REIMBURSEMENT FOR NEUROPSYCHOLOGICALSERVICES

Antonio E. PuenteUNC-Wilmington

NAN: 11.03.99, San Antonio

OUTLINE

ACKNOWLEDGMENTHISTORY & BACKGROUNDMODEL FOR BILLING SERVICESDIAGNOSESTESTSCODINGDOCUMENTATION

OUTLINE II

MEDICARE MODEL POLICYREIMBURSEMENT ISSUESAUDITSADDITIONAL CONCERNSCURRENT PROBLEMSSUMMARYFUTURE DIRECTIONS

ACKNOWLEDGMENTS

AMERICAN PSYCHOLOGICAL ASSOCATION’S PRACTICE DIRECTORATE

DIVISION 40 OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION

NATIONAL ACADEMY OF NEUROPSYCHOLOGY

BACKGROUND/HISTORY

NORTH CAROLINA PSYCHOLOGICAL ASSOCIATION (1988-89)

AMERICAN MEDICAL ASSOCIATION- CPT IV (1994)

AMERICAN MEDICAL ASSOCIATION- CPT v (1997)

MEDICARE COVERAGE ADVISORY COMMITTEE (1999)

MODEL BILLING

DIAGNOSISPROFESSIONAL SERVICELOCATION OF SERVICEPROVIDER

DIAGNOSIS

SYSTEM (see NAN directory) DSM (290-319) ICD (ALL OTHER DXs)

RULE-OUT BY DESIGN BUT STATED

MULTIPLE DXs ADVISABLE FOR MEDICALLY NECESSARY FIRST ONE IS MOST IMPORTANT

TESTS

WHAT TESTS ARE BEING USEDHOW LONG DOES IT TAKE FOR EACH

OF THESE TESTSADDRESS MORE SPECIFICALLY PRE,

DURING, AND POST PROFESSIONAL TIME

Outline of Presentation

I. IntroductionII. SampleIII. ResultsIV. Summary

Study Sample I

Organization: National Academy of Neuropsychology

Description: Approximately 4,000 members Independent organization dedicated to

clinical neuropsychology

Study Sample II

Rationale: Not an interest group (e.g., Division 40

of APA) Not multidisciplinary (e.g., International

Neuropsychological Society)

Study Sample III

Sample DescriptionSample Description 2700= Total members of NAN in 1994 1200= Total # sampled 324= Initial response (27%) 242= Second response (20%) 566= Total responses (47%) 119= Reported <5hrs/week of evaluations 447= Total used from original sample

Introduction

RationaleRationale HCFA/Third Party Reimbursers Establish a baseline of test used with time

valuesPrior ResearchPrior Research

Practice Surveys (e.g., Hartlage, et al; Putnam, et al)

Test Surveys (e.g., Ball, et al; Lees-Haley, et al)

Results

Hours Spent TestingPercentage of BatteriesMinutes to AdministerPercentage of Testing with

ComputersTests

Results ITime Spent Testing

HoursHours NN %%0-4 116 215-9 62 1110-14 92 1615-20 105 19>20 188 33No Response 4 1

Results IINumber & % of BatteriesPractice AreasPractice Areas NN %%Adaptive 194 43Aphasia 205 46Behavioral Med 127 28Developmental 115 27Intellectual 354 79Neurobehavioral 228 51Neuropsychological 427 95Personality 353 79

Results IIIMinutes to Administer TestPractice AreasPractice Areas Admin.Admin. Score Score Int.Int.Adaptive 74 32 48Aphasia 61 24 39Behavioral Med 110 35 58Developmental 113 36 59Intellectual 122 34 61Neurobehavioral 80 26 47Neuropsych. 304 79 135Personality 103 46 75

Results IV Testing with Computers

ActivityActivity %%Administration 2Scoring 10Interpretation 3

Results VTest Frequency

Total # of tests= 102

Tests used exclusively by neuropsychologists= 8

Longest tests used= HRNB (400 mins.) Wechsler Scales (130 mins.)

Results VTop 26 Tests

MMPI WAIS-R WMS-R TRAIL MAKING FAS WORD FLUENCY FINGER TAPPING HRNB BOSTON NAMING CATEGORY TEST WRAT-R/III BECK DEPRESSION REY COMPLEX FIGURE TEST WISCONSIN CARD SORTING

CALIFORNIA VERBAL LEARN. GROOVED PEGBOARD WISC-R/III APHASIA SCREENING TEST RORSCHACH INKBLOT HOOPER VISUAL ORGAN. HAND DYNAMOTER DEMENTIA RATING SCALE STROOP PASAT MILLON BENDER GESTALT THEMATIC APPERCEPTION

Summary

First extended study on: Tests used in clinical practice Overallratings Assessment of time values

Implications: Clinical Practice Public Policy

CODING

SYSTEMS ICD/WHO SNOMED CPT

CODING II

DEFINITION OF CPT- CURRENT PROCEDURAL TERMINOLOGY LISTING OF DESCRIPTIVE TERMS FOR

REPORTING PROFESSIONAL SERVICESUSE OF CPT

MOST WIDELY ACCEPTED NOMENCLATURE USED TO REPORT HEALTH SERVICES

CODING III

DEVELOPMENT OF CPT DEVELOPED= AMA FIRST EDITION= 1966 CURRENT EDITION= 4TH NEXT EDITION= 5TH, 2002

CODING IV

INTERVIEW PSYCHIATRIC= 90801 NEUROLOGICAL= 96115

TESTING PSYCHIATRIC= 96100 NEUROLOGICAL= 96117

CODING V

INTERVENTION PSYCHIATRIC=908xx

Individual Vs GroupBrief vs Regular vs ExtendedInpatient vs OutpatientRegular vs Interactive

