Medicare, CPT, RVU: Update, Problems, & Directions
Download
Report
Transcript Medicare, CPT, RVU: Update, Problems, & Directions
Coding, Billing and Documenting
Professional Psychological Services:
With Special Emphasis on the 2006
Testing Codes
Antonio E. Puente
University of North Carolina Wilmington
North Carolina Psychological Association
Division of Professional Practice
Chapel Hill, North Carolina 02.03.06
NCPA/DIPP 2006
1
Contact Information
Websites
Univ = www.uncw.edu/people/puente
Practice = www.clinicalneuropsychology.us
NAN = www.nanonline.org/paio
E-mail
University = [email protected]
Practice = [email protected]
Telephone
University = 910.962.3812
Practice = 910.509.9371
NCPA/DIPP 2006
2
Disclaimer
The information contained in this extended presentation
is not intended to reflect either NCPA, APA nor NAN
policy. Further, this presentation is intended to be
informative and not meant to imply that it supersedes
APA or state ethical guidelines and/or local, state or
national regulations and/or laws. Further, LMRP and
specific health care contracts may supersede the
information presented. The information contained herein
is meant to provide practitioners as well as health care
institutions (e.g., insurance companies) involved in
psychology with the latest information available
regarding the issues addressed. This is a living document
that can and will be revised as additional information
becomes available. Suggestions or changes should be
addressed to the author. Thank you…
NCPA/DIPP 2006
3
Acknowledgments
North Carolina Psychological Association
Practice Directorate of the American
Psychological Association (APA)
American Medical Association (AMA) CPT Staff
National Academy of Neuropsychology (NAN)
Department of Psychology, UNC-Wilmington
Division of Clinical Neuropsychology- APA
Center for Medicare & Medicaid ServicesMedical
Policy Staff- Medicare
Inter-Divisional Health Care Committee- APA
Selected Individuals (e.g., Jim Georgoulakis; Neil
Pliskin, Ted Peck; Research Team and Clinical Staff)
NCPA/DIPP 2006
4
Specific Support Provided by Primary
Organizations
APA = All expenses paid for travel associated with
CPT activities
NAN = (from PAIO budget) applied to UNCW
activities
2002-2004 = $10,000 per year – one course for two
semesters teaching reduction
2005 = $5,000 per year – one course for one semester
teaching reduction
2006 = $25,000 per year – in negotiation
UNCW = Time off plus incidentals such as copying,
telephone calls, and secretarial support
NCPA/DIPP 2006
5
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,
NCPA/DIPP 2006
e = election)
6
Primary Goals of
Presentation
Understand the Role of Medicare in Setting Standards for
Neuropsychology
Understand the AMA Current Procedural Terminology
(CPT) for Coding of Professional Services
Introduce the New Testing and Interview Codes
Suggest a Model System for Coding
Provide Suggestions for Documentation
Explain the Concept of Fraud Versus Errors
Explain Potential Problems & Trajectory for 2006
NCPA/DIPP 2006
7
Outline of Presentation
I. Medicare
II. Current Procedural Terminology
III. Problems & Possible Solutions
IV. Predictions for the Future
V. Resources
NCPA/DIPP 2006
8
I. Medicare: Why
The Standard for Universal Health Care:
Coding (what can be done)
Value (how much it will be paid)
Documentation (what needs to be said)
Auditing (determination of whether it occurred)
As a Consequence, the Benchmark for:
Workers Compensation
Forensic Work
Sports & Industrial Applications
NCPA/DIPP 2006
9
Medicare: Overview
Centers for Medicare and Medicaid
Services
Benefits
Part A (Hospital)
Part B (Supplementary)
Part C (Medicare+ Choice)
New Pharmaceutical Benefit
NCPA/DIPP 2006
10
Medicare: Local Review
Local Medical Review Policy (LMRP)
National Policy Sets Overall Model
LMRP Sets Local/Regional Policy
More restrictive than national policy
Over-rides national policy
Changes frequently without warning or publicity
Information best found on respective web pages
NCPA/DIPP 2006
11
III. Current Procedural
Terminology (CPT):
Overview
Background
Codes & Coding
Existing Codes
Model System X Type of Problem
Medical Necessity
Documenting
Time
NCPA/DIPP 2006
12
CPT: Background
American Medical Association
Developed by Surgeons (& Physicians) in
1966 for Billing Purposes
7,500+ Discrete Codes
CPT Meets a Minimum of 4 Times/Year
Center for Medicare & Medicaid Services
AMA Under License by CMS
CMS Now Provides Active Input into CPT
NCPA/DIPP 2006
13
CPT:
Background/Direction
Current System = CPT 5
Categories
I= Standard Coding for Professional Services
II = Performance Measurement
III = Emerging Technology
NCPA/DIPP 2006
14
CPT: Composition
AMA House of Delegates
HCPAC
109 Medical Specialties
11 Allied Health 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
NCPA/DIPP 2006
15
CPT: Theory
Order of Value - Personnel
Surgeons, Physicians, Doctorate Level Allied
Health, Non-Doctorate Level Allied Health
Order of Value - Costs
Cognitive Work, Expense, Malpractice
NCPA/DIPP 2006
16
What Is a CPT Code?
