Transcript Medicare, CPT, RVU: Update, Problems, & Directions

Advanced Coding,
Documentation and
Billing Workshop for
Neuropsychological
Services
National Academy of Neuropsychology
Seattle, Washington
November 20, 2004
(www.nanonline.org)
NAN 2004
Contact Information

Websites



E-mail



Univ = www.uncw.edu/people/puente
Practice = www.clinicalneuropsychology.us
University = [email protected]
Practice = [email protected]
Telephone


University = 910.962.3812
Practice = 910.509.9371
NAN 2004
Acknowledgments









Department of Psychology, UNC-Wilmington
NCPA Board of Directors, Practice Division, &
Staff
National Academy of Neuropsychology
Division 40 of APA
Practice Directorate of the American
Psychological Association
American Medical Association’s CPT Staff
CMS Medical Policy Staff
Inter-Divisional Health Care Committee; APA
Selected Individuals (e.g., Jim Georgoulakis)
NAN 2004
Acknowledgments


Professional Affairs Office
All the Individuals;


Keep Me in the Loop
Risk Their Time and Effort to Educate Third
Party Insurers & Licensing Boards
NAN 2004
Background
(1988 – present)
North Carolina Psychological Association (e)
 APA’s Policy & Planning Board; Div. 40 (e)
 American Medical Association’s Current Procedural
Terminology Committee (IV/V) (a)
 Health Care Finance Administration’s Working Group
for Mental Health Policy (a)
 Center for Medicare/Medicaid Services’ Medicare
Coverage Advisory Committee (fa)
 Consultant with the North Carolina Medicaid
Office;North Carolina Blue Cross/Blue Shield (a)
 NAN’s Professional Affairs & Information Office (a)
(legend; a = appointment, fa = federal appointment, e
= elected)

NAN 2004
Purpose of Presentation





Increase Reimbursement to Appropriate Levels
Increase Range, Type & Quality of Services
Decrease Fraud & Abuse
Provide Broad Practice Parameters for
Professional Services
Increase Professional Stature in Health Care, in
General, and Within Psychology, in Particular
NAN 2004
Outline of Presentation






Medicare
Current Procedural Terminology (& documentation)
Relative Value Units
Current Problems & Possible Solutions
Predictions for the Future
Resources
NAN 2004
Medicare: Overview



Why Focus on Medicare
The Medicare Program
Local Medical Review (policy & panels)
NAN 2004
Medicare: Why

The Standard for Universal Health Care




Coding
Value
Documentation
Auditing
NAN 2004
Medicare: Overview


Centers for Medicare and Medicaid
Services
Benefits



Part A (Hospital)
Part B (Supplementary)
Part C (Medicare+ Choice)
NAN 2004
Medicare: Local Review

Local Medical Review Policy



Carrier Medical Director


LMRP vs National Policy
Location of LMRPs
A Physician-based Model
Policy Panels


Lack of Understanding of Their Roles
Lack of Representation on Such Panels
NAN 2004
Medicare Payment
(since 1993)

Surgical


Higher Reimbursement than Cognitive
Cognitive

Physician Cognitive Work
NAN 2004
Unique Physician
Identification Number:
Who You Are

Currently



UPIN #
Entered in Box 17 a of CMS 1500 form
Starting 2005

National Provider Identification Number
NAN 2004
National Provider
Identifier
January 23, 2004
45 CFR Part 16c

Basic Information





Dates




10 position numeric & individual number
Will contain no specific information about provider
Managed by CMS’ National Provide System
Link will be placed on the NAN PAIO web pages
Can apply by May 23, 2005
Most entities will use by May 23, 2007
All entities will use by May 23, 2008
Applicability



All federal health plans, immediately
All state Medicaid programs, soon
General register for all health plans, thereafter
NAN 2004
Current Procedural
Terminology: Overview







Background
Codes & Coding
Existing Codes
Model System X Type of Problem
Medical Necessity
Documenting
Time
NAN 2004
CPT: Background

American Medical Association



Developed by Surgeons (& Physicians) in
1966 for Billing Purposes
7,500+ Discrete Codes
CMS


AMA Under License with CMS
CMS Now Provides Active Input into CPT
NAN 2004
CPT:
Background/Direction


