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APA SLC 2005 Recent Changes in Coding and Related Issues American Psychological Association American Psychological Association State Leadership Conference.

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Presentation on theme: "APA SLC 2005 Recent Changes in Coding and Related Issues American Psychological Association American Psychological Association State Leadership Conference."— Presentation transcript:

1 APA SLC 2005 Recent Changes in Coding and Related Issues American Psychological Association American Psychological Association State Leadership Conference State Leadership Conference Washington, D.C. Washington, D.C

2 APA SLC 2005 Outline Current Procedural Terminology Current Procedural Terminology Documentation Documentation Defining Time Defining Time Relative Value Units Relative Value Units Ongoing CPT Developments Ongoing CPT Developments

3 APA SLC 2005 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 CMS CMS AMA Under License with CMS AMA Under License with CMS CMS Now Provides Active Input into CPT CMS Now Provides Active Input into CPT

4 APA SLC 2005 CPT: Background/Direction Current System = CPT 5 Current System = CPT 5 Categories Categories I= Standard Coding for Professional Services I= Standard Coding for Professional Services II = Performance Measurement II = Performance Measurement III = Emerging Technology III = Emerging Technology

5 APA SLC 2005 CPT: Composition AMA House of Delegates AMA House of Delegates 109 Medical Specialties 109 Medical Specialties HCPAC HCPAC 11 Societies (e.g., APA) 11 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

6 APA SLC 2005 What Is a CPT Code? Professional Health Service Provided Across the Country at Multiple locations Professional Health Service Provided Across the Country at Multiple locations Many Physicians Perform Services Many Physicians Perform Services Clinical Efficacy is Established and Documented in Peer-Reviewed Literature Clinical Efficacy is Established and Documented in Peer-Reviewed Literature

7 APA SLC 2005 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 Separate Sections Sections = Five Separate Sections Psychiatry Psychiatry Biofeedback Biofeedback Central Nervous Assessment Central Nervous Assessment Physical Medicine & Rehabilitation Physical Medicine & Rehabilitation Health & Behavior Assessment & Management Health & Behavior Assessment & Management

8 APA SLC 2005 CPT: Development of a Code Initial Initial Health Care Advisory Committee (non-MDs) Health Care Advisory Committee (non-MDs) Primary Primary CPT Work Group CPT Work Group CPT Panel CPT Panel Time Frame Time Frame 3-5 to over a decade 3-5 to over a decade

9 APA SLC 2005 CPT: Psychiatry Sections Sections Interview (90801) vs. Intervention (e.g., ) Interview (90801) vs. Intervention (e.g., ) 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

10 APA SLC 2005 CPT: CNS Assessment Interview Interview Testing Testing Psychological = 96100; 96110/11 Psychological = 96100; 96110/11 Neuropsychological = Neuropsychological = Aphasia = Aphasia = Developmental = 96110/111 Developmental = 96110/111

11 APA SLC 2005 CPT: Physical Medicine & Rehabilitation now now Note: 15 minute increments Note: 15 minute increments

12 APA SLC 2005 CPT: Health & Behavior Assessment & Management Purpose: Medical Diagnosis Purpose: Medical Diagnosis Time: 15 Minute Increments Time: 15 Minute Increments Assessment Assessment Intervention Intervention

13 APA SLC 2005 Rationale: General Acute or chronic (health) illness may not meet the criteria for a psychiatric diagnosis Acute or chronic (health) illness may not meet the criteria for a psychiatric diagnosis Avoids inappropriate labeling of a patient as having a mental health disorder Avoids inappropriate labeling of a patient as having a mental health disorder Increases the accuracy of correct coding of professional services Increases the accuracy of correct coding of professional services Increase range of services Increase range of services

14 APA SLC 2005 Overview of Codes New Subsection New Subsection Six New Codes Six New Codes Assessment Assessment Intervention Intervention Established Medical Illness or Diagnosis Established Medical Illness or Diagnosis Focus on Biopsychosocial Factors Focus on Biopsychosocial Factors

