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Medicare, CPT, RVU: Update, Problems, & Directions Antonio E. Puente, Ph.D. UNC-Wilmington National Academy of Neuropsychology San Fransisco, October 31,

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Presentation on theme: "Medicare, CPT, RVU: Update, Problems, & Directions Antonio E. Puente, Ph.D. UNC-Wilmington National Academy of Neuropsychology San Fransisco, October 31,"— Presentation transcript:

1 Medicare, CPT, RVU: Update, Problems, & Directions Antonio E. Puente, Ph.D. UNC-Wilmington National Academy of Neuropsychology San Fransisco, October 31, 2001

2 Acknowledgments zNAN Board of Directors & Policy and Planning Committee zDivision 40 Board of Directors & Policy and Planning Committee zPractice Directorate of the American Psychological Association zAmerican Medical Association’s CPT Staff zJames Georgoulakis, Ph.D.; Leslie Rosenstein, Ph.D., Barbara Uzzell, Ph.D.

3 Background zAmerican Medical Association’s Current Procedural Terminology Committee zHealth Care Finance Administration; Center for Medicare/Medicaid Services’ Medicare Coverage Advisory Committee

4 Outline of Presentation zMedicare zCurrent Procedural Terminology: Basic zCurrent Procedural Terminology: Related zRelative Value Units zCurrent Problems & Possible Solutions zFuture Directions zQuestions

5 Overview: Highlights zNew Codes zExpanding Paradigms zFraud, Abuse; Coding & Documentation zThe Problem with Testing

6 Medicare: Overview zWhy Medicare zMedicare Program zLocal Medical Review

7 Medicare: Why zThe Standard yCoding yValue yDocumentation zApproximately 50% for Institutions zApproximately 33% for Outpatient Offices y Less than 18 - Medicaid yOver 65 - Medicare

8 Medicare: Overview zNew Name: HCFA now CMS yCenters for Medicare and Medicaid Services zNew Charge: Simplify zNew Organization: Beneficiary, Medicare, Medicaid

9 Medicare: Local Review zLocal Medical Review Policy zCarrier Medical Director zPolicy Panels

10 Current Procedural Terminology: Overview zBackground zCodes & Coding zExisting Codes zNew Codes (effective 01.01.02) zModel System X Type of Problem zMedical Necessity zDocumenting zTime

11 CPT: Highlights zNew Codes zMedical Necessity zDocumentation

12 CPT: Background zAmerican Medical Association yDeveloped by Surgeons (& Physicians) in 1966 for Billing Purposes y7,500 Discrete Codes zHCFA/CMS yAMA Under License with CMS yCMS Now Provides Active Input into CPT zCongress yTrent Lott (2001)

13 CPT: Background/Direction zCurrent System = CPT 5 zCategories yI= Standard Coding for Professional Services yII = Performance Measurement yIII = Emerging Technology

14 CPT: Applicable Codes zTotal = Approximately 40 to 60 zSections = Five Separate Sections yPsychiatry yBiofeedback yCentral Nervous Assessment yPhysical Medicine & Rehabilitation yHealth & Behavior Assessment & Management

15 CPT: Psychiatry zSections yInterview vs Intervention yOffice vs Inpatient yRegular vs Evaluation & Management yOther zTypes of Interventions yInsight, Behavior Modifying, and/or Supportive vs Interactive

16 CPT: Biofeedback zPsychophysiological Training zBiofeedback

17 CPT: CNS Assessment zInterview y96115 zTesting yPsychological = 96100 yNeuropsychological = 96117 yOther = 96105, 96110/111

18 CPT: 96117 in Detail zNumber of Encounters in 2000 = 293,000 zNumber of Medical Specialties Using 96117 = over 40 zPsychiatry & Neurology = Approximately 3% each zClinics or Other Groups = 3% zUnknown Data = Use of Technicians