Current System = CPT 5
Categories



I= Standard Coding for Professional Services
II = Performance Measurement
III = Emerging Technology
NAN 2004
CPT: Composition

AMA House of Delegates


HCPAC


109 Medical Specialties
11 Societies (e.g., APA)
CPT Editorial Panel

17 Voting Members



11 Appointed by AMA Board
1 each from BC/BS, AHA, HIAA, CMS
2 HCPAC
NAN 2004
What Is a CPT Code?



Professional Health Service Provided
Across the Country at Multiple locations
Many Physicians Perform Services
Clinical Efficacy is Established and
Documented in Peer-Reviewed Literature
NAN 2004
CPT: Applicable Codes



Total Possible Codes = Approximately 7,500
Possible Codes for Psychology = Approximately
40 to 60
Sections = Five Separate Sections





Psychiatry
Biofeedback
Central Nervous Assessment
Physical Medicine & Rehabilitation
Health & Behavior Assessment & Management
NAN 2004
CPT: Development of a
Code

Initial


Primary



Health Care Advisory Committee (non-MDs)
CPT Work Group
CPT Panel
Time Frame

3-5 to over a decade
NAN 2004
CPT: Psychiatry

Sections





Interview (90801) vs. Intervention (e.g., 908.06)
Office vs. Inpatient
Regular vs. Evaluation & Management
Other
Types of Interventions

Insight, Behavior Modifying, and/or Supportive vs.
Interactive
NAN 2004
CPT: CNS Assessment

Interview


96115
Testing




Psychological = 96100; 96110/11
Neuropsychological = 96117
Aphasia = 96105
Developmental = 96110/111
NAN 2004
CPT: Physical Medicine
& Rehabilitation


97770 now 97532
Note: 15 minute increments
NAN 2004
Current Problem With
Cognitive Rehabilitation

Cognitive Rehabilitation (97532)

Applied Rationale


Not Being Accepted by Some Carriers


Physical Medicine Codes are incorrectly being interpreted as
not being useable by psychologists
AH – Mental Health
Acceptability



GN = Speech Therapists
GO = Occupational Therapists
GP = Physical Therapists
NAN 2004
CPT: Health & Behavior
Assessment &
Management




Purpose: Medical Diagnosis
Time: 15 Minute Increments
Assessment
Intervention
NAN 2004
Rationale: General




Acute or chronic (health) illness may not
meet the criteria for a psychiatric
diagnosis
Avoids inappropriate labeling of a patient
as having a mental health disorder
Increases the accuracy of correct coding
of professional services
Increase range of services
NAN 2004
Rationale: Specific
Examples





Patient Adherence to Medical Treatment
Symptom Management & Expression
Health-promoting Behaviors
Health-related Risk-taking Behaviors
Overall Adjustment to Medical Illness
NAN 2004
Overview of Codes


New Subsection
Six New Codes




Assessment
Intervention
Established Medical Illness or Diagnosis
Focus on Biopsychosocial Factors
NAN 2004
Assessment Explanation



Identification of psychological, behavioral,
emotional, cognitive, and social factors
In the prevention, treatment, and/or
management of physical health problems
Focus on biopsychosocial factors (not
mental health)
NAN 2004
Assessment (continued)

May include (examples);





health-focused clinical interview
behavioral observations
psychophysiological monitoring
health-oriented questionnaires
and, assessment/interpretation of the
aforementioned
NAN 2004
Intervention Explanation



Modification of psychological, behavioral,
emotional, cognitive, and/or social factors
Affecting physiological functioning, disease
status, health, and/or well being
Focus = improvement of health with
cognitive, behavioral, social, and/or
psychophysiological procedures
NAN 2004
Intervention (continued)

May include the following procedures
(examples);




Cognitive
Behavioral
Social
Psychophysiological
NAN 2004
Diagnosis Match



Associated with acute or chronic medical
illness
Prevention of a physical illness or disability
Not meeting criteria for a psychiatric
diagnosis or representing a preventative
medicine service
NAN 2004
Related Psychiatric Codes


If psychiatric services are required
(90801-90899) along with these, report
predominant service
Do not report psychiatric and these codes
on the same day
NAN 2004
Code X Personnel
(examples)





