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Making a Living in Professional Psychology: Coding, Billing and Documenting Psychological Services Antonio E. Puente University of North Carolina Wilmington.

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Presentation on theme: "Making a Living in Professional Psychology: Coding, Billing and Documenting Psychological Services Antonio E. Puente University of North Carolina Wilmington."— Presentation transcript:

1 Making a Living in Professional Psychology: Coding, Billing and Documenting Psychological Services Antonio E. Puente University of North Carolina Wilmington Florida Institute of Technology April 14, 2006 cpt NCPA/DIPP 2006

2 Acknowledgments 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) cpt

3 Specific Support Provided by Primary Organizations
APA = All expenses paid for travel associated with CPT activities NAN = (from PAIO budget) applied to UNCW activities = $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 cpt

4 Background (1988 – present)
North Carolina Psychological Association (e) APA’s Policy & Planning Board; Div. 40 (e) American Medical Association’s Current Procedural Terminology Committee (IV/V) (a) Health Care Finance Administration’s Working Group for Mental Health Policy (a) Center for Medicare/Medicaid Services’ Medicare Coverage Advisory Committee (fa) Consultant with the North Carolina Medicaid Office;North Carolina Blue Cross/Blue Shield (a) NAN’s Professional Affairs & Information Office (a) (legend; a = appointment, fa = federal appointment, e = election) cpt

5 Primary Goal & General Outcome of CPT Work
Goal (20 year plan) Parity with Physicians Expansion of Scope of Services Outcome (presently) 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 Potential impact on certain practice patterns cpt

6 Primary Goals of Presentation
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 Explain the Concept of Medical Necessity Provide Suggestions for Documentation Define Time Explain Reimbursement Practices Address Supervision and Incident to Explain the Concept of Fraud Versus Errors Address Current and Potential Problems Provide Trajectory for 2006 and Beyond cpt

7 Outline of Presentation
Part I: Coding, Billing and Documentation (Introductory) Part II: Specific Issues with CPT (Intermediate) Part III: Projections; Questions & Answers (Advanced) cpt

8 Part I: Coding, Billing & Documentation (Introductory)
Medicare Current Procedural Terminology Diagnosing Medical Necessity Documentation Time Site of Service cpt

9 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) cpt

10 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) cpt

11 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 cpt

12 Medicare: Overview Centers for Medicare and Medicaid Services Benefits
Part A (Hospital) Part B (Supplementary) Part C (Medicare+ Choice) Part D (Pharmaceutical) cpt

13 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 cpt

14 B. Current Procedural Terminology (CPT): Overview
Background Codes & Coding Existing Codes Model System X Type of Problem cpt

15 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 cpt

16 CPT: Composition AMA House of Delegates HCPAC CPT Editorial Panel
109 Medical Specialties HCPAC 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 cpt

17 What Is a CPT Code? A Coding System Developed by AMA in Conjunction with CMS to Describe Professional Services Each Code has a Specific Number and Description as well as 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 cpt

18 CPT: Applicable Codes Total Possible Codes = Approximately 7,500
Possible Codes for Psychology = Approximately 40 to 60 Sections = Five Primary Separate Sections Psychiatry (e.g., mental health) Biofeedback Central Nervous System Assessment (testing) Physical Medicine & Rehabilitation Health & Behavior Assessment & Management (h.p.) Evaluation and Management cpt

19 CPT: Development of a Code
Initial Health Care Advisory Committee (non-MDs) Primary CPT Work Group (selected organizations) CPT Panel (all specialties) Time Frame 3-5 years to well over a decade cpt

20 CPT: Psychiatry Sections (or Categories) Types of Interventions
Interview (90801) vs. Intervention (e.g., 90806) These codes are one unit Office vs. Inpatient Regular vs. Evaluation & Management Other Types of Interventions Insight, Behavior Modifying, and/or Supportive vs. Interactive cpt

21 Psychiatric Codes Interviewing 90801
One time per illness incident or bout Untimed Comprehensive analysis of records, observations as well as structured and/or unstructured clinical interview cpt

