1. Coding, Documenting, Billing & Auditing Psychological Services: a 10 year of progress report Antonio E. Puente Department of Psychology University of North Carolina at Wilmington 28403-3297 Tel 910.962.3812, Fax 910.962.7010, e-mail Puente@uncwil.edu; web “clinicalneuropsychology.com” North Carolina Psychological Association Raleigh, NC, March 3, 2000

2. Disclaimer zThis workshop presents a list of recommendation for obtaining reimbursement for and documenting professional psychological services. These recommendations are based on the the author’s work with the AMA-CPT Panel (4th and 5th editions) as well as HCFA’s Medical Directors’ Workgroup and the Medicare Coverage Advisory Committee.

3. Disclaimer (continued) zThese suggestions are being constantly revised and serve as general guidelines. Legal and third-party state and federal regulations may vary relative to these recommendations.

4. Acknowledgements zNorth Carolina Psychological Association zAmerican Psychological Association yPractice Directorate yDivision of Clinical Neuropsychology zNational Academy of Neuropsychology zUniversity of North Carolina at Wilmington

5. Outline of Presentation zHistory/Background of Involvement zDiagnoses zProcedural Coding zTime, Site of Service, Provider zReimbursement zDocumentation zAuditing zRelated Issues zMedicare zTests zFuture Trends

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

7. History/Background zNorth Carolina Psychological Association yNCPA & NCPF President yBlue-Cross Blue Shield zAmerican Psychological Association yChair or Member of Approximately a Dozen Committees/Boards, (e.g., CE, BCA) yDivision 40 Board- 1987 to present yTwo Terms on APA’s Council of Representatives- Div. 40 (1994 to present) yPolicy and Planning Board

8. History/Background (continued) zAmerican Medical Association yCPT- 4 yCPT- 5 zAPA’s Practice Directorate zBlue Cross/Blue Shield of North Carolina zHealth Care Financing Administration yModel Mental Health Policy Workgroup yMedicare Coverage Advisory Committee

9. Medicare: Overview zBenefits yPart A (Hospital) yPart B (Supplementary) yPart C (Medicare + Choice) zHCFA Vs. Local Carrier

10. Medicare: Local Medical Review Policy zDevelopment of Local Policy zRestrictive

11. Reimbursement Model zDiagnoses zProcedural Code zTime zSite of Service zProvider zFormula yDx X Code X Time X Site X Provider

12. Procedural Coding zDefining Coding zHistory of Coding zCoding

13. Diagnoses zSystem (World Health Organization) yDSM= 290-319 yICD = all other diagnoses zReferral Diagnosis yReferral versus Final Diagnoses yRule-Out Diagnoses zMultiple Diagnoses yAdvisable for Medically Necessary yFirst Diagnosis is Most Important

14. Defining Coding zDescription of Professional Service Rendered zPurpose of Coding yReimbursement yArchival/Research yPerformance Assessment zCurrent Coding Systems ySNOMED yWHO / ICD yAMA / CPT

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

16. CPT & HCFA zFederal Register, August 17,2000 yHealth Insurance Reform: Standards for Electronic Transactions yThe CPT is the standard code set for reporting physician and other health care services

17. Developing Codes zMember/Society Generated Idea zAPA Practice Directorate zHealth Care Professionals Advisory Committee zIntegration with Specialty Groups within American Medical Association/Workgroup zFormal Panel Presentation zRelative Value of Code zTime Frame (3-6 years)

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

19. Overview of Coding: An evolution of coding zPsychiatry zNeurology zPhysical Medicine & Rehabilitation z“Evaluation & Management”

20. Overview of Coding (cont.) zPsychiatry yInterview (90801) yPsychotherapy (90804 - 90857) xTypes of Psychotherapy (regular vs interactive) x# of “Patients” (individual vs group vs family) xLocations of Intervention (in vs outpatient) xEvaluation & Management vs Regular xLength of Time (30, 60, 90) yBiofeedback xRegular vs Psychophysiological (90901 vs 90875)

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

22. Overview of Coding (cont.) zPhysical Medicine y 97770 = Cognitive Skills Development y Look for New/split Codes in the Near Future

23. Overview of Coding (cont.) zHealth & Behavior y909X1assessment (15 minutes) y909X2re-assessment y909X3intervention- individual y909X4intervention- group y909X5intervention- family y909X6intervention- family w/o pt. yNOTE: codes have been valued and will be available for use in 01.2002