19 CPT: Physical Medicine & Rehabilitation z97770 now 97532 zNote: 15 minute increments

20 CPT: Health & Behavior Assessment & Mngmt. zPurpose: Non-Psychiatric Dx z15 Minute Increments zAssessment y96150; initial y96151; re-assessment zIntervention y96152; individual y96153; group y96154; family (with patient present) y96155; family (without patient present)

21 CPT: Model System zPsychiatric zNeurological zNon-Neurological Medical

22 CPT: Psychiatric Model zInterview y90801 zTesting y96100 zIntervention ye.g., 90806

23 CPT: Neurological Model zInterview y96115 zTesting y96117 zIntervention y97532

24 CPT: Non-Neurological Medical Model zInterview & Assessment y96150/51 zIntervention y96152/55

25 CPT: New Paradigms zInitial Psychiatric zNext Neurological zNow Medical

26 CPT: Diagnosing zPsychiatric yDSM zNeurological & Non-Neurological Medical yICD

27 CPT: Medical Necessity zScientific & Clinical Necessity zLocal Medical Review or Carrier Definition of Necessity zNecessity Dictates Type and Level of Service zNecessity Can Only be Proven with Documentation

28 CPT: Documenting zPurpose zPayer Requirements zGeneral Principles zHistory zExamination zDecision Making

29 Documentation: Purpose zMedical Necessity zEvaluate and Plan for Treatment zCommunication and Continuity of Care zClaims Review and Payment zResearch and Education

30 Documentation: Payer Requirements zSite of Service zMedical Necessity for Service Provided zAppropriate Reporting of Activity

31 Documentation: General Principles zRationale for Service zComplete and Legible zReason/Rationale for Service zAssessment, Progress, Impression, or Diagnosis zPlan for Care zDate and Identity of Observe zTimely zConfidential

32 Documentation: Chief Complaint zConcise Statement Describing the Symptom, Problem, Condition, & Diagnosis zFoundation for Medical Necessity zMust be Complete & Exhaustive

33 Documentation: Ethical Issues zHow Much and To Whom Should Information be Divulged zMedical Necessity vs Confidentiality

34 Time zDefining yProfessional (not patient) Time Including: xpre, intra & post-clinical service activities zInterview & Assessment Codes yGenerally use hourly increments yFor new codes, use 15 minute increments zIntervention Codes yUse 15, 30, or 60 minute increments

35 Time: Definition zAMA Definition of Time zPhysicians 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.

36 Time (continued) zCommunicating further with others zFollow-up with patient, family, and/or others zArranging for ancillary and/or other services

37 Time: Testing zQuantifying Time yRound up or down to nearest increment yTesting = 15 or 60 (probably soon 30) zTime Does Not Include yPatient completing tests, forms, etc. yWaiting time by patient yTyping of reports yNon-Professional (e.g., clerical) time yLiterature searches, new techniques, etc.

38 Time (continued) zPreparing to See Patient zReviewing of Records zInterviewing Patient, Family, and Others zWhen Doing Assessments: ySelection of tests yScoring of tests yReviewing results yInterpretation of results yPreparation and report writing

39 Time: Example of 96117 zPre-Service yReview of medical records yPlanning of testing zIntra-Service yAdministration zPost-Service yScoring, interpretation, integration with other records, written report, follow-up...

40 CPT: Related Issues zIncident To zSupervision zFraud & Abuse

41 Relative Value Units: Overview zComponents zUnits zValues zCurrent Problems

42 RVU: Components zPhysician Work Resource Value zPractice Expense Resource Value zMalpractice zGeographic zConversion Factor

43 RVU: Values zPsychotherapy: yPrior Value =1.86 yNew Value = 2.0+ (01.01.02) zTesting: yWork value= 0 yHsiao study recommendation = 2.2 yNew Value = undetermined

44 RVU: Acceptance zMedicare zBlue Cross/Blue Shield 87% zManaged Care 69% zMedicaid 55% zOther 44% zNew Trends: compensation formulas

45 Current Problems zDefinition of Physician zIncident to zFace-to-Face zTime zWork Values zQualification of Technicians zPractice Expense zPayment zNew Focus for Fraud & Abuse