22 Psychiatric Codes Therapy 20 minutes = 90804 45-50 minutes = 90806

23 CPT Changes: CNS Assessment Codes Timetable
Activity x Date Codes Without Cognitive Work Obtained, 1994 Initial Request for Practice Expense by APA, Summer, 2002 APA Appeared Before AMA RUC, September, 2003 Initial Decision by AMA CPT Panel, November 7, 2004 Call for Other Societies to Participate, November 19, 2004 Final Decision by AMA CPT Panel, December 1, 2004 Submission of CPT Codes to AMA RUC Committee immediately thereafter Review by AMA RUC Research Subcommittee in January, 2005 Review by AMA RUC Panel in February 3-6, 2005 Survey of Codes, second & third week of February, 2005 Analysis of surveys, March, 2005 Presentation to RUC Committee in April, 2005 Inclusion in the 2006 Physician Fee Schedule on January 1, 2006 CPT Assistant article April, 2006 cpt

24 CPT: CNS Assessment Effective 01.01.06 (no grace period)
Psychological Testing (e.g., 5 units) Three New Codes New Numbers & Descriptors Neurobehavioral Status Exam (e.g., 2 units) New Number & Revised Descriptor Neuropsychological Testing (e.g., 10 units) cpt

25 Psychological Testing: By Professional
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) (note: “psychologist’s or physician’s” will probably be changed to “qualified health professional”) cpt

26 Psychological Testing: By Technician
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 cpt

27 Psychological Testing: By Computer
Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, (e.g., MMPI) administered by a computer, with qualified health professional interpretation and the report cpt

28 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 (note: “psychologist’s or physician’s” will probably be changed to “qualified health professional”) cpt

29 Neuropsychological Testing- By Professional
(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 (note: “psychologist’s or physician’s” will probably be changed to “qualified health professional”) cpt

30 Neuropsychological Testing: By Technician
(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 cpt

31 Neuropsychological Testing- By Computer
(e.g., WCST) administered by a computer with qualified health care professional interpretation and the report cpt

32 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) cpt

33 CPT: Physical Medicine & Rehabilitation
97770 now 97532 Note: 15 minute increments cpt

34 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) cpt

35 CPT: Health & Behavior Assessment & Management (CPT Assistant, 03
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 cpt

36 Overview of H & B Codes Codes Effective as (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 cpt

37 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 cpt

38 H & B: Examples of Service
Symptom Management & Expression Patient Adherence to Medical Treatment Health Promoting Behaviors Overall Adjustment to Medical Illness cpt

39 Health & Behavior Assessment Codes
96150 Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires) each 15 minutes face-to-face with the patient initial assessment 96151 re-assessment cpt

40 H & B: Assessment Explanation
Identification of Psychological, Behavioral, Emotional, Cognitive and/or Social Factors In the Prevention, Treatment and/or Management of Physical Health Problems Focus on Biopsychosocial and not Mental Health Factors cpt

41 H & B: Assessment Examples
Health-Focused Clinical Interview Behavioral Observations Psychophysiological Monitoring Health-Oriented Questionnaires cpt

42 Health & Behavior Intervention Codes
96152 Health and behavior intervention each 15 minutes face-to-face individual 96153 group (2 or more patients) 96154 family (with the patient present) 96155 (limited acceptability) family (without the patient present; not being reimbursed) cpt

43 H & B: Intervention Explanation
Modification of Psychological, Behavioral, Emotional, Cognitive and/or Social Factors Affecting Physiological Functioning, Disease Status, Health and/or Well-Being Focus = Improvement of Health with Cognitive, Behavioral, Social and/or Psychophysiological Procedures cpt

44 H & B: Intervention Examples
Cognitive Behavioral Social Psychophysiological cpt

45 H & B: Diagnoses Associated with an Acute or Chronic Medical Illness
Not Applicable to Psychiatric Diagnoses cpt

46 CPT: Model System Psychiatric Neurological Non-Neurological Medical

47 CPT Model Rationale for CPT Code:
Choose Code that Best Describes the Service Match the Interview with the Testing with the Intervention Code with the Diagnosis Goal = Uniformity and Fluency cpt