A Coding System Developed by AMA in
Conjunction with AMA
Each Code has a Reimbursable Value
Professional Health Service Provided Across the
Country at Multiple Locations
Many “Physicians” or “Qualified Health
Professional” Perform Services
Clinical Efficacy is Established and Documented
in Peer-Reviewed Literature
NCPA/DIPP 2006
17
CPT: Applicable Codes
Total Possible Codes = Approximately 7,500
Possible Codes for Psychology = Approximately
40 to 60
Sections = Five Primary Separate Sections
Psychiatry
Biofeedback
Central Nervous Assessment
Physical Medicine & Rehabilitation
Health & Behavior Assessment & Management
Possibility of Evaluation and Management
NCPA/DIPP 2006
18
CPT: Development of a
Code
Initial
Primary
Health Care Advisory Committee (non-MDs)
CPT Work Group (selected organizations)
CPT Panel (all specialties)
Time Frame
3-5 years to well over a decade
NCPA/DIPP 2006
19
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
NCPA/DIPP 2006
20
CPT: CNS Assessment
Until 12.31.05
Interview
96115
Testing
Psychological = 96100; 96110/11
Neuropsychological = 96117
Aphasia = 96105
Developmental = 96110/111
NCPA/DIPP 2006
21
Rationale for CPT
Changes:
CNS Assessment Codes
Rationale for Changes
Avoidance of Continuation of Reimbursement Strictly
Based on Practice Expense
Greater Clarity of Professional and Non-Professional
Activities
Potential catastrophe in terms of reimbursement
Recognition of cognitive work for testing codes
Differentiation of professional, technical and computer
activity
Accounting/auditing, research, and salary purposes
Recognition of “Physician” Work
Ending over a 10 year struggle
NCPA/DIPP 2006
22
CPT Changes:
CNS Assessment Codes Timetable
Activity x Date
Codes Without Cognitive Work Obtained, 1994
Initial Request for Practice Expense by APA, Summer, 2002
APA Appeared Before AMA RUC, September, 2003
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
Inclusion in the 2006 Physician Fee Schedule on January 1, 2006
NCPA/DIPP 2006
23
CPT: CNS Assessment
Effective 01.01.06 (no grace period)
Psychological Testing
Neurobehavioral Status Exam
Three New Codes
New Numbers & Descriptors
New Number & Revised Descriptor
Neuropsychological Testing
Three New Codes
New Numbers & Descriptors
NCPA/DIPP 2006
24
Psychological Testing:
By Professional
96101 –Psychological Testing
Psychodiagnostic assessment of emotionality,
intellectual abilities, personality and
psychopathology, e.g., MMPI, Rorschach,
WAIS (per hour of psychologist’s or
physician’s time, both face-to-face time with
the patient and time interpreting test results
and preparing the report)
NCPA/DIPP 2006
25
Psychological Testing:
By Technician
96102- Psychological Testing
Psychodiagnostic assessment of emotionality,
intellectual abilities, personality and
psychopathology (e.g., MMPI, Rorschach,
WAIS) with qualified health care professional
interpretation and report, administered by
technician, per hour of technician time,
face-to-face
NCPA/DIPP 2006
26
Psychological Testing:
By Computer
96103 - Psychological Testing
Psychodiagnostic assessment of emotionality,
intellectual abilities, personality and
psychopathology, (e.g., MMPI) administered
by a computer, with qualified health
professional interpretation and the report
NCPA/DIPP 2006
27
Neurobehavioral Status Exam
96116 - Neurobehavioral status exam
Clinical assessment of thinking, reasoning and
judgment ( e.g., acquired knowledge,
attention, language, memory, planning and
problem solving, and visual-spatial abilities)
per hour of psychologist’s or physician’s
time, both face-to-face time with the patient
and time interpreting test results and
preparing the report
NCPA/DIPP 2006
28
Neuropsychological TestingBy Professional
96118 - Neuropsychological testing
(e.g., Halstead-Reitan Neuropsychological,
WMS, Wisconsin Card Sorting) per hour of the
psychologist’s or physician’s time, both
face-to-face time with the patient and time
interpreting test results and preparing the
report
NCPA/DIPP 2006
29
Neuropsychological Testing:
By Technician
96119 - Neuropsychological testing
(e.g., Halstead-Reitan Neuropsychological,
WMS, Wisconsin Card Sorting) with qualified
health care professional interpretation and
report, administered by a technician per
hour of technician time, face-to-face
NCPA/DIPP 2006
30
Neuropsychological TestingBy Computer
96120 - Neuropsychological testing
(e.g., WCST) administered by a computer
with qualified health care professional
interpretation and the report
NCPA/DIPP 2006
31
CNS Assessment Examples
Neurobehavioral Status with
Neuropsychological Testing
Interview by Professional
Testing by
Professional, and/or
Technician, and/or
Computer.