Physicians (pediatricians, family physicians,
internists, & psychiatrists)
Psychologists
Advanced Practice Nurses
Clinical Social Workers Excluded
Other health care professionals within their
scope of practice who have specialty or
subspecialty training in health and behavior
assessments and interventions
NAN 2004
Health & Behavior
Assessment Codes

96150





Health and behavior assessment (e.g., healthfocused clinical interview, behavioral observations,
psychophysiological monitoring, health-oriented
questionnaires)
each 15 minutes
face-to-face with the patient
initial assessment
96151

re-assessment
NAN 2004
Health & Behavior
Intervention Codes
96152
 Health and behavior intervention
 each 15 minutes
 face-to-face
 individual
96153
 group (2 or more patients)
96154
 family (with the patient present)
96155
 family (without the patient present; not being
NAN 2004
reimbursed)




Relative Values for
Health & Behavior A/I
Codes






96150
96151
96152
96153
96154
96155
=
=
=
=
=
=
.50
.48
.46
.10
.45
.44
NAN 2004
Expected Payment for
Health & Behavior
Codes

Individual (per hour)


Range $98-106
Group (per person/ per hour)

Approximately $22
NAN 2004
CPT: Model System




Psychiatric
Neurological
Non-Neurological Medical
Alternatives
NAN 2004
CPT Model

Rationale for CPT Code:




Choose Code that Best Describes the Service
Provided
Match the Interview with the Testing with the
Intervention Code
Match All that With a Diagnosis
Goal = Uniformity and Fluency
NAN 2004
CPT: Psychiatric Model
(Children & Adult)

Interview



Testing



90801- adult
90802- child
96100- adult
96110/11- child
Intervention


e.g., 90806- adult
e.g., 90820-child
NAN 2004
CPT: Neurological
Model
(Children & Adult)

Interview


Testing


96115
96117
Intervention
 97532
NAN 2004
CPT: Non-Neurological
Medical Model
(Children & Adult)

Interview & Assessment



96150 (initial)
96151 (re-evaluation)
Intervention




96152
96153
96154
96155
(individual)
(group)
(family with patient)
(family without
patient)
NAN 2004
Alternative CPT Codes





99050 – Office, outside regular office hrs.
99052 - Service provided btw. 10pm-8am
99054 – Service provided on Sun/holidays
0074T – Online service
90825 – Review of records
NAN 2004
CPT: Correct Coding
Initiative

Purpose



Used to evaluate submissions when provider
bills more than one service for the same
beneficiary and same date of service
Example; psychotherapy and testing
Activation

Automatic edits
NAN 2004
CPT: Diagnosing

Psychiatric

DSM


The problem with DSM and neuropsych testing of
developmentally-related neurological problems
Neurological & Non-Neurological Medical

ICD
NAN 2004
Recent CPT Changes

Biofeedback (90911)

Minor editorial changes in biofeedback
training
NAN 2004
Recent CPT Changes

Developmental Testing Codes

Applicability


Background




Children
Part of Central Nervous System family of codes
Hence, no work value (& lower reimbursement rate)
Recently “re-surveyed” by pediatricians
Specific Changes

96110



Continues to have no work value
Use for completion of forms (Connors; by parents)
96111


Has physician work value
Assessment of child’s social, emotional, etc status (WJ)
NAN 2004
Probable CPT Changes :
Health & Behavior Assessment Codes

Brief History



Inter-divisional Health Care Committee (22, 38, 40, 54; Glueckauf)
Convened in 1995 by APA Practice Directorate (Phelps)
Drafts


Presentations



First Survey January 31, 2001; Final Survey April 26, 2001
Revisions to Language


First Presentation to AMA November 6, 1998 ; Final Presentation – August 8, 2000
7 total presentations- Ft. Lauderdale, Chicago, Denver, San Francisco, Washington, DC,
Chicago, Chicago
Surveys


First Draft - September 11, 1998; Final Working Draft – July 1, 2000
First Preamble revision – March, 2002; Last Preamble revision – November, 2004
Applicability

When behavioral, cognitive, emotional, and/or psychological techniques are used
to assess and/or treat health (medical not psychiatric) problems
NAN 2004
Probable CPT Changes:
Health & Behavior Assessment Codes