48 CPT: Psychiatric Model (Children & Adult)
Interview adult child Testing Also, for children Intervention e.g., adult e.g., child cpt

49 CPT: Neurological Model (Children & Adult)
Interview 96116 Testing 96118/19/20 Intervention 97532 cpt

50 CPT: Non-Neurological Medical Model (Children & Adult)
Interview & Assessment 96150 (initial) 96151 (re-evaluation) Intervention 96152 (individual) 96153 (group) 96154 (family with patient) cpt

51 C. CPT: Diagnosing Psychiatric Neurological & Non-Neurological Medical
DSM The problem with DSM and neuropsych testing of developmentally-related neurological problems Neurological & Non-Neurological Medical ICD – 9 CM (physical diagnosis coding) cpt

52 D. CPT: Medical Necessity
Scientific & Clinical Necessity Local Medical Review or Carrier Definitions of Necessity Necessity = CPT x DX formulary 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? cpt

53 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 cpt

54 E. CPT: Documenting Purpose Payer Requirements General Principles
History Examination Decision Making cpt

55 Documentation: Purpose
Medical Necessity Evaluate and Plan for Treatment Communication and Continuity of Care Claims Review and Payment Research and Education cpt

56 Documentation: General Principles
Rationale for Service Assessment, Progress, Impression, or Diagnosis Plan for Care Date and Identity of Observer Also Legible Timely Confidential cpt

57 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 cpt

58 Documentation: Chief Complaint
Concise Statement Describing the Symptom, Problem, Condition, & Diagnosis Foundation for Medical Necessity Must be Complete & Exhaustive cpt

59 Documentation: Present Illness
Symptoms Location, Quality, Severity, Duration, timing, Context, Modifying Factors Associated Signs Follow-up Changes in Condition Compliance cpt

60 Documentation: History
Past Family Social Medical/Psychological cpt

61 Documentation: Assessment
Reason for Service Dates (amount of service time?) Identity of Tester (technician) Tests and Protocols (included editions) Narrative of Results Impression Disposition cpt

62 Documentation: Intervention
Reason for Service Status of Patient Intervention Performed Results Obtained Impression or Diagnosis (es) Disposition Time cpt

63 CPT X Report Each CPT Code Should Generate a Separate Report
Alternatively, Clearly Label/Title Sections of the Report to Match Codes Used cpt

64 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

65 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

66 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

67 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

68 Time: Testing Quantifying Time Time Does Not Include
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

69 Time (CPT Assistant, 08. 05, 15, #8, pg. 12) (www. cms. hhs
Time (CPT Assistant, 08.05, 15, #8, pg. 12) ( For Timed Codes (in physical medicine): The Beginning and Ending Time Should be Documented Time Should be Documented Along with the Treatment Description cpt

70 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

71 Time: Defining 15 Minutes (from CPT Assistant, 08.05, 11-12) ( Defining 15 Minute Increments Units Amount of Minutes >08; <23 2 >22; <38 3 >38; <53 4 >53; <68 5 >68; <83 6 >83; <98 7 >98; <113 8 >113;<128 Over 2 hours similar pattern as above cpt

72 Part II: Specific Issues with CPT (Intermediate)
Reimbursement Supervision & Incident to Technicians Time Coverage & Payment Fraud & Abuse UPIN # cpt

73 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

74 Relative Value Units: Overview
Components Units Values Current Problems cpt

75 RVU: Components Physician Work Resource Value
Practice Expense Resource Value Malpractice Geographic Conversion Factor (approx. $ ) cpt

76 RVU Components Percentages
Physician Work = 52% Practice Expense = 44% Liability = % 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

77 Defining Physician Work
Clinical Work Mental Effort and Judgment Technical Skill/Physical Effort Psychological Stress cpt

