NAN 2004 Advanced Coding, Documentation and Billing Workshop for Neuropsychological Services National Academy of Neuropsychology Seattle, Washington November 20, 2004 (

NAN 2004 Contact Information Websites Websites Univ = Univ = Practice = Practice = University = University = Practice = Practice = Telephone Telephone University = University = Practice = Practice =

NAN 2004 Acknowledgments Department of Psychology, UNC-Wilmington Department of Psychology, UNC-Wilmington NCPA Board of Directors, Practice Division, & Staff NCPA Board of Directors, Practice Division, & Staff National Academy of Neuropsychology National Academy of Neuropsychology Division 40 of APA Division 40 of APA Practice Directorate of the American Psychological Association Practice Directorate of the American Psychological Association American Medical Associations CPT Staff American Medical Associations CPT Staff CMS Medical Policy Staff CMS Medical Policy Staff Inter-Divisional Health Care Committee; APA Inter-Divisional Health Care Committee; APA Selected Individuals (e.g., Jim Georgoulakis) Selected Individuals (e.g., Jim Georgoulakis)

NAN 2004 Acknowledgments Professional Affairs Office Professional Affairs Office All the Individuals; All the Individuals; Keep Me in the Loop Keep Me in the Loop Risk Their Time and Effort to Educate Third Party Insurers & Licensing Boards Risk Their Time and Effort to Educate Third Party Insurers & Licensing Boards

NAN 2004 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 = elected)

NAN 2004 Purpose of Presentation Increase Reimbursement to Appropriate Levels Increase Reimbursement to Appropriate Levels Increase Range, Type & Quality of Services Increase Range, Type & Quality of Services Decrease Fraud & Abuse Decrease Fraud & Abuse Provide Broad Practice Parameters for Professional Services Provide Broad Practice Parameters for Professional Services Increase Professional Stature in Health Care, in General, and Within Psychology, in Particular Increase Professional Stature in Health Care, in General, and Within Psychology, in Particular

NAN 2004 Outline of Presentation Medicare Medicare Current Procedural Terminology (& documentation) Current Procedural Terminology (& documentation) Relative Value Units Relative Value Units Current Problems & Possible Solutions Current Problems & Possible Solutions Predictions for the Future Predictions for the Future Resources Resources

NAN 2004 Medicare: Overview Why Focus on Medicare Why Focus on Medicare The Medicare Program The Medicare Program Local Medical Review (policy & panels) Local Medical Review (policy & panels)

NAN 2004 Medicare: Why The Standard for Universal Health Care The Standard for Universal Health Care Coding Coding Value Value Documentation Documentation Auditing Auditing

NAN 2004 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)

NAN 2004 Medicare: Local Review Local Medical Review Policy Local Medical Review Policy LMRP vs National Policy LMRP vs National Policy Location of LMRPs Location of LMRPs Carrier Medical Director Carrier Medical Director A Physician-based Model A Physician-based Model Policy Panels Policy Panels Lack of Understanding of Their Roles Lack of Understanding of Their Roles Lack of Representation on Such Panels Lack of Representation on Such Panels

NAN 2004 Medicare Payment (since 1993) Surgical Surgical Higher Reimbursement than Cognitive Higher Reimbursement than Cognitive Cognitive Cognitive Physician Cognitive Work Physician Cognitive Work

NAN 2004 Unique Physician Identification Number : Who You Are Currently Currently UPIN # UPIN # Entered in Box 17 a of CMS 1500 form Entered in Box 17 a of CMS 1500 form Starting 2005 Starting 2005 National Provider Identification Number National Provider Identification Number

NAN 2004 National Provider Identifier January 23, CFR Part 16c Basic Information Basic Information 10 position numeric & individual number 10 position numeric & individual number Will contain no specific information about provider Will contain no specific information about provider Managed by CMS National Provide System Managed by CMS National Provide System Link will be placed on the NAN PAIO web pages Link will be placed on the NAN PAIO web pages Dates Dates Can apply by May 23, 2005 Can apply by May 23, 2005 Most entities will use by May 23, 2007 Most entities will use by May 23, 2007 All entities will use by May 23, 2008 All entities will use by May 23, 2008 Applicability Applicability All federal health plans, immediately All federal health plans, immediately All state Medicaid programs, soon All state Medicaid programs, soon General register for all health plans, thereafter General register for all health plans, thereafter

NAN 2004 Current Procedural Terminology: Overview Background Background Codes & Coding Codes & Coding Existing Codes Existing Codes Model System X Type of Problem Model System X Type of Problem Medical Necessity Medical Necessity Documenting Documenting Time Time

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 CPT: Physical Medicine & Rehabilitation now now Note: 15 minute increments Note: 15 minute increments