Acceptability




All Medicare carriers (minus Florida’s)
Some Medicaid programs (e.g., Colorado, Vermont)
Some private insurers (BC/BS in NC, DC; Nationwide)
Changes


Preamble
Clarification



Future Expectation



Not a preventive medicine code
Patient can have a history or presence of mental illness
No further changes
Increased carrier acceptance, especially if providers educate carriers
Final Verification Anticipated


December 1, 2004
Applicability starting January 1, 2005
NAN 2004
Probable CPT Changes:
CNS Assessment Codes

Neurobehavioral Status Exam



Psychological Testing



Re-write (different language; same concept)
Addition of “Physician” Work Value
Expansion of existing code
Addition of “Physician” Work Value
Neuropsychological Testing


Expansion of existing code
Addition of “Physician” Work Value
NAN 2004
Probable CPT Changes:
CNS Assessment Codes

Net Effect

Avoidance of Continuation of Reimbursement Strictly Based on
Practice Expense




Greater Clarity of Professional and Non-Professional Activities

Differentiation of professional, technical and computer activity

Accounting/auditing, research, and salary purposes
Recognition of “Physician” Work


Potential catastrophe in terms of reimbursement
Potential reimbursement rates in the vicinity of $40/hr
Ending a 10 year struggle
Possibly, Increased Reimbursement
NAN 2004
Probable CPT Changes:
CNS Assessment Codes

Timetable (activity x date)










Initial Decision by AMA CPT Panel, November 7, 2004
Call for Other Societies to Participate, November 19, 2004
Final Decision by AMA CPT Panel, December 1, 2004
Submission of CPT Codes to AMA RUC Committee immediately
thereafter
Review by AMA RUC Research Subcommittee in January, 2005
Review by AMA RUC Panel in February 3-6, 2005
Survey of Codes, second & third week of February, 2005
Analysis of surveys, March, 2005
Presentation to RUC Committee in April, 2005
Hopeful inclusion in the 2006 Physician Fee Schedule for January
1, 2006
NAN 2004
CPT: Medical Necessity








Scientific & Clinical Necessity
Local Medical Review or Carrier Definitions of Necessity
Necessity = CPT x DX
Necessity Dictates Type and Level of Service
Necessity Can Only be Proven with Documentation
Screening or Regularly Scheduled Evals Do Not Meet
Criteria for Necessity
Will Results Affect Outcome of Patient?
Will New Information Be Obtained?
NAN 2004
Medically Reasonable
and Necessary
Section 1862 (a)(1) 1963
42, C.F.R., 411.15 (k)


“Services which are reasonable and
necessary for the diagnosis and treatment
of illness or injury or to improve the
functioning of a malformed body member”
Re-evaluation should only occur when
there is a potential change in;


Diagnosis
Symptoms
NAN 2004
CPT: Documenting






Purpose
Payer Requirements
General Principles
History
Examination
Decision Making
NAN 2004
Documentation: Purpose





Medical Necessity
Evaluate and Plan for Treatment
Communication and Continuity of Care
Claims Review and Payment
Research and Education
NAN 2004
Documentation: Payer
Requirements



Site of Service
Medical Necessity for Service Provided
Appropriate Reporting of Activity
NAN 2004
Documentation:
General Principles








Rationale for Service
Complete and Legible
Reason/Rationale for Service
Assessment, Progress, Impression, or
Diagnosis
Plan for Care
Date and Identity of Observe
Timely
Confidential
NAN 2004
Documentation: Basic
Information Across All
Codes










Date
Time, if applicable
Identify of Observer (technician ?)
Reason for Service
Status
Procedure
Results/Finding
Impression/Diagnoses
Disposition
Stand Alone
NAN 2004
Documentation: Chief
Complaint



Concise Statement Describing the
Symptom, Problem, Condition, &
Diagnosis
Foundation for Medical Necessity
Must be Complete & Exhaustive
NAN 2004
Documentation: Present
Illness

Symptoms


Location, Quality, Severity, Duration, timing,
Context, Modifying Factors Associated Signs
Follow-up