Interpretation & Report Writing by Qualified
Health Professional
NCPA/DIPP 2006
32
CPT: Physical Medicine
& Rehabilitation
97770 now 97532
Note: 15 minute increments
NCPA/DIPP 2006
33
CPT: Cognitive Rehabilitation
Application Rationale
Allied Health & Physical Medicine Code
Acceptability
GN – Speech Therapists
GO – Occupational Therapists
GP – Physical Therapists
AH – Mental Health (not applicable)
NCPA/DIPP 2006
34
CPT: Health & Behavior
Assessment &
Management
(CPT Assistant, 03.04)
(CPT Assistant, 08.05, 15, #6, 10)
Purpose: Medical Diagnosis
Time: 15 Minute Increments
Assessment
Intervention
NCPA/DIPP 2006
35
History of H & B Codes
Inter-divisional Health Care Committee of APA (22, 38,
40, 54; Glueckauf, chair)
Convened in 1995 by APA PD (Phelps)
First draft 09.11.98; Working draft 07.01.00
First AMA presentation 11.06.98; Final 08.08.00 (Ft.
Lauderdale, Chicago, Denver, San Fransisco, Washington,
Chicago, Chicago)
First survey 01.31.01; Final survey 04.26.01
Revisions to language –
First preamble 03.02
Last preamble 11.04
NCPA/DIPP 2006
36
Overview of H & B Codes
Codes Effective as 01.01.2002
Assessment
Intervention
Established Medical Illness or Diagnosis
Focus on Biopsychosocial Factors
NCPA/DIPP 2006
37
H & B: Rationale
Acute or Chronic Health Illness
Not Applicable to Psychiatric Illness
However, Both Could be Treated
Simultaneously
NCPA/DIPP 2006
38
H & B: Examples of Service
Symptom Management & Expression
Patient Adherence to Medical Treatment
Health Promoting Behaviors
Overall Adjustment to Medical Illness
NCPA/DIPP 2006
39
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
NCPA/DIPP 2006
40
H & B: Assessment Explanation
Identification of Psychological, Behavioral,
Emotional, Cognitive and/or Social Factors
In the Prevention, Treatment and/or
Management of Physical Health Problems
Focus on Biopsychosocial and not Mental
Health Factors
NCPA/DIPP 2006
41
H & B: Assessment Examples
Health-Focused Clinical Interview
Behavioral Observations
Psychophysiological Monitoring
Health-Oriented Questionnnaires
NCPA/DIPP 2006
42
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 (limited acceptability)
family (without the patient present; not being reimbursed)
NCPA/DIPP 2006
43
H & B: 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
NCPA/DIPP 2006
44
H & B: Intervention Examples
Cognitive
Behavioral
Social
Psychophysiological
NCPA/DIPP 2006
45
H & B: Diagnoses
Associated with an Acute or Chronic
Medical Illness
Not Applicable to Psychiatric Diagnoses
NCPA/DIPP 2006
46
CPT: Model System
Psychiatric
Neurological
Non-Neurological Medical
NCPA/DIPP 2006
47
CPT Model
Rationale for CPT Code:
Choose Code that Best Describes the Service
Match the Interview with the Testing with the
Intervention Code with the Diagnosis
Goal = Uniformity and Fluency
NCPA/DIPP 2006
48
CPT: Psychiatric Model
(Children & Adult)
Interview
Testing
90801- adult
90802- child
96101-03
Also, 96111 for children
Intervention
e.g., 90806- adult
e.g., 90820-child
NCPA/DIPP 2006
49
CPT: Neurological
Model
(Children & Adult)
Interview
Testing
96116
96118/19/20
Intervention
97532
NCPA/DIPP 2006
50
CPT: Non-Neurological
Medical Model
(Children & Adult)
Interview & Assessment
96150 (initial)
96151 (re-evaluation)
Intervention
96152
96153
96154
96155
(individual)
(group)
(family with patient)
(familyNCPA/DIPP
without
2006 patient)
51
Alternative CPT Codes
(probably reimbursable)
Developmental Testing Codes
Target
Children
Applicable Codes
96110 - Brief
Continues to have no work value
Use for completion of forms (Connors; by parents)
