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
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Websites
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Univ = www.uncw.edu/people/puente
Practice = www.clinicalneuropsychology.us
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NAN = www.nanonline.org/paio
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E-mail
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University = [email protected]
Practice = [email protected]
Telephone
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University = 910.962.3812
Practice = 910.509.9371
NCPA/DIPP 2006
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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
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Acknowledgments
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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
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Specific Support Provided by Primary
Organizations
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APA = All expenses paid for travel associated with
CPT activities
NAN = (from PAIO budget) applied to UNCW
activities
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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
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Background
(1988 – present)
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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)
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Primary Goals of
Presentation
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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
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Outline of Presentation
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I. Medicare
II. Current Procedural Terminology
III. Problems & Possible Solutions
IV. Predictions for the Future
V. Resources
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I. Medicare: Why
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The Standard for Universal Health Care:
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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:
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Workers Compensation
Forensic Work
Sports & Industrial Applications
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Medicare: Overview
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Centers for Medicare and Medicaid
Services
Benefits
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Part A (Hospital)
Part B (Supplementary)
Part C (Medicare+ Choice)
New Pharmaceutical Benefit
NCPA/DIPP 2006
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Medicare: Local Review

Local Medical Review Policy (LMRP)
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National Policy Sets Overall Model
LMRP Sets Local/Regional Policy
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More restrictive than national policy
Over-rides national policy
Changes frequently without warning or publicity
Information best found on respective web pages
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III. Current Procedural
Terminology (CPT):
Overview
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Background
Codes & Coding
Existing Codes
Model System X Type of Problem
Medical Necessity
Documenting
Time
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CPT: Background
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American Medical Association
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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
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AMA Under License by CMS
CMS Now Provides Active Input into CPT
NCPA/DIPP 2006
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CPT:
Background/Direction
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Current System = CPT 5
Categories
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I= Standard Coding for Professional Services
II = Performance Measurement
III = Emerging Technology
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CPT: Composition
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AMA House of Delegates
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HCPAC
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109 Medical Specialties
11 Allied Health Societies (e.g., APA)
CPT Editorial Panel
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17 Voting Members
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11 Appointed by AMA Board
1 each from BC/BS, AHA, HIAA, CMS
2 HCPAC
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CPT: Theory
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Order of Value - Personnel
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Surgeons, Physicians, Doctorate Level Allied
Health, Non-Doctorate Level Allied Health
Order of Value - Costs
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Cognitive Work, Expense, Malpractice
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What Is a CPT Code?
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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
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CPT: Applicable Codes
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Total Possible Codes = Approximately 7,500
Possible Codes for Psychology = Approximately
40 to 60
Sections = Five Primary Separate Sections
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Psychiatry
Biofeedback
Central Nervous Assessment
Physical Medicine & Rehabilitation
Health & Behavior Assessment & Management
Possibility of Evaluation and Management
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CPT: Development of a
Code
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Initial
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Primary
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Health Care Advisory Committee (non-MDs)
CPT Work Group (selected organizations)
CPT Panel (all specialties)
Time Frame
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3-5 years to well over a decade
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CPT: Psychiatry
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Sections
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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
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CPT: CNS Assessment
Until 12.31.05

Interview
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96115
Testing
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Psychological = 96100; 96110/11
Neuropsychological = 96117
Aphasia = 96105
Developmental = 96110/111
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Rationale for CPT
Changes:
CNS Assessment Codes
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Rationale for Changes
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Avoidance of Continuation of Reimbursement Strictly
Based on Practice Expense
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Greater Clarity of Professional and Non-Professional
Activities
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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
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CPT Changes:
CNS Assessment Codes Timetable
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Activity x Date
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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
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CPT: CNS Assessment
Effective 01.01.06 (no grace period)

Psychological Testing
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Neurobehavioral Status Exam
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Three New Codes
New Numbers & Descriptors
New Number & Revised Descriptor
Neuropsychological Testing
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Three New Codes
New Numbers & Descriptors
NCPA/DIPP 2006
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Psychological Testing:
By Professional

96101 –Psychological Testing
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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
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Psychological Testing:
By Technician
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96102- Psychological Testing
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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
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Psychological Testing:
By Computer
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96103 - Psychological Testing
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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
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Neurobehavioral Status Exam