78 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

79 RVU: Values Psychotherapy: Psych/NP Testing: Health & Behavior
Prior Value =1.86 New Value = 2.65 Psych/NP Testing: Work value= 0 Hsiao study recommendation = 2.2 New Value = undetermined Health & Behavior .25 (per 15 minutes increments) cpt

80 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

81 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

82 CPT x RVU Pre 2006 cpt

83 National Work RVU/Estimated $ 2006 Values op=outpatient, ip=inpatient, est=estimate rvu = work
Code # OP RVU IP RVU OP $ est IN $est 96101 2.56 2.54 92.61 91.89 96102 1.17 0.68 42.33 24.60 96103 0.74 0.70 26.77 25.32 96116 2.87 2.68 103.83 96.95 96118 3.43 2.67 124.09 96.59 96119 1.75 0.92 63.31 33.28 96120 1.27 45.94 cpt

84 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

85 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

86 Supervision Program Memorandum Carriers Department of Health and Human Services- HCFA Transmittal b-01-28; April 19, 2001 Levels of Supervision General Furnished under overall direction and control, presence is not required Direct 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

87 Incident to Rationale for Incident to Definition of Physician Extender
Congress intended to provide coverage for services not typically covered elsewhere Definition of Physician Extender How Limitations Definition of In vs. Outpatient Geographic Vs Financial Probably Limited Future to Incident to Due to Inclusion of New Testing Codes cpt

88 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

89 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 NCPA/DIPP 2006

90 Incident to & Site of Service
Outpatient vs. Inpatient Geographical Location- Separate Corporate Entities- Separate Billing Service- Separate Chart Information & Location- Separate cpt

91 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

92 Difficulties with Incident to
The “Physician” Must Evaluate and/or Treat the Patient First No Clear Guidelines Regarding Reasonable Mix of Physician to Extender Activities What are the Limits of the Extender? cpt

93 Difference Between Supervision and “Incident to”
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” 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 cpt

94 The Future of Incident to vs. Supervision
Intervention Technical Interventions such as biofeedback and cognitive rehabilitation Testing None , if technical codes accepted If not, presumably it can continue Supervision Regardless, some form of supervision required if a technician is used cpt

95 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

96 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

97 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

98 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

99 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

100 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

101 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

102 The Problem with Training
Medicare Will Pay When: The physician provides the service alone The physician provides the service in conjunction with the medical student The physician is present in the same room when the student provides the service Possibility of Students as Incident to A Student/Extern/Intern/Postdoc, For All Practical Purposes = a Technician cpt

103 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

104 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

105 E. Office of Inspector General (2005 Orange Book)
Identify Nursing Home Residents with Serious Mental Illness (OEI Improve Assessments of Mental Illness (OEI ) Eliminate Inappropriate Payments for Mental Health Services cpt

106 Expenditures & Fraud Projections Current By 2011; 14%
17% ($2.8 trillion) cpt

107 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

108 Defining Fraud Fraud Intentional Pattern Error Clerical Dates cpt

109 Problem: Fraud & Abuse 26 Different Kinds of Fraud Types
Psychological Services Have Been Identified as Problematic cpt

110 Fraud & Office of Inspector General
Primary Problems Medical Necessity (approximately $5 billion) Documentation Psychotherapy (oig.hhs/gov/reports/region5/ ) Individual Group # of Hours Who Does the Therapy Psychological Testing cpt

111 Fraud (continued) Nursing Homes Children Identification
Overuse of Services Children cpt

112 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

113 OIG Report (continued)
Provider Not Qualified = 11% Medically Unnecessary = 23% Billed Incorrectly = 41% Insufficient Documentation = 65% cpt

114 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

115 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

116 Fraud: CERT Program (
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

117 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

118 Fraud: 2006 Red Book Section 1862(a)(1)(A) of the Social Security Practice Act requires all services to be reasonable and necessary for the diagnosis or treatment of an illness or injury. Claim errors have exceed 34% cpt