NAN 2004 Current Problem With Cognitive Rehabilitation Cognitive Rehabilitation (97532) Cognitive Rehabilitation (97532) Applied Rationale Applied Rationale Physical Medicine Codes are incorrectly being interpreted as not being useable by psychologists Physical Medicine Codes are incorrectly being interpreted as not being useable by psychologists Not Being Accepted by Some Carriers Not Being Accepted by Some Carriers AH – Mental Health AH – Mental Health Acceptability Acceptability GN = Speech Therapists GN = Speech Therapists GO = Occupational Therapists GO = Occupational Therapists GP = Physical Therapists GP = Physical Therapists

NAN 2004 CPT: Health & Behavior Assessment & Management Purpose: Medical Diagnosis Purpose: Medical Diagnosis Time: 15 Minute Increments Time: 15 Minute Increments Assessment Assessment Intervention Intervention

NAN 2004 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

NAN 2004 Rationale: Specific Examples Patient Adherence to Medical Treatment Patient Adherence to Medical Treatment Symptom Management & Expression Symptom Management & Expression Health-promoting Behaviors Health-promoting Behaviors Health-related Risk-taking Behaviors Health-related Risk-taking Behaviors Overall Adjustment to Medical Illness Overall Adjustment to Medical Illness

NAN 2004 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

NAN 2004 Assessment Explanation Identification of psychological, behavioral, emotional, cognitive, and social factors Identification of psychological, behavioral, emotional, cognitive, and 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 factors (not mental health) Focus on biopsychosocial factors (not mental health)

NAN 2004 Assessment (continued) May include (examples); May include (examples); health-focused clinical interview health-focused clinical interview behavioral observations behavioral observations psychophysiological monitoring psychophysiological monitoring health-oriented questionnaires health-oriented questionnaires and, assessment/interpretation of the aforementioned and, assessment/interpretation of the aforementioned

NAN 2004 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

NAN 2004 Intervention (continued) May include the following procedures (examples); May include the following procedures (examples); Cognitive Cognitive Behavioral Behavioral Social Social Psychophysiological Psychophysiological

NAN 2004 Diagnosis Match Associated with acute or chronic medical illness Associated with acute or chronic medical illness Prevention of a physical illness or disability Prevention of a physical illness or disability Not meeting criteria for a psychiatric diagnosis or representing a preventative medicine service Not meeting criteria for a psychiatric diagnosis or representing a preventative medicine service

NAN 2004 Related Psychiatric Codes If psychiatric services are required ( ) along with these, report predominant service If psychiatric services are required ( ) along with these, report predominant service Do not report psychiatric and these codes on the same day Do not report psychiatric and these codes on the same day

NAN 2004 Code X Personnel (examples) Physicians (pediatricians, family physicians, internists, & psychiatrists) Physicians (pediatricians, family physicians, internists, & psychiatrists) Psychologists Psychologists Advanced Practice Nurses Advanced Practice Nurses Clinical Social Workers Excluded Clinical Social Workers Excluded Other health care professionals within their scope of practice who have specialty or subspecialty training in health and behavior assessments and interventions Other health care professionals within their scope of practice who have specialty or subspecialty training in health and behavior assessments and interventions

NAN 2004 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

NAN 2004 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)

NAN 2004 Relative Values for Health & Behavior A/I Codes = = = = = = = = = = = =.44

NAN 2004 Expected Payment for Health & Behavior Codes Individual (per hour) Individual (per hour) Range $ Range $ Group (per person/ per hour) Group (per person/ per hour) Approximately $22 Approximately $22

NAN 2004 CPT: Model System Psychiatric Psychiatric Neurological Neurological Non-Neurological Medical Non-Neurological Medical Alternatives Alternatives

NAN 2004 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

NAN 2004 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

NAN 2004 CPT: Neurological Model (Children & Adult) Interview Interview Testing Testing Intervention Intervention

NAN 2004 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)

NAN 2004 Alternative CPT Codes – Office, outside regular office hrs – Office, outside regular office hrs Service provided btw. 10pm-8am Service provided btw. 10pm-8am – Service provided on Sun/holidays – Service provided on Sun/holidays 0074T – Online service 0074T – Online service – Review of records – Review of records

NAN 2004 CPT: Correct Coding Initiative Purpose Purpose Used to evaluate submissions when provider bills more than one service for the same beneficiary and same date of service Used to evaluate submissions when provider bills more than one service for the same beneficiary and same date of service Example; psychotherapy and testing Example; psychotherapy and testing Activation Activation Automatic edits Automatic edits

NAN 2004 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 ICD

NAN 2004 Recent CPT Changes Biofeedback (90911) Biofeedback (90911) Minor editorial changes in biofeedback training Minor editorial changes in biofeedback training

NAN 2004 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)

NAN 2004 Probable 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

NAN 2004 Probable 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

NAN 2004 Probable 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

NAN 2004 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

NAN 2004 Probable 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

NAN 2004 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 Necessity = CPT x DX 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 Evals Do Not Meet Criteria for Necessity Screening or Regularly Scheduled Evals Do Not Meet Criteria for Necessity Will Results Affect Outcome of Patient? Will Results Affect Outcome of Patient? Will New Information Be Obtained? Will New Information Be Obtained?