15 APA SLC 2005 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

16 APA SLC 2005 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) family (without the patient present; not being reimbursed) family (without the patient present; not being reimbursed)

17 APA SLC 2005 CPT: Model System Psychiatric Psychiatric Neurological Neurological Non-Neurological Medical Non-Neurological Medical Alternatives Alternatives

18 APA SLC 2005 CPT Model Rationale for CPT Code: Rationale for CPT Code: Choose Code that Best Describes the Service Provided Choose Code that Best Describes the Service Provided Match the Interview with the Testing with the Intervention Code Match the Interview with the Testing with the Intervention Code Match All that With a Diagnosis Match All that With a Diagnosis Goal = Uniformity and Fluency Goal = Uniformity and Fluency

19 APA SLC 2005 CPT: Psychiatric Model (Children & Adult) Interview Interview adult adult child child Testing Testing adult adult 96110/11- child 96110/11- child Intervention Intervention e.g., adult e.g., adult e.g., child e.g., child

20 APA SLC 2005 CPT: Neurological Model (Children & Adult) Interview Interview Testing Testing Intervention Intervention

21 APA SLC 2005 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) (family without patient) (family without patient)

22 APA SLC 2005 Recent CPT Changes Biofeedback (90911) Biofeedback (90911) Minor editorial changes in biofeedback training Minor editorial changes in biofeedback training

23 APA SLC 2005 Recent CPT Changes Developmental Testing Codes Developmental Testing Codes Applicability Applicability Children Children Background Background Part of Central Nervous System family of codes Part of Central Nervous System family of codes Hence, no work value (& lower reimbursement rate) Hence, no work value (& lower reimbursement rate) Recently re-surveyed by pediatricians Recently re-surveyed by pediatricians Specific Changes Specific Changes Continues to have no work value Continues to have no work value Use for completion of forms (Connors; by parents) Use for completion of forms (Connors; by parents) Has physician work value Has physician work value Assessment of childs social, emotional, etc status (WJ) Assessment of childs social, emotional, etc status (WJ)

24 APA SLC 2005 Recent CPT Changes : Health & Behavior Assessment Codes Brief History Brief History Inter-divisional Health Care Committee (22, 38, 40, 54; Glueckauf) Inter-divisional Health Care Committee (22, 38, 40, 54; Glueckauf) Convened in 1995 by APA Practice Directorate (Phelps) Convened in 1995 by APA Practice Directorate (Phelps) Drafts Drafts First Draft - September 11, 1998; Final Working Draft – July 1, 2000 First Draft - September 11, 1998; Final Working Draft – July 1, 2000 Presentations Presentations First Presentation to AMA November 6, 1998 ; Final Presentation – August 8, 2000 First Presentation to AMA November 6, 1998 ; Final Presentation – August 8, total presentations- Ft. Lauderdale, Chicago, Denver, San Francisco, Washington, DC, Chicago, Chicago 7 total presentations- Ft. Lauderdale, Chicago, Denver, San Francisco, Washington, DC, Chicago, Chicago Surveys Surveys First Survey January 31, 2001; Final Survey April 26, 2001 First Survey January 31, 2001; Final Survey April 26, 2001 Revisions to Language Revisions to Language First Preamble revision – March, 2002; Last Preamble revision – November, 2004 First Preamble revision – March, 2002; Last Preamble revision – November, 2004 Applicability Applicability When behavioral, cognitive, emotional, and/or psychological techniques are used to assess and/or treat health (medical not psychiatric) problems When behavioral, cognitive, emotional, and/or psychological techniques are used to assess and/or treat health (medical not psychiatric) problems