Changes in Condition
Compliance
NAN 2004
Documentation: History




Past
Family
Social
Medical/Psychological
NAN 2004
Documentation:
Intervention







Reason for Service
Status
Intervention
Results
Impression
Disposition
Time
NAN 2004
Documentation:
Assessment






Reason for Service
Dates (amount of service time?)
Tests and Protocols (included editions)
Narrative of Results
Impression
Disposition
NAN 2004
CPT X Report


Each CPT Code Should Generate a
Separate Report
Alternative Clearly Label/Title Sections of
the Report to Match Codes Used
NAN 2004
Documentation:
Suggestions






Avoid Handwritten Notes
Do Not Use Red Ink
Avoid Color Paper
Document On and After Every Encounter,
Every Procedure, Every Patient
Review Changes Whenever Applicable
Avoid Standard Phrases & Protocols
NAN 2004
When to Document


Intervention = Immediately After
Testing- Immediately After Vs. at End of
Evaluation
NAN 2004
Time

Defining

Professional (not patient) Time Including:


Interview & Assessment Codes


pre, intra & post-clinical service activities
Use 15 minute increments
Intervention Codes

Use 15 minute increments
NAN 2004
Time: Definition


AMA Definition of Time
Physicians also spend time during work, before,
or after the face-to-face time with the patient,
performing such tasks as reviewing records &
tests, arranging for services & communicating
further with other professionals & the patient
through written reports & telephone contact.
NAN 2004
Time (continued)



Communicating further with others
Follow-up with patient, family, and/or
others
Arranging for ancillary and/or other
services
NAN 2004
Time: Testing

Quantifying Time


Round up or down to nearest increment
Time Does Not Include





Patient completing tests, forms, etc.
Waiting time by patient
Typing of reports
Non-Professional (e.g., clerical) time
Literature searches, learning new techniques, etc.
NAN 2004
Reimbursement History





Cost Plus
Prospective Payment System (PPS)
Diagnostic Related Groups (DRGs)
Customary, Prevailing & Reasonable (CPR)
Resource Based Relative Value System
(RBRVS)
NAN 2004
Relative Value Units:
Overview




Components
Units
Values
Current Problems
NAN 2004
RVU: Components





Physician Work Resource Value
Practice Expense Resource Value
Malpractice
Geographic
Conversion Factor (approx. $34)
NAN 2004
RVU Components
Percentages



Physician Work
=
Practice Expense =
Liability
=
NAN 2004
52%
44%
4%
Defining Physician Work

Clinical Work



Mental Effort and Judgment
Technical Skill/Physical Effort
Psychological Stress
NAN 2004
Estimate of Psychologists’
Value

Audiologist
Dietician
RN
Speech Pathologist
.52
.43
.42
.55

Psychologist
.82



NAN 2004
Defining Practice Expense

Medical Supplies


Medical Equipment


Expendable medical equipment (e.g., forms)
Durable medical equipment (e.g., tests)
Professional Support Staff

e.g., time
NAN 2004
RVU: Values

Psychotherapy:



Psych/NP Testing:




Prior Value =1.86
New Value = 2.65
Work value= 0
Hsiao study recommendation = 2.2
New Value = undetermined
Health & Behavior

.25 (per 15 minutes increments)
NAN 2004
RVU: Acceptance



Medicare (100% since 01.01.92)
Medicaid 100%
Private Payors 74%




Blue Cross/Blue Shield 87%
Managed Care 69%
Other 44%
New Trends:


RVUs as a Model for All Insurance Companies
RVUs as a Basis for Compensation Formulas
NAN 2004
CPT x RVU
CPT
Code
Work
Value
Practice Malpractice
Expense Expense
Total
RVU
Mutually
Exclusive
90801 2.80
1.14
0.06
90806 1.86
0.75
0.04
4.00 90802, 90846, 90847,
90853, 99291, 99292
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
96152 0.46
0.18
0.02
0.72 96151, 96152, 96153,
96154, 96155
0.66 96150, 96151, 96153,
96154, 96155
NAN 2004
Medicare Rates
Type
Deductible
Co-Payment
Part A
$912
0-$456 (days)
Part B
$110
Health – 20%
Psych- 50%
Note: Premiums are $78.20/month
NAN 2004
Continuing Problems










