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
03.04.06
(presented at the National Rehabilitation Hospital, Washington, D.C.)
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Disclaimer

The information contained in this extended
presentation is not intended to reflect APA, NAN
nor Division 40 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, Local Coverage
Determination 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 to2
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the author. Thank you…
Acknowledgments


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
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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)
Division of Clinical Neuropsychology- APA
Center for Medicare & Medicaid Services
Medical Policy Staff- Medicare
Inter-Divisional Health Care Committee- APA
Department of Psychology, UNC-Wilmington
Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted
Peck; AEP Research Team and Clinical Staff)
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Sponsorship

National Academy of Neuropsychology


www.nanonline.org
Division 40 (Clinical Neuropsychology) of
the American Psychological Association

www.div40.org
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In Collaboration With:



Practice Directorate of the American
Psychological Association
Society for Personality Assessment
National Rehabilitation Hospital

NOTE: These collaborations do not mean or imply
an endorsement of this workshop nor of the
information presented in this workshop)
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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 away from university duties (e.g., teaching)
plus incidental support such as copying, telephone calls,
and secretarial and work-study student assistance
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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,
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e = election)
7
Primary Goal & General Outcome
of CPT Work

Goal



Parity with Physicians
Expansion of Scope of Diagnostic Services
Outcome

Intended/Anticipated/Hoped




Similar reimbursement as physician services
General increase in the scope of practice
Greater inclusion into health care system
Less Anticipated



Transparency
Accountability
Uniformity
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Primary Goals of
Presentation



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Understand the Role of Medicare in Setting Standards for
Psychology
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
Address Potential Problems & Trajectory for 2006 and
Beyond
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Outline of Workshop

Part I: Coding, Billing and Documentation
(Introductory)

Part II: Specific Issues with CPT
(Intermediate)

Part III: Projections; Questions & Answers
(Advanced)
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Part I: Coding, Billing &
Documentation
(Introductory)

Part I:



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
Medicare
Current Procedural Terminology
Diagnosing
Medical Necessity
Documentation
Time
Site of Service
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A. 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)
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Medicare: Immediate Impact

As a Consequence, the Benchmark for:


All Commercial Carriers (e.g., HMOs)
As well as;
Workers Compensation
 Forensic Applications
 Related Applications (e.g., industrial, sports)

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Medicare: Long-term Impact




By 2015, Medicare will represent
approximately 50% of all health care
payments in the United States
Eventually, a national (US) health
insurance will be established
One possible model will be to introduce
Medicare to younger citizens will be in age
increments (e.g., 60-64, then 50-59, etc)
Hence, Medicare will come to set the
standard for all of health care
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Medicare: Overview


Centers for Medicare and Medicaid
Services
Benefits




Part
Part
Part
Part
A (Hospital)
B (Supplementary)
C (Medicare+ Choice)
D (Pharmaceutical)
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Medicare: Local Review

Medical Review Policy


National Policy Sets Overall Model
Local Coverage Determination (LCD) 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
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B. Current Procedural
Terminology (CPT):
Overview




Background
Codes & Coding
Existing Codes
Model System X Type of Problem
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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
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CPT:
Background/Direction


Current System = CPT 5
Categories

I= Standard Coding for Professional Services


II = Performance Measurement


Codes of interest
Starting to emerge; will be the future of CPT
III = Emerging Technology

New technology and procedures
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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
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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
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What Is a CPT Code?





A Coding System Developed by AMA in
Conjunction with CMS
Each Code has a Specific Description and 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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Abbreviated CPT Glossary

CPT


Qualified Health Professional



Non-facility = all settings other than a hospital or skilled nursing facility
Units


Anybody else
Facility vs. Non-facility


Who has the contract with the insurance carrier
Defined by training, state and federal statutes/laws/regulations
Technician


Current Procedure Terminology = professional service code
Time based factor which is applied as a multiplier to the RVUs agreed to
by AMA CPT and CMS
Face-to-face

In front of the patient
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CPT Copyright


CPT is Copyrighted by the American
Medical Association
CPT Manuals May be Ordered from the
AMA at 1.800.621.8335
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CPT: Applicable Codes



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
Evaluation and Management
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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
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CPT: Psychiatry

Sections (or Categories)






Interview (90801) vs. Intervention (e.g., 908.06)
These codes are one unit
Office vs. Inpatient
Regular vs. Evaluation & Management
Other
Types of Interventions

Insight, Behavior Modifying, and/or Supportive vs.
Interactive
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CPT: CNS Assessment
Until 12.31.05