46 Current Problems: Highlights zWork Value zProvision & Coding of Technical Services (e.g., who is qualified to provide them)

47 Problem: Defining Physician zDefinition of a Physician ySocial Security Practice Act of 1980 yDefinition of a Physician yNeed for Congressional Act yLikelihood of Congressional Act yThe Value of Technical Services of a Psychologist is $.83/hour (second highest after physicist)

48 Problem: Incident to zDefinition of Physician Extender yHow yLimitations zDefinition of In vs Outpatient yGeographic Vs Financial zWhy No Incident to (DRG) zSolution Available for Some Training Programs zProbably no Future to Incident to

49 Problem: More Incident to zWhen is Incident to Acceptable: yTesting (Cognitive Rehabiliation; Biofeedback) yPsychotherapy zDefinition yCommonly furnished service yIntegral, though incidental to psychologist yPerformed under the supervision yEither furnished without charge or as part of the psychologist’s charge

50 Problem: Even More Incident to zSupervision y1.General = overall direction y2.Direct = present in office suite y3.Personal = in actual room y4.Psychological = when supervised by a psychologist

51 Problem: Face-to-Face zImplications zTechnical versus Professional Services zSurgery is the Foundation for CPT (and most work is face-to-face) zHard to Document & Trace Non-Face-to- Face Work

52 Problem: Time zTime Based Professional Activity zCurrent =15, 30, 60, & 90 zExpected = 15 & 30

53 Problem: Work Value zPhysician Activities (e.g., Psychotherapy) Result in Work Values zPsychological Based Activities (I.e., Testing) Have no Work Values zNet Result = Maybe Up to a Third Lower

54 Problem: Qualification of Technician zWhat is the Minimum Level of Training Required for a Technician? zWill a Registry be Available?

55 Practice Expense: The Problem with Testing zFive Year Reviews zPrior Methodology zCurrent Methodology zCurrent Value = approximately 1.5 of 1.75 is practice zExpected Value = closer to 50% of total value

56 Problem: Payment zRefiling y51% require refiling zErrors y54% = plan administrator y17% = provider y 29% = member zState Legislation

57 Problem: Payment zUse of HMOs & Third Party yShift in Practice Patterns by Psychiatry (14% increase) yExclusion of MSW, etc. yWorst Hit Are Psychologists (2% decrease) zCompensation yGross Charges yAdjusted Charges yRVUs

58 Problem: New Focus for Fraud & Abuse for GAO z26 Different Kinds of Fraud Types zMental Health zPsychological Testing zNursing Homes zEstimates of Less Than 10% Recovered zPsychotherapy Estimates/Day = 9.67 hours zProblems with Methodology; yMS level and RN yLimited Sampling

59 Possible Solutions zBetter Understanding & Application of CPT zMore Involvement in Billing zMore Representation/Involvement with AMA & CMS zMeeting with CMS zSurvey for Testing Codes zAPA: Increased Staff & Relationship with CAPP zNAN: New “Office”

60 Possible Solutions: Resources zWeb Sites yNAN; 40; CMS zPublications yTesting Times: Camara, Puente, & Nathan (2000) yGeneral CPT: NAN & Div 40 Newsletters

61 Future Perspectives zIncome ySteadier (if economy does not further erode) zRecognition yPhysician Level zParadigms yIndustrial vs Boutique yHealth vs Non-Health yPrimary Care vs Consulting

62 Future Perspectives zProbably most important thing to remember is that despite the roller coaster of the 1990s and the unpredictability and volatility of the current decade, we have been doing this presentation for approximately one dozen years. And not only are most of us still here, many have prospered. zAnticipate, adapt and flow with change; that’s the new paradigm

63 CPT, et al: Questions zGeneral Questions zBreak-Out Groups zNew NAN Office (booth) yParticularly interested in suggestions of data clinicians need yConsultation Time: Wednesday 11-1 EST

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