25 APA SLC 2005 Recent CPT Changes: Health & Behavior Assessment Codes Acceptability Acceptability All Medicare carriers (minus Floridas) All Medicare carriers (minus Floridas) Some Medicaid programs (e.g., Colorado, Vermont) Some Medicaid programs (e.g., Colorado, Vermont) Some private insurers (BC/BS in NC, DC; Nationwide) Some private insurers (BC/BS in NC, DC; Nationwide) Changes Changes Preamble Preamble Clarification Clarification Not a preventive medicine code Not a preventive medicine code Patient can have a history or presence of mental illness Patient can have a history or presence of mental illness Future Expectation Future Expectation No further changes No further changes Increased carrier acceptance, especially if providers educate carriers Increased carrier acceptance, especially if providers educate carriers Final Verification Anticipated Final Verification Anticipated December 1, 2004 December 1, 2004 Applicability starting January 1, 2005 Applicability starting January 1, 2005

26 APA SLC 2005 Develiping CPT Changes: CNS Assessment Codes Neurobehavioral Status Exam Neurobehavioral Status Exam Re-write (different language; same concept) Re-write (different language; same concept) Addition of Physician Work Value Addition of Physician Work Value Psychological Testing Psychological Testing Expansion of existing code Expansion of existing code Addition of Physician Work Value Addition of Physician Work Value Neuropsychological Testing Neuropsychological Testing Expansion of existing code Expansion of existing code Addition of Physician Work Value Addition of Physician Work Value

27 APA SLC 2005 Probable CPT Changes: CNS Assessment Codes Net Effect Net Effect Avoidance of Continuation of Reimbursement Strictly Based on Practice Expense Avoidance of Continuation of Reimbursement Strictly Based on Practice Expense Potential catastrophe in terms of reimbursement Potential catastrophe in terms of reimbursement Potential reimbursement rates in the vicinity of $40/hr Potential reimbursement rates in the vicinity of $40/hr Greater Clarity of Professional and Non-Professional Activities Greater Clarity of Professional and Non-Professional Activities Differentiation of professional, technical and computer activity Differentiation of professional, technical and computer activity Accounting/auditing, research, and salary purposes Accounting/auditing, research, and salary purposes Recognition of Physician Work Recognition of Physician Work Ending a 10 year struggle Ending a 10 year struggle Possibly, Increased Reimbursement Possibly, Increased Reimbursement

28 APA SLC 2005 Pro28bable CPT Changes: CNS Assessment Codes Timetable (activity x date) Timetable (activity x date) 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 Hopeful inclusion in the 2006 Physician Fee Schedule for January 1, 2006 Hopeful inclusion in the 2006 Physician Fee Schedule for January 1, 2006

29 APA SLC 2005 CPT X Report Each CPT Code Should Generate a Separate Report Each CPT Code Should Generate a Separate Report Alternative Clearly Label/Title Sections of the Report to Match Codes Used Alternative Clearly Label/Title Sections of the Report to Match Codes Used

30 APA SLC 2005 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

31 APA SLC 2005 Time Defining Defining Professional (not patient) Time Including: Professional (not patient) Time Including: pre, intra & post-clinical service activities pre, intra & post-clinical service activities Interview & Assessment Codes Interview & Assessment Codes Use 15 minute increments Use 15 minute increments Intervention Codes Intervention Codes Use 15 minute increments Use 15 minute increments

32 APA SLC 2005 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.

33 APA SLC 2005 Time: Testing Quantifying Time Quantifying Time Round up or down to nearest increment Round up or down to nearest increment Time Does Not Include Time Does Not Include Patient completing tests, forms, etc. Patient completing tests, 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.