24. Coding Modifiers zAcceptability yMedicare = 95% yOthers = Approximately 80% zModifiers y22 = Unusual or More Extensive Service y51 = Multiple Procedures y52 = Reduced Service y53 = Discontinued Service

25. New Category II Codes: Performance Measurement zPurpose yReduction of detailed chart review yProvide performance measurement zUse yAlphanumeric identifier with a letter in the last field yEvidenced-based measurement that address conditions of high prevalence, risk or cost with established health outcomes

26. New Category III Codes: Emerging Technology zPurpose yCollect data and assess efficacy of new procedures zUse yAlphanumeric identifier zExample y0018T yRepetitive Transcranial Magnetic Stimulation yDelivery of high power, focal magnetic pulses for direct stimulation of cortical neurons

27. Next Set of Codes zSplitting of the Neuropsychological (and possibly, later) the Testing Codes yRationale x5 Year Re-evaluation xLack of Cognitive Component yApproach xIntegration with HCFA xInvolvement of NAN, 40 xGroup Survey Testing

28. Coding Overview zCoding Categories yPsychiatry yNeurology; CNS/Assessment yPhysical Medicine y“Evaluation & Management” zProcedures yAssessment yIntervention

29. Overview of Coding (cont.) zDiagnosing yIf Problem is Psychiatric = DSM yIf Problem is Neurological = ICD zMatching Dx with CPT yDSM = 90801, 96100, 90806 yICD = 96115, 96117, 97770

30. Reimbursement zHistory zProspective Payment System zDefining RBRVS zReimbursement Difficulties

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

32. RBRVS: Purpose & History zPurpose: To Provide Equitable Payment for Medical Services zHistory yPhase I: Initial 12 physician specialties yPhase II: Psychiatry yPhase III: Psychology

33. RBRVS: Overview zMajor Components yPhysician Work Resource Value Unit yPractice Expense Resource Value Unit yMalpractice Component Resource Value Unit yGeographical Practice Cost Index

34. RBRVS: Conversion Factor zDollar Value That Is Utilized to Convert the Resource Value Units and Geographic Practice Cost Indexes Into a Payment

35. RBRVS: Adoption zMedicare zBlue Cross/Blue Shield = 87% zManaged Care = 69% zMedicaid = 55% zOther = 44%

36. Prospective Payment System zStandard Scenario yIncluded in inpatient bundled service zAlternative Scenario yBill under own provider number zInpatient versus Patient

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

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

39. Time zDefining Time yProfessional (not patient) Activity zAMA Definition yPhysicians also spend time during work, before, or after the face-to-face time with the patient, performing such tasks as reviewing records and tests, arranging for services and communicating further with other professional and the patient through written reports and telephone contact

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

41. Testing Time Defined (continued) zCommunicating Further With Others zFollow-up With Patient, Family, and/or Others zArranging for Ancillary and/or Other Services

42. Intervention Time Defined zAll Time is Bundled in the Allocated Time y90806 = 45 minutes of total time y97770 = 15 minutes of total time

43. Time X Code zInterview & Assessment yHourly Increments zIntervention y15 y30 y45 y90?

44. Quantifying Time zRounding yRound up or down to nearest increment zTime Does Not Include; yPatient completing tests, forms, etc. yWaiting time by patient yType of reports yNon-professional time yLiterature searches, learning new techniques, etc.

45. Site of Service zInpatient yPhysical location yBilling and business relations yOrigin of the patient ySkilled and assisted nursing fascilities zOutpatient yBy definition, anything that is not inpatient

46. Provider zDoctorate yMedicare: PhD/PsyD/EdD = MD yNon-Medicare: 0-50% less than MD zNon-Doctorate ySocial Security yThe special case of North Carolina

47. Medical Necessity zDefinition yReasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member zStand Alone yEach activity must stand alone yPoint-to-point correspondence between symptoms and procedures zLikely Types yAcute and emergency

48. Documentation zPurpose zGeneral Guidelines zSpecific Documentation zTrends zSuggestions

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

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

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

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

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

54. Review of Systems zPsychiatric zNeurological zOther

55. Documentation of History zPast History zFamily History zSocial History

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

57. Specific Documentation Suggestions: Neurobehavioral Status Exam zName, Date, Observer, Dx/Impression zDefinition yClinical assessment of thinking, reasoning and judgment zVariables yAttention, Memory, Visuo-Spatial, Language, Planning yAcquired knowledge, attention, memory, visual spatial abilities, language functioning, planning

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

59. Defining Psychotherapy zPurpose yResolving problems or alleviating of emotional disturbances, or changing maladaptive patterns of behavior, or encouraging personal growth and development zApproaches yDevelopment of insight or affective understanding, the use of behavior modifying techniques, the use of supportive interactions, the use of cognitive discussion of reality ythe use of physical aids or non-verbal techs.