96111 - Extended
Has physician work value
Assessment of child’s social, emotional status (WJ)
NCPA/DIPP 2006
52
Alternative CPT Codes
(probably not reimbursable)
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
0074T – Online evaluation and management
Evaluation and management codes
NCPA/DIPP 2006
53
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
NCPA/DIPP 2006
54
Currently Debated Issues
Associated with CCI
90801 and 96115
ReasoningSimilar to Medicine
Cannot perform two procedures for same illness
and be reimbursed for both
Reimbursed for most complex
H & M and Psychiatric Diagnoses
Psychiatric Procedures nor Diagnoses can be
used at the same time
NCPA/DIPP 2006
55
CPT: Diagnosing
Psychiatric
DSM
The problem with DSM and neuropsych testing of
developmentally-related neurological problems
Neurological & Non-Neurological Medical
ICD – 9 CM (physical diagnosis coding)
www.cdc.gov/nchs/about/otheract/icd9
NCPA/DIPP 2006
56
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 Evaluations Do Not
Meet Criteria for Necessity
Will Results Affect Outcome of Patient?
Will New Information Be Obtained?
NCPA/DIPP 2006
57
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
NCPA/DIPP 2006
58
CPT: Documenting
Purpose
Payer Requirements
General Principles
History
Examination
Decision Making
NCPA/DIPP 2006
59
Documentation: Purpose
Medical Necessity
Evaluate and Plan for Treatment
Communication and Continuity of Care
Claims Review and Payment
Research and Education
NCPA/DIPP 2006
60
Documentation: Payer
Requirements
Site of Service
Medical Necessity for Service Provided
Appropriate Reporting of Activity
NCPA/DIPP 2006
61
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
NCPA/DIPP 2006
62
Documentation: Basic
Information Across
Codes
Date
Time, if applicable
Identify of Observer (technician ?)
Reason for Service
Status
Procedure
Results/Finding
Impression/Diagnoses
Disposition
Stand Alone
NCPA/DIPP 2006
63
Documentation:
Chief Complaint
Concise Statement Describing the
Symptom, Problem, Condition, &
Diagnosis
Foundation for Medical Necessity
Must be Complete & Exhaustive
NCPA/DIPP 2006
64
Documentation:
Present Illness
Symptoms
Location, Quality, Severity, Duration, timing,
Context, Modifying Factors Associated Signs
Follow-up
Changes in Condition
Compliance
NCPA/DIPP 2006
65
Documentation: History
Past
Family
Social
Medical/Psychological
NCPA/DIPP 2006
66
Documentation:
Assessment
Reason for Service
Dates (amount of service time?)
Tests and Protocols (included editions)
Narrative of Results
Impression
Disposition
NCPA/DIPP 2006
67
Documentation: Intervention
Reason for Service
Status of Patient
Intervention Performed
Results Obtained
Impression or Diagnosis (es)
Disposition
Time
NCPA/DIPP 2006
68
Documentation: Time
(CPT Assistant, 08.05, 15, #8, pg. 12)
(www.cms.hhs.gov/providers/therapy)
For Timed Codes (in physical medicine):
The Beginning and Ending Time Should be
Documented
Time Should be Documented Along with
the Treatment Description
NCPA/DIPP 2006
69
CPT X Report
Each CPT Code Should Generate a
Separate Report
Alternatively, Clearly Label/Title Sections
of the Report to Match Codes Used
NCPA/DIPP 2006
70
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
NCPA/DIPP 2006
71
Time
Defining
Professional (not patient) Time Including:
Interview & Assessment Codes
pre, intra & post-clinical service activities
Use 15 or 60 minute increments, as applicable
Intervention Codes
Use 15, 30, 60 or 90 minute increments, as
applicable
NCPA/DIPP 2006
72
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.
