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Cpt1 Making a Living in Professional Psychology: Coding, Billing and Documenting Psychological Services Antonio E. Puente University of North Carolina.

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Presentation on theme: "Cpt1 Making a Living in Professional Psychology: Coding, Billing and Documenting Psychological Services Antonio E. Puente University of North Carolina."— Presentation transcript:

1 cpt1 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

2 cpt2 Acknowledgments North Carolina Psychological Association North Carolina Psychological Association Practice Directorate of the American Psychological Association (APA) Practice Directorate of the American Psychological Association (APA) American Medical Association (AMA) CPT Staff American Medical Association (AMA) CPT Staff National Academy of Neuropsychology (NAN) National Academy of Neuropsychology (NAN) Division of Clinical Neuropsychology- APA Division of Clinical Neuropsychology- APA Center for Medicare & Medicaid Services Medical Policy Staff- Medicare Center for Medicare & Medicaid Services Medical Policy Staff- Medicare Inter-Divisional Health Care Committee- APA Inter-Divisional Health Care Committee- APA Department of Psychology, UNC-Wilmington Department of Psychology, UNC-Wilmington Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted Peck; AEP Research Team and Clinical Staff) Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted Peck; AEP Research Team and Clinical Staff)

3 cpt3 Specific Support Provided by Primary Organizations APA = All expenses paid for travel associated with CPT activities APA = All expenses paid for travel associated with CPT activities NAN = (from PAIO budget) applied to UNCW activities NAN = (from PAIO budget) applied to UNCW activities = $10,000 per year – one course for two semesters teaching reduction = $10,000 per year – one course for two semesters teaching reduction 2005 = $5,000 per year – one course for one semester teaching reduction 2005 = $5,000 per year – one course for one semester teaching reduction 2006 = $25,000 per year – in negotiation 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 UNCW = Time away from university duties (e.g., teaching) plus incidental support such as copying, telephone calls, and secretarial and work-study student assistance

4 cpt4 Background (1988 – present) North Carolina Psychological Association (e) North Carolina Psychological Association (e) APAs Policy & Planning Board; Div. 40 (e) APAs Policy & Planning Board; Div. 40 (e) American Medical Associations Current Procedural Terminology Committee (IV/V) (a) American Medical Associations Current Procedural Terminology Committee (IV/V) (a) Health Care Finance Administrations Working Group for Mental Health Policy (a) Health Care Finance Administrations Working Group for Mental Health Policy (a) Center for Medicare/Medicaid Services Medicare Coverage Advisory Committee (fa) Center for Medicare/Medicaid Services Medicare Coverage Advisory Committee (fa) Consultant with the North Carolina Medicaid Office;North Carolina Blue Cross/Blue Shield (a) Consultant with the North Carolina Medicaid Office;North Carolina Blue Cross/Blue Shield (a) NANs Professional Affairs & Information Office (a) NANs Professional Affairs & Information Office (a) ( legend; a = appointment, fa = federal appointment, e = election)

5 cpt5 Primary Goal & General Outcome of CPT Work Goal (20 year plan) Goal (20 year plan) Parity with Physicians Parity with Physicians Expansion of Scope of Services Expansion of Scope of Services Outcome (presently) Outcome (presently) Intended/Anticipated/Hoped Intended/Anticipated/Hoped Similar reimbursement as physician services Similar reimbursement as physician services General increase in the scope of practice General increase in the scope of practice Greater inclusion into health care system Greater inclusion into health care system Less Anticipated Less Anticipated Transparency Transparency Accountability Accountability Uniformity Uniformity Potential impact on certain practice patterns Potential impact on certain practice patterns

6 cpt6 Primary Goals of Presentation Understand the Role of Medicare in Setting Standards for Psychology Understand the Role of Medicare in Setting Standards for Psychology Understand the AMA Current Procedural Terminology (CPT) for Coding of Professional Services Understand the AMA Current Procedural Terminology (CPT) for Coding of Professional Services Introduce the New Testing and Interview Codes Introduce the New Testing and Interview Codes Suggest a Model System for Coding Suggest a Model System for Coding Explain the Concept of Medical Necessity Explain the Concept of Medical Necessity Provide Suggestions for Documentation Provide Suggestions for Documentation Define Time Define Time Explain Reimbursement Practices Explain Reimbursement Practices Address Supervision and Incident to Address Supervision and Incident to Explain the Concept of Fraud Versus Errors Explain the Concept of Fraud Versus Errors Address Current and Potential Problems Address Current and Potential Problems Provide Trajectory for 2006 and Beyond Provide Trajectory for 2006 and Beyond

7 cpt7 Outline of Presentation Part I: Coding, Billing and Documentation (Introductory) Part I: Coding, Billing and Documentation (Introductory) Part II: Specific Issues with CPT (Intermediate) Part II: Specific Issues with CPT (Intermediate) Part III: Projections; Questions & Answers (Advanced) Part III: Projections; Questions & Answers (Advanced)

8 cpt8 Part I: Coding, Billing & Documentation (Introductory) Part I: Part I: Medicare Medicare Current Procedural Terminology Current Procedural Terminology Diagnosing Diagnosing Medical Necessity Medical Necessity Documentation Documentation Time Time Site of Service Site of Service

9 cpt9 A. Medicare: Why? The Standard for Universal Health Care: The Standard for Universal Health Care: Coding (what can be done) Coding (what can be done) Value (how much it will be paid) Value (how much it will be paid) Documentation (what needs to be said) Documentation (what needs to be said) Auditing (determination of whether it occurred) Auditing (determination of whether it occurred)

10 cpt10 Medicare: Immediate Impact As a Consequence, the Benchmark for: As a Consequence, the Benchmark for: All Commercial Carriers (e.g., HMOs) All Commercial Carriers (e.g., HMOs) As well as; As well as; Workers Compensation Workers Compensation Forensic Applications Forensic Applications Related Applications (e.g., industrial, sports) Related Applications (e.g., industrial, sports)

11 cpt11 Medicare: Long-term Impact By 2015, Medicare will represent approximately 50% of all health care payments in the United States 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 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) 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 Hence, Medicare will come to set the standard for all of health care

12 cpt12 Medicare: Overview Centers for Medicare and Medicaid Services Centers for Medicare and Medicaid Services Benefits Benefits Part A (Hospital) Part A (Hospital) Part B (Supplementary) Part B (Supplementary) Part C (Medicare+ Choice) Part C (Medicare+ Choice) Part D (Pharmaceutical) Part D (Pharmaceutical)

13 cpt13 Medicare: Local Review Medical Review Policy Medical Review Policy National Policy Sets Overall Model National Policy Sets Overall Model Local Coverage Determination (LCD) Sets Local/Regional Policy- Local Coverage Determination (LCD) Sets Local/Regional Policy- More restrictive than national policy More restrictive than national policy Over-rides national policy Over-rides national policy Changes frequently without warning or publicity Changes frequently without warning or publicity Information best found on respective web pages Information best found on respective web pages

14 cpt14 B. Current Procedural Terminology (CPT): Overview Background Background Codes & Coding Codes & Coding Existing Codes Existing Codes Model System X Type of Problem Model System X Type of Problem