Definition of Physician
Supervision
Incident to
Face-to-Face
Time
RVUs
Work Values
Practice Expense & Testing Survey
Payment
Focus for Fraud & Abuse
NAN 2004
Problem: Defining
Physician

Definition of a Physician






Social Security Practice Act of 1980
Definition of a Physician
Need for Congressional Act
Likelihood of Congressional Act
The Value of Technical Services of a
Psychologist is $.83/hour (second highest
after physicist)
Consequence of the preceding; grouping with
non-doctoral level allied health providers
NAN 2004
Supervision
Federal Register
Volume 69, No. 150, August 5, 2004, page 47553




Hold Doctoral Degree in Psychology
Licensed or Certified as a Psychologist
Applicable Only to “clinical psychologists” (and
not “independent” psychologists (e.g., Ed. Psych.)
Rationale




Allows for higher level of expertise to supervise
Could relieve burden on physicians and facilities
May increase service in rural areas
Recommended Supervision Level = General
NAN 2004
Problem:Supervision

Supervision




1.General = overall direction
2.Direct = present in office suite
3.Personal = in actual room
4.Psychological = when supervised by a
psychologist
NAN 2004
Supervision
Program Memorandum Carriers
Department of Health and Human Services- HCFA
Transmittal b-01-28; April 19, 2001

Levels of Supervision

General


Direct


Furnished under overall direction and control, presence is not
required
Must be present in the office suite and immediately available
to furnish assistance and direction throughout the
performance of the procedure
Personal

Must be in attendance in the room during the performance of
the procedure
NAN 2004
Problem: Incident to

Rationale for Incident to


Definition of Physician Extender





How
Limitations
Definition of In vs. Outpatient


Congress intended to provide coverage for services
not typically covered elsewhere
Geographic Vs Financial
Why No Incident to (DRG)
Solution Available for Some Training Programs
Probably no Future to Incident to
NAN 2004
Problem: More Incident to

When is “Incident to” Acceptable:




Testing
Cognitive Rehabilitation; Biofeedback
Psychotherapy
Definition




Commonly furnished service
Integral, though incidental to psychologist
Performed under the supervision
Either furnished without charge or as part of the
psychologist’s charge
NAN 2004
Problem: Incident to &
Site of Service

Outpatient vs. Inpatient




Geographical Location
Corporate Relationship
Billing Service
Chart Information & Location
NAN 2004
Problem:
Incident to versus
Independent Service

When Does Incident to Become
Independent Service





Appearance of No Supervision
Clinical Decisions are Made by Staff
Ratio of Physician to Staff Time Becomes
Disproportionate
Distance Difficulties
Supervision Difficulties
NAN 2004
Problems:
Recent Difficulties with
Incident to

Who Bills Incident to



Treating Physician Bills not the Supervising
Physician
Then, Who is the Responsible Party
The Physician Must Evaluate and/or
Treat the Patient First
NAN 2004
Difference Between Supervision
and “Incident to”

Supervision




Applies to whether and
how a “physician” oversees
the work of ancillary
personnel
A clinical concept
Can occur at any level of
supervision (from general
to personal)
NAN 2004
“Incident to”




Applies when billing for
services supervised by a
“physician”
An economic concept
Can only occur when
supervision is “direct” (i.e.,
in the same office suite)
Note: no “incident to” in
inpatient settings for
Medicare
Problem: Face-to-Face




Implications
Technical versus Professional Services
Surgery is the Foundation for CPT (and
most work is face-to-face)
Hard to Document & Trace Non-Face-toFace Work
NAN 2004
Problem: Work Value




Physician Activities (e.g., Psychotherapy)
Result in Work Values
Psychological Based Activities (i.e.,
Testing) Have no Work Values
RVUs are Heavily Based on Practice
Expenses (which are being reduced)
Net Result = Maybe Up to a Half Lower
NAN 2004
Problem:
An Artificial Practice
Expense





Five Year Reviews
Prior Methodology
Current Methodology
Current Value = approximately 1.5 of 1.75 is
practice expense
Deadline for New Practice Expense = 11.04


New numbers recently submitted
Expected Value = closer to 50% of total value at
best
NAN 2004
Problem: Qualification
of Technician

What is the Minimum Level of Training
Required for a Technician?


