding system will be implemented also on October 1, 2014.
The DSM-5 is harmonized with the ICD-10-CM and there is now one classification system for coding of diseases. Although the American Psychiatric Association is recommending implementation of the DSM-5 diagnostic criteria by December 31, 2013, many insurance companies have reported they may not be prepared to implement the diagnostic criteria changes at that time. Since the implementation date of the DSM-5 diagnostic criteria may vary per third-party payers, NASW recommends members to contact insurance companies with whom they are paneled to determine their implementation date.
The Centers for Medicare and Medicaid Services (CMS) has announced the Physician Quality Reporting System (PQRS) will subject clinical social workers and other health care professionals who are Medicare providers to a 2.0 percent penalty fee in 2016 if they do not use quality measures when performing services to Medicare beneficiaries during the year of 2014.
PQRS is a program promoting the reporting of measures to determine quality services. To avoid this 2.0 percent penalty in 2016, clinical social workers must use measures developed by the PQRS for 2014 when providing psychotherapy services to Medicare beneficiaries.
Additional information about 2014 changes is available at www.dsm5.org/Pages/Default.aspx.
Information about PQRS is available at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html.
CMS-1500 information is available at www.nucc.org/.
ICD-10-CM information is available at www.cms.gov/ICD10.