15 cpt15 CPT: Background American Medical Association American Medical Association Developed by Surgeons (& Physicians) in 1966 for Billing Purposes Developed by Surgeons (& Physicians) in 1966 for Billing Purposes 7,500+ Discrete Codes 7,500+ Discrete Codes CPT Meets a Minimum of 4 Times/Year CPT Meets a Minimum of 4 Times/Year Center for Medicare & Medicaid Services Center for Medicare & Medicaid Services AMA Under License by CMS AMA Under License by CMS CMS Now Provides Active Input into CPT CMS Now Provides Active Input into CPT

16 cpt16 CPT: Composition AMA House of Delegates AMA House of Delegates 109 Medical Specialties 109 Medical Specialties HCPAC HCPAC 11 Allied Health Societies (e.g., APA) 11 Allied Health Societies (e.g., APA) CPT Editorial Panel CPT Editorial Panel 17 Voting Members 17 Voting Members 11 Appointed by AMA Board 11 Appointed by AMA Board 1 each from BC/BS, AHA, HIAA, CMS 1 each from BC/BS, AHA, HIAA, CMS 2 HCPAC 2 HCPAC

17 cpt17 What Is a CPT Code? A Coding System Developed by AMA in Conjunction with CMS to Describe Professional Services 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 Each Code has a Specific Number and Description as well as a Reimbursable Value Professional Health Service Provided Across the Country at Multiple Locations Professional Health Service Provided Across the Country at Multiple Locations Many Physicians or Qualified Health Professional Perform Services Many Physicians or Qualified Health Professional Perform Services Clinical Efficacy is Established and Documented in Peer-Reviewed Literature Clinical Efficacy is Established and Documented in Peer-Reviewed Literature

18 cpt18 CPT: Applicable Codes Total Possible Codes = Approximately 7,500 Total Possible Codes = Approximately 7,500 Possible Codes for Psychology = Approximately 40 to 60 Possible Codes for Psychology = Approximately 40 to 60 Sections = Five Primary Separate Sections Sections = Five Primary Separate Sections Psychiatry (e.g., mental health) Psychiatry (e.g., mental health) Biofeedback Biofeedback Central Nervous System Assessment (testing) Central Nervous System Assessment (testing) Physical Medicine & Rehabilitation Physical Medicine & Rehabilitation Health & Behavior Assessment & Management (h.p.) Health & Behavior Assessment & Management (h.p.) Evaluation and Management Evaluation and Management

19 cpt19 CPT: Development of a Code Initial Initial Health Care Advisory Committee (non-MDs) Health Care Advisory Committee (non-MDs) Primary Primary CPT Work Group (selected organizations) CPT Work Group (selected organizations) CPT Panel (all specialties) CPT Panel (all specialties) Time Frame Time Frame 3-5 years to well over a decade 3-5 years to well over a decade

20 cpt20 CPT: Psychiatry Sections (or Categories) Sections (or Categories) Interview (90801) vs. Intervention (e.g., 90806) Interview (90801) vs. Intervention (e.g., 90806) These codes are one unit These codes are one unit Office vs. Inpatient Office vs. Inpatient Regular vs. Evaluation & Management Regular vs. Evaluation & Management Other Other Types of Interventions Types of Interventions Insight, Behavior Modifying, and/or Supportive vs. Interactive Insight, Behavior Modifying, and/or Supportive vs. Interactive

21 cpt21 Psychiatric Codes Interviewing Interviewing One time per illness incident or bout One time per illness incident or bout Untimed Untimed Comprehensive analysis of records, observations as well as structured and/or unstructured clinical interview Comprehensive analysis of records, observations as well as structured and/or unstructured clinical interview

22 cpt22 Psychiatric Codes Therapy Therapy 20 minutes = minutes = minutes = minutes = minutes = minutes = 90808

23 cpt23 CPT Changes: CNS Assessment Codes Timetable CPT Changes: CNS Assessment Codes Timetable Activity x Date Activity x Date Codes Without Cognitive Work Obtained, 1994 Codes Without Cognitive Work Obtained, 1994 Initial Request for Practice Expense by APA, Summer, 2002 Initial Request for Practice Expense by APA, Summer, 2002 APA Appeared Before AMA RUC, September, 2003 APA Appeared Before AMA RUC, September, 2003 Initial Decision by AMA CPT Panel, November 7, 2004 Initial Decision by AMA CPT Panel, November 7, 2004 Call for Other Societies to Participate, November 19, 2004 Call for Other Societies to Participate, November 19, 2004 Final Decision by AMA CPT Panel, December 1, 2004 Final Decision by AMA CPT Panel, December 1, 2004 Submission of CPT Codes to AMA RUC Committee immediately thereafter Submission of CPT Codes to AMA RUC Committee immediately thereafter Review by AMA RUC Research Subcommittee in January, 2005 Review by AMA RUC Research Subcommittee in January, 2005 Review by AMA RUC Panel in February 3-6, 2005 Review by AMA RUC Panel in February 3-6, 2005 Survey of Codes, second & third week of February, 2005 Survey of Codes, second & third week of February, 2005 Analysis of surveys, March, 2005 Analysis of surveys, March, 2005 Presentation to RUC Committee in April, 2005 Presentation to RUC Committee in April, 2005 Inclusion in the 2006 Physician Fee Schedule on January 1, 2006 Inclusion in the 2006 Physician Fee Schedule on January 1, 2006 CPT Assistant article April, 2006 CPT Assistant article April, 2006

24 cpt24 CPT: CNS Assessment Effective (no grace period) Psychological Testing (e.g., 5 units) Psychological Testing (e.g., 5 units) Three New Codes Three New Codes New Numbers & Descriptors New Numbers & Descriptors Neurobehavioral Status Exam (e.g., 2 units) Neurobehavioral Status Exam (e.g., 2 units) New Number & Revised Descriptor New Number & Revised Descriptor Neuropsychological Testing (e.g., 10 units) Neuropsychological Testing (e.g., 10 units) Three New Codes Three New Codes New Numbers & Descriptors New Numbers & Descriptors

25 cpt25 Psychological Testing: By Professional –Psychological Testing –Psychological Testing Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS (per hour of psychologists or physicians time, both face-to-face time with the patient and time interpreting test results and preparing the report) Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS (per hour of psychologists or physicians time, both face-to-face time with the patient and time interpreting test results and preparing the report) (note: psychologists or physicians will probably be changed to qualified health professional)

26 cpt26 Psychological Testing: By Technician Psychological Testing 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 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

27 cpt27 Psychological Testing: By Computer Psychological Testing 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 Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, (e.g., MMPI) administered by a computer, with qualified health professional interpretation and the report

28 cpt28 Neurobehavioral Status Exam Neurobehavioral status exam 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 psychologists or physicians time, both face-to- face time with the patient and time interpreting test results and preparing the report 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 psychologists or physicians time, both face-to- face time with the patient and time interpreting test results and preparing the report (note: psychologists or physicians will probably be changed to qualified health professional)

29 cpt29 Neuropsychological Testing- By Professional Neuropsychological testing Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological, WMS, Wisconsin Card Sorting) per hour of the psychologists or physicians time, both face-to- face time with the patient and time interpreting test results and preparing the report (e.g., Halstead-Reitan Neuropsychological, WMS, Wisconsin Card Sorting) per hour of the psychologists or physicians time, both face-to- face time with the patient and time interpreting test results and preparing the report (note: psychologists or physicians will probably be changed to qualified health professional)