NCPA/DIPP 2006
73
Time (continued)
Communicating further with others
Follow-up with patient, family, and/or
others
Arranging for ancillary and/or other
services
NCPA/DIPP 2006
74
Time: Testing
Quantifying Time
Round up or down to nearest increment
Time Does Not Include
Patient completing tests, scales, forms, etc.
Waiting time by patient
Typing of reports
Non-Professional (e.g., clerical) time
Literature searches, learning new techniques, etc.
NCPA/DIPP 2006
75
Time: Physical Medicine Codes
(effective 07.01.05)
Physical Medicine Codes are in 15’
Increments
Multiple Units Can Be Billed on a Date of
Service for Same or Different Procedures
“A substantial amount portion of 15
minutes must be spent in performing the
pre, intra, and post-service work…”
NCPA/DIPP 2006
76
Time: Defining 15 Minutes
(from CPT Assistant, 08.05, 11-12)
(www.cms.hhs.gov/manuals/104_claims/clm104c05.pdf)
Defining 15 Minute Increments
Units
1
2
3
4
5
6
7
8
Over 2 hours
Amount of Minutes
>08; <23
>22; <38
>38; <53
>53; <68
>68; <83
>83; <98
>98; <113
>113;<128
similar pattern as above
NCPA/DIPP 2006
77
Reimbursement History
Cost Plus
Prospective Payment System (PPS)
Diagnostic Related Groups (DRGs)
Customary, Prevailing & Reasonable (CPR)
Resource Based Relative Value System
(RBRVS)
Note: On average, insurance companies
will pay approximate 75% of its income)
NCPA/DIPP 2006
78
Relative Value Units:
Overview
Components
Units
Values
Current Problems
NCPA/DIPP 2006
79
RVU: Components
Physician Work Resource Value
Practice Expense Resource Value
Malpractice
Geographic
Conversion Factor (approx. $37.8975
02.2005)
NCPA/DIPP 2006
80
RVU Components
Percentages
Physician Work
=
Practice Expense =
Liability
=
52%
44%
4%
NCPA/DIPP 2006
81
Defining Physician Work
Clinical Work
Mental Effort and Judgment
Technical Skill/Physical Effort
Psychological Stress
NCPA/DIPP 2006
82
Estimate of Psychologists’
Value
Audiologist
Dietician
RN
Speech Pathologist
.52
.43
.42
.55
Psychologist
.82
NCPA/DIPP 2006
83
Defining Practice Expense
Constitutes 43% of Medicare Payments
Components of Practice Expense
Clinical non-physician labor (43 categories)
RN/LPN/MTA = $.37/minute ( $37,440/year)
Medical disposable supplies (842 items)
Equipment (553 items)
NCPA/DIPP 2006
84
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)
NCPA/DIPP 2006
85
RVU: Acceptance
Medicare (100% since 01.01.92)
Medicaid = 100%
Private Payors = 74% and increasing to 95%
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
NCPA/DIPP 2006
86
2006 RVU Changes
(CPT Assistant, January, 2006, 16, 1)
283 RVU Changes Submitted
Medicare Accepted 97%
Professional Liability to Change to 1.00
Geographic Index is Revised Every 3 yrs.
