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Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of a 10 year of progress report Antonio E. Puente Department of Psychology.

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Presentation on theme: "Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of a 10 year of progress report Antonio E. Puente Department of Psychology."— Presentation transcript:

1 Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of a 10 year of progress report Antonio E. Puente Department of Psychology University of North Carolina at Wilmington Tel , Fax , web Massachusetts Neuropsychological Society Boston, MA, December 5, 2000

2 Outline of Presentation zHistory/Background of Involvement zProcedural Coding zReimbursement zDocumentation zAuditing zRelated Issues zFuture Trends

3 Purpose of My Involvement with Coding & Medicare zShort Term yReimbursement zLong Term yWhy the Focus on Medicare yBring Some Standardization to the Field yExpand the Scope and Value of Clinical Neuropsychology yParity with Other Doctoral Level Health Providers in Health Care yShape Psychology Towards a Biological Model

4 History/Background zNorth Carolina Psychological Association yBlue-Cross Blue Shield zAmerican Psychological Association yChair or Member of Approx.a Dozen Committees/Boards, (e.g., Neuropsychology) yDivision 40 Board to present yTwo Terms on APAs Council of Representatives (1994 to present) yPolicy and Planning Board

5 History/Background (continued) zAmerican Medical Association yCPT- 4 yCPT- 5 zHealth Care Financing Administration yModel Mental Health Policy Workgroup yMedicare Coverage Advisory Committee

6 Procedural Coding zDefining Coding zHistory of Coding zCoding

7 Defining Coding zDescription of Professional Service Rendered zPurpose of Coding yArchival/Research yReimbursement zCoding Systems ySNOMED yWHO / ICD yAMA / CPT

8 History of CPT Coding zFirst Developed in 1966 zCurrently Using the 4th Edition zThe 5th Edition Will be Used in 2002 zA Total of 7,500 Codes zAMA Developed and Owns the CPT zUnder Contract with the HCFA

9 Overview of Coding zTotal Possible Codes = 60+ z# Of Typically Reimbursed Codes = 5 yinterview, testing, & psychotherapy z# Of Codes Sometimes Reimbursed = 35 yfamily/group therapy ybiofeedback z# Of Codes Rarely Reimbursed = 20+ yevaluation and management yreport evaluation and writing

10 Overview of Coding: An evolution of coding zPsychiatry zNeurology zPhysical Medicine & Rehabilitation zEvaluation & Management

11 Overview of Coding (cont.) zPsychiatry yInterview (90801) yPsychotherapy ( ) xTypes of Psychotherapy (regular vs interactive) x# of Patients (individual vs group vs family) xLocations of Intervention (in vs outpatient) xEvaluation & Management vs Regular xLength of Time (30, 60, 90) yBiofeedback xRegular vs Psychophysiological (90901 vs 90875)

12 Overview of Coding (cont.) zCentral Nervous System Assessments/Test y96100 = Psychological Testing y96105 = Aphasia Testing y96110/1 = Developmental Testing y96115 = Neurobehavioral Status Exam y96177 = Neuropsychological Testing

13 Overview of Coding (cont.) zPhysical Medicine y = Cognitive Skills Development y Look for New/split Codes in the Near Future

14 Overview of Coding (cont.) zHealth & Behavior y909X1assessment (15 minutes) y909X2re-assessment y909X3intervention- individual y909X4intervention- group y909X5intervention- family y909X6intervention- family w/o pt. yNOTE: these codes need to be valued...

15 Coding Overview zCoding Categories yPsychiatry yNeurology; CNS/Assessment yPhysical Medicine yEvaluation & Management zProcedures yAssessment yIntervention

16 Overview of Coding (cont.) zDiagnosing yIf Problem is Psychiatric = DSM yIf Problem is Neurological = ICD zMatching Dx with CPT yDSM = 90801, 96100, yICD = 96115, 96117, 97770

17 Reimbursement zHistory zDefining RBRVS zFormula zDefining Time zDefining Site zDefining Necessity zDefining and Applying Incident to

18 History of Reimbursement zCost plus Reimbursement zProspective Payment (PPS) & Diagnostic Related Groups (DRGs) zCustomary. Prevailing, & Reasonable(CPR) zResource Based Relative Value System (RBRVS) zProspective Payment System

19 RBRVS zMajor Components yPhysician Work Resource Value Unit yPractice Expense Resource Value Unit yMalpractice Component Resource Value Unit zConversion Factor zAdoption of the RBRVS yMedicare yBlue Cross/Blue Shield- 87% yManaged Care- 55%

20 Reimbursement Formula zProcedural Code zTime zDiagnosis zSite of Service zProvider zFormula yCode X Time X Dx X Site X Provider

21 Reimbursement Difficulties zPhysician Work Value zPhd/PsyD/EdD vs MD zLocation Defined

22 Common Reasons for Lack of Reimbursement zClerical Errors zService Is Not Covered zNo Prior Authorization Obtained zExceeded Allocated Time Limits zInvalid or Incorrect Dx Code zCPT and Dx Do Not Match

23 Defining Time zDefining Time yProfessional (not patient) Activity zInterview vs Assessment Codes yHourly Increments yIncludes Pre and Post-clinical Service zIntervention Codes y15, 30, 60, & 90 yFace-to-face Contact yNo Pre or Post-clinical Service Time Included

24 Testing Time Defined zPreparing to Test Patient zReviewing of Records zSelection of Tests zScoring of Tests zReviewing of Results zInterpretation of Results zPreparation and Report Writing

25 Documentation zPurpose zGeneral Guidelines zSpecific Documentation zTrends zSuggestions

26 Purpose of Documentation zEvaluate and Plan for Treatment zCommunication and Continuity of Care zClaims Review and Payment zResearch and Education

27 General Principles of Documentation zComplete and Legible zReason/Rationale for the Encounter zAssessment, Impression, or Diagnosi/es zPlan for Care zDate and Identity of Observer

28 Documentation History zChief Complaint zHistory of Present Illness (HPI) zReview of Systems zPast, Family, and/or Social History

29 Documentation of Chief Complaint zConcise Statement Describing the Symptom, Problem, Condition, Diagnosis, Physician Recommended Return, or other Factor that is the Reason for the Encounter.