30 cpt30 Neuropsychological Testing: By Technician Neuropsychological testing 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 (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

31 cpt31 Neuropsychological Testing- By Computer Neuropsychological testing Neuropsychological testing (e.g., WCST) administered by a computer with qualified health care professional interpretation and the report (e.g., WCST) administered by a computer with qualified health care professional interpretation and the report

32 cpt32 CNS Assessment Examples Neurobehavioral Status with Neuropsychological Testing Neurobehavioral Status with Neuropsychological Testing Interview by the Professional Interview by the Professional Testing by Testing by Professional, and/or Professional, and/or Technician, and/or Technician, and/or Computer. Computer. Interpretation & Report Writing by Qualified Health Professional 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) A Technician or Computer Code are Typically Billed Together with a Professional Code (since the final product should be a comprehensive/integrative report)

33 cpt33 CPT: Physical Medicine & Rehabilitation now now Note: 15 minute increments Note: 15 minute increments

34 cpt34 CPT: Cognitive Rehabilitation Application Rationale Application Rationale Allied Health & Physical Medicine Code Allied Health & Physical Medicine Code Acceptability Acceptability GN – Speech Therapists GN – Speech Therapists GO – Occupational Therapists GO – Occupational Therapists GP – Physical Therapists GP – Physical Therapists AH – Mental Health (not applicable) AH – Mental Health (not applicable)

35 cpt35 CPT: Health & Behavior Assessment & Management (CPT Assistant, 03.04) (CPT Assistant, 08.05, 15, #6, 10) Purpose: Medical Diagnosis Purpose: Medical Diagnosis Time: 15 Minute Increments Time: 15 Minute Increments Assessment Assessment Intervention Intervention

36 cpt36 Overview of H & B Codes Codes Effective as (with ongoing revisions of language) Codes Effective as (with ongoing revisions of language) Assessment (e.g., 4 units) Assessment (e.g., 4 units) Intervention (e.g., up to a total of 48 units) Intervention (e.g., up to a total of 48 units) Established Medical Illness or Diagnosis Established Medical Illness or Diagnosis Focus on Biopsychosocial Factors Focus on Biopsychosocial Factors

37 cpt37 H & B: Rationale Acute or Chronic Health Illness Acute or Chronic Health Illness Not Applicable to Psychiatric Illness Not Applicable to Psychiatric Illness However, Both Could be Treated Simultaneously But Not Within the Same Session However, Both Could be Treated Simultaneously But Not Within the Same Session

38 cpt38 H & B: Examples of Service Symptom Management & Expression Symptom Management & Expression Patient Adherence to Medical Treatment Patient Adherence to Medical Treatment Health Promoting Behaviors Health Promoting Behaviors Overall Adjustment to Medical Illness Overall Adjustment to Medical Illness

39 cpt39 Health & Behavior Assessment Codes Health and behavior assessment (e.g., health- focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires) Health and behavior assessment (e.g., health- focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires) each 15 minutes each 15 minutes face-to-face with the patient face-to-face with the patient initial assessment initial assessment re-assessment re-assessment

40 cpt40 H & B: Assessment Explanation Identification of Psychological, Behavioral, Emotional, Cognitive and/or Social Factors Identification of Psychological, Behavioral, Emotional, Cognitive and/or Social Factors In the Prevention, Treatment and/or Management of Physical Health Problems In the Prevention, Treatment and/or Management of Physical Health Problems Focus on Biopsychosocial and not Mental Health Factors Focus on Biopsychosocial and not Mental Health Factors

41 cpt41 H & B: Assessment Examples Health-Focused Clinical Interview Health-Focused Clinical Interview Behavioral Observations Behavioral Observations Psychophysiological Monitoring Psychophysiological Monitoring Health-Oriented Questionnaires Health-Oriented Questionnaires

42 cpt42 Health & Behavior Intervention Codes Health and behavior intervention Health and behavior intervention each 15 minutes each 15 minutes face-to-face face-to-face individual individual group (2 or more patients) group (2 or more patients) family (with the patient present) family (with the patient present) (limited acceptability) (limited acceptability) family (without the patient present; not being reimbursed ) family (without the patient present; not being reimbursed )

43 cpt43 H & B: Intervention Explanation Modification of Psychological, Behavioral, Emotional, Cognitive and/or Social Factors Modification of Psychological, Behavioral, Emotional, Cognitive and/or Social Factors Affecting Physiological Functioning, Disease Status, Health and/or Well-Being Affecting Physiological Functioning, Disease Status, Health and/or Well-Being Focus = Improvement of Health with Cognitive, Behavioral, Social and/or Psychophysiological Procedures Focus = Improvement of Health with Cognitive, Behavioral, Social and/or Psychophysiological Procedures

44 cpt44 H & B: Intervention Examples Cognitive Cognitive Behavioral Behavioral Social Social Psychophysiological Psychophysiological

45 cpt45 H & B: Diagnoses Associated with an Acute or Chronic Medical Illness Associated with an Acute or Chronic Medical Illness Not Applicable to Psychiatric Diagnoses Not Applicable to Psychiatric Diagnoses

46 cpt46 CPT: Model System Psychiatric Psychiatric Neurological Neurological Non-Neurological Medical Non-Neurological Medical

47 cpt47 CPT Model Rationale for CPT Code: Rationale for CPT Code: Choose Code that Best Describes the Service Choose Code that Best Describes the Service Match the Interview with the Testing with the Intervention Code with the Diagnosis Match the Interview with the Testing with the Intervention Code with the Diagnosis Goal = Uniformity and Fluency Goal = Uniformity and Fluency

48 cpt48 CPT: Psychiatric Model (Children & Adult) Interview Interview adult adult child child Testing Testing Also, for children Also, for children Intervention Intervention e.g., adult e.g., adult e.g., child e.g., child

49 cpt49 CPT: Neurological Model (Children & Adult) Interview Interview Testing Testing 96118/19/ /19/20 Intervention Intervention

50 cpt50 CPT: Non-Neurological Medical Model (Children & Adult) Interview & Assessment Interview & Assessment (initial) (initial) (re-evaluation) (re-evaluation) Intervention Intervention (individual) (individual) (group) (group) (family with patient) (family with patient)

51 cpt51 C. CPT: Diagnosing Psychiatric Psychiatric DSM DSM The problem with DSM and neuropsych testing of developmentally-related neurological problems The problem with DSM and neuropsych testing of developmentally-related neurological problems Neurological & Non-Neurological Medical Neurological & Non-Neurological Medical ICD – 9 CM (physical diagnosis coding) ICD – 9 CM (physical diagnosis coding)

52 cpt52 D. CPT: Medical Necessity Scientific & Clinical Necessity Scientific & Clinical Necessity Local Medical Review or Carrier Definitions of Necessity Local Medical Review or Carrier Definitions of Necessity Necessity = CPT x DX formulary Necessity = CPT x DX formulary Necessity Dictates Type and Level of Service Necessity Dictates Type and Level of Service Necessity Can Only be Proven with Documentation Necessity Can Only be Proven with Documentation Screening or Regularly Scheduled Evaluations Do Not Meet Criteria for Necessity Screening or Regularly Scheduled Evaluations Do Not Meet Criteria for Necessity Will Results Affect Outcome of Patient? Will Results Affect Outcome of Patient? Will New Information Be Obtained as a Function of the Activity? Will New Information Be Obtained as a Function of the Activity?

