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NAN 2004NAN 2004
Advanced Coding, Advanced Coding, Documentation and Documentation and Billing Workshop for Billing Workshop for Neuropsychological Neuropsychological
ServicesServices
National Academy of National Academy of NeuropsychologyNeuropsychology
Seattle, WashingtonSeattle, WashingtonNovember 20, 2004November 20, 2004
(www.nanonline.org)(www.nanonline.org)
NAN 2004NAN 2004
Contact InformationContact Information
WebsitesWebsites Univ = Univ = www.uncw.edu/people/puentewww.uncw.edu/people/puente Practice = www.clinicalneuropsychology.usPractice = www.clinicalneuropsychology.us
E-mailE-mail University = University = [email protected]@uncw.edu Practice = [email protected] = [email protected]
TelephoneTelephone University = 910.962.3812University = 910.962.3812 Practice = 910.509.9371Practice = 910.509.9371
NAN 2004NAN 2004
AcknowledgmentsAcknowledgments Department of Psychology, UNC-WilmingtonDepartment of Psychology, UNC-Wilmington NCPA Board of Directors, Practice Division, NCPA Board of Directors, Practice Division,
& Staff& Staff National Academy of NeuropsychologyNational Academy of Neuropsychology Division 40 of APADivision 40 of APA Practice Directorate of the American Practice Directorate of the American
Psychological AssociationPsychological Association American Medical Association’s CPT StaffAmerican Medical Association’s CPT Staff CMS Medical Policy StaffCMS Medical Policy Staff Inter-Divisional Health Care Committee; APAInter-Divisional Health Care Committee; APA Selected Individuals (e.g., Jim Georgoulakis)Selected Individuals (e.g., Jim Georgoulakis)
NAN 2004NAN 2004
AcknowledgmentsAcknowledgments
Professional Affairs Office Professional Affairs Office All the Individuals;All the Individuals;
Keep Me in the LoopKeep Me in the Loop Risk Their Time and Effort to Educate Risk Their Time and Effort to Educate
Third Party Insurers & Licensing BoardsThird Party Insurers & Licensing Boards
NAN 2004NAN 2004
BackgroundBackground(1988 – present)(1988 – present)
North Carolina Psychological Association (e)North Carolina Psychological Association (e) APA’s Policy & Planning Board; Div. 40 (e)APA’s Policy & Planning Board; Div. 40 (e) American Medical Association’s Current American Medical Association’s Current
Procedural Terminology Committee (IV/V) (a)Procedural Terminology Committee (IV/V) (a) Health Care Finance Administration’s Working Health Care Finance Administration’s Working
Group for Mental Health Policy (a)Group for Mental Health Policy (a) Center for Medicare/Medicaid Services’ Center for Medicare/Medicaid Services’
Medicare Coverage Advisory Committee (fa)Medicare Coverage Advisory Committee (fa) Consultant with the North Carolina Medicaid Consultant with the North Carolina Medicaid
Office;North Carolina Blue Cross/Blue Shield (a)Office;North Carolina Blue Cross/Blue Shield (a) NAN’s Professional Affairs & Information Office NAN’s Professional Affairs & Information Office
(a)(a)(legend; a = appointment, fa = federal (legend; a = appointment, fa = federal
appointment, e = elected)appointment, e = elected)
NAN 2004NAN 2004
Purpose of PresentationPurpose of Presentation
Increase Reimbursement to Appropriate Increase Reimbursement to Appropriate LevelsLevels
Increase Range, Type & Quality of ServicesIncrease Range, Type & Quality of Services Decrease Fraud & AbuseDecrease Fraud & Abuse Provide Broad Practice Parameters for Provide Broad Practice Parameters for
Professional ServicesProfessional Services Increase Professional Stature in Health Increase Professional Stature in Health
Care, in General, and Within Psychology, in Care, in General, and Within Psychology, in ParticularParticular
NAN 2004NAN 2004
Outline of PresentationOutline of Presentation
MedicareMedicare Current Procedural Terminology Current Procedural Terminology (& (&
documentation)documentation)
Relative Value UnitsRelative Value Units Current Problems & Possible Current Problems & Possible
SolutionsSolutions Predictions for the FuturePredictions for the Future ResourcesResources
NAN 2004NAN 2004
Medicare: OverviewMedicare: Overview
Why Focus on MedicareWhy Focus on Medicare The Medicare ProgramThe Medicare Program Local Medical Review (policy & Local Medical Review (policy &
panels)panels)
NAN 2004NAN 2004
Medicare: WhyMedicare: Why
TheThe Standard for Universal Health Standard for Universal Health CareCare CodingCoding ValueValue DocumentationDocumentation AuditingAuditing
NAN 2004NAN 2004
Medicare: OverviewMedicare: Overview
Centers for Medicare and Medicaid Centers for Medicare and Medicaid ServicesServices
BenefitsBenefits Part A (Hospital)Part A (Hospital) Part B (Supplementary)Part B (Supplementary) Part C (Medicare+ Choice)Part C (Medicare+ Choice)
NAN 2004NAN 2004
Medicare: Local ReviewMedicare: Local Review
Local Medical Review PolicyLocal Medical Review Policy LMRP vs National PolicyLMRP vs National Policy Location of LMRPsLocation of LMRPs
Carrier Medical DirectorCarrier Medical Director A Physician-based ModelA Physician-based Model
Policy PanelsPolicy Panels Lack of Understanding of Their RolesLack of Understanding of Their Roles Lack of Representation on Such PanelsLack of Representation on Such Panels
NAN 2004NAN 2004
Medicare PaymentMedicare Payment(since 1993)(since 1993)
Surgical Surgical Higher Reimbursement than CognitiveHigher Reimbursement than Cognitive
CognitiveCognitive Physician Cognitive WorkPhysician Cognitive Work
NAN 2004NAN 2004
Unique Physician Identification Unique Physician Identification NumberNumber::
Who You AreWho You Are
CurrentlyCurrently UPIN #UPIN # Entered in Box 17 a of CMS 1500 formEntered in Box 17 a of CMS 1500 form
Starting 2005Starting 2005 National Provider Identification NumberNational Provider Identification Number
NAN 2004NAN 2004
National Provider IdentifierNational Provider IdentifierJanuary 23, 2004January 23, 200445 CFR Part 16c45 CFR Part 16c
Basic InformationBasic Information 10 position numeric & individual number10 position numeric & individual number Will contain no specific information about providerWill contain no specific information about provider Managed by CMS’ National Provide SystemManaged by CMS’ National Provide System Link will be placed on the NAN PAIO web pagesLink will be placed on the NAN PAIO web pages
DatesDates Can apply by May 23, 2005 Can apply by May 23, 2005 Most entities will use by May 23, 2007Most entities will use by May 23, 2007 All entities will use by May 23, 2008All entities will use by May 23, 2008
ApplicabilityApplicability All federal health plans, immediatelyAll federal health plans, immediately All state Medicaid programs, soonAll state Medicaid programs, soon General register for all health plans, thereafterGeneral register for all health plans, thereafter
NAN 2004NAN 2004
Current Procedural Current Procedural Terminology: OverviewTerminology: Overview
BackgroundBackground Codes & CodingCodes & Coding Existing CodesExisting Codes Model System X Type of ProblemModel System X Type of Problem Medical NecessityMedical Necessity DocumentingDocumenting TimeTime
NAN 2004NAN 2004
CPT: BackgroundCPT: Background
American Medical AssociationAmerican Medical Association Developed by Surgeons (& Physicians) Developed by Surgeons (& Physicians)
in 1966 for Billing Purposesin 1966 for Billing Purposes 7,500+ Discrete Codes7,500+ Discrete Codes
CMSCMS AMA Under License with CMSAMA Under License with CMS CMS Now Provides Active Input into CPTCMS Now Provides Active Input into CPT
NAN 2004NAN 2004
CPT: Background/DirectionCPT: Background/Direction
Current System = CPT 5Current System = CPT 5 CategoriesCategories
I= Standard Coding for Professional I= Standard Coding for Professional ServicesServices
II = Performance MeasurementII = Performance Measurement III = Emerging TechnologyIII = Emerging Technology
NAN 2004NAN 2004
CPT: CompositionCPT: Composition
AMA House of DelegatesAMA House of Delegates 109 Medical Specialties109 Medical Specialties
HCPACHCPAC 11 Societies (e.g., APA)11 Societies (e.g., APA)
CPT Editorial PanelCPT Editorial Panel 17 Voting Members17 Voting Members
11 Appointed by AMA Board11 Appointed by AMA Board 1 each from BC/BS, AHA, HIAA, CMS1 each from BC/BS, AHA, HIAA, CMS 2 HCPAC 2 HCPAC
NAN 2004NAN 2004
What Is a CPT Code?What Is a CPT Code?