NEUROLOGICAlCognitive Rehab= 97770 (and others)Biofeedback= 90875 or 90901

CODING VI

MATCH THE DX WITH THE RX PSYCHIATRIC= DSM WITH 90801 NEUROLOGICAL= ICD WITH 96115

DOCUMENTATION

GENERAL VS SPECIFICIMPORTANCE OF DOCUMENTING

DOCUMENTATION II

PSYCH INTERVIEW HISTORY CHIEF COMPLAINT MENTAL STATUS DISPOTION COMMUNICATION WITH OTHERS ORDERING OR INTERPRETING TESTS DIAGNOSIS

DOCUMENTATION III

PSYCH THERAPEUTIC PROCEDURES PURPOSE= RESOLVING PROBLEMS OR

ALLEVIATING OF EMOTIONAL DISTURBANCES, OR CHANGING MALADAPTIVE PATTERNS OF BEHAVIOR, OR ENCOURAGING PERSONAL GROWTH AND DEVELOPMENT

DOCUMENTATION IV

APPROACHES= REGULAR- DEVELOPMENT OF INSIGHT OR

AFFECTIVE UNDERSTANDING, THE USE OF BEHAVIOR MODIFICATION TECHNIQUES, THE USE OF SUPPORTIVE INTERACTIONS, THE USE OF COGNITIVE DISCUSSION OF REALITY…

INTERACTIVE= THE USE OF PHSYICAL AIDS OR NON-VERBAL COMMUNICATION

DOCUMENTATION V (Psy)

SPEECHLANGUAGETHOUGHT PROCESS INSIGHT JUDGMENTRELIABILITYREASONINGPERCEPTIONS

SUICIDALITYVIOLENCEMOOD & AFFECTORIENTATIONMEMORYATTENTION INTELLIGENCE MIN-MENTAL

STATUS

DOCUMENTATION VI

COMPLETE AND LEGIBLEASSESSMENT, IMPRESSION, OR DXPLAN FOR CAREDATE & IDENTITY OF OBSERVERTESTING RATIONALE SHOULD BE CLEARRISK FACTORS SHOULD BE IDENTIFIEDCONFIDENTIALITY

DOCUMENTATION VII

TESTING DATE REASON FOR SERVICE NAME OF TESTS USED INTERPRETATION OF TESTS RESULTS IMPRESSION/DIAGNOSIS DISPOSITION IDENTITY OF OBSERVER TIME

DOCUMENTATION VIII- neurobehavioral status

DATEREASON FOR

SERVICEATTENTIONMEMORYVISUAL-SPATIALLANGUAGE

PLANNINGIMPRESSION/DXDISPOSITIONIDENTITY OF

OBSER.TIME

DOCUMENTATION IX

PSYCH THERAPY DATE REASON INTERVENTION RESULTS IMPRESSION DISPOSITION IDENTITY TIME

COG REHAB DATE REASON TRAINING ACTIVITY IDENTITY TIME

MODEL POLICY

BACKGROUNDAPPLICATION

CODE CATEGORY INDICATION DESCRIPTION DOCUMENTATION COMMENTS

MODEL POLICY II

NEUROPSYCHOLOGICAL TESTING DESCRIPTION= INTEGRITY OF THE

BRAIN TIME= 5-7 HOURS, IF OVER 11 HOURS

THEN A REPORT SHOULD BE SUBMITTED DIAGNOSES= ICD

REIMBURSEMENT

MEDICARE RATES 90801= 127.81 90806= 88.57 96100= 68.77 96115= 68.77 96117= 68.77 97770= 100.04

AUDITS

BACKGROUND Balanced Budget Act

CODING & DOCUMENTATIONMEDICALLY NECESSARY

Is the service rendered needed for the question considered?

TIME

DEFINING TIME professional time- pre, during, post not patient activity alone (e.g., MMPI)

ADDITIONAL CONCERNS

GENERAL MEDICAL EDUCATION DEFINING

TRAINING OF HEALTH-CARE PROFESSIONALS

PROVISION OF SERVICES FOR INDIGENT

SCOPEINTERNSPOST-DOCTORAL FELLOWS

ADDITIONAL CONCERNS II

INCIDENT TO DEFINING

EXTENSION OF PROFESSIONAL SERVICES

SCOPEAPPLIES ONLY TO MEDICARESERVICE CAN BE DONE BUT WILL NOT BE

REIMBURSEDNO INCIDENT TO IN INPATIENT SETTINGSINCIDENT TO IN “OUTPATIENT” SETTINGS IS

ACCEPTABLE

CURRENT PROBLEMS

AUDITING (CODING/DOCUMENTATION)DECREASED REIMBURSEMENTGREATER LIMITS ON WHAT IS

MEDICALLY NECESSARYMENTAL HEALTH VS MEDICAL &

CARVE-OUTSNON-PSYCHOLOGISTS (BOTH MDs AND

NON-MDS)

SUMMARY

MODELSYSTEMEACH CARRIER HAS UNIQUE SYSTEMEDUCATION IS CRITICALLITIGATION MAY BE NECESSARY

FUTURE DIRECTIONS

CODINGGREATER ACCOUNTABILITYLESS REIMBURSEMENT FOR

STANDARD CLINICAL SERVICESSPILL-OVER INTO RELATED AREAS

INCLUDING FORENSICS, NON-NEUROLOGICAL MEDICINE, SPORTS, INDUSTRY

FUTURE DIRECTIONS II

CONTRACTS & CONSULTATION VS FEE FOR SERVICE

USE OF TECHNICIANS SHOULD BE OR WILL BE FURTHER CLARIFIED

DECREASE OF PRACTICE EXPENSESINCREASED USE OF INFORMATION

SYSTEMS & ELECTRONIC OFFICESDECREASED INSTITUTIONAL ACTIVITY