53 cpt53 Medically Reasonable and Necessary Section 1862 (a)(1) , C.F.R., (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 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; Re-evaluation should only occur when there is a potential change in; Diagnosis Diagnosis Symptoms Symptoms

54 cpt54 E. CPT: Documenting Purpose Purpose Payer Requirements Payer Requirements General Principles General Principles History History Examination Examination Decision Making Decision Making

55 cpt55 Documentation: Purpose Medical Necessity Medical Necessity Evaluate and Plan for Treatment Evaluate and Plan for Treatment Communication and Continuity of Care Communication and Continuity of Care Claims Review and Payment Claims Review and Payment Research and Education Research and Education

56 cpt56 Documentation: General Principles Rationale for Service Rationale for Service Assessment, Progress, Impression, or Diagnosis Assessment, Progress, Impression, or Diagnosis Plan for Care Plan for Care Date and Identity of Observer Date and Identity of Observer Also Also Legible Legible Timely Timely Confidential Confidential

57 cpt57 Documentation: Basic Information Across Codes Date Date Time, if applicable Time, if applicable Identity of Observer (technician ?) Identity of Observer (technician ?) Reason for Service Reason for Service Status Status Procedure Procedure Results/Finding Results/Finding Impression/Diagnoses Impression/Diagnoses Disposition Disposition Stand Alone Stand Alone

58 cpt58 Documentation: Chief Complaint Concise Statement Describing the Symptom, Problem, Condition, & Diagnosis Concise Statement Describing the Symptom, Problem, Condition, & Diagnosis Foundation for Medical Necessity Foundation for Medical Necessity Must be Complete & Exhaustive Must be Complete & Exhaustive

59 cpt59 Documentation: Present Illness Symptoms Symptoms Location, Quality, Severity, Duration, timing, Context, Modifying Factors Associated Signs Location, Quality, Severity, Duration, timing, Context, Modifying Factors Associated Signs Follow-up Follow-up Changes in Condition Changes in Condition Compliance Compliance

60 cpt60 Documentation: History Past Past Family Family Social Social Medical/Psychological Medical/Psychological

61 cpt61 Documentation: Assessment Reason for Service Reason for Service Dates (amount of service time?) Dates (amount of service time?) Identity of Tester (technician) Identity of Tester (technician) Tests and Protocols (included editions) Tests and Protocols (included editions) Narrative of Results Narrative of Results Impression Impression Disposition Disposition

62 cpt62 Documentation: Intervention Reason for Service Reason for Service Status of Patient Status of Patient Intervention Performed Intervention Performed Results Obtained Results Obtained Impression or Diagnosis (es) Impression or Diagnosis (es) Disposition Disposition Time Time

63 cpt63 CPT X Report Each CPT Code Should Generate a Separate Report Each CPT Code Should Generate a Separate Report Alternatively, Clearly Label/Title Sections of the Report to Match Codes Used Alternatively, Clearly Label/Title Sections of the Report to Match Codes Used

64 cpt64 Documentation: Suggestions Avoid Handwritten Notes Avoid Handwritten Notes Do Not Use Red Ink Do Not Use Red Ink Avoid Color Paper Avoid Color Paper Document On and After Every Encounter, Every Procedure, Every Patient Document On and After Every Encounter, Every Procedure, Every Patient Review Changes Whenever Applicable Review Changes Whenever Applicable Avoid Standard Phrases & Protocols Avoid Standard Phrases & Protocols

65 cpt65 Documentation Suggestions (continued) Two Tiered System of Documentation (using HIPPA as Model) Two Tiered System of Documentation (using HIPPA as Model) Raw data = handwritten and not for distribution psychotherapy notes Raw data = handwritten and not for distribution psychotherapy notes Report = typed notes for more public consumption Report = typed notes for more public consumption

66 cpt66 E. Time Time is Broadly Defined as What the Professional Does Time is Broadly Defined as What the Professional Does For Intervention – Time is face-to-face For Intervention – Time is face-to-face For Assessment - Time could be either face-to-face or professional time For Assessment - Time could be either face-to-face or professional time

67 cpt67 Time: Definition AMA Definition of Time 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. 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.

68 cpt68 Time: Testing Quantifying Time Quantifying Time Round up or down to nearest increment Round up or down to nearest increment Actual time vs. Elapsed time? Actual time vs. Elapsed time? Time Does Not Include Time Does Not Include Patient completing tests, scales, forms, etc. Patient completing tests, scales, forms, etc. Waiting time by patient Waiting time by patient Typing of reports Typing of reports Non-Professional (e.g., clerical) time Non-Professional (e.g., clerical) time Literature searches, learning new techniques, etc. Literature searches, learning new techniques, etc.

69 cpt69 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 For Timed Codes (in physical medicine): The Beginning and Ending Time Should be Documented Time Should be Documented Along with the Treatment Description Time Should be Documented Along with the Treatment Description

70 cpt70 Time: Physical Medicine Codes (effective ) Physical Medicine Codes are in 15 Increments Physical Medicine Codes are in 15 Increments Multiple Units Can Be Billed on a Date of Service for Same or Different Procedures 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… A substantial amount portion of 15 minutes must be spent in performing the pre, intra, and post-service work…

71 cpt71 Time: Defining 15 Minutes (from CPT Assistant, 08.05, 11-12) ( Defining 15 Minute Increments Defining 15 Minute Increments UnitsAmount of Minutes UnitsAmount of Minutes 1 >08; 08; <23 2>22; 22; <38 3>38; 38; <53 4>53; 53; <68 5>68; 68; <83 6>83; 83; <98 7>98; 98; <113 8>113; 113;<128 Over 2 hourssimilar pattern as above Over 2 hourssimilar pattern as above

72 cpt72 Part II: Specific Issues with CPT (Intermediate) Reimbursement Reimbursement Supervision & Incident to Supervision & Incident to Technicians Technicians Time Time Coverage & Payment Coverage & Payment Fraud & Abuse Fraud & Abuse UPIN # UPIN #

73 cpt73 A. Reimbursement History Cost Plus Cost Plus Prospective Payment System (PPS) Prospective Payment System (PPS) Diagnostic Related Groups (DRGs) Diagnostic Related Groups (DRGs) Customary, Prevailing & Reasonable (CPR) Customary, Prevailing & Reasonable (CPR) Resource Based Relative Value System (RBRVS) Resource Based Relative Value System (RBRVS) Note: On average, insurance companies will pay approximate 75% of its income) Note: On average, insurance companies will pay approximate 75% of its income)

74 cpt74 Relative Value Units: Overview Components Components Units Units Values Values Current Problems Current Problems

75 cpt75 RVU: Components Physician Work Resource Value Physician Work Resource Value Practice Expense Resource Value Practice Expense Resource Value Malpractice Malpractice Geographic Geographic Conversion Factor (approx. $ ) Conversion Factor (approx. $ )

76 cpt76 RVU Components Percentages Physician Work=52% Physician Work=52% Practice Expense=44% Practice Expense=44% Liability= 4% Liability= 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 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