Bachelor’s vs. Master’s
Student vs. Staff
NAN 2004
Problem: Payment

Origins of the Problem



What Should Your Code Be Payed at?


Balanced Budget Act of 1997
Employer’s Cost for Health Care in 2002 =
$5,000 per employee
www.webstore.ama-assn.org-
State Legislation

www.insure.com/health/lawtool.cfm
NAN 2004
Problem:
Payment Problems

Refilling



51% require refilling of original forms
But, up to 60% do not follow up
Errors



54% = plan administrator
17% = provider
29% = member
NAN 2004
Problem: Payment

Use of HMOs & Third Party




Shift in Practice Patterns by Psychiatry (14%
increase)
Exclusion of MSW, etc. (Increase)
Worst Hit Are Psychologists (2% decrease)
Compensation




Gross Charges
Adjusted Charges
RVUs
Receivables
NAN 2004
Problem: Payment of
Health & Behavior
Codes


Medicare Almost all Resolved
Non-Medicare Resolving
NAN 2004
Medicare Questions



Cannot Impose a Limitation on a Medicare
Patient That is Not Imposed on Other Pts.
Non-Covered Services Can Be Charged if Patient
Knows and Agrees Ahead of Time
Records Should be Retained, state law or;



Adult- 5 years post service
Children- until 21
Billing


In Continuing Cases- End of month
Otherwise- At end of service
NAN 2004
Problem: Expenditures &
Fraud

Projections

Current


14%
By 2011;

17% ($2.8 trillion)
NAN 2004
Fraud: Medicare’s
Interpretation of
Physician Liability





Overpayment From Incorrect Charge
Billing for Items Known Not to be Covered
Services Provided by Non-qualified
Practitioner
Mathematical or Clerical Error
Inappropriate Documentation
NAN 2004
Defining Fraud

Fraud



Intentional
Pattern
Error


Clerical
Dates
NAN 2004
Problem: Fraud &
Abuse




26 Different Kinds of Fraud Types
Mental Health Profiled
Estimates of Less Than 10% Recovered
Psychotherapy Estimates/Day = 9.67
hours


Review Likely if Over 12 Hours Per Day
Problems with Fraud Methodology


Primarily in how the research was done
Also, in the application of sampling
NAN 2004
Problem: Fraud
Office of Inspector General

Primary Problems



Psychotherapy
(oig.hhs/gov/reports/region5/50100068)





Medical Necessity (approximately $5 billion)
Documentation
Individual
Group
# of Hours
Who Does the Therapy
Psychological Testing


# of Hours
Documentation
NAN 2004
Problem:
Fraud & The (Red) Book

Contractor Operations




Hospital Operations



Strengthen Regional Offices Oversight
Improve Evaluation of Fraud Unit
Prevent Duplicate Payments for Same Service
Identify Patterns of Aberrant Overpayment
Improve External Review of Psychiatric Hospitals
Nursing Homes

Mental Illness
NAN 2004
Problem:
The Medicare Book
(continued)

Physicians/Allied Health Professionals



Improve Oversight of Rural Health Clinics
Eliminate Inappropriate Payments for Mental
Health Services
Yet, Improve Medicaid Mental Health
Programs
NAN 2004
Problem: Fraud (cont.)

Nursing Homes




Identification
Overuse of Services
Children
Experience




Corporation Audit
Company Audit
Personal Audit
Consultant for Companies & Individuals
NAN 2004
Problem: Fraud (cont.)

Estimated Pattern of Fraud Analysis







For-profit Medical Centers
For-profit Medical Clinics
Non-profit Medical Centers
Non-profit Medical Clinics
Nursing Homes
Group Practices
Individual Practices (Current & Widespread)
NAN 2004
Fraud: (can go back 10 years)

Initial Review (14 points of submitted claims)





Legibility
Coverage
Matching dates
Signature
Subsequent Review (occurs if over 5-6 items are
failed in initial review)

Does the service affect a potential change in medical
condition?
NAN 2004
Problem: Mental vs.
Physical

Historical vs. Traditional vs. Recent Diagnostic
Trends
Recent Insurance Interpretations of Dxs
Limitations of the DSM
The Endless Loop of Mental vs. Physical