119 Fraud: Red Book (continued)
Problem Areas Acute Hospital outpatient Services ($224) Partial Hospitalization ($180) Psychiatric Hospital outpatient ($57) Nursing Home ($30) General Mental Health ($185) Beneficiaries who are unable to benefit from psychotherapy services Note: in millions (total for $676,000,000) cpt

120 F. Unique Physician Identification Number (UPIN)
Historical UPIN # Box 17 a CMS (insurance) 1500 form Present National Provide Identification Number cpt

121 National Provider Identification Number (CMS memo, 45 CFR Part 16c)
Basic Information 10 Position numeric & individual number No specific information about provider Managed by CMS’s Provider System Dates of Implementation 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

122 Part III: Summary, Trajectories, Resources & Questions/Answers
Summary of Present Problems Trajectories Resources Questions & Answers cpt

123 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

124 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

125 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

126 Summary of Present Problems with Codes- Provider-Based (continued)
Technicians Training programs (externs, 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

127 Summary of Present Problems with Testing Codes- Potential Concerns
Qualifications Who can perform neuropsychological services? CMS/AMA delegates that restriction to states licensing boards and carriers 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 Time estimates (HMOs) for test administration & interpretation Documentation of start/stop times Listing of actual tests for documentation Formulary (both in terms of tests as well as time allocated) cpt

128 Summary of Present Problems with Testing Codes- Potential Concerns
Documentation Inclusion of #s along with narratives in documentation Matching of documentation with carrier requirements Inclusion of Actual Time Inclusion of name of technician Masters Level Practitioners Will they be viewed as “qualified health practitioners? cpt

129 B. Future Perspectives: 2003 Predictions
Paradigms Industrial vs. Boutique/Niche Clinical vs. Forensic Mental Health vs. Health Existing vs. Developing cpt

130 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

131 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

132 2004 (Continued) Institutionally Based
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

133 2005 Medicare Institutional Individual Practice
% decrease over next 6 years (compared to 1.5% increase each over the last 3 years; AAP Advance, Summer, 2005) Institutional Further defining of supervision & incident to Significantly limited access to funds (e.g., GME) Individual 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, ) WellPoint, WellChoice, HealthNet, MVP Health Care, Blue Cross of California and 32 states (105 programs in mid 2005) cpt

134 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

135 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

136 Pay for Performance (P4P) Initiatives
Premise Evidence-based guidelines Outcome more than procedure based Initial Application Dartmouth, Duke & Michigan Final Application 5-10 years cpt

137 Beyond 2006 (CMS) Health Care Spending & GDP 1960 = 5.0% 1970 = 7.0%
1960 = 5.0% 1970 = 7.0% 1990 = 9.0% 2002 = % 2004 = % 2005 = % 2010= 18.0% 2015 = % ( or 4 trillion $) Final = 33.3% cpt

138 Beyond 2006: 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 (e.g., Medicare) Will, However, Set the Standard for Health Care cpt

139 Mechanisms to Keep Informed
APA Practice Website ( NAN Website ( 40 Website ( Support these continuing efforts by joining APA, NAN, Division 40, SPA as well as your state association cpt

140 C. Resources General Web Sites
(medicare/medicaid) (health & human services) (inspector general) (apa’s cpt information) (agency for healthcare research) (medical payment advisory comm.) (statistics) (clinical neuropsychology div of apa) (national association of psychometrists) (federal statutes and regulations) (staff salaries) cpt

141 Resources (continued)
Payment/Coverage (covered services) (non-covered) (apa lmrp) (medicare lmrp) (census x type of procedure data) LMRP Reconsideration Process Compliance Web Sites (office of inspector general) (medicare) (united states codes) (psychologists & hipaa) (hipaa) (health care compliance assoc.) cpt

142 Resources (continued)
ICD (who) (ccd) Coding Web Sites (ama cpt) (academy of coders) (coding edits) cpt

143 Resources Telephone Numbers
APA Practice Directorate’s Government Relations Office; AMA CPT Office; Medicare National Coverage Determinations; cpt

144 Contact Information Websites Univ = Practice = NAN = University = Practice = Telephone University = Practice = cpt NCPA/DIPP 2006

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