77 cpt77 Defining Physician Work Clinical Work Clinical Work Mental Effort and Judgment Mental Effort and Judgment Technical Skill/Physical Effort Technical Skill/Physical Effort Psychological Stress Psychological Stress

78 cpt78 Defining Practice Expense Constitutes 43% of Medicare Payments Constitutes 43% of Medicare Payments Components of Practice Expense Components of Practice Expense Clinical non-physician labor (43 categories) Clinical non-physician labor (43 categories) RN/LPN/MTA = $.37/minute ( $37,440/year) RN/LPN/MTA = $.37/minute ( $37,440/year) Medical disposable supplies (842 items) Medical disposable supplies (842 items) Equipment (553 items) Equipment (553 items)

79 cpt79 RVU: Values Psychotherapy: Psychotherapy: Prior Value =1.86 Prior Value =1.86 New Value = 2.65 New Value = 2.65 Psych/NP Testing: Psych/NP Testing: Work value= 0 Work value= 0 Hsiao study recommendation = 2.2 Hsiao study recommendation = 2.2 New Value = undetermined New Value = undetermined Health & Behavior Health & Behavior.25 (per 15 minutes increments).25 (per 15 minutes increments)

80 cpt80 RVU: Acceptance Medicare (100% since ) Medicare (100% since ) Medicaid = 100% Medicaid = 100% Private Payors = 74% and increasing to 95% Private Payors = 74% and increasing to 95% Blue Cross/Blue Shield = 87% Blue Cross/Blue Shield = 87% Managed Care = 69% Managed Care = 69% Other = 44% Other = 44% New Trends: New Trends: RVUs as a Model for All Insurance Companies RVUs as a Model for All Insurance Companies RVUs as a Basis for Compensation Formulas RVUs as a Basis for Compensation Formulas

81 cpt RVU Changes ( CPT Assistant, January, 2006, 16, 1) 283 RVU Changes Submitted 283 RVU Changes Submitted Medicare Accepted 97% Medicare Accepted 97% Professional Liability to Change to 1.00 Professional Liability to Change to 1.00 Geographic Index is Revised Every 3 yrs. Geographic Index is Revised Every 3 yrs.

82 cpt82 CPT x RVU Pre 2006

83 cpt83 National Work RVU/Estimated $ 2006 Values op=outpatient, ip=inpatient, est=estimate rvu = work Code # OP RVU IP RVU OP $ est IN $est

84 cpt84 B. Supervision ( Federal Register, 69, #150, August 5, 2004, page 47553) Hold Doctoral Degree in Psychology Hold Doctoral Degree in Psychology Licensed or Certified as a Psychologist Licensed or Certified as a Psychologist Applicable Only to clinical psychologists (and not independent psychologists as defined by Medicare) Applicable Only to clinical psychologists (and not independent psychologists as defined by Medicare) Rationale Rationale Allows for higher level of expertise to supervise Allows for higher level of expertise to supervise Could relieve burden on physicians and facilities Could relieve burden on physicians and facilities May increase service in rural areas May increase service in rural areas Recommended Supervision Level = General Recommended Supervision Level = General

85 cpt85 Supervision Supervision Supervision 1.General = overall direction 1.General = overall direction 2.Direct = present in office suite 2.Direct = present in office suite 3.Personal = in actual room 3.Personal = in actual room 4.Psychological = when supervised by a psychologist 4.Psychological = when supervised by a psychologist

86 cpt86 Supervision Program Memorandum Carriers Department of Health and Human Services- HCFA Transmittal b-01-28; April 19, 2001 Levels of Supervision Levels of Supervision General General Furnished under overall direction and control, presence is not required Furnished under overall direction and control, presence is not required Direct Direct Must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure Must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure Personal Personal Must be in attendance in the room during the performance of the procedure Must be in attendance in the room during the performance of the procedure

87 cpt87 Incident to Rationale for Incident to Rationale for Incident to Congress intended to provide coverage for services not typically covered elsewhere Congress intended to provide coverage for services not typically covered elsewhere Definition of Physician Extender Definition of Physician Extender How How Limitations Limitations Definition of In vs. Outpatient Definition of In vs. Outpatient Geographic Vs Financial Geographic Vs Financial Probably Limited Future to Incident to Due to Inclusion of New Testing Codes Probably Limited Future to Incident to Due to Inclusion of New Testing Codes

88 cpt88 Defining Incident to Defining Incident to Definition Definition Commonly furnished service Commonly furnished service Integral, though incidental to psychologist Integral, though incidental to psychologist Performed under direct supervision Performed under direct supervision Either furnished without charge or as part of the psychologists charge Either furnished without charge or as part of the psychologists charge The employee meets the contractual requirement sent by CMS (e.g., 1099) The employee meets the contractual requirement sent by CMS (e.g., 1099)

89 cpt89 More Incident to When is Incident to Acceptable: When is Incident to Acceptable: Testing - Definite Testing - Definite Cognitive Rehabilitation; Biofeedback - Probably 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 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

90 cpt90 Incident to & Site of Service Incident to & Site of Service Outpatient vs. Inpatient Outpatient vs. Inpatient Geographical Location- Separate Geographical Location- Separate Corporate Entities- Separate Corporate Entities- Separate Billing Service- Separate Billing Service- Separate Chart Information & Location- Separate Chart Information & Location- Separate

91 cpt91 Incident to versus Independent Service When Does Incident to Become Independent Service When Does Incident to Become Independent Service Appearance of No Supervision Appearance of No Supervision Clinical Decisions are Made by Staff Clinical Decisions are Made by Staff Ratio of Physician to Staff Time Becomes Disproportionate Ratio of Physician to Staff Time Becomes Disproportionate Distance Difficulties Distance Difficulties Supervision Difficulties Supervision Difficulties

92 cpt92 Difficulties with Incident to The Physician Must Evaluate and/or Treat the Patient First The Physician Must Evaluate and/or Treat the Patient First No Clear Guidelines Regarding Reasonable Mix of Physician to Extender Activities No Clear Guidelines Regarding Reasonable Mix of Physician to Extender Activities What are the Limits of the Extender? What are the Limits of the Extender?

93 cpt93 Difference Between Supervision and Incident to Supervision Supervision Applies to whether and how a physician oversees the work of ancillary personnel Applies to whether and how a physician oversees the work of ancillary personnel A clinical concept A clinical concept Can occur at any level of supervision (from general to personal) Can occur at any level of supervision (from general to personal) Incident toIncident 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

94 cpt94 The Future of Incident to vs. Supervision Incident to Incident to Intervention Intervention Technical Interventions such as biofeedback and cognitive rehabilitation Technical Interventions such as biofeedback and cognitive rehabilitation Testing Testing None, if technical codes accepted None, if technical codes accepted If not, presumably it can continue If not, presumably it can continue Supervision Supervision Regardless, some form of supervision required if a technician is used Regardless, some form of supervision required if a technician is used

95 cpt95 C. Defining a Technician What is the Minimum Level of Training Required for a Technician? What is the Minimum Level of Training Required for a Technician? National Association of Psychometrists National Association of Psychometrists NAN Position Paper NAN Position Paper Level of Education- Probably a minimum of Bachelors Level of Education- Probably a minimum of Bachelors Level of Training Level of Training Level of Supervision Level of Supervision