Professional Health Service Provided Professional Health Service Provided Across the Country at Multiple Across the Country at Multiple locationslocations
Many Physicians Perform ServicesMany Physicians Perform Services Clinical Efficacy is Established and Clinical Efficacy is Established and
Documented in Peer-Reviewed Documented in Peer-Reviewed LiteratureLiterature
NAN 2004NAN 2004
CPT: Applicable CodesCPT: Applicable Codes
Total Possible Codes = Approximately Total Possible Codes = Approximately 7,5007,500
Possible Codes for Psychology = Possible Codes for Psychology = Approximately 40 to 60Approximately 40 to 60
Sections = Five Separate SectionsSections = Five Separate Sections PsychiatryPsychiatry BiofeedbackBiofeedback Central Nervous AssessmentCentral Nervous Assessment Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Health & Behavior Assessment & ManagementHealth & Behavior Assessment & Management
NAN 2004NAN 2004
CPT: Development of a CodeCPT: Development of a Code
InitialInitial Health Care Advisory Committee (non-Health Care Advisory Committee (non-
MDs)MDs) PrimaryPrimary
CPT Work GroupCPT Work Group CPT PanelCPT Panel
Time FrameTime Frame 3-5 to over a decade3-5 to over a decade
NAN 2004NAN 2004
CPT: PsychiatryCPT: Psychiatry
SectionsSections Interview (90801) vs. Intervention (e.g., Interview (90801) vs. Intervention (e.g.,
908.06)908.06) Office vs. InpatientOffice vs. Inpatient Regular vs. Evaluation & ManagementRegular vs. Evaluation & Management OtherOther
Types of InterventionsTypes of Interventions Insight, Behavior Modifying, and/or Supportive Insight, Behavior Modifying, and/or Supportive
vs. Interactivevs. Interactive
NAN 2004NAN 2004
CPT: CNS AssessmentCPT: CNS Assessment
InterviewInterview 9611596115
TestingTesting Psychological = 96100; 96110/11Psychological = 96100; 96110/11 Neuropsychological = 96117Neuropsychological = 96117 Aphasia = 96105Aphasia = 96105 Developmental = 96110/111Developmental = 96110/111
NAN 2004NAN 2004
CPT: Physical Medicine & CPT: Physical Medicine & RehabilitationRehabilitation
97770 now 9753297770 now 97532 Note: 15 minute incrementsNote: 15 minute increments
NAN 2004NAN 2004
Current Problem With Current Problem With Cognitive RehabilitationCognitive Rehabilitation
Cognitive Rehabilitation (97532)Cognitive Rehabilitation (97532) Applied RationaleApplied Rationale
Physical Medicine Codes are incorrectly being Physical Medicine Codes are incorrectly being interpreted as not being useable by psychologistsinterpreted as not being useable by psychologists
Not Being Accepted by Some CarriersNot Being Accepted by Some Carriers AH – Mental HealthAH – Mental Health
AcceptabilityAcceptability GN = Speech TherapistsGN = Speech Therapists GO = Occupational TherapistsGO = Occupational Therapists GP = Physical TherapistsGP = Physical Therapists
NAN 2004NAN 2004
CPT: Health & Behavior CPT: Health & Behavior Assessment & ManagementAssessment & Management
Purpose: Medical DiagnosisPurpose: Medical Diagnosis Time: 15 Minute IncrementsTime: 15 Minute Increments AssessmentAssessment InterventionIntervention
NAN 2004NAN 2004
Rationale: GeneralRationale: General
Acute or chronic (health) illness may not Acute or chronic (health) illness may not meet the criteria for a psychiatric meet the criteria for a psychiatric diagnosisdiagnosis
Avoids inappropriate labeling of a patient Avoids inappropriate labeling of a patient as having a mental health disorderas having a mental health disorder
Increases the accuracy of correct coding Increases the accuracy of correct coding of professional servicesof professional services
Increase range of servicesIncrease range of services
NAN 2004NAN 2004
Rationale: Specific ExamplesRationale: Specific Examples
Patient Adherence to Medical Patient Adherence to Medical TreatmentTreatment
Symptom Management & ExpressionSymptom Management & Expression Health-promoting BehaviorsHealth-promoting Behaviors Health-related Risk-taking BehaviorsHealth-related Risk-taking Behaviors Overall Adjustment to Medical IllnessOverall Adjustment to Medical Illness
NAN 2004NAN 2004
Overview of CodesOverview of Codes
New SubsectionNew Subsection Six New CodesSix New Codes
AssessmentAssessment InterventionIntervention
Established Medical Illness or Established Medical Illness or DiagnosisDiagnosis
Focus on Biopsychosocial FactorsFocus on Biopsychosocial Factors
NAN 2004NAN 2004
Assessment ExplanationAssessment Explanation
Identification of psychological, Identification of psychological, behavioral, emotional, cognitive, and behavioral, emotional, cognitive, and social factorssocial factors
In the prevention, treatment, and/or In the prevention, treatment, and/or management of management of physical healthphysical health problemsproblems
Focus on biopsychosocial factors (not Focus on biopsychosocial factors (not mental health)mental health)
NAN 2004NAN 2004
Assessment (continued)Assessment (continued)
May include (examples);May include (examples); health-focused clinical interviewhealth-focused clinical interview behavioral observationsbehavioral observations psychophysiological monitoringpsychophysiological monitoring health-oriented questionnaireshealth-oriented questionnaires and, assessment/interpretation of the and, assessment/interpretation of the
aforementioned aforementioned
NAN 2004NAN 2004
Intervention ExplanationIntervention Explanation
Modification of psychological, Modification of psychological, behavioral, emotional, cognitive, and/or behavioral, emotional, cognitive, and/or social factors social factors
Affecting physiological functioning, Affecting physiological functioning, disease status, health, and/or well beingdisease status, health, and/or well being
Focus = improvement of health with Focus = improvement of health with cognitive, behavioral, social, and/or cognitive, behavioral, social, and/or psychophysiological procedurespsychophysiological procedures
NAN 2004NAN 2004
Intervention (continued)Intervention (continued)
May include the following procedures May include the following procedures (examples);(examples); CognitiveCognitive BehavioralBehavioral SocialSocial Psychophysiological Psychophysiological
NAN 2004NAN 2004
Diagnosis MatchDiagnosis Match
Associated with acute or chronic Associated with acute or chronic medical illnessmedical illness
Prevention of a physical illness or Prevention of a physical illness or disabilitydisability
Not meeting criteria for a psychiatric Not meeting criteria for a psychiatric diagnosis or representing a diagnosis or representing a preventative medicine servicepreventative medicine service
NAN 2004NAN 2004
Related Psychiatric CodesRelated Psychiatric Codes
If psychiatric services are required If psychiatric services are required (90801-90899) along with these, (90801-90899) along with these, report predominant servicereport predominant service
Do not report psychiatric and these Do not report psychiatric and these codes on the same daycodes on the same day
NAN 2004NAN 2004
Code X Personnel (examples)Code X Personnel (examples)
Physicians (pediatricians, family Physicians (pediatricians, family physicians, internists, & psychiatrists)physicians, internists, & psychiatrists)