30 Documentation of Present Illness zChronological Description of the Development of the Patients Present Illness from the First Sign and/or Symptom or from the Previous Encounter to the Present. yFor Symptoms: Location, Quality, Severity, Duration, Timing, Context, Modifying Factors Including Medications, Associated Signs, Symptoms, etc. yFor Follow up: Changes in Condition Since Last Visit, Compliance with Treatment, etc.

31 Review of Systems zPsychiatric zNeurological zOther

32 Documentation of History zPast History zFamily History zSocial History

33 Specific Documentation Suggestions: Psychiatric Interview zName, Date, Observer, Dx/Impression zMental Status Exam yLanguage, Thought Processes, Insight, Judgment, Reliability, Reasoning, Perceptions, Suicidality, Violence, Mood & Affect, Orientation, Memory, Attention, Intelligence

34 Specific Documentation Suggestions: Neurobehavioral Status Exam zName, Date, Observer, Dx/Impression zVariables yAttention, Memory, Visuo-Spatial, Lanague, Planning

35 Specific Documentation Suggestions: Testing zName, Date, Observer, Dx/Impression zNames of Tests zInterpretation of Tests Results zDisposition zTime

36 Documentation Suggestions zAvoid Handwritten Notes zDo Not Use Red Ink zDocument on Every Encounter, Every Procedure, and Every Patient zRe-Cap Status, Whenever Possible, At Least Change From Session to Session zDocument Soon After Procedure

37 Trends zIssues of Confidentiality zOver-Diagnosing zOver-Documenting

38 Auditing zFraud & Abuse vs Erroneous zSelf-Auditing Suggestions zRisk Situations zDevelopment of an Internal Auditing System

39 Fraud vs Error zFraud = Intentional, Pattern zErroneous = Clerical, etc.

40 Self-Auditing Suggestions zWritten Policies zCompliance Officer zTraining & Education zLines of Communication Should Exist zInternal Monitoring & Auditing zEnforce Standards zAlter as Necessary

41 Risk Areas for Fraud zCoding & Billing zReasonable & Necessary Services zDocumentation zImproper Inducements

42 Fraudulent Claims Flags zUpcoding zExcessive or Unnecessary Visits to ACF zOutpatient Service 72 Hrs. Post-Discharge zCPT Code Usage Shift zHigh Percentage of the Same Codes zUse of Similar Time for Testing Across Pts. zMedical Necessity (dx; interpretation)

43 Defining Necessity zreasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member zAll services must stand alone zAcute and emergency services more like to be considered necessary

44 Evaluating Effectiveness zAdequacy of Evidence yBias yExternal Validity zSize of Effect yFrom Not Effective to Breakthrough

45 Evaluating Effectiveness (continued) zOrganized Approaches to Evaluation of Scientific Evidence yAmerican College of Physicians yAgency for Health Care Policy and Research yBC/BS Technology Evaluation Center yAmerican College of Cardiology yAmerican College of Urology

46 Additional Issues zIncident to yin vs outpatient ytechnical vs professional component yperforming vs billing zGraduate Medical Education yallied health vs medical yinterns vs postdoctoral fellows zCPT I, II, & III yI = standard codes yII = performance measures yIII = emerging technology

47 Future Trends zSurveys; Practice, Ongoing & New Codes zHealth Care Finance Administration zCommittee for the Advance of Professional Practice zPractice Directorate of the APA zGeneral Trends zFuture of Clinical Neuropsychology zResources

48 Surveys zRationale for Surveys yAll Decisions are Empirical yReasonably Large Ns yAdequate Data zSupport Required yIf Asked, Participate yTwo Ongoing; xNAN/Division 40 Practice Survey xRe-evaluation of Cognitive Rehabilitation

49 Health Care Financing Administration zProblems yDefinition of Physician (Social Security Practice Act of 1989) yDoctoral vs Non-Doctoral Providers zDirections yPhysician Work Value yPractice Expense yMatching of CPT with Reimbursement

50 Committee for the Advancement of Professional Practice zObservers yJoe Fishburn (NAN), Ida Sue Baron (Div 40) zAttitude yDivision 40; NAN Gift yPositive, Receptive yAdditional Staff Member for Medicare Program

51 General Trends zFraud, Abuse, & Effects of Regulations zClinical Neuropsychology Standardizing & Expanding Into Non-Traditional Areas zBoutique vs Industrial Neuropsych. zPsychometrics as Clinical Neuropsychology zAssessment & Rehabilitation zNeuropsychologys Technical Pipeline zEstablishment of Grassroots Network

52 Future of Clinical Neuropsychology: A Holiday Wish List zMore (normative?) Data & A Few Theories zMeasurement of the Cultural & Subjective zLess Focus on Conserving the Medicare Trust Fund & Stockholder Profits by Focusing on the Aged & Disabled zAppreciating that Brain is Inside a Person Which is Inside a System (Value?) zConscilience

53 Resources zWeb Sites yneuropsych;, ygovernment;, ypersonal; zPublications yAPA Medicare Handbook (PP; 2000) yNAN Bulletin (1994, 1997, 1998, 2000) yJournal of Psychopathology & Behavioral Assessment (1987) yProfessional Psychology (with Camara & Nathan, 2000)

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