96 cpt96 Defining a Technician (Federal Register, Vol. 66, #149, page 40382) Requirement Requirement Employee (e.g., 1099); employees, leased employees, or independent contractor Employee (e.g., 1099); employees, leased employees, or independent contractor Most common is 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. 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 Common Practice Independent Contractor Independent Contractor

97 cpt97 Defining a Technician HCFA/CMS Line 25 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 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 Anybody else, from high school to post-doctoral fellow, is, for all practical purposes, a technician Extern, Intern, Postdoctoral Fellow, Technician Extern, Intern, Postdoctoral Fellow, Technician

98 cpt98 Acceptance of Technicians Medicare Medicare Outside of North Central & California, yes Outside of North Central & California, yes Some states require specific modifiers (e.g., North Carolina, use the AH modifier) Some states require specific modifiers (e.g., North Carolina, use the AH modifier) Private Carriers Private Carriers Magellan, United Health… – yes Magellan, United Health… – yes Others (e.g., Value Options) – under consideration Others (e.g., Value Options) – under consideration

99 cpt99 Uses of Technicians The Qualified Health Provider must; The Qualified Health Provider must; See the patient first See the patient first Supervise the activity Supervise the activity Interpret and write the note/report Interpret and write the note/report Engaged in an ongoing capacity Engaged in an ongoing capacity NOTE: Pattern similar to medical providers NOTE: Pattern similar to medical providers

100 cpt100 Use of Technician Use of Technician Technicians in a Facility Technicians in a Facility A facility in essentially an inpatient setting 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 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 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

101 cpt101 Use of Technicians Practice Expense & Practice Implications Practice Expense & Practice Implications Each tech code has.51 work value Each tech code has.51 work value This means that the provider is engaged in the work This means that the provider is engaged in the work That engagement would include; That engagement would include; Selection of tests Selection of tests Determination of testing protocol Determination of testing protocol Supervision of testing Supervision of testing Interpretation of individual tests Interpretation of individual tests Reporting on individual tests Reporting on individual tests

102 cpt102 The Problem with Training Medicare Will Pay When: Medicare Will Pay When: The physician provides the service alone The physician provides the service alone The physician provides the service in conjunction with the medical student 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 The physician is present in the same room when the student provides the service Possibility of Students as Incident to Possibility of Students as Incident to A Student/Extern/Intern/Postdoc, For All Practical Purposes = a Technician A Student/Extern/Intern/Postdoc, For All Practical Purposes = a Technician

103 cpt103 Medicare Billing Suggestions When to Bill When to Bill Overall = after documentation is in place Overall = after documentation is in place Diagnostic Services Diagnostic Services After the Interview After the Interview After all testing is completed and a report has been completed After all testing is completed and a report has been completed Billing should occur only once after testing Billing should occur only once after testing Therapeutic Services Therapeutic Services Could occur after each session Could occur after each session Should occur at least by the end of the month Should occur at least by the end of the month

104 cpt104 Billing Model Components Components Procedure Completed Procedure Completed Number of Units of that Procedure Number of Units of that Procedure Location or Site Where the Service was Provided Location or Site Where the Service was Provided Date of Service Date of Service CPT X # of Units X Dx X Site of Service X Date CPT X # of Units X Dx X Site of Service X Date

105 cpt105 E. Office of Inspector General (2005 Orange Book) Identify Nursing Home Residents with Serious Mental Illness (OEI Identify Nursing Home Residents with Serious Mental Illness (OEI Improve Assessments of Mental Illness (OEI ) Improve Assessments of Mental Illness (OEI ) Eliminate Inappropriate Payments for Mental Health Services Eliminate Inappropriate Payments for Mental Health Services

106 cpt106 Expenditures & Fraud Projections Projections Current Current 14% 14% By 2011; By 2011; 17% ($2.8 trillion) 17% ($2.8 trillion)

107 cpt107 Fraud: Medicares Interpretation of Physician Liability Overpayment From Incorrect Charge Overpayment From Incorrect Charge Mathematical or Clerical Error Mathematical or Clerical Error Billing for Items Known Not to be Covered Billing for Items Known Not to be Covered Services Provided by Non-qualified Practitioner Services Provided by Non-qualified Practitioner Inappropriate Documentation Inappropriate Documentation

108 cpt108 Defining Fraud Fraud Fraud Intentional Intentional Pattern Pattern Error Error Clerical Clerical Dates Dates

109 cpt109 Problem: Fraud & Abuse 26 Different Kinds of Fraud Types 26 Different Kinds of Fraud Types Psychological Services Have Been Identified as Problematic Psychological Services Have Been Identified as Problematic

110 cpt110 Fraud & Office of Inspector General Primary Problems Primary Problems Medical Necessity (approximately $5 billion) Medical Necessity (approximately $5 billion) Documentation Documentation Psychotherapy (oig.hhs/gov/reports/region5/ ) Psychotherapy (oig.hhs/gov/reports/region5/ ) Individual Individual Group Group # of Hours # of Hours Who Does the Therapy Who Does the Therapy Psychological Testing Psychological Testing # of Hours # of Hours Documentation Documentation

111 cpt111 Fraud (continued) Nursing Homes Nursing Homes Identification Identification Overuse of Services Overuse of Services Children Children

112 cpt112 Fraud: OIGs May 2001 Study (OEI ) Overall Payments in 1998 = $1.2 billion Overall Payments in 1998 = $1.2 billion (62% outpatient = $718 million) Inappropriate Outpatient Mental Health Inappropriate Outpatient Mental Health Particularly Problematic due to Particularly Problematic due to Medically unnecessary Medically unnecessary Billed incorrectly Billed incorrectly Rendered by unqualified providers Rendered by unqualified providers Undocumented or poorly documented Undocumented or poorly documented

113 cpt113 OIG Report (continued) Provider Not Qualified= 11% Provider Not Qualified= 11% Medically Unnecessary = 23% Medically Unnecessary = 23% Billed Incorrectly= 41% Billed Incorrectly= 41% Insufficient Documentation= 65% Insufficient Documentation= 65%

114 cpt114 Fraud (cont.) Estimated Pattern of Fraud Analysis Estimated Pattern of Fraud Analysis For-profit Medical Centers For-profit Medical Centers For-profit Medical Clinics For-profit Medical Clinics Non-profit Medical Centers Non-profit Medical Centers Non-profit Medical Clinics Non-profit Medical Clinics Nursing Homes Nursing Homes Group Practices Group Practices Individual Practices Individual Practices Research Grants and, if applicable, Clinical Trials Research Grants and, if applicable, Clinical Trials

115 cpt115 Fraud: (can go back 10 years) Initial Review (14 points of submitted claims) Initial Review (14 points of submitted claims) Legibility Legibility Coverage Coverage Matching dates Matching dates Signature Signature Subsequent Review (occurs if over 5-6 items are failed in initial review) Subsequent Review (occurs if over 5-6 items are failed in initial review) Does the service affect a potential change in medical condition? Does the service affect a potential change in medical condition?