PsychologistsPsychologists Advanced Practice NursesAdvanced Practice Nurses Clinical Social Workers Clinical Social Workers ExcludedExcluded Other health care professionals within Other health care professionals within
their scope of practice who have specialty their scope of practice who have specialty or subspecialty training in health and or subspecialty training in health and behavior assessments and interventionsbehavior assessments and interventions
NAN 2004NAN 2004
Health & Behavior Health & Behavior Assessment CodesAssessment Codes
9615096150 Health and behavior assessment (e.g., health-Health and behavior assessment (e.g., health-
focused clinical interview, behavioral focused clinical interview, behavioral observations, psychophysiological monitoring, observations, psychophysiological monitoring, health-oriented questionnaires)health-oriented questionnaires)
each 15 minuteseach 15 minutes face-to-face with the patientface-to-face with the patient initial assessmentinitial assessment
9615196151 re-assessmentre-assessment
NAN 2004NAN 2004
Health & Behavior Health & Behavior Intervention CodesIntervention Codes
9615296152 Health and behavior interventionHealth and behavior intervention each 15 minuteseach 15 minutes face-to-faceface-to-face individualindividual
9615396153 group (2 or more patients)group (2 or more patients)
9615496154 family (with the patient present)family (with the patient present)
9615596155 family (without the patient present; not being family (without the patient present; not being
reimbursed)reimbursed)
NAN 2004NAN 2004
Relative Values for Health & Relative Values for Health & Behavior A/I CodesBehavior A/I Codes
96150 = .5096150 = .50 96151 = .4896151 = .48 96152 = .4696152 = .46 96153 = .1096153 = .10 96154 = .4596154 = .45 96155 = .4496155 = .44
NAN 2004NAN 2004
Expected Payment for Expected Payment for Health & Behavior CodesHealth & Behavior Codes
Individual (per hour)Individual (per hour) Range $98-106Range $98-106
Group (per person/ per hour)Group (per person/ per hour) Approximately $22Approximately $22
NAN 2004NAN 2004
CPT: Model SystemCPT: Model System
PsychiatricPsychiatric NeurologicalNeurological Non-Neurological MedicalNon-Neurological Medical AlternativesAlternatives
NAN 2004NAN 2004
CPT ModelCPT Model
Rationale for CPT Code:Rationale for CPT Code: Choose Code that Best Describes the Choose Code that Best Describes the
Service ProvidedService Provided Match the Interview with the Testing Match the Interview with the Testing
with the Intervention Codewith the Intervention Code Match All that With a DiagnosisMatch All that With a Diagnosis Goal = Uniformity and FluencyGoal = Uniformity and Fluency
NAN 2004NAN 2004
CPT: Psychiatric ModelCPT: Psychiatric Model(Children & Adult)(Children & Adult)
InterviewInterview 90801- adult90801- adult 90802- child90802- child
TestingTesting 96100- adult96100- adult 96110/11- child96110/11- child
InterventionIntervention e.g., 90806- adulte.g., 90806- adult e.g., 90820-childe.g., 90820-child
NAN 2004NAN 2004
CPT: Neurological ModelCPT: Neurological Model(Children & Adult)(Children & Adult)
InterviewInterview 9611596115
TestingTesting 9611796117
InterventionIntervention 9753297532
NAN 2004NAN 2004
CPT: Non-Neurological CPT: Non-Neurological Medical ModelMedical Model
(Children & Adult)(Children & Adult)
Interview & AssessmentInterview & Assessment 96150 (initial)96150 (initial) 96151 (re-evaluation)96151 (re-evaluation)
InterventionIntervention 96152 (individual)96152 (individual) 96153 (group)96153 (group) 96154 (family with patient)96154 (family with patient) 96155 (family without patient)96155 (family without patient)
NAN 2004NAN 2004
Alternative CPT CodesAlternative CPT Codes
99050 – Office, outside regular office 99050 – Office, outside regular office hrs.hrs.
99052 - Service provided btw. 10pm-99052 - Service provided btw. 10pm-8am8am
99054 – Service provided on 99054 – Service provided on Sun/holidaysSun/holidays
0074T – Online service0074T – Online service 90825 – Review of records90825 – Review of records
NAN 2004NAN 2004
CPT: Correct Coding InitiativeCPT: Correct Coding Initiative
PurposePurpose Used to evaluate submissions when Used to evaluate submissions when
provider bills more than one service for provider bills more than one service for the same beneficiary and same date of the same beneficiary and same date of serviceservice
Example; psychotherapy and testingExample; psychotherapy and testing ActivationActivation
Automatic editsAutomatic edits
NAN 2004NAN 2004
CPT: DiagnosingCPT: Diagnosing
PsychiatricPsychiatric DSMDSM
The problem with DSM and neuropsych The problem with DSM and neuropsych testing of developmentally-related testing of developmentally-related neurological problemsneurological problems
Neurological & Non-Neurological Neurological & Non-Neurological MedicalMedical ICDICD
NAN 2004NAN 2004
Recent CPT ChangesRecent CPT Changes
Biofeedback (90911)Biofeedback (90911) Minor editorial changes in biofeedback Minor editorial changes in biofeedback
trainingtraining
NAN 2004NAN 2004
Recent CPT ChangesRecent CPT Changes
Developmental Testing CodesDevelopmental Testing Codes ApplicabilityApplicability
ChildrenChildren BackgroundBackground
Part of Central Nervous System family of codesPart of Central Nervous System family of codes Hence, no work value (& lower reimbursement rate)Hence, no work value (& lower reimbursement rate) Recently “re-surveyed” by pediatriciansRecently “re-surveyed” by pediatricians
Specific ChangesSpecific Changes 96110 96110
Continues to have no work valueContinues to have no work value Use for completion of forms (Connors; by parents)Use for completion of forms (Connors; by parents)
96111 96111 Has physician work value Has physician work value Assessment of child’s social, emotional, etc status (WJ)Assessment of child’s social, emotional, etc status (WJ)
NAN 2004NAN 2004
Probable CPT Changes :Probable CPT Changes :Health & Behavior Assessment Health & Behavior Assessment
CodesCodes Brief HistoryBrief History
Inter-divisional Health Care Committee (22, 38, 40, 54; Glueckauf)Inter-divisional Health Care Committee (22, 38, 40, 54; Glueckauf) Convened in 1995 by APA Practice Directorate (Phelps)Convened in 1995 by APA Practice Directorate (Phelps) DraftsDrafts
First Draft - September 11, 1998; Final Working Draft – July 1, 2000First Draft - September 11, 1998; Final Working Draft – July 1, 2000 PresentationsPresentations
First Presentation to AMA November 6, 1998 ; Final Presentation – August 8, First Presentation to AMA November 6, 1998 ; Final Presentation – August 8, 20002000
7 total presentations- Ft. Lauderdale, Chicago, Denver, San Francisco, 7 total presentations- Ft. Lauderdale, Chicago, Denver, San Francisco, Washington, DC, Chicago, ChicagoWashington, DC, Chicago, Chicago
SurveysSurveys First Survey January 31, 2001; Final Survey April 26, 2001First Survey January 31, 2001; Final Survey April 26, 2001
Revisions to LanguageRevisions to Language First Preamble revision – March, 2002; Last Preamble revision – November, First Preamble revision – March, 2002; Last Preamble revision – November,
20042004 ApplicabilityApplicability