Interview


96115
Testing




Psychological = 96100; 96110/11
Neuropsychological = 96117
Aphasia = 96105
Developmental = 96110/111
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Rationale for CPT Changes:
CNS Assessment Codes





Avoidance of Continuation of
Reimbursement Heavily Based on Practice
Expense
Greater Clarification of Activities
Recognition of Cognitive Work
Great Clarity of What Actual is Happening
Differentiation of Professional, Technical
and (non-assisted) Computer Testing
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CPT Changes:
CNS Assessment Codes Timetable

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
CPT Assistant article April, 2006
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CPT: CNS Assessment
Effective 01.01.06 (no grace period)

Psychological Testing (e.g., 5 units)

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Neurobehavioral Status Exam (e.g., 2 units)

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Three New Codes
New Numbers & Descriptors
New Number & Revised Descriptor
Neuropsychological Testing (e.g., 10 units)


Three New Codes
New Numbers & Descriptors
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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)
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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
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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
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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
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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
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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
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Neuropsychological TestingBy Computer

96120 - Neuropsychological testing

(e.g., WCST) administered by a computer
with qualified health care professional
interpretation and the report
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CNS Assessment Examples

Neurobehavioral Status with Neuropsychological Testing
 Interview by the Professional
 Testing by
 Professional, and/or
 Technician, and/or
 Computer.
 Interpretation & Report Writing by Qualified Health
Professional
 A Technician or Computer Code are Typically Billed
Together with a Professional Code (since the final
product should be a comprehensive/integrative
report)
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CPT: Physical Medicine
& Rehabilitation


97770 now 97532
Note: 15 minute increments
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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)
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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
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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 Francisco, Washington,
Chicago, Chicago)
First survey 01.31.01; Final survey 04.26.01
Revisions to language –


First preamble 03.02
Last preamble 11.04
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Overview of H & B Codes

Codes Effective as 01.01.2002
(with ongoing
revisions of language)




Assessment (e.g., 4 units)
Intervention (e.g., up to a total of 48 units)
Established Medical Illness or Diagnosis
Focus on Biopsychosocial Factors
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H & B: Rationale



Acute or Chronic Health Illness
Not Applicable to Psychiatric Illness
However, Both Could be Treated
Simultaneously But Not Within the Same
Session
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H & B: Examples of Service




Symptom Management & Expression
Patient Adherence to Medical Treatment
Health Promoting Behaviors
Overall Adjustment to Medical Illness
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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
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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
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H & B: Assessment Examples




Health-Focused Clinical Interview
Behavioral Observations
Psychophysiological Monitoring
Health-Oriented Questionnaires
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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)
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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
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H & B: Intervention Examples




Cognitive
Behavioral
Social
Psychophysiological
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H & B: Diagnoses


Associated with an Acute or Chronic
Medical Illness
Not Applicable to Psychiatric Diagnoses
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CPT: Model System



Psychiatric
Neurological
Non-Neurological Medical
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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
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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
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CPT: Neurological
Model
(Children & Adult)

Interview


Testing


96116
96118/19/20
Intervention
 97532
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CPT: Non-Neurological
Medical Model
(Children & Adult)

Interview & Assessment



96150 (initial)
96151 (re-evaluation)
Intervention



96152 (individual)
96153 (group)
96154 (family with patient)
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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)
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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
99148-99150- Addition of a second provider
0074T – Online evaluation and management
Evaluation and management codes
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Modifiers

Examples






22 = reduced service
25 = additional payment for an E & M code as a
specific procedure code
51 = multiple procedures
59 = when two procedures occur on same day
GN, GO, AH, etc. = local carrier specific
Problems

Incomplete support for modifier from 15 to 35% of
documentation results in paybacks
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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
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Currently Debated Issues
Associated with CCI

90801 and 96116

ReasoningSimilar to Medicine
 Cannot perform two procedures for same illness
and be reimbursed for both
 Reimbursed for most complex


H & B and Psychiatric Diagnoses

Psychiatric Procedures nor Diagnoses can be
used with H & B codes
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C. 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
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D. 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 as a Function of the
Activity?
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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;


Diagnosis
Symptoms
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E. CPT: Documenting






Purpose
Payer Requirements
General Principles
History
Examination
Decision Making
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Documentation: Purpose





Medical Necessity
Evaluate and Plan for Treatment
Communication and Continuity of Care
Claims Review and Payment
Research and Education
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Documentation: Payer
Requirements



Site of Service
Medical Necessity for Service Provided
Appropriate Reporting of Activity
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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 Observer
Timely
Confidential
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Documentation: Basic
Information Across
Codes