116 cpt116 Fraud: CERT Program (www.oig.hhs.gov) Comprehensive Error Rate Testing Program Comprehensive Error Rate Testing Program National National Contractor-specific Contractor-specific Service-specific Service-specific Reviews both denied and accepted claims 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 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

117 cpt117 Fraud: New Information The Good Enough or Common Sense Approach The Good Enough or Common Sense Approach If Medicare Audit Occurs then an Increased Likelihood of Medicaid Audit If Medicare Audit Occurs then an Increased Likelihood of Medicaid Audit Practice Situations That Increase Potential Audits; Practice Situations That Increase Potential Audits; Skilled Nursing Facilities Skilled Nursing Facilities Statistical Outliers Statistical Outliers Testing Testing States with Increased Audit Activity; States with Increased Audit Activity; TX, CA, FL, PR TX, CA, FL, PR

118 cpt118 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. 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% Claim errors have exceed 34%

119 cpt119 Fraud: Red Book (continued) Problem Areas Problem Areas Acute Hospital outpatient Services ($224) Acute Hospital outpatient Services ($224) Partial Hospitalization ($180) Partial Hospitalization ($180) Psychiatric Hospital outpatient ($57) Psychiatric Hospital outpatient ($57) Nursing Home ($30) Nursing Home ($30) General Mental Health ($185) General Mental Health ($185) Beneficiaries who are unable to benefit from psychotherapy services Beneficiaries who are unable to benefit from psychotherapy services Note: in millions (total for $676,000,000) Note: in millions (total for $676,000,000)

120 cpt120 F. Unique Physician Identification Number (UPIN) Historical Historical UPIN # UPIN # Box 17 a CMS (insurance) 1500 form Box 17 a CMS (insurance) 1500 form Present Present National Provide Identification Number National Provide Identification Number

121 cpt121 National Provider Identification Number (CMS memo, 45 CFR Part 16c) Basic Information Basic Information 10 Position numeric & individual number 10 Position numeric & individual number No specific information about provider No specific information about provider Managed by CMSs Provider System Managed by CMSs Provider System Dates of Implementation Dates of Implementation May 23, 2005 – Apply May 23, 2005 – Apply May 23, 2007 – Most entities will use May 23, 2007 – Most entities will use May 23, 2008 – All entities will use May 23, 2008 – All entities will use Applicability Applicability Federal plans – immediately Federal plans – immediately State plans – this year State plans – this year Other health plans- as soon as feasible Other health plans- as soon as feasible

122 cpt122 Part III: Summary, Trajectories, Resources & Questions/Answers Summary of Present Problems Summary of Present Problems Trajectories Trajectories Resources Resources Questions & Answers Questions & Answers

123 cpt123 A. Present Problems Commercial Carriers Commercial Carriers Medical vs. Mental Health vs. No Coverage Medical vs. Mental Health vs. No Coverage Upper limits on # of hours/evaluation Upper limits on # of hours/evaluation Limited test formularies Limited test formularies Specific time per test Specific time per test Phantom benefits- carrier states a service is covered but no authorization is possible Phantom benefits- carrier states a service is covered but no authorization is possible

124 cpt124 Summary of Present Problems with New Codes- Carrier-Based Code Acceptance- Code Acceptance- Use of new codes at all Use of new codes at all If 96101/96118 accepted, technical and computer codes not being accepted If 96101/96118 accepted, technical and computer codes not being accepted Overall interpretation of codes (EOBs are still out) Overall interpretation of codes (EOBs are still out) Code Payment- Code Payment- Lower than expected RVU % by private carriers Lower than expected RVU % by private carriers Medicare carriers not paying- too high of a value placed by AMA and CMS Medicare carriers not paying- too high of a value placed by AMA and CMS Human error in interpreting code submission (manuals/software) Human error in interpreting code submission (manuals/software) Congressional action pending Congressional action pending Technicians Technicians Current and operational definition Current and operational definition Acceptance by carriers & licensing boards (e.g., NY) Acceptance by carriers & licensing boards (e.g., NY)

125 cpt125 Summary of Present Problems with New Codes- Provider-Based General Understanding & Usage General Understanding & Usage Specific Code Usage- Specific Code Usage- Mixing of psychiatric with neuropsychological procedures as well as mixing of diagnostic codes Mixing of psychiatric with neuropsychological procedures as well as mixing of diagnostic codes Time (estimates, rounding) Time (estimates, rounding) Professional having to see the patient at all Professional having to see the patient at all Professional having to interpret and write the evaluation 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) 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)

126 cpt126 Summary of Present Problems with Codes- Provider-Based (continued) Technicians Technicians Training programs (externs, interns and postdoctoral fellows) Training programs (externs, interns and postdoctoral fellows) Essentially no difference between a bachelors level technician and a postdoctoral fellow Essentially no difference between a bachelors level technician and a postdoctoral fellow Difference between training and providing professional services Difference between training and providing professional services Limited interpretation of scoring (away from the patient) Limited interpretation of scoring (away from the patient) Difference among psychometricians and psychometrists as well as technicians Difference among psychometricians and psychometrists as well as technicians Psychometricians = doctoral level scientist involved in testing issue Psychometricians = doctoral level scientist involved in testing issue Technicians = any provider that does not have a contract with the insurance carrier Technicians = any provider that does not have a contract with the insurance carrier Psychometrists= typically a certified technician (e.g., NAP) Psychometrists= typically a certified technician (e.g., NAP)

127 cpt127 Summary of Present Problems with Testing Codes- Potential Concerns Qualifications Qualifications Who can perform neuropsychological services? Who can perform neuropsychological services? CMS/AMA delegates that restriction to states licensing boards and carriers CMS/AMA delegates that restriction to states licensing boards and carriers Technicians Technicians Could no acceptance of technical code = incident to? Could no acceptance of technical code = incident to? Understanding that scoring time is built in the code value 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 One could score while the patient is being tested, easier for adults than for children but information about the observation has to occur Tests Tests Time estimates (HMOs) for test administration & interpretation Time estimates (HMOs) for test administration & interpretation Documentation of start/stop times Documentation of start/stop times Listing of actual tests for documentation Listing of actual tests for documentation Formulary (both in terms of tests as well as time allocated) Formulary (both in terms of tests as well as time allocated)

128 cpt128 Summary of Present Problems with Testing Codes- Potential Concerns Documentation Documentation Inclusion of #s along with narratives in documentation Inclusion of #s along with narratives in documentation Matching of documentation with carrier requirements Matching of documentation with carrier requirements Inclusion of Actual Time Inclusion of Actual Time Inclusion of name of technician Inclusion of name of technician Masters Level Practitioners Masters Level Practitioners Will they be viewed as qualified health practitioners? Will they be viewed as qualified health practitioners?