When behavioral, cognitive, emotional, and/or psychological techniques When behavioral, cognitive, emotional, and/or psychological techniques are used to assess and/or treat health (medical not psychiatric) are used to assess and/or treat health (medical not psychiatric) problemsproblems
NAN 2004NAN 2004
Probable CPT Changes:Probable CPT Changes:Health & Behavior Assessment Health & Behavior Assessment
CodesCodes AcceptabilityAcceptability
All Medicare carriers (minus Florida’s)All Medicare carriers (minus Florida’s) Some Medicaid programs (e.g., Colorado, Vermont)Some Medicaid programs (e.g., Colorado, Vermont) Some private insurers (BC/BS in NC, DC; Nationwide) Some private insurers (BC/BS in NC, DC; Nationwide)
ChangesChanges PreamblePreamble ClarificationClarification
Not a preventive medicine codeNot a preventive medicine code Patient can have a history or presence of mental illnessPatient can have a history or presence of mental illness
Future ExpectationFuture Expectation No further changesNo further changes Increased carrier acceptance, especially if providers educate carriersIncreased carrier acceptance, especially if providers educate carriers
Final Verification AnticipatedFinal Verification Anticipated December 1, 2004December 1, 2004 Applicability starting January 1, 2005Applicability starting January 1, 2005
NAN 2004NAN 2004
Probable CPT Changes:Probable CPT Changes:CNS Assessment CodesCNS Assessment Codes
Neurobehavioral Status ExamNeurobehavioral Status Exam Re-write (different language; same concept)Re-write (different language; same concept) Addition of “Physician” Work ValueAddition of “Physician” Work Value
Psychological TestingPsychological Testing Expansion of existing codeExpansion of existing code Addition of “Physician” Work ValueAddition of “Physician” Work Value
Neuropsychological TestingNeuropsychological Testing Expansion of existing codeExpansion of existing code Addition of “Physician” Work ValueAddition of “Physician” Work Value
NAN 2004NAN 2004
Probable CPT Changes:Probable CPT Changes:CNS Assessment CodesCNS Assessment Codes
Net EffectNet Effect Avoidance of Continuation of Reimbursement Strictly Avoidance of Continuation of Reimbursement Strictly
Based on Practice Expense Based on Practice Expense Potential catastrophe in terms of reimbursementPotential catastrophe in terms of reimbursement Potential reimbursement rates in the vicinity of $40/hrPotential reimbursement rates in the vicinity of $40/hr
Greater Clarity of Professional and Non-Professional Greater Clarity of Professional and Non-Professional ActivitiesActivities
Differentiation of professional, technical and computer Differentiation of professional, technical and computer activityactivity
Accounting/auditing, research, and salary purposesAccounting/auditing, research, and salary purposes Recognition of “Physician” WorkRecognition of “Physician” Work
Ending a 10 year struggleEnding a 10 year struggle Possibly, Increased ReimbursementPossibly, Increased Reimbursement
NAN 2004NAN 2004
Probable CPT Changes:Probable CPT Changes:CNS Assessment CodesCNS Assessment Codes
Timetable (activity x date)Timetable (activity x date) Initial Decision by AMA CPT Panel, November 7, 2004Initial Decision by AMA CPT Panel, November 7, 2004 Call for Other Societies to Participate, November 19, 2004Call for Other Societies to Participate, November 19, 2004 Final Decision by AMA CPT Panel, December 1, 2004Final Decision by AMA CPT Panel, December 1, 2004 Submission of CPT Codes to AMA RUC Committee Submission of CPT Codes to AMA RUC Committee
immediately thereafterimmediately thereafter Review by AMA RUC Research Subcommittee in January, Review by AMA RUC Research Subcommittee in January,
20052005 Review by AMA RUC Panel in February 3-6, 2005Review by AMA RUC Panel in February 3-6, 2005 Survey of Codes, second & third week of February, 2005Survey of Codes, second & third week of February, 2005 Analysis of surveys, March, 2005Analysis of surveys, March, 2005 Presentation to RUC Committee in April, 2005Presentation to RUC Committee in April, 2005 Hopeful inclusion in the 2006 Physician Fee Schedule for Hopeful inclusion in the 2006 Physician Fee Schedule for
January 1, 2006January 1, 2006
NAN 2004NAN 2004
CPT: Medical NecessityCPT: Medical Necessity
Scientific & Clinical NecessityScientific & Clinical Necessity Local Medical Review or Carrier Definitions of Local Medical Review or Carrier Definitions of
NecessityNecessity Necessity = CPT x DXNecessity = CPT x DX Necessity Dictates Type and Level of ServiceNecessity Dictates Type and Level of Service Necessity Can Only be Proven with Necessity Can Only be Proven with
DocumentationDocumentation Screening or Regularly Scheduled Evals Do Not Screening or Regularly Scheduled Evals Do Not
Meet Criteria for NecessityMeet Criteria for Necessity Will Results Affect Outcome of Patient?Will Results Affect Outcome of Patient? Will New Information Be Obtained?Will New Information Be Obtained?
NAN 2004NAN 2004
Medically Reasonable and Medically Reasonable and NecessaryNecessary
Section 1862 (a)(1) 1963Section 1862 (a)(1) 196342, C.F.R., 411.15 (k)42, C.F.R., 411.15 (k)
““Services which are reasonable and Services which are reasonable and necessary for the diagnosis and necessary for the diagnosis and treatment of illness or injury or to treatment of illness or injury or to improve the functioning of a improve the functioning of a malformed body member”malformed body member”
Re-evaluation should only occur Re-evaluation should only occur when there is a potential change in;when there is a potential change in; DiagnosisDiagnosis SymptomsSymptoms
NAN 2004NAN 2004
CPT: DocumentingCPT: Documenting
PurposePurpose Payer RequirementsPayer Requirements General PrinciplesGeneral Principles HistoryHistory ExaminationExamination Decision MakingDecision Making
NAN 2004NAN 2004
Documentation: PurposeDocumentation: Purpose
Medical NecessityMedical Necessity Evaluate and Plan for TreatmentEvaluate and Plan for Treatment Communication and Continuity of Communication and Continuity of
CareCare Claims Review and PaymentClaims Review and Payment Research and EducationResearch and Education
NAN 2004NAN 2004
Documentation: Payer Documentation: Payer RequirementsRequirements
Site of ServiceSite of Service Medical Necessity for Service Medical Necessity for Service
ProvidedProvided Appropriate Reporting of ActivityAppropriate Reporting of Activity
NAN 2004NAN 2004
Documentation: General Documentation: General PrinciplesPrinciples
Rationale for ServiceRationale for Service Complete and LegibleComplete and Legible Reason/Rationale for ServiceReason/Rationale for Service Assessment, Progress, Impression, or Assessment, Progress, Impression, or
DiagnosisDiagnosis Plan for CarePlan for Care Date and Identity of ObserveDate and Identity of Observe TimelyTimely ConfidentialConfidential
NAN 2004NAN 2004
Documentation: Basic Documentation: Basic Information Across All CodesInformation Across All Codes DateDate Time, if applicableTime, if applicable Identify of Observer (technician ?)Identify of Observer (technician ?) Reason for ServiceReason for Service StatusStatus ProcedureProcedure Results/FindingResults/Finding Impression/DiagnosesImpression/Diagnoses DispositionDisposition Stand AloneStand Alone