34 APA SLC 2005 Relative Value Units: Overview Components Components Units Units Values Values Current Problems Current Problems

35 APA SLC 2005 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. $34) Conversion Factor (approx. $34)

36 APA SLC 2005 RVU Components Percentages Physician Work=52% Physician Work=52% Practice Expense=44% Practice Expense=44% Liability= 4% Liability= 4%

37 APA SLC 2005 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

38 APA SLC 2005 Estimate of Psychologists Value Audiologist.52 Audiologist.52 Dietician.43 Dietician.43 RN.42 RN.42 Speech Pathologist.55 Speech Pathologist.55 Psychologist.82 Psychologist.82

39 APA SLC 2005 Defining Practice Expense Medical Supplies Medical Supplies Expendable medical equipment (e.g., forms) Expendable medical equipment (e.g., forms) Medical Equipment Medical Equipment Durable medical equipment (e.g., tests) Durable medical equipment (e.g., tests) Professional Support Staff Professional Support Staff e.g., time e.g., time

40 APA SLC 2005 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)

41 APA SLC 2005 RVU: Acceptance Medicare (100% since ) Medicare (100% since ) Medicaid 100% Medicaid 100% Private Payors 74% Private Payors 74% 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

42 APA SLC 2005 CPT x RVU

43 APA SLC 2005 Medicare Rates TypeDeductibleCo-Payment Part A$9120-$456 (days) Part B$110Health – 20% Psych- 50% Note: Premiums are $78.20/month

44 APA SLC 2005 Problem: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

45 APA SLC 2005 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

46 APA SLC 2005 Problem: 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 Why No Incident to (DRG) Why No Incident to (DRG) Solution Available for Some Training Programs Solution Available for Some Training Programs Probably no Future to Incident to Probably no Future to Incident to

47 APA SLC 2005 Problem: More Incident to When is Incident to Acceptable: When is Incident to Acceptable: Testing Testing Cognitive Rehabilitation; Biofeedback Cognitive Rehabilitation; Biofeedback Psychotherapy Psychotherapy Definition Definition Commonly furnished service Commonly furnished service Integral, though incidental to psychologist Integral, though incidental to psychologist Performed under the supervision Performed under the supervision Either furnished without charge or as part of the psychologists charge Either furnished without charge or as part of the psychologists charge

48 APA SLC 2005 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 to 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

49 APA SLC 2005 Problem: Face-to-Face Implications Implications Technical versus Professional Services Technical versus Professional Services Surgery is the Foundation for CPT (and most work is face-to-face) Surgery is the Foundation for CPT (and most work is face-to-face) Hard to Document & Trace Non-Face-to- Face Work Hard to Document & Trace Non-Face-to- Face Work

50 APA SLC 2005 Problem: Work Value Physician Activities (e.g., Psychotherapy) Result in Work Values Physician Activities (e.g., Psychotherapy) Result in Work Values Psychological Based Activities (i.e., Testing) Have no Work Values Psychological Based Activities (i.e., Testing) Have no Work Values RVUs are Heavily Based on Practice Expenses (which are being reduced) RVUs are Heavily Based on Practice Expenses (which are being reduced) Net Result = Maybe Up to a Half Lower Net Result = Maybe Up to a Half Lower

51 APA SLC 2005 Problem: An Artificial Practice Expense Five Year Reviews Five Year Reviews Prior Methodology Prior Methodology Current Methodology Current Methodology Current Value = approximately 1.5 of 1.75 is practice expense Current Value = approximately 1.5 of 1.75 is practice expense Deadline for New Practice Expense = Deadline for New Practice Expense = New numbers recently submitted New numbers recently submitted Expected Value = closer to 50% of total value at best Expected Value = closer to 50% of total value at best

52 APA SLC 2005 Continued Expansion of Audits (Office of Inspector General; Red Book) Increase from Last Year Increase from Last Year Requested records 124, 379 times Requested records 124, 379 times Increase activity has resulted in outsourcing of auditing services Increase activity has resulted in outsourcing of auditing services Major Applicable Areas Major Applicable Areas 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

53 APA SLC 2005 Resources (continued) LMRP Reconsideration Process LMRP Reconsideration Process Coding Web Sites Coding Web Sites (academy of coders) (academy of coders) (coding edits) (coding edits) Compliance Web Sites Compliance Web Sites (psychologists & hipaa) (psychologists & hipaa) (hipaa) (hipaa) (health care compliance assoc.) (health care compliance assoc.)


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