NCPA/DIPP 2006
87
CPT x RVU
Pre 2006
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
NCPA/DIPP 2006
88
National RVU 2006 Values
op=outpatient, ip=inpatient, est=estimate
Code #
OP RVU
IP RVU
OP $ est
96101
96102
96103
96116
96118
96119
96120
2.56
1.17
0.74
2.87
3.43
1.75
1.27
2.54
0.68
0.70
2.68
2.67
0.92
0.70
92.61
42.33
26.77
103.83
124.09
63.31
45.94
NCPA/DIPP 2006
IN $est
91.89
24.60
25.32
96.95
96.59
33.28
25.32
89
CIGNA Medicare Part B
2006 Fee Schedule
(participating provider)
Code #
96101
96102
96103
96116
96118
96119
96120
OP $
IP $
90.08
40.29
25.90
99.08
117.72
58.01
43.54
89.42
23.09
24.57
92.76
92.42
30.39
24.57
NCPA/DIPP 2006
90
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
NCPA/DIPP 2006
91
Unique Physician Identification
Number (UPIN)
Historical
UPIN #
Box 17 a CMS (insurance) 1500 form
Present
National Provide Identification Number
NCPA/DIPP 2006
92
National Provider Identification
Number (CMS memo, 45 CFR Part 16c)
Basic Information
Dates
10 Position numeric & individual number
No specific information about provider
Managed by CMS’s Provider System
May 23, 2005 – Apply
May 23, 2007 – Most entities will use
May 23, 2008 – All entities will use
Applicability
Federal plans – immediately
State plans – this year
Other health plans- as soon as feasible
NCPA/DIPP 2006
93
Place of Service
#
Location
11
Doctor’s Office
12
Patient’s Home
21
Inpatient Hospital
22
Outpatient Hospital
31
Skilled Nursing Facility
32
Nursing Facility
33
Custodial Care Facility
56
Psychiatric Residential
61
Inpatient Rehabilitation 94
NCPA/DIPP 2006
IV. Continuing
Problems
Supervision vs Incident to
Technicians
Time
Payment
Fraud & Abuse
NCPA/DIPP 2006
95
Supervision
( Federal Register, 69, #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
NCPA/DIPP 2006
96
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
NCPA/DIPP 2006
97
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
NCPA/DIPP 2006
98
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
Probably no Future to Incident to
NCPA/DIPP 2006
99
Problem: Defining Incident to
Definition
Commonly furnished service
Integral, though incidental to psychologist
Performed under direct supervision
Either furnished without charge or as part of
the psychologist’s charge
NCPA/DIPP 2006
100
Problem: More Incident to
When is “Incident to” Acceptable:
Testing - Definite
Cognitive Rehabilitation; Biofeedback Probably
Psychotherapy – Uncertain to Probably Not
NCPA/DIPP 2006
101
Problem: Incident to &
Site of Service
Outpatient vs. Inpatient
Geographical Location- Separate
Corporate Entities- Separate
Billing Service- Separate
Chart Information & Location- Separate
NCPA/DIPP 2006
102
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
NCPA/DIPP 2006
103
Problems:
Difficulties with
Incident to
The Physician Must Evaluate and/or
Treat the Patient First
No Clear Guidelines Regarding
Reasonable Mix of Physician to
Extender?
What are the Limits of the Extender?
NCPA/DIPP 2006
104
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)
“Incident to”
NCPA/DIPP 2006
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
105
The Future of Incident to vs.
Supervision
Incident to
Intervention
Testing
Technical Interventions such as biofeedback and cognitive
rehabilitation
None , if technical codes accepted
If not, presumably it can continue
Supervision
Regardless, some form of supervision required if a
technician is used
NCPA/DIPP 2006
106
Problem: Defining a
Technician
What is the Minimum Level of Training
Required for a Technician?
National Association of Psychometrists
NAN Position Paper
Level of Education- Probably a minimum of
Bachelors
Level of Training
Level of Supervision
NCPA/DIPP 2006
107
Problem: Defining a Technician
(Federal Register, Vol. 66, #149, page 40382)
Requirement
Employee (e.g., 1099)
Common Practice
Independent Contractor
NCPA/DIPP 2006
108
Problem: Defining a Technician
HCFA/CMS Line 25
This is the line that identifies in a common insurance
form who is the “qualified health provider” that is
responsible for and completing the service
Anybody else, from high school to post-doctoral
fellow, is, for all practical purposes, a technician
Extern, Intern, Postdoctoral Fellow, Technician