NAN 2004NAN 2004
Documentation: Chief Documentation: Chief ComplaintComplaint
Concise Statement Describing the Concise Statement Describing the Symptom, Problem, Condition, & Symptom, Problem, Condition, & DiagnosisDiagnosis
Foundation for Medical NecessityFoundation for Medical Necessity Must be Complete & ExhaustiveMust be Complete & Exhaustive
NAN 2004NAN 2004
Documentation: Present IllnessDocumentation: Present Illness
SymptomsSymptoms Location, Quality, Severity, Duration, Location, Quality, Severity, Duration,
timing, Context, Modifying Factors timing, Context, Modifying Factors Associated SignsAssociated Signs
Follow-upFollow-up Changes in ConditionChanges in Condition ComplianceCompliance
NAN 2004NAN 2004
Documentation: HistoryDocumentation: History
PastPast Family Family SocialSocial Medical/PsychologicalMedical/Psychological
NAN 2004NAN 2004
Documentation: Documentation: InterventionIntervention
Reason for ServiceReason for Service StatusStatus InterventionIntervention ResultsResults ImpressionImpression DispositionDisposition TimeTime
NAN 2004NAN 2004
Documentation: AssessmentDocumentation: Assessment
Reason for ServiceReason for Service Dates (amount of service time?)Dates (amount of service time?) Tests and Protocols (included Tests and Protocols (included
editions)editions) Narrative of ResultsNarrative of Results ImpressionImpression DispositionDisposition
NAN 2004NAN 2004
CPT X ReportCPT X Report
Each CPT Code Should Generate a Each CPT Code Should Generate a Separate ReportSeparate Report
Alternative Clearly Label/Title Alternative Clearly Label/Title Sections of the Report to Match Sections of the Report to Match Codes UsedCodes Used
NAN 2004NAN 2004
Documentation:Documentation:SuggestionsSuggestions
Avoid Handwritten NotesAvoid Handwritten Notes Do Not Use Red InkDo Not Use Red Ink Avoid Color PaperAvoid Color Paper Document On and After Every Document On and After Every
Encounter, Every Procedure, Every Encounter, Every Procedure, Every PatientPatient
Review Changes Whenever ApplicableReview Changes Whenever Applicable Avoid Standard Phrases & ProtocolsAvoid Standard Phrases & Protocols
NAN 2004NAN 2004
When to DocumentWhen to Document
Intervention = Immediately AfterIntervention = Immediately After Testing- Immediately After Vs. at End Testing- Immediately After Vs. at End
of Evaluationof Evaluation
NAN 2004NAN 2004
TimeTime
DefiningDefining Professional (not patient) Time Professional (not patient) Time
Including:Including: pre, intra & post-clinical service activitiespre, intra & post-clinical service activities
Interview & Assessment CodesInterview & Assessment Codes Use 15 minute incrementsUse 15 minute increments
Intervention CodesIntervention Codes Use 15 minute incrementsUse 15 minute increments
NAN 2004NAN 2004
Time: DefinitionTime: Definition
AMA Definition of TimeAMA Definition of Time
Physicians also spend time during work, Physicians also spend time during work, before, or after the face-to-face time with before, or after the face-to-face time with the patient, performing such tasks as the patient, performing such tasks as reviewing records & tests, arranging for reviewing records & tests, arranging for services & communicating further with services & communicating further with other professionals & the patient through other professionals & the patient through written reports & telephone contact.written reports & telephone contact.
NAN 2004NAN 2004
Time (continued)Time (continued)
Communicating further with othersCommunicating further with others Follow-up with patient, family, and/or Follow-up with patient, family, and/or
othersothers Arranging for ancillary and/or other Arranging for ancillary and/or other
servicesservices
NAN 2004NAN 2004
Time: TestingTime: Testing
Quantifying TimeQuantifying Time Round up or down to nearest incrementRound up or down to nearest increment
Time Does Not IncludeTime Does Not Include Patient completing tests, forms, etc.Patient completing tests, forms, etc. Waiting time by patientWaiting time by patient Typing of reportsTyping of reports Non-Professional (e.g., clerical) timeNon-Professional (e.g., clerical) time Literature searches, learning new techniques, Literature searches, learning new techniques,
etc.etc.
NAN 2004NAN 2004
Reimbursement HistoryReimbursement History
Cost Plus Cost Plus Prospective Payment System (PPS)Prospective Payment System (PPS) Diagnostic Related Groups (DRGs)Diagnostic Related Groups (DRGs) Customary, Prevailing & Reasonable Customary, Prevailing & Reasonable
(CPR)(CPR) Resource Based Relative Value Resource Based Relative Value
System (RBRVS)System (RBRVS)
NAN 2004NAN 2004
Relative Value Units: OverviewRelative Value Units: Overview
ComponentsComponents UnitsUnits ValuesValues Current ProblemsCurrent Problems
NAN 2004NAN 2004
RVU: ComponentsRVU: Components
Physician Work Resource ValuePhysician Work Resource Value Practice Expense Resource ValuePractice Expense Resource Value MalpracticeMalpractice GeographicGeographic Conversion Factor (approx. $34)Conversion Factor (approx. $34)
NAN 2004NAN 2004
RVU Components PercentagesRVU Components Percentages
Physician WorkPhysician Work == 52%52% Practice ExpensePractice Expense == 44%44% LiabilityLiability = 4%= 4%
NAN 2004NAN 2004
Defining Physician WorkDefining Physician Work
Clinical WorkClinical Work Mental Effort and JudgmentMental Effort and Judgment Technical Skill/Physical EffortTechnical Skill/Physical Effort Psychological StressPsychological Stress
NAN 2004NAN 2004
Estimate of Psychologists’ Estimate of Psychologists’ ValueValue
AudiologistAudiologist .52.52 DieticianDietician .43.43 RNRN .42.42 Speech PathologistSpeech Pathologist .55.55
PsychologistPsychologist .82.82
NAN 2004NAN 2004
Defining Practice ExpenseDefining Practice Expense
Medical SuppliesMedical Supplies Expendable medical equipment (e.g., Expendable medical equipment (e.g.,
forms)forms) Medical EquipmentMedical Equipment
Durable medical equipment (e.g., tests)Durable medical equipment (e.g., tests) Professional Support StaffProfessional Support Staff
e.g., timee.g., time
NAN 2004NAN 2004
RVU: ValuesRVU: Values
Psychotherapy:Psychotherapy: Prior Value =1.86Prior Value =1.86 New Value = 2.65New Value = 2.65
Psych/NP Testing: Psych/NP Testing: Work value= 0Work value= 0 Hsiao study recommendation = 2.2Hsiao study recommendation = 2.2 New Value = undeterminedNew Value = undetermined
Health & BehaviorHealth & Behavior .25 (per 15 minutes increments).25 (per 15 minutes increments)
NAN 2004NAN 2004
RVU: AcceptanceRVU: Acceptance
Medicare (100% since 01.01.92)Medicare (100% since 01.01.92) Medicaid 100%Medicaid 100% Private Payors 74%Private Payors 74%
Blue Cross/Blue Shield 87%Blue Cross/Blue Shield 87% Managed Care 69%Managed Care 69%
Other 44%Other 44% New Trends: New Trends:
RVUs as a Model for All Insurance CompaniesRVUs as a Model for All Insurance Companies RVUs as a Basis for Compensation FormulasRVUs as a Basis for Compensation Formulas
NAN 2004NAN 2004
CPT x RVUCPT x RVUCPTCode
WorkValue
PracticeExpense
MalpracticeExpense
TotalRVU
MutuallyExclusive
90801 2.80 1.14 0.06 4.00 90802, 90846, 90847,90853, 99291, 99292
90806 1.86 0.75 0.04 2.65 90801 (?)