60. Specific Documentation Suggestion: Psychotherapy zBasic Elements yDate yReason for Service yIntervention yResults yImpression yDisposition yIdentity yTime

61. Specific Documentation Suggestion: Cog. Rehab. zBasic Elements yDate yReason for Service yTraining activity yResults yIdentity of Observer yTime

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

63. Trends zIssues of Confidentiality zOver-Diagnosing zOver-Documenting zLimited Interventions & Diagnostic Procedure

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

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

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

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

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

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

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

71. Related Issues zGraduate Medical Education yallied health vs medical yinterns vs postdoctoral fellows

72. Related Issues zIncident to yDefinition xtechnical services that are an extension of the professional service(s) xinpatient as inpatient yBilling xappropriate to provide technical services anywhere xnot appropriate to bill technical services inpatient

73. Tests zPurpose zFunding zSample zResults Summary

74. Tests: Purpose zWhich Tests Are Being Used zHow Long Does Each Test Take zAddress More Carefully Pre, During, and Post-Testing Time

75. Tests: Sample zClinical yAPA zNeuropsychological yNAN yTotal Possible Sample = 2700 yTotal Sampled = 1200 yTotal Used = 447

76. Tests: Time Spent Testing zHours% z0-421 z5-911 z10-1416 z15-2019 z>2033

77. Tests: Types zType of Testing% zAdaptive43 zAphasia46 zBehavioral Med28 zDevelopmental27 zIntellectual79 zNeurobehavioral51 zNeuropsychological 95 zPersonality79

78. Tests: Time X Test zType AdminScoreInterpret zAdaptive 74 32 48 zAphasia 61 24 39 zBeh Med 110 35 58 zDevelop 113 36 59 zIQ 122 34 61 zNeurobeh 80 26 47 zNeuropsy 304 79 135

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

80. Surveys zRationale for Surveys yAll Decisions are Empirical yReasonably Large Ns yAdequate Data zSupport Required yIf Asked, Participate yThree Ongoing; xNAN/Division 40 Practice Survey xRe-evaluation of “Cognitive Rehabilitation” xSplitting of Testing Codes

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

82. Committee for the Advancement of Professional Practice zObservers zAttitude yPositive, Receptive yNew Full-time Staff Member for Medicare Program (American College of Surgeons)

83. General Trends zFraud, Abuse, & Effects of Regulations zStandardizing & Expanding Into Non- Traditional Areas z“Boutique” Vs “Industrial” Psychology zPsychometrics as Clinical Psychology zAssessment & Rehabilitation zPsychology’s “Technical” Pipeline zEstablishment of “Grassroots Network”

84. Future of Professional Psychology zMore (normative?) Data & A Few Theories zMeasurement of the Cultural & Subjective zLess Focus on Conserving the Medicare Trust Fund & Stockholder Profits by Focusing on the Aged & Disabled zAppreciating that Brain is Inside a Person Which is Inside a System (Value?) zConscilience

85. Resources zWeb Sites yneuropsych; NANonline.org, Div40.org ygovernment; HCFA.gov, NIH.gov ypersonal; clinicalneuropsychology.com zPublications yAPA Medicare Handbook (PP; 2000) yNAN Bulletin (1994, 1997, 1998, 2000) yJournal of Psychopathology & Behavioral Assessment (1987) yProfessional Psychology (with Camara & Nathan, 2000)

86. Resources (continued) zInitial Intake Forms zPatient Service Forms zCoding Sheet zBilling Forms zMedicare/Cigna Information Including Local Medical Review Revision Policy zBlue Cross/Blue Shield Information zCigna Behavioral Health Forms & Example zWorkers Compensation Forms

87. Resources (continued) zCPT Process zNew Health and Behavior Assessment and Intervention Codes zExisting CPT Codes zPsychological Test Usage in Professional Psychology (Camara, Nathan & Puente, 2000)