NAN 2004 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

NAN 2004 CPT: Documenting Purpose Purpose Payer Requirements Payer Requirements General Principles General Principles History History Examination Examination Decision Making Decision Making

NAN 2004 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

NAN 2004 Documentation: Payer Requirements Site of Service Site of Service Medical Necessity for Service Provided Medical Necessity for Service Provided Appropriate Reporting of Activity Appropriate Reporting of Activity

NAN 2004 Documentation: General Principles Rationale for Service Rationale for Service Complete and Legible Complete and Legible Reason/Rationale for Service Reason/Rationale for Service Assessment, Progress, Impression, or Diagnosis Assessment, Progress, Impression, or Diagnosis Plan for Care Plan for Care Date and Identity of Observe Date and Identity of Observe Timely Timely Confidential Confidential

NAN 2004 Documentation: Basic Information Across All Codes Date Date Time, if applicable Time, if applicable Identify of Observer (technician ?) Identify 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

NAN 2004 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

NAN 2004 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

NAN 2004 Documentation: History Past Past Family Family Social Social Medical/Psychological Medical/Psychological

NAN 2004 Documentation: Intervention Reason for Service Reason for Service Status Status Intervention Intervention Results Results Impression Impression Disposition Disposition Time Time

NAN 2004 Documentation: Assessment Reason for Service Reason for Service Dates (amount of service time?) Dates (amount of service time?) Tests and Protocols (included editions) Tests and Protocols (included editions) Narrative of Results Narrative of Results Impression Impression Disposition Disposition

NAN 2004 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

NAN 2004 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

NAN 2004 When to Document Intervention = Immediately After Intervention = Immediately After Testing- Immediately After Vs. at End of Evaluation Testing- Immediately After Vs. at End of Evaluation

NAN 2004 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

NAN 2004 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.

NAN 2004 Time (continued) Communicating further with others Communicating further with others Follow-up with patient, family, and/or others Follow-up with patient, family, and/or others Arranging for ancillary and/or other services Arranging for ancillary and/or other services

NAN 2004 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.

NAN 2004 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)

NAN 2004 Relative Value Units: Overview Components Components Units Units Values Values Current Problems Current Problems

NAN 2004 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)

NAN 2004 RVU Components Percentages Physician Work=52% Physician Work=52% Practice Expense=44% Practice Expense=44% Liability= 4% Liability= 4%

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 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)

NAN 2004 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

NAN 2004 CPT x RVU

NAN 2004 Medicare Rates TypeDeductibleCo-Payment Part A$9120-$456 (days) Part B$110Health – 20% Psych- 50% Note: Premiums are $78.20/month

NAN 2004 Continuing Problems Definition of Physician Definition of Physician Supervision Supervision Incident to Incident to Face-to-Face Face-to-Face Time Time RVUs RVUs Work Values Work Values Practice Expense & Testing Survey Practice Expense & Testing Survey Payment Payment Focus for Fraud & Abuse Focus for Fraud & Abuse

NAN 2004 Problem: Defining Physician Definition of a Physician Definition of a Physician Social Security Practice Act of 1980 Social Security Practice Act of 1980 Definition of a Physician Definition of a Physician Need for Congressional Act Need for Congressional Act Likelihood of Congressional Act Likelihood of Congressional Act The Value of Technical Services of a Psychologist is $.83/hour (second highest after physicist) The Value of Technical Services of a Psychologist is $.83/hour (second highest after physicist) Consequence of the preceding; grouping with non-doctoral level allied health providers Consequence of the preceding; grouping with non-doctoral level allied health providers

NAN 2004 Supervision Federal Register Volume 69, No. 150, August 5, 2004, page 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 (e.g., Ed. Psych. ) Applicable Only to clinical psychologists (and not independent psychologists (e.g., Ed. Psych. ) 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

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 Problem: Incident to & Site of Service Outpatient vs. Inpatient Outpatient vs. Inpatient Geographical Location Geographical Location Corporate Relationship Corporate Relationship Billing Service Billing Service Chart Information & Location Chart Information & Location

NAN 2004 Problem: 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

NAN 2004 Problems: Recent Difficulties with Incident to Who Bills Incident to Who Bills Incident to Treating Physician Bills not the Supervising Physician Treating Physician Bills not the Supervising Physician Then, Who is the Responsible Party Then, Who is the Responsible Party The Physician Must Evaluate and/or Treat the Patient First The Physician Must Evaluate and/or Treat the Patient First

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 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

NAN