96100 0 1.67 0.15 1.82 96110, 96 115
96115 0 1.67 0.15 1.82 - // -
96117 0 1.67 0.15 1.82 96110, 96111
96150 0.5 0.2 0.02 0.72 96151, 96152, 96153,96154, 96155
96152 0.46 0.18 0.02 0.66 96150, 96151, 96153,96154, 96155
NAN 2004NAN 2004
Medicare RatesMedicare Rates
TypeType DeductibleDeductible Co-Co-PaymentPayment
Part APart A $912$912 0-$456 (days)0-$456 (days)
Part BPart B $110$110 Health – 20%Health – 20%
Psych- 50%Psych- 50%
Note: Premiums are $78.20/monthNote: Premiums are $78.20/month
NAN 2004NAN 2004
Continuing ProblemsContinuing Problems Definition of PhysicianDefinition of Physician SupervisionSupervision Incident toIncident to Face-to-FaceFace-to-Face TimeTime RVUsRVUs Work ValuesWork Values Practice Expense & Testing SurveyPractice Expense & Testing Survey PaymentPayment FocusFocus for Fraud & Abuse for Fraud & Abuse
NAN 2004NAN 2004
Problem: Defining PhysicianProblem: Defining Physician Definition of a PhysicianDefinition of a Physician
Social Security Practice Act of 1980Social Security Practice Act of 1980 Definition of a PhysicianDefinition of a Physician Need for Congressional ActNeed for Congressional Act Likelihood of Congressional ActLikelihood of Congressional Act The Value of Technical Services of a Psychologist is The Value of Technical Services of a Psychologist is
$.83/hour (second highest after physicist)$.83/hour (second highest after physicist) Consequence of the preceding; grouping with non-Consequence of the preceding; grouping with non-
doctoral level allied health providersdoctoral level allied health providers
NAN 2004NAN 2004
SupervisionSupervision Federal RegisterFederal Register
Volume 69, No. 150, August 5, 2004, page 47553Volume 69, No. 150, August 5, 2004, page 47553 Hold Doctoral Degree in PsychologyHold Doctoral Degree in Psychology Licensed or Certified as a PsychologistLicensed or Certified as a Psychologist Applicable Only to “clinical psychologists” Applicable Only to “clinical psychologists”
(and not “independent” psychologists (and not “independent” psychologists (e.g., Ed. (e.g., Ed.
Psych.Psych.)) RationaleRationale
Allows for higher level of expertise to superviseAllows for higher level of expertise to supervise Could relieve burden on physicians and facilitiesCould relieve burden on physicians and facilities May increase service in rural areasMay increase service in rural areas
Recommended Supervision Level = GeneralRecommended Supervision Level = General
NAN 2004NAN 2004
Problem:SupervisionProblem:Supervision
SupervisionSupervision 1.General = overall direction1.General = overall direction 2.Direct = present in office suite2.Direct = present in office suite 3.Personal = in actual room3.Personal = in actual room 4.Psychological = when supervised by a 4.Psychological = when supervised by a
psychologistpsychologist
NAN 2004NAN 2004
SupervisionSupervisionProgram Memorandum CarriersProgram Memorandum Carriers
Department of Health and Human Services- HCFADepartment of Health and Human Services- HCFATransmittal b-01-28; April 19, 2001Transmittal b-01-28; April 19, 2001
Levels of SupervisionLevels of Supervision GeneralGeneral
Furnished under overall direction and control, Furnished under overall direction and control, presence is not requiredpresence is not required
DirectDirect Must be present in the office suite and immediately Must be present in the office suite and immediately
available to furnish assistance and direction available to furnish assistance and direction throughout the performance of the procedurethroughout the performance of the procedure
PersonalPersonal Must be in attendance in the room during the Must be in attendance in the room during the
performance of the procedureperformance of the procedure
NAN 2004NAN 2004
Problem: Incident toProblem: Incident to Rationale for Incident toRationale for Incident to
Congress intended to provide coverage for services Congress intended to provide coverage for services not typically covered elsewherenot typically covered elsewhere
Definition of Physician ExtenderDefinition of Physician Extender HowHow LimitationsLimitations
Definition of In vs. OutpatientDefinition of In vs. Outpatient Geographic Vs FinancialGeographic Vs Financial
Why No Incident to (DRG)Why No Incident to (DRG) Solution Available for Some Training ProgramsSolution Available for Some Training Programs Probably no Future to Incident toProbably no Future to Incident to
NAN 2004NAN 2004
Problem: More Incident toProblem: More Incident to
When is “Incident to” Acceptable:When is “Incident to” Acceptable: Testing Testing Cognitive Rehabilitation; BiofeedbackCognitive Rehabilitation; Biofeedback PsychotherapyPsychotherapy
DefinitionDefinition Commonly furnished serviceCommonly furnished service Integral, though incidental to psychologistIntegral, though incidental to psychologist Performed under the supervisionPerformed under the supervision Either furnished without charge or as part of Either furnished without charge or as part of
the psychologist’s chargethe psychologist’s charge
NAN 2004NAN 2004
Problem: Incident to & Site Problem: Incident to & Site of Serviceof Service
Outpatient vs. InpatientOutpatient vs. Inpatient Geographical LocationGeographical Location Corporate RelationshipCorporate Relationship Billing ServiceBilling Service Chart Information & LocationChart Information & Location
NAN 2004NAN 2004
Problem: Problem: Incident to versus Incident to versus
Independent ServiceIndependent Service When Does Incident to Become When Does Incident to Become
Independent ServiceIndependent Service Appearance of No SupervisionAppearance of No Supervision Clinical Decisions are Made by StaffClinical Decisions are Made by Staff Ratio of Physician to Staff Time Ratio of Physician to Staff Time
Becomes DisproportionateBecomes Disproportionate Distance DifficultiesDistance Difficulties Supervision DifficultiesSupervision Difficulties
NAN 2004NAN 2004
Problems:Problems:Recent Difficulties with Recent Difficulties with
Incident toIncident to Who Bills Incident toWho Bills Incident to
Treating Physician Bills not the Treating Physician Bills not the Supervising PhysicianSupervising Physician
Then, Who is the Responsible PartyThen, Who is the Responsible Party The Physician Must Evaluate The Physician Must Evaluate
and/or Treat the Patient Firstand/or Treat the Patient First
NAN 2004NAN 2004
Difference Between Difference Between Supervision and “Incident to”Supervision and “Incident to”
SupervisionSupervision Applies to whether and Applies to whether and
how a “physician” how a “physician” oversees the work of oversees the work of ancillary personnelancillary personnel
A A clinicalclinical concept concept Can occur at any level Can occur at any level
of supervision (from of supervision (from general to personal)general to personal)
““Incident to”Incident to” Applies when billing for Applies when billing for
services supervised by services supervised by a “physician”a “physician”
An An economiceconomic concept concept Can only occur when Can only occur when
supervision is “direct” supervision is “direct” (i.e., in the same office (i.e., in the same office suite)suite)
Note: no “incident to” in Note: no “incident to” in inpatient settings for inpatient settings for MedicareMedicare
NAN 2004NAN 2004
Problem: Face-to-FaceProblem: Face-to-Face
ImplicationsImplications Technical versus Professional Technical versus Professional
ServicesServices Surgery is the Foundation for CPT Surgery is the Foundation for CPT
(and most work is face-to-face)(and most work is face-to-face) Hard to Document & Trace Non-Face-Hard to Document & Trace Non-Face-
to-Face Workto-Face Work
NAN 2004NAN 2004
Problem: Work ValueProblem: Work Value
Physician Activities (e.g., Physician Activities (e.g., Psychotherapy) Result in Work ValuesPsychotherapy) Result in Work Values
Psychological Based Activities (i.e., Psychological Based Activities (i.e., Testing) Have Testing) Have nono Work Values Work Values
RVUs are Heavily Based on Practice RVUs are Heavily Based on Practice Expenses (which are being reduced)Expenses (which are being reduced)
Net Result = Maybe Up to a Half LowerNet Result = Maybe Up to a Half Lower
NAN 2004NAN 2004
Problem:Problem:An Artificial Practice An Artificial Practice
ExpenseExpense Five Year ReviewsFive Year Reviews Prior MethodologyPrior Methodology Current MethodologyCurrent Methodology Current Value = approximately 1.5 of 1.75 Current Value = approximately 1.5 of 1.75
is practice expenseis practice expense Deadline for New Practice Expense = 11.04Deadline for New Practice Expense = 11.04
New numbers recently submittedNew numbers recently submitted Expected Value = closer to 50% of total Expected Value = closer to 50% of total
value value at bestat best
NAN 2004NAN 2004
Problem: Qualification of Problem: Qualification of TechnicianTechnician
What is the Minimum Level of What is the Minimum Level of Training Required for a Technician?Training Required for a Technician? Bachelor’s vs. Master’sBachelor’s vs. Master’s Student vs. StaffStudent vs. Staff
NAN 2004NAN 2004
Problem: PaymentProblem: Payment
Origins of the ProblemOrigins of the Problem Balanced Budget Act of 1997Balanced Budget Act of 1997 Employer’s Cost for Health Care in 2002 Employer’s Cost for Health Care in 2002
= $5,000 per employee= $5,000 per employee What Should Your Code Be Payed at?What Should Your Code Be Payed at?