Date
Time, if applicable
Identity of Observer (technician ?)
Reason for Service
Status
Procedure
Results/Finding
Impression/Diagnoses
Disposition
Stand Alone
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Documentation:
Chief Complaint



Concise Statement Describing the
Symptom, Problem, Condition, &
Diagnosis
Foundation for Medical Necessity
Must be Complete & Exhaustive
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72
Documentation:
Present Illness

Symptoms


Location, Quality, Severity, Duration, timing,
Context, Modifying Factors Associated Signs
Follow-up


Changes in Condition
Compliance
cpt
73
Documentation: History




Past
Family
Social
Medical/Psychological
cpt
74
Documentation:
Assessment







Reason for Service
Dates (amount of service time?)
Identity of Tester
Tests and Protocols (included editions)
Narrative of Results
Impression
Disposition
cpt
75
Documentation: Intervention







Reason for Service
Status of Patient
Intervention Performed
Results Obtained
Impression or Diagnosis (es)
Disposition
Time
cpt
76
CPT X Report


Each CPT Code Should Generate a
Separate Report
Alternatively, Clearly Label/Title Sections
of the Report to Match Codes Used
cpt
77
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
cpt
78
Documentation Suggestions
(continued)

Two Tiered System of Documentation
(using HIPPA as Model)


Raw data = handwritten and not for
distribution psychotherapy notes
Report = “typed” notes for more public
consumption
cpt
79
E. Time



Time is Broadly Defined as What the
Professional Does
For Intervention – Time is face-to-face
For Assessment - Time could be either
face-to-face or professional time
cpt
80
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
cpt
81
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.
cpt
82
Time (continued)



Communicating further with others
Follow-up with patient, family, and/or
others
Arranging for ancillary and/or other
services
cpt
83
Time: Testing

Quantifying Time



Round up or down to nearest increment
Actual time vs. Elapsed time?
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.
cpt
84
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
cpt
85
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…”
cpt
86
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
cpt
87
E. 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 88
cpt
Part II: Specific Issues
with CPT (Intermediate)







Reimbursement
Supervision & Incident to
Technicians
Time
Coverage & Payment
Fraud & Abuse
UPIN #
cpt
89
A. 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)
cpt
90
Relative Value Units:
Overview




Components
Units
Values
Current Problems
cpt
91
RVU: Components





Physician Work Resource Value
Practice Expense Resource Value
Malpractice
Geographic
Conversion Factor (approx. $37.8975
02.2005)
cpt
92
RVU Components
Percentages




Physician Work
Practice Expense
Liability
=
=
=
52%
44%
4%
NOTE: Within 5-10 years, another major
component will be performance; in other words,
not only the work must be performed but some
results should occur as a function of the service
cpt
93
Defining Physician Work

Clinical Work



Mental Effort and Judgment
Technical Skill/Physical Effort
Psychological Stress
cpt
94
Estimate of Psychologists’
Value

Audiologist
Dietician
RN
Speech Pathologist
.52
.43
.42
.55

Psychologist
.82



cpt
95
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)
cpt
96
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)
cpt
97
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
cpt
98
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.
cpt
99
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
cpt
100
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
cpt
IN $est
91.89
24.60
25.32
96.95
96.59
33.28
25.32
101
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
cpt
102
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
cpt
103
Medicare Budget


Medicare Budget Frozen at 2005 Rates
Effective 01.01.06
Effectively, the Proposed/Accepted Figures
Previously Announced Will Remain Intact
(note that there are geographical
variations)
cpt
104
B. 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 as defined by
Medicare)
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
cpt
105
Supervision

Supervision




1.General = overall direction
2.Direct = present in office suite
3.Personal = in actual room
4.Psychological = when supervised by a
psychologist
cpt
106
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
cpt
107
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 Limited Future to Incident to Due to
Inclusion of New Testing Codes
cpt
108
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
The employee meets the contractual
requirement sent by CMS (e.g., 1099)
cpt
109
More Incident to

When is “Incident to” Acceptable:



Testing - Definite
Cognitive Rehabilitation; Biofeedback Probably
Psychotherapy – CMS does not have a
national policy prohibiting psychotherapy as a
incident to but it has supported local carriers
when they took the position that
psychotherapy should not be incident to
cpt
110
Incident to &
Site of Service

Outpatient vs. Inpatient




Geographical Location- Separate
Corporate Entities- Separate
Billing Service- Separate
Chart Information & Location- Separate
cpt
111
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
cpt
112
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?
cpt
113
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”




cpt
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
114
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
cpt
115
C. 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

cpt
116
Defining a Technician
(Federal Register, Vol. 66, #149, page 40382)