96116 - Neurobehavioral status exam
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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
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Neuropsychological TestingBy Professional
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96118 - Neuropsychological testing
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(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
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Neuropsychological Testing:
By Technician
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96119 - Neuropsychological testing
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(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
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Neuropsychological TestingBy Computer
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96120 - Neuropsychological testing
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(e.g., WCST) administered by a computer
with qualified health care professional
interpretation and the report
NCPA/DIPP 2006
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CNS Assessment Examples
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Neurobehavioral Status with
Neuropsychological Testing
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Interview by Professional
Testing by
Professional, and/or
 Technician, and/or
 Computer.
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Interpretation & Report Writing by Qualified
Health Professional
NCPA/DIPP 2006
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CPT: Physical Medicine
& Rehabilitation
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97770 now 97532
Note: 15 minute increments
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CPT: Cognitive Rehabilitation
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Application Rationale
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Allied Health & Physical Medicine Code
Acceptability
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GN – Speech Therapists
GO – Occupational Therapists
GP – Physical Therapists
AH – Mental Health (not applicable)
NCPA/DIPP 2006
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CPT: Health & Behavior
Assessment &
Management
(CPT Assistant, 03.04)
(CPT Assistant, 08.05, 15, #6, 10)
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Purpose: Medical Diagnosis
Time: 15 Minute Increments
Assessment
Intervention
NCPA/DIPP 2006
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History of H & B Codes
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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 –
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First preamble 03.02
Last preamble 11.04
NCPA/DIPP 2006
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Overview of H & B Codes
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Codes Effective as 01.01.2002
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Assessment
Intervention
Established Medical Illness or Diagnosis
Focus on Biopsychosocial Factors
NCPA/DIPP 2006
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H & B: Rationale
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Acute or Chronic Health Illness
Not Applicable to Psychiatric Illness
However, Both Could be Treated
Simultaneously
NCPA/DIPP 2006
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H & B: Examples of Service
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Symptom Management & Expression
Patient Adherence to Medical Treatment
Health Promoting Behaviors
Overall Adjustment to Medical Illness
NCPA/DIPP 2006
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Health & Behavior
Assessment Codes
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96150
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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
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re-assessment
NCPA/DIPP 2006
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H & B: Assessment Explanation
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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
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H & B: Assessment Examples
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Health-Focused Clinical Interview
Behavioral Observations
Psychophysiological Monitoring
Health-Oriented Questionnnaires
NCPA/DIPP 2006
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Health & Behavior
Intervention Codes
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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
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H & B: Intervention Explanation
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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
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H & B: Intervention Examples
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Cognitive
Behavioral
Social
Psychophysiological
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H & B: Diagnoses
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Associated with an Acute or Chronic
Medical Illness
Not Applicable to Psychiatric Diagnoses
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CPT: Model System
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Psychiatric
Neurological
Non-Neurological Medical
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CPT Model
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Rationale for CPT Code:
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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
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CPT: Psychiatric Model
(Children & Adult)
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Interview
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Testing
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90801- adult
90802- child
96101-03
Also, 96111 for children
Intervention
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e.g., 90806- adult
e.g., 90820-child
NCPA/DIPP 2006
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CPT: Neurological
Model
(Children & Adult)
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Interview
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Testing
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96116
96118/19/20
Intervention
 97532
NCPA/DIPP 2006
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CPT: Non-Neurological
Medical Model
(Children & Adult)
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Interview & Assessment
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96150 (initial)
96151 (re-evaluation)
Intervention
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96152
96153
96154
96155
(individual)
(group)
(family with patient)
(familyNCPA/DIPP
without
2006 patient)
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Alternative CPT Codes
(probably reimbursable)
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Developmental Testing Codes
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Target
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Children
Applicable Codes
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96110 - Brief
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Continues to have no work value
Use for completion of forms (Connors; by parents)
96111 - Extended
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Has physician work value
Assessment of child’s social, emotional status (WJ)
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Alternative CPT Codes
(probably not reimbursable)
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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
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CPT: Correct Coding
Initiative
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Purpose
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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
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Automatic edits
NCPA/DIPP 2006
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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

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H & M and Psychiatric Diagnoses
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Psychiatric Procedures nor Diagnoses can be
used at the same time
NCPA/DIPP 2006
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CPT: Diagnosing

Psychiatric

DSM
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The problem with DSM and neuropsych testing of
developmentally-related neurological problems
Neurological & Non-Neurological Medical
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ICD – 9 CM (physical diagnosis coding)
www.cdc.gov/nchs/about/otheract/icd9
NCPA/DIPP 2006
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CPT: Medical Necessity
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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
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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;
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
Diagnosis
Symptoms
NCPA/DIPP 2006
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CPT: Documenting

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Purpose
Payer Requirements
General Principles
History
Examination
Decision Making
NCPA/DIPP 2006
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Documentation: Purpose
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Medical Necessity
Evaluate and Plan for Treatment
Communication and Continuity of Care
Claims Review and Payment
Research and Education
NCPA/DIPP 2006
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Documentation: Payer
Requirements
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
Site of Service
Medical Necessity for Service Provided
Appropriate Reporting of Activity
NCPA/DIPP 2006
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Documentation:
General Principles
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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
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Documentation: Basic
Information Across
Codes
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
Date
Time, if applicable
Identify of Observer (technician ?)
Reason for Service
Status
Procedure
Results/Finding
Impression/Diagnoses
Disposition
Stand Alone
NCPA/DIPP 2006
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Documentation:
Chief Complaint

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
Concise Statement Describing the
Symptom, Problem, Condition, &
Diagnosis
Foundation for Medical Necessity
Must be Complete & Exhaustive
NCPA/DIPP 2006
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Documentation:
Present Illness

Symptoms


Location, Quality, Severity, Duration, timing,
Context, Modifying Factors Associated Signs
Follow-up


Changes in Condition
Compliance
NCPA/DIPP 2006
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Documentation: History




Past
Family
Social
Medical/Psychological
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Documentation:
Assessment






Reason for Service
Dates (amount of service time?)
Tests and Protocols (included editions)
Narrative of Results
Impression
Disposition
NCPA/DIPP 2006
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Documentation: Intervention







Reason for Service
Status of Patient
Intervention Performed
Results Obtained
Impression or Diagnosis (es)
Disposition
Time
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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
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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
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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
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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)
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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.)
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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)
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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

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