www.webstore.ama-assn.org-www.webstore.ama-assn.org- State LegislationState Legislation
www.insure.com/health/lawtool.cfmwww.insure.com/health/lawtool.cfm
NAN 2004NAN 2004
Problem:Problem:Payment ProblemsPayment Problems
RefillingRefilling 51% require refilling of original forms51% require refilling of original forms But, up to 60% do not follow upBut, up to 60% do not follow up
ErrorsErrors 54% = plan administrator54% = plan administrator 17% = provider17% = provider 29% = member29% = member
NAN 2004NAN 2004
Problem: PaymentProblem: Payment
Use of HMOs & Third PartyUse of HMOs & Third Party Shift in Practice Patterns by Psychiatry (14% Shift in Practice Patterns by Psychiatry (14%
increase)increase) Exclusion of MSW, etc. (Increase)Exclusion of MSW, etc. (Increase) Worst Hit Are Psychologists (2% decrease)Worst Hit Are Psychologists (2% decrease)
CompensationCompensation Gross ChargesGross Charges Adjusted ChargesAdjusted Charges RVUsRVUs ReceivablesReceivables
NAN 2004NAN 2004
Problem: Payment of Problem: Payment of Health & Behavior CodesHealth & Behavior Codes
Medicare Almost all ResolvedMedicare Almost all Resolved Non-Medicare ResolvingNon-Medicare Resolving
NAN 2004NAN 2004
Medicare QuestionsMedicare Questions
Cannot Impose a Limitation on a Medicare Cannot Impose a Limitation on a Medicare Patient That is Not Imposed on Other Pts.Patient That is Not Imposed on Other Pts.
Non-Covered Services Can Be Charged if Non-Covered Services Can Be Charged if Patient Knows and Agrees Ahead of TimePatient Knows and Agrees Ahead of Time
Records Should be Retained, state law or;Records Should be Retained, state law or; Adult- 5 years post serviceAdult- 5 years post service Children- until 21Children- until 21
BillingBilling In Continuing Cases- End of monthIn Continuing Cases- End of month Otherwise- At end of service Otherwise- At end of service
NAN 2004NAN 2004
Problem: Expenditures & FraudProblem: Expenditures & Fraud
ProjectionsProjections CurrentCurrent
14%14% By 2011;By 2011;
17% ($2.8 trillion)17% ($2.8 trillion)
NAN 2004NAN 2004
Fraud: Medicare’s Fraud: Medicare’s Interpretation of Physician Interpretation of Physician
LiabilityLiability Overpayment From Incorrect ChargeOverpayment From Incorrect Charge Billing for Items Known Not to be Billing for Items Known Not to be
CoveredCovered Services Provided by Non-qualified Services Provided by Non-qualified
PractitionerPractitioner Mathematical or Clerical ErrorMathematical or Clerical Error Inappropriate DocumentationInappropriate Documentation
NAN 2004NAN 2004
Defining FraudDefining Fraud
FraudFraud IntentionalIntentional PatternPattern
ErrorError ClericalClerical DatesDates
NAN 2004NAN 2004
Problem: Fraud & AbuseProblem: Fraud & Abuse
26 Different Kinds of Fraud Types26 Different Kinds of Fraud Types Mental Health ProfiledMental Health Profiled Estimates of Less Than 10% Estimates of Less Than 10%
RecoveredRecovered Psychotherapy Estimates/Day = 9.67 Psychotherapy Estimates/Day = 9.67
hourshours Review Likely if Over 12 Hours Per DayReview Likely if Over 12 Hours Per Day
Problems with Fraud MethodologyProblems with Fraud Methodology Primarily in how the research was donePrimarily in how the research was done Also, in the application of samplingAlso, in the application of sampling
NAN 2004NAN 2004
Problem: FraudProblem: FraudOffice of Inspector GeneralOffice of Inspector General
Primary ProblemsPrimary Problems Medical Necessity (approximately $5 billion)Medical Necessity (approximately $5 billion) DocumentationDocumentation
Psychotherapy Psychotherapy (oig.hhs/gov/reports/region5/50100068)(oig.hhs/gov/reports/region5/50100068) IndividualIndividual GroupGroup # of Hours# of Hours Who Does the TherapyWho Does the Therapy
Psychological TestingPsychological Testing # of Hours# of Hours DocumentationDocumentation
NAN 2004NAN 2004
Problem: Problem: Fraud & The (Red) BookFraud & The (Red) Book
Contractor OperationsContractor Operations Strengthen Regional Offices OversightStrengthen Regional Offices Oversight Improve Evaluation of Fraud UnitImprove Evaluation of Fraud Unit Prevent Duplicate Payments for Same ServicePrevent Duplicate Payments for Same Service
Hospital OperationsHospital Operations Identify Patterns of Aberrant OverpaymentIdentify Patterns of Aberrant Overpayment Improve External Review of Psychiatric HospitalsImprove External Review of Psychiatric Hospitals
Nursing HomesNursing Homes Mental IllnessMental Illness
NAN 2004NAN 2004
Problem:Problem:The Medicare Book The Medicare Book (continued)(continued)
Physicians/Allied Health ProfessionalsPhysicians/Allied Health Professionals Improve Oversight of Rural Health Improve Oversight of Rural Health
ClinicsClinics Eliminate Inappropriate Payments for Eliminate Inappropriate Payments for
Mental Health ServicesMental Health Services Yet, Improve Medicaid Mental Health Yet, Improve Medicaid Mental Health
ProgramsPrograms
NAN 2004NAN 2004
Problem: Fraud (cont.)Problem: Fraud (cont.)
Nursing HomesNursing Homes Identification Identification Overuse of ServicesOveruse of Services
ChildrenChildren ExperienceExperience
Corporation AuditCorporation Audit Company AuditCompany Audit Personal AuditPersonal Audit Consultant for Companies & IndividualsConsultant for Companies & Individuals
NAN 2004NAN 2004
Problem: Fraud (cont.)Problem: Fraud (cont.)
Estimated Pattern of Fraud AnalysisEstimated Pattern of Fraud Analysis For-profit Medical CentersFor-profit Medical Centers For-profit Medical ClinicsFor-profit Medical Clinics Non-profit Medical CentersNon-profit Medical Centers Non-profit Medical ClinicsNon-profit Medical Clinics Nursing HomesNursing Homes Group PracticesGroup Practices Individual Practices (Current & Individual Practices (Current &
Widespread)Widespread)
NAN 2004NAN 2004
Fraud: (can go back 10 Fraud: (can go back 10 years)years)
Initial Review (14 points of submitted claims)Initial Review (14 points of submitted claims) LegibilityLegibility CoverageCoverage Matching datesMatching dates SignatureSignature
Subsequent Review (occurs if over 5-6 items Subsequent Review (occurs if over 5-6 items are failed in initial review)are failed in initial review) Does the service affect a potential change in Does the service affect a potential change in
medical condition?medical condition?