Requirement




Employee (e.g., 1099); “employees, leased
employees, or independent contractor”
Most common is independent contractor
“We do not believe that the nature of the employment
relationship is critical for purposes of payment to the
services of physician…as long as…(the personnel) is
under the required level of supervision.”
Common Practice

Independent Contractor
cpt
117
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
cpt
118
Acceptance of Technicians

Medicare



Outside of North Central & California, yes
Some states require specific modifiers (e.g.,
North Carolina, use the “AH” modifier)
Private Carriers


Magellan, United Health… – yes
Others (e.g., Value Options) – under
consideration
cpt
119
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

NOTE: Pattern similar to medical providers



cpt
120
Use of Technician

Technicians in a “Facility”



A “facility” in essentially an inpatient setting
If a technician is an employee of a private provider
but the service is provided in an inpatient setting, the
inpatient fee would be used
If a technician is an employee of a a facility, there is
some question as to whether they could be
supervised by a provider who is not an employee of
the facility
cpt
121
Use of Technicians

Practice Expense & Practice Implications



Each tech code has .51 work value
This means that the provider is engaged in the work
That engagement would include;





Selection of tests
Determination of testing protocol
Supervision of testing
Interpretation of individual tests
Reporting on individual tests
cpt
122
D. Coverage & 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
cpt
123
Payment

Medicare



Proposed 4.4% cut reversed 02.01.06
No changes from 2005 fee schedule
Other Carriers

Non-Equitable % of RVU payment
cpt
124
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
cpt
125
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
cpt
126
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
cpt
127
Evolution of Payment
Practices

Evolution of Compensation




Gross Charges
Adjusted Charges
RVUs
Receivables
cpt
128
Medicare Payment
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
cpt
129
Medicare Billing Suggestions

When to Bill


Overall = after documentation is in place
Diagnostic Services




After the Interview
After all testing is completed and a report has been
completed
Billing should occur only once after testing
Therapeutic Services


Could occur after each session
Should occur at least by the end of the month
cpt
130
Billing Model

Components





Procedure Completed
Number of Units of that Procedure
Location or Site Where the Service was
Provided
Date of Service
CPT X # of Units X Dx X Site of Service X
Date
cpt
131
E. 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
cpt
132
Expenditures & Fraud

Projections

Current


14%
By 2011;

17% ($2.8 trillion)
cpt
133
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
cpt
134
Defining Fraud

Fraud



Intentional
Pattern
Error


Clerical
Dates
cpt
135
Problem: Fraud &
Abuse


26 Different Kinds of Fraud Types
Psychological Services Have Been
Identified as Problematic
cpt
136
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
cpt
137
Fraud (continued)

Nursing Homes



Identification
Overuse of Services
Children
cpt
138
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
“Particularly Problematic” due to




Medically unnecessary
Billed incorrectly
Rendered by unqualified providers
Undocumented or poorly documented
cpt
139
OIG Report (continued)




Provider Not Qualified
Medically Unnecessary
Billed Incorrectly
Insufficient Documentation
cpt
=
=
=
=
11%
23%
41%
65%
140
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
cpt
141
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?
cpt
142
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
cpt
143
Fraud: New Information



The Good Enough or Common Sense Approach
If Medicare Audit Occurs then an Increased
Likelihood of Medicaid Audit
Practice Situations That Increase Potential
Audits;




Skilled Nursing Facilities
Statistical Outliers
Testing
States with Increased Audit Activity;

TX, CA, FL, PR
cpt
144
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.)
cpt
145
F. Unique Physician Identification
Number (UPIN)

Historical



UPIN #
Box 17 a CMS (insurance) 1500 form
Present

National Provide Identification Number
cpt
146
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
cpt
147
Part III:
Summary, Trajectories, Resources &
Questions/Answers




Summary of Present Problems
Trajectories
Resources
Questions & Answers
cpt
148
A. Present Problems

Commercial Carriers





Medical vs. Mental Health vs. No Coverage
Upper limits on # of hours/evaluation
Limited test formularies
Specific time per test
“Phantom benefits”- carrier states a service is
covered but no authorization is possible
cpt
149
Summary of Present Problems with
New Codes- Carrier-Based