NCPA/DIPP 2006
109
Problem: Acceptance of Technicians
Medicare
Outside of North Central & California, yes
In North Carolina, use the “AH” modifier
Private Carriers
Magellan – yes
Others – not accepting the code
NCPA/DIPP 2006
110
Problem: Uses of Technicians
The Qualified Health Provider must;
See the patient first
Supervise the activity
Interpret and write the note/report
Engaged in an ongoing capacity
NCPA/DIPP 2006
111
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
NCPA/DIPP 2006
112
Problem:
Payment
Medicare
Pending 4.4% cut
Other Carriers
Non-Equitable % of RVU payment
NCPA/DIPP 2006
113
Payment: National Coverage Policy
Services That Are Not Reasonable and
Necessary for the Diagnosing and
Treatment of an Illness or Injury
Screening Services, in the Absence of
Symptoms or History of Disease are
Denied
NCPA/DIPP 2006
114
Payment in Skilled Nursing Facilities
(CMS Manual, Pub. 100-04; #449; 01.21.05;
Effective Date 04.01.05)
Healthcare Common Procedure Coding
System (HCPCS)
Subject to consolidated billing under SNF
Prospective Payment System
Applies to physical, occupational and speech
therapy ONLY
NCPA/DIPP 2006
115
CMS Determination of Coverage
Coverage Types
Coverage with Conditions (specific DX, facility or provider)
Coverage without Conditions
Data Reviewed
Benefit
Risks Vs. Benefits
Available Clinical Studies
Databases
Longitudinal or cohort studies
Prospective studies
Randomized clinical trials
NCPA/DIPP 2006
116
Problem: Payment
Evolution of Compensation
Gross Charges
Adjusted Charges
RVUs
Receivables
NCPA/DIPP 2006
117
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
NCPA/DIPP 2006
118
Problem: Office of Inspector
General (2005 Orange Book)
Identify Nursing Home Residents with
Serious Mental Illness (OEI-05-99-00701
Improve Assessments of Mental Illness
(OEI-05-99-00700)
Eliminate Inappropriate Payments for
Mental Health Services
NCPA/DIPP 2006
119
Problem: Expenditures &
Fraud
Projections
Current
14%
By 2011;
17% ($2.8 trillion)
NCPA/DIPP 2006
120
Fraud: Medicare’s
Interpretation of
Physician Liability
Overpayment From Incorrect Charge
Mathematical or Clerical Error
Billing for Items Known Not to be Covered
Services Provided by Non-qualified
Practitioner
Inappropriate Documentation
NCPA/DIPP 2006
121
Defining Fraud
Fraud
Intentional
Pattern
Error
Clerical
Dates
NCPA/DIPP 2006
122
Problem: Fraud &
Abuse
26 Different Kinds of Fraud Types
Psychology Only Professional Group
Identified by OIG for Closer Scrutiny in
2005-2006
NCPA/DIPP 2006
123
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 NCPA/DIPP 2006
124
Problem: Fraud (cont.)
Nursing Homes
Identification
Overuse of Services
Children
NCPA/DIPP 2006
125
Fraud: OIG’s May 2001 Study
(OEI-03-99-00130)
Overall Payments in 1998 = $1.2 billion
(62% outpatient = $718 million)
Inappropriate Outpatient Mental Health
“Particulary Problematic” due to
Medically unnecessary
Billed incorrectly
Rendered by unqualified providers
Undocumented or poorly documented
NCPA/DIPP 2006
126
OIG Report (continued)
Provider Not Qualified
Medically Unnecessary
Billed Incorrectly
Insufficient Documentation
NCPA/DIPP 2006
=
=
=
=
11%
23%
41%
65%
127
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
Research Grants and, if applicable, Clinical Trials
NCPA/DIPP 2006
128
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?
NCPA/DIPP 2006
129
Fraud: CERT Program
(www.oig.hhs.gov)
Comprehensive Error Rate Testing Program
National
Contractor-specific
Service-specific
Reviews both denied and accepted claims
An initial written request is followed by 4 letters and 3
phone calls followed by an overpayment demand
letter and interpreted as services non-rendered
NCPA/DIPP 2006
130
Fraud: New Information
The Good Enough or Common Sense Approach
If Medicare Audit Occurs then an Increased
Likelihood of Medicaid Audit
Sensitive Situations for Potential Audits;
Skilled Nursing Facilities
Statistical Outliers
Testing
Greater audits in general and in particular;
TX, CA, FL, PR
NCPA/DIPP 2006
131
Fraud: Voluntary Compliance
(D. Raisin-Waters, APA, 2005)
Address Risk or Problematic Areas (e.g.,
denied claims)
Develop a Compliance Program (with
designated individual, written plan, etc.)