NAN 2004NAN 2004
Problem: Mental vs. PhysicalProblem: Mental vs. Physical
Historical vs. Traditional vs. Recent Historical vs. Traditional vs. Recent Diagnostic TrendsDiagnostic Trends
Recent Insurance Interpretations of Dxs Recent Insurance Interpretations of Dxs Limitations of the DSM Limitations of the DSM The Endless Loop of Mental vs. PhysicalThe Endless Loop of Mental vs. Physical
NOTE: NOTE: Important to realize that LMRP is Important to realize that LMRP is almost always more restrictive than almost always more restrictive than national guidelinesnational guidelines
NAN 2004NAN 2004
Possible Solutions:Possible Solutions:General ApproachesGeneral Approaches
Better Understanding & Application of CPTBetter Understanding & Application of CPT More Involvement in Billing More Involvement in Billing Comprehensive Understanding of LMRPComprehensive Understanding of LMRP More Representation/Involvement with More Representation/Involvement with
AMA, CMS & Local Medical Review PanelsAMA, CMS & Local Medical Review Panels Meetings with CMSMeetings with CMS Foster Relationship APA Practice and CAPPFoster Relationship APA Practice and CAPP Integration with Division 40 of APAIntegration with Division 40 of APA
NAN 2004NAN 2004
News to be Confirmed & News to be Confirmed & InterpretedInterpreted
(CR3016/Pub. 100-02/Transmittal 4/January 2, 2004)(CR3016/Pub. 100-02/Transmittal 4/January 2, 2004)
CMS Announced that Psychologists CMS Announced that Psychologists can Opt Not to Participate in the can Opt Not to Participate in the Medicare Program and to Sign Medicare Program and to Sign Private Agreements with Private Agreements with BeneficiariesBeneficiaries
NAN 2004NAN 2004
Future Perspectives:Future Perspectives:20032003
IncomeIncome Steadier due to decreased changesSteadier due to decreased changes Probable incremental declines, up to Probable incremental declines, up to
10-20% if traditional practice is 10-20% if traditional practice is pursuedpursued
If Medicaid dependent (25% or more), If Medicaid dependent (25% or more), then declines could be even higherthen declines could be even higher
Possible “final” stabilization by 2005Possible “final” stabilization by 2005 Results of election, economy, & new codesResults of election, economy, & new codes
NAN 2004NAN 2004
Future PerspectivesFuture Perspectives20032003
ParadigmsParadigms Industrial vs. Boutique/NicheIndustrial vs. Boutique/Niche Clinical vs. ForensicClinical vs. Forensic Mental Health vs. HealthMental Health vs. Health Existing vs. Developing Existing vs. Developing
NAN 2004NAN 2004
Future Perspectives:Future Perspectives:20032003
Evolving Paradigm = Continued and Evolving Paradigm = Continued and Significant Change Significant Change
Success = Predict, Embrace and Success = Predict, Embrace and Shape ChangeShape Change
NAN 2004NAN 2004
Future Perspectives:Future Perspectives:20042004
NegativeNegative NeutralNeutral PositivePositive
NAN 2004NAN 2004
Continued Expansion of AuditsContinued Expansion of Audits(Office of Inspector General; Red Book)(Office of Inspector General; Red Book)
Increase from Last YearIncrease from Last Year Requested records 124, 379 timesRequested records 124, 379 times Increase activity has resulted in outsourcing of auditing Increase activity has resulted in outsourcing of auditing
servicesservices Major Applicable Areas Major Applicable Areas
Psychological and Neuropsychological TestingPsychological and Neuropsychological Testing Individual PractitionersIndividual Practitioners Skilled Nursing FacilitiesSkilled Nursing Facilities In Institutions, supervision and “incident to”In Institutions, supervision and “incident to”
Primary Issues of ConcernPrimary Issues of Concern Medical NecessityMedical Necessity DocumentationDocumentation
NAN 2004NAN 2004
Anticipated General Upcoming Anticipated General Upcoming ChangesChanges
Federal Federal (due to results of Presidential election)(due to results of Presidential election) Technical – Health Electronic Records by 2008Technical – Health Electronic Records by 2008 Legal – Cap of $250,000 for non-economic damagesLegal – Cap of $250,000 for non-economic damages Coverage – Goal is to provide slightly increased coverage in Coverage – Goal is to provide slightly increased coverage in
terms of additional individuals but not additional services terms of additional individuals but not additional services coveredcovered
Performance Based PaymentPerformance Based Payment Traditionally = Fee for service providedTraditionally = Fee for service provided Anticipated = Fee for performance/results obtainedAnticipated = Fee for performance/results obtained
NAN 2004NAN 2004
Anticipated General Upcoming Anticipated General Upcoming ChangesChanges
EconomicEconomic Overall, Positive (maybe 3-5% growth)Overall, Positive (maybe 3-5% growth) Clinical Neuropsychology-Clinical Neuropsychology-
Institutionally BasedInstitutionally Based Limitations secondary to “incident to”Limitations secondary to “incident to” Difficulties in gaining access to GME fundsDifficulties in gaining access to GME funds
Practitioner BasedPractitioner Based Increased in Medicare and Major Third Party auditsIncreased in Medicare and Major Third Party audits Shifting in practice patterns (e.g., hours per evaluation)Shifting in practice patterns (e.g., hours per evaluation)
Practice Parameter BasedPractice Parameter Based Difficulties with battery-based approaches to diagnosticsDifficulties with battery-based approaches to diagnostics Expansion and alterations of reimbursement practicesExpansion and alterations of reimbursement practices Significant expansion of types of services and clients Significant expansion of types of services and clients
servedserved
NAN 2004NAN 2004
SummarySummary
Overall-Continued and Significant ChangesOverall-Continued and Significant Changes Overall, Increase in Recognition, Especially in Overall, Increase in Recognition, Especially in
General Health (vs. mental health) SectorsGeneral Health (vs. mental health) Sectors Shifting to Diagnostic and Supervisory Shifting to Diagnostic and Supervisory
Professional Activities over RehabilitativeProfessional Activities over Rehabilitative Continuing Shifting from Inpatient to Outpatient Continuing Shifting from Inpatient to Outpatient
and from Institutional to Private Practice and from Institutional to Private Practice Stabilization and Increase of Reimbursement Stabilization and Increase of Reimbursement Amounts Amounts
Reimbursement Practices Will Expand Including Reimbursement Practices Will Expand Including Electronic BillingElectronic Billing
Overall Increase, Especially in “Traditional” Overall Increase, Especially in “Traditional” NeuropsychologyNeuropsychology
NAN 2004NAN 2004
Possible Solutions: ResourcesPossible Solutions: Resources
General Web SitesGeneral Web Sites www.nanonline.org/paiowww.nanonline.org/paio www.cms.orgwww.cms.org (medicare/medicaid) (medicare/medicaid) www.hhs.orgwww.hhs.org (health & human services) (health & human services) www.oig.hhs.govwww.oig.hhs.gov (inspector general) (inspector general) www.ahrq.gov (agency for healthcare www.ahrq.gov (agency for healthcare
research)research) www.medpac.govwww.medpac.gov (medical payment (medical payment
advisory comm.)advisory comm.) www.whitehouse.gov/fsbr/healthwww.whitehouse.gov/fsbr/health (statistics) (statistics) www.div40.orgwww.div40.org (clinical neuropsychology div (clinical neuropsychology div
of apa)of apa) www.healthcare.group.comwww.healthcare.group.com (staff salaries) (staff salaries)
NAN 2004NAN 2004
Resources Resources (continued)(continued)
LMRP Reconsideration ProcessLMRP Reconsideration Process www.cms.gov/manuals/pm_trans/R28PIM.pdfwww.cms.gov/manuals/pm_trans/R28PIM.pdf
Coding Web SitesCoding Web Sites www.aapcnatl.orgwww.aapcnatl.org (academy of coders) (academy of coders) www.ntis.gov/product/correct-codingwww.ntis.gov/product/correct-coding (coding edits) (coding edits)
Compliance Web SitesCompliance Web Sites www.apa.orgwww.apa.org (psychologists & hipaa) (psychologists & hipaa) www.cms.hhs.gov/hipaawww.cms.hhs.gov/hipaa. (hipaa). (hipaa) www.hcca-info.orgwww.hcca-info.org (health care compliance assoc.) (health care compliance assoc.)