Code Acceptance Use of new codes at all
 If 96101/96118 accepted, technical and computer codes not being
accepted
 Overall interpretation of codes (EOBs are still out)
Code Payment Lower than expected RVU % by private carriers
 Medicare carriers not paying- too high of a value placed by AMA and
CMS
 Human error in interpreting code submission (manuals/software)
 “Congressional action pending”
Technicians
 Current and operational definition
 Acceptance by carriers & licensing boards (e.g., NY)
cpt
150
Summary of Present Problems with
New Codes- Provider-Based


General Understanding & Usage
Specific Code Usage




Mixing of psychiatric with neuropsychological procedures as well
as mixing of diagnostic codes
Time (estimates, rounding)
Professional having to see the patient at all
Professional having to interpret and write the evaluation
Misunderstanding of potential difference between computerized
testing and computer code (interactive computerized testing
with tech or professional is coded as such) and computerized
testing (non-interactive is coded as a computer code)
cpt
151
Summary of Present Problems with
Codes- Provider-Based (continued)

Technicians





Training programs (interns and postdoctoral fellows)
Essentially no difference between a bachelor’s level technician
and a postdoctoral fellow
Difference between training and providing professional services
“Limited” interpretation of scoring (away from the patient)
Difference among psychometricians and psychometrists as well
as technicians



Psychometricians = doctoral level scientist involved in testing issue
Technicians = any provider that does not have a contract with the
insurance carrier
Psychometrists= typically a certified technician (e.g., NAP)
cpt
152
Summary of Present Problems with
Testing Codes- Potential Concerns

Qualifications



Technicians




Could no acceptance of technical code = incident to?
Understanding that scoring time is built in the code value
One could score while the patient is being tested, easier for adults than for
children but information about the observation has to occur
Tests





Who can perform neuropsychological services?
CMS/AMA delegates that restriction to states licensing boards and carriers
Time estimates (HMOs) for test administration & interpretation
Documentation of start/stop times
Listing of actual tests for documentation
Formulary
Documentation


Inclusion of #s along with narratives in documentation
Matching of documentation with carrier requirements
cpt
153
Emerging Strategy for Advocacy

Information Dissemination



Advocacy


NAN: CPT update via e-mail blasts & website posts
APA: Q & A posts on APA Practice website
Insurance company X insurance company (NAN, APA; state
associations); e.g., Magellan
Clarification


CMS’ interpretation of carriers interpretation of codes (APA?)
especially California, North Central, Mass.
CMS’ interpretation of medical residents and interns (AEP?) and
its potential impact on current licensing practices of postdoctoral supervisees (?)
cpt
154
B. Future Perspectives:
2003 Predictions

Paradigms




Industrial vs. Boutique/Niche
Clinical vs. Forensic
Mental Health vs. Health
Existing vs. Developing
cpt
155
2004 Predictions


Federal
 Technical – Health Electronic Records by 2008
 Performance Based Payment
 Traditionally = Fee for service provided
 Anticipated = Fee for performance/results
obtained
Economic
 Overall, Positive
cpt
156
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
cpt
157
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
cpt
158
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)
cpt
159
2005

Issues to be Addressed

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
cpt
160
2006





Early Portions of 2006 = Confusion in Use &
Reimbursement of Codes
 The Use of Technicians
 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
By 2010 = Addition of Performance to Work as a Factor
for Reimbursement
cpt
161
Beyond 2006
(CMS)

Health Care Spending & GDP









1960 =
1970 =
1990 =
2002 =
2004 =
2005 =
20010=
2015 =
Final =
5.0%
7.0%
9.0%
15.4%
16.0%
16.2%
18.0%
20.0% ( or 4 trillion $)
33.3%
cpt
162
What Does the American Public
Want?






Life Expectancy #1
Life Value = approximately $5 million
Expected Expenditure on Health Care= will
finally settle at about 1/3 of earned income
To be Competitive, Industry and Business will
Shift Cost of Health Care to Consumers and the
Government
Government Will, In Turn, Cost Share with the
Consumer
They Will, However, Set the Standard for Health
Care
cpt
163
Mechanisms to Keep Informed



APA Practice Website (www.apa.org)
NAN Website (www.nanonline.org)
Support these continuing efforts by
joining, APA, Division 40 and NAN
cpt
164
C. 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)
cpt
165
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.quickfacts.census.gov/qfd (census x type of procedure data)
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.)
cpt
166
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)
cpt
167
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

cpt
168
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
cpt
169
D. Questions & Answers



Representing the National Academy of
Neuropsychology- Ted Peck, Ph.D.
Representing the Division of Clinical
Neuropsychology- Neil Pliskin, Ph.D.
Additional Participants- Staff from the
National Rehabilitation Hospital & Selected
NAN and 40 Committee Members
cpt
170