NCPA/DIPP 2006
132
V. Future Perspectives:
2003
Paradigms
Industrial vs. Boutique/Niche
Clinical vs. Forensic
Mental Health vs. Health
Existing vs. Developing
NCPA/DIPP 2006
133
Future Perspectives:
2004 Continued
Federal
Technical – Health Electronic Records by 2008
Performance Based Payment
Traditionally = Fee for service provided
Anticipated = Fee for performance/results
obtained
Economic
Overall, Positive
NCPA/DIPP 2006
134
Future Perspectives:
2004 Continued
Increased Probability of Audits
Psychological and Neuropsychological Testing
Individual Practitioners
Skilled Nursing Facilities
In Institutions, supervision and “incident to”
Primary Issues of Concern
Medical Necessity
Documentation
NCPA/DIPP 2006
135
Future Perspectives:
2004 Continued
Professional
Institutionally Based
Limitations secondary to “incident to”
Difficulties in gaining access to GME funds
Practitioner Based
Increase in audits
Shifting in practice patterns
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
NCPA/DIPP 2006
136
Future Perspectives:
2005
Medicare
Institutional
Further defining of supervision & incident to
Significantly limited access to funds (e.g., GME)
Individual
4.3-4.6% decrease over next 6 years (compared to 1.5% increase each over the
last 3 years; AAP Advance, Summer, 2005)
Increased focus on business issues
Technician based practice will increase
Continued emphasizes on expanding non-health care services (e.g., forensic)
Practice
Diagnostic work will continue being emphasized (e.g.,fMRI)
Pay-for-Performance or P4P (5-10% differences; Medicare Payment Advisory
Commission, 09.15.05)
WellPoint, WellChoice, HealthNet, MVP Health Care, Blue Cross of California and 32
states (105 programs in mid 2005)
NCPA/DIPP 2006
137
Future Perspectives:
2005
Issues to be Addressed
Final values for work and practice for testing codes
Information dissemination
Colleagues
Third-party insurers/payors
Potential mix of “old” and “new” testing codes for 2006
Typical use of combination of codes
Technician qualifications and training
Use of computerized tests Vs. tests that are computerized but
interactive
Appropriate documentation
Technician identification
Time for testing and therapy
NCPA/DIPP 2006
138
Future Perspectives:
2006
Early Portions of 2006 = Confusion in Use &
Reimbursement of Codes
The Use of Techs
Insurance Carriers Acceptance of Codes
Decreased Revenue Stream
Middle Portions of 2006 = Increased Stabilization in Use
& Reimbursement of Codes
Later Portion of 2006 = Potential Increase in Overall
Reimbursement
By 2007 = Likely and Stable Increase in Reimbursement
Patterns
NCPA/DIPP 2006
139
Mechanisms to Keep Informed
APA Practice Website (www.apa.org)
NAN Website (www.nanonline.org)
NCPA Website (www.ncpsychology.org)
NCPA/DIPP 2006
140
V. Resources
General Web Sites
www.apa.org
www.nanonline.org/paio
www.ncpsychology.org
www.cms.org (medicare/medicaid)
www.hhs.org (health & human services)
www.oig.hhs.gov (inspector general)
www.apa.org/practice/cpt (apa’s cpt information)
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.napnet.org (national association of psychometrists)
www.access.gpo.gov (federal statutes and regulations)
www.healthcare.group.com (staff salaries)
NCPA/DIPP 2006
141
Resources (continued)
Payment/Coverage
LMRP Reconsideration Process
www.myhealthscore.com/consumer/phyoutcptsearch.htm
www.cms.hhs.gov/statistics/feeforservice/defailt.asp (covered services)
www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=167 (non-covered)
www.apa.org/pi/aging/lmrp/toolkit/homepage.html (apa lmrp)
www.cms.hhs.gov/providers/mr/lmrp/asp (medicare lmrp)
www.cms.gov/manuals/pm_trans/R28PIM.pdf
Compliance Web Sites
www.oig.hhs.gov (office of inspector general)
www.cms.hhs.gov/manuals (medicare)
www.uscode.house.gov/usc.htm (united states codes)
www.apa.org (psychologists & hipaa)
www.cms.hhs.gov/hipaa. (hipaa)
www.hcca-info.org (health care compliance assoc.)
NCPA/DIPP 2006
142
Resources
ICD
(continued)
www.who.int/icd/vol1htm2003/fr-icd.htm (who)
www.cdc.gov/nchas/about/otheract/icd9/abticd9.htm
(ccd)
Coding Web Sites
www.catalog.amaassn.org/Catalog/cpt/cpt_search.jsp (ama cpt)
www.aapcnatl.org (academy of coders)
www.ntis.gov/product/correct-coding (coding
edits)
NCPA/DIPP 2006
143
Resources
Telephone Numbers
APA Practice Directorate’s Government
Relations Office; 202.336.5889
AMA CPT Office; 800.621.8335
Medicare National Coverage Determinations;
410.786.2281
NCPA/DIPP 2006
144