NOTE: Important to realize that LMRP is almost



always more restrictive than national guidelines
NAN 2004
Possible Solutions:
General Approaches







Better Understanding & Application of CPT
More Involvement in Billing
Comprehensive Understanding of LMRP
More Representation/Involvement with AMA,
CMS & Local Medical Review Panels
Meetings with CMS
Foster Relationship APA Practice and CAPP
Integration with Division 40 of APA
NAN 2004
News to be Confirmed &
Interpreted
(CR3016/Pub. 100-02/Transmittal 4/January 2, 2004)

CMS Announced that Psychologists can
Opt Not to Participate in the Medicare
Program and to Sign Private Agreements
with Beneficiaries
NAN 2004
Future Perspectives:
2003

Income




Steadier due to decreased changes
Probable incremental declines, up to 1020% if traditional practice is pursued
If Medicaid dependent (25% or more),
then declines could be even higher
Possible “final” stabilization by 2005

Results of election, economy, & new codes
NAN 2004
Future Perspectives
2003

Paradigms




Industrial vs. Boutique/Niche
Clinical vs. Forensic
Mental Health vs. Health
Existing vs. Developing
NAN 2004
Future Perspectives:
2003


Evolving Paradigm = Continued and
Significant Change
Success = Predict, Embrace and Shape
Change
NAN 2004
Future Perspectives:
2004



Negative
Neutral
Positive
NAN 2004
Continued Expansion of
Audits
(Office of Inspector General; Red Book)

Increase from Last Year



Major Applicable Areas





Requested records 124, 379 times
Increase activity has resulted in outsourcing of auditing services
Psychological and Neuropsychological Testing
Individual Practitioners
Skilled Nursing Facilities
In Institutions, supervision and “incident to”
Primary Issues of Concern


Medical Necessity
Documentation
NAN 2004
Anticipated General
Upcoming Changes

Federal




(due to results of Presidential election)
Technical – Health Electronic Records by 2008
Legal – Cap of $250,000 for non-economic damages
Coverage – Goal is to provide slightly increased coverage in terms of
additional individuals but not additional services covered
Performance Based Payment


Traditionally = Fee for service provided
Anticipated = Fee for performance/results obtained
NAN 2004
Anticipated General
Upcoming Changes

Economic


Overall, Positive (maybe 3-5% growth)
Clinical Neuropsychology
Institutionally Based



Practitioner Based



Limitations secondary to “incident to”
Difficulties in gaining access to GME funds
Increased in Medicare and Major Third Party audits
Shifting in practice patterns (e.g., hours per evaluation)
Practice Parameter Based



Difficulties with battery-based approaches to diagnostics
Expansion and alterations of reimbursement practices
Significant expansion of types of services and clients served
NAN 2004
Summary

Overall-Continued and Significant Changes





Overall, Increase in Recognition, Especially in General
Health (vs. mental health) Sectors
Shifting to Diagnostic and Supervisory Professional
Activities over Rehabilitative
Continuing Shifting from Inpatient to Outpatient and
from Institutional to Private Practice Stabilization and
Increase of Reimbursement Amounts
Reimbursement Practices Will Expand Including
Electronic Billing
Overall Increase, Especially in “Traditional”
Neuropsychology
NAN 2004
Possible Solutions:
Resources

General Web Sites









www.nanonline.org/paio
www.cms.org (medicare/medicaid)
www.hhs.org (health & human services)
www.oig.hhs.gov (inspector general)
www.ahrq.gov (agency for healthcare research)
www.medpac.gov (medical payment advisory
comm.)
www.whitehouse.gov/fsbr/health (statistics)
www.div40.org (clinical neuropsychology div of
apa)
www.healthcare.group.com (staff salaries)
NAN 2004
Resources (continued)

LMRP Reconsideration Process


Coding Web Sites



www.cms.gov/manuals/pm_trans/R28PIM.pdf
www.aapcnatl.org (academy of coders)
www.ntis.gov/product/correct-coding (coding edits)
Compliance Web Sites



www.apa.org (psychologists & hipaa)
www.cms.hhs.gov/hipaa. (hipaa)
www.hcca-info.org (health care compliance assoc.)
NAN 2004