Transcript Reimbursement for Neuropsychological Services: Major

Reimbursement for
Neuropsychological
Services:
Major Changes
In Third Party Interfaces
for 2004-2005
National Academy of Neuropsychology
Seattle, Washington
November 17, 2004
Outline
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Acknowledgements
Background
Fraud & Abuse Issues
Identification Numbers
Supervision Changes and “Incident to”
CPT Changes
Background
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Assumptions
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Knowledge of CPT System; expansion of prior
NAN presentations
Medicare is benchmark for all of health care
and, indirectly, for other neuropsychological
applications including forensic ones
Background information found;
Current - www.nanonline.org (paio web page)
 Revision to be posted by 12.01.04 (same location)
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CPT Model System
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Psychiatric
Neurological
General Medical
CPT: Psychiatric
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Interview
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Testing
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90801
96100
Intervention
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e.g., 90806
CPT: Neurological
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Interview
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Testing
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96115
96117
Intervention
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97532
CPT: General Medical
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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)
(family without patient; not being reimburfsed)
CPT: Diagnosing
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Psychiatric CPT Codes = DSM
Other CPT Codes
= ICD
Continued Expansion of
Audits
(Office of Inspector General; Red Book)
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Increase from Last Year
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Major Applicable Areas
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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
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Medical Necessity
Documentation
Unique Physician
Identification Number:
Who You Are
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Currently
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UPIN #
Entered in Box 17 a of CMS 1500 form
Starting 2005
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National Provider Identification Number
National Provider
Identifier
January 23, 2004
45 CFR Part 16c
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Basic Information
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Dates
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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
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All federal health plans, immediately
All state Medicaid programs, soon
General register for all health plans, thereafter
Supervision
Program Memorandum Carriers
Department of Health and Human Services- HCFA
Transmittal b-01-28; April 19, 2001
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Levels of Supervision
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General
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Direct
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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
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Must be in attendance in the room during the performance of
the procedure
Supervision
Federal Register
Volume 69, No. 150, August 5, 2004, page 47553
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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
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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
Difference Between Supervision
and “Incident to”
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Supervision
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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)
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“Incident to”
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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
Current CPT Problems
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Cognitive Rehabilitation (97532)
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Applied Rationale
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Not Being Accepted by Some Carriers
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Physical Medicine Codes are incorrectly being interpreted as
not being useable by psychologists
AH – Mental Health
Acceptability
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GN = Speech Therapists
GO = Occupational Therapists
GP = Physical Therapists
Recent CPT Changes
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Developmental Testing Codes
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Applicability
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Background
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Children
Part of Central Nervous System family of codes
Hence, no work value (& lower reimbursement rate)
Recently “re-surveyed” by pediatricians
Specific Changes
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96110
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Continues to have no work value
Use for completion of forms (Connors; by parents)
96111
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Has physician work value
Assessment of child’s social, emotional, etc status (WJ)
Recent CPT Changes
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Biofeedback (90911)
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Minor editorial changes in biofeedback
training
Probable CPT Changes :
Health & Behavior Assessment Codes
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Brief History
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Inter-divisional Health Care Committee (22, 38, 40, 54; Glueckauf)
Convened in 1995 by APA Practice Directorate (Phelps)
Drafts
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Presentations
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First Survey January 31, 2001; Final Survey April 26, 2001
Revisions to Language
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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
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First Draft - September 11, 1998; Final Working Draft – July 1, 2000
First Preamble revision – March, 2002; Last Preamble revision – November, 2004
Applicability
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When behavioral, cognitive, emotional, and/or psychological techniques are used
to assess and/or treat health (medical not psychiatric) problems
Probable CPT Changes:
Health & Behavior Assessment Codes
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Acceptability
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All Medicare carriers (minus Florida’s)
Some Medicaid programs (e.g., Colorado, Vermont)
Some private insurers (BC/BS in NC, DC; Nationwide)
Changes
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Preamble
Clarification
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Future Expectation
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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
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December 1, 2004
Applicability starting January 1, 2005
Probable CPT Changes:
CNS Assessment Codes
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Neurobehavioral Status Exam
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Psychological Testing
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Re-write (different language; same concept)
Addition of “Physician” Work Value
Expansion of existing code
Addition of “Physician” Work Value
Neuropsychological Testing
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Expansion of existing code
Addition of “Physician” Work Value
Probable CPT Changes:
CNS Assessment Codes
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Timetable (activity x date)
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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
Probable CPT Changes:
CNS Assessment Codes
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Net Effect
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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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Differentiation of professional, technical and computer activity
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Accounting/auditing, research, and salary purposes
Recognition of “Physician” Work
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Potential catastrophe in terms of reimbursement
Potential reimbursement rates in the vicinity of $40/hr
Ending a 10 year struggle
Possibly, Increased Reimbursement
Anticipated General
Upcoming Changes
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Federal
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(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
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Traditionally = Fee for service provided
Anticipated = Fee for performance/results obtained
Anticipated General
Upcoming Changes
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Economic
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Overall, Positive (maybe 3-5% growth)
Clinical Neuropsychology
Institutionally Based
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Practitioner Based
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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
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Difficulties with battery-based approaches to diagnostics
Expansion and alterations of reimbursement practices
Significant expansion of types of services and clients served
Summary
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Overall-Continued and Significant Changes
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Stabilization and Increase of Reimbursement
Amounts but Not of Reimbursement Practices
Overall, Increase in Recognition, Especially in
General Health (vs. mental health) Sectors
Shifting to Diagnostic and Supervisory
Professional Activities