129 cpt129 B. Future Perspectives : 2003 Predictions Paradigms Paradigms Industrial vs. Boutique/Niche Industrial vs. Boutique/Niche Clinical vs. Forensic Clinical vs. Forensic Mental Health vs. Health Mental Health vs. Health Existing vs. Developing Existing vs. Developing

130 cpt Predictions Federal Federal Technical – Health Electronic Records by 2008 Technical – Health Electronic Records by 2008 Performance Based Payment Performance Based Payment Traditionally = Fee for service provided Traditionally = Fee for service provided Anticipated = Fee for performance/results obtained Anticipated = Fee for performance/results obtained Economic Economic Overall, Positive Overall, Positive

131 cpt (Continued) Increased Probability of Audits Increased Probability of Audits Psychological and Neuropsychological Testing Psychological and Neuropsychological Testing Individual Practitioners Individual Practitioners Skilled Nursing Facilities Skilled Nursing Facilities In Institutions, supervision and incident to In Institutions, supervision and incident to Primary Issues of Concern Primary Issues of Concern Medical Necessity Medical Necessity Documentation Documentation

132 cpt (Continued) Professional Professional Institutionally Based Institutionally Based Limitations secondary to incident to Limitations secondary to incident to Difficulties in gaining access to GME funds Difficulties in gaining access to GME funds Practitioner Based Practitioner Based Increase in audits Increase in audits Shifting in practice patterns Shifting in practice patterns Practice Parameter Based Practice Parameter Based Difficulties with battery-based approaches to diagnostics Difficulties with battery-based approaches to diagnostics Expansion and alterations of reimbursement practices Expansion and alterations of reimbursement practices Significant expansion of types of services and clients served Significant expansion of types of services and clients served

133 cpt Medicare Medicare % decrease over next 6 years (compared to 1.5% increase each over the last 3 years; AAP Advance, Summer, 2005) % decrease over next 6 years (compared to 1.5% increase each over the last 3 years; AAP Advance, Summer, 2005) Institutional Institutional Further defining of supervision & incident to Further defining of supervision & incident to Significantly limited access to funds (e.g., GME) Significantly limited access to funds (e.g., GME) Individual Individual Increased focus on business issues Increased focus on business issues Technician based practice will increase Technician based practice will increase Continued emphasizes on expanding non-health care services (e.g., forensic) Continued emphasizes on expanding non-health care services (e.g., forensic) Practice Practice Diagnostic work will continue being emphasized (e.g.,fMRI) Diagnostic work will continue being emphasized (e.g.,fMRI) Pay-for-Performance or P4P (5-10% differences; Medicare Payment Advisory Commission, ) 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) WellPoint, WellChoice, HealthNet, MVP Health Care, Blue Cross of California and 32 states (105 programs in mid 2005)

134 cpt Issues to be Addressed Issues to be Addressed Information dissemination Information dissemination Colleagues Colleagues Third-party insurers/payors Third-party insurers/payors Potential mix of old and new testing codes for 2006 Potential mix of old and new testing codes for 2006 Typical use of combination of codes Typical use of combination of codes Technician qualifications and training Technician qualifications and training Use of computerized tests Vs. tests that are computerized but interactive Use of computerized tests Vs. tests that are computerized but interactive Appropriate documentation Appropriate documentation Technician identification Technician identification Time for testing and therapy Time for testing and therapy

135 cpt Early Portions of 2006 = Confusion in Use & Reimbursement of Codes Early Portions of 2006 = Confusion in Use & Reimbursement of Codes The Use of Technicians The Use of Technicians Insurance Carriers Acceptance of Codes Insurance Carriers Acceptance of Codes Decreased Revenue Stream Decreased Revenue Stream Middle Portions of 2006 = Increased Stabilization in Use & Reimbursement of Codes Middle Portions of 2006 = Increased Stabilization in Use & Reimbursement of Codes Later Portion of 2006 = Potential Increase in Overall Reimbursement Later Portion of 2006 = Potential Increase in Overall Reimbursement By 2007 = Likely and Stable Increase in Reimbursement Patterns By 2007 = Likely and Stable Increase in Reimbursement Patterns By 2010 = Addition of Performance to Work as a Factor for Reimbursement By 2010 = Addition of Performance to Work as a Factor for Reimbursement

136 cpt136 Pay for Performance (P4P) Initiatives Premise Premise Evidence-based guidelines Evidence-based guidelines Outcome more than procedure based Outcome more than procedure based Initial Application Initial Application Dartmouth, Duke & Michigan Dartmouth, Duke & Michigan Final Application Final Application 5-10 years 5-10 years

137 cpt137 Beyond 2006 (CMS) Health Care Spending & GDP Health Care Spending & GDP 1960 = 5.0% 1960 = 5.0% 1970 = 7.0% 1970 = 7.0% 1990 = 9.0% 1990 = 9.0% 2002 = 15.4% 2002 = 15.4% 2004 = 16.0% 2004 = 16.0% 2005 = 16.2% 2005 = 16.2% 2010=18.0% 2010=18.0% 2015 = 20.0% ( or 4 trillion $) 2015 = 20.0% ( or 4 trillion $) Final =33.3% Final =33.3%

138 cpt138 Beyond 2006: What Does the American Public Want? Life Expectancy #1 Life Expectancy #1 Life Value = approximately $5 million Life Value = approximately $5 million Expected Expenditure on Health Care= will finally settle at about 1/3 of earned income 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 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 Government (e.g., Medicare) Will, However, Set the Standard for Health Care

139 cpt139 Mechanisms to Keep Informed APA Practice Website (www.apa.org) APA Practice Website (www.apa.org) NAN Website (www.nanonline.org) NAN Website (www.nanonline.org)www.nanonline.org 40 Website (www.div40.org) 40 Website (www.div40.org) Support these continuing efforts by joining APA, NAN, Division 40, SPA as well as your state association Support these continuing efforts by joining APA, NAN, Division 40, SPA as well as your state association

140 cpt140 C. Resources General Web Sites General Web Sites (medicare/medicaid) (medicare/medicaid) (health & human services) (health & human services) (inspector general) (inspector general) (apas cpt information) (apas cpt information) (agency for healthcare research) (agency for healthcare research) (medical payment advisory comm.) (medical payment advisory comm.) (statistics) (statistics) (clinical neuropsychology div of apa) (clinical neuropsychology div of apa) (national association of psychometrists) (national association of psychometrists) (federal statutes and regulations) (federal statutes and regulations) (staff salaries) (staff salaries)

141 cpt141 Resources (continued) Payment/Coverage Payment/Coverage (covered services) (covered services) (non-covered) (non-covered) (apa lmrp) (apa lmrp) (medicare lmrp) (medicare lmrp) (census x type of procedure data) (census x type of procedure data) LMRP Reconsideration Process LMRP Reconsideration Process Compliance Web Sites Compliance Web Sites (office of inspector general) (office of inspector general) (medicare) (medicare) (united states codes) (united states codes) (psychologists & hipaa) (psychologists & hipaa) (hipaa) (hipaa) (health care compliance assoc.) (health care compliance assoc.)

142 cpt142 Resources (continued) ICD ICD (who) (who) (ccd) (ccd) Coding Web Sites Coding Web Sites assn.org/Catalog/cpt/cpt_search.jsp (ama cpt) assn.org/Catalog/cpt/cpt_search.jsp (ama cpt) assn.org/Catalog/cpt/cpt_search.jsp assn.org/Catalog/cpt/cpt_search.jsp (academy of coders) (academy of coders) (coding edits) (coding edits)

143 cpt143 Resources Telephone Numbers Telephone Numbers APA Practice Directorates Government Relations Office; APA Practice Directorates Government Relations Office; AMA CPT Office; AMA CPT Office; Medicare National Coverage Determinations; Medicare National Coverage Determinations;

144 cpt144 Contact Information Websites Websites Univ = Univ = Practice = Practice = NAN = NAN = University = University = Practice = Practice = Telephone Telephone University = University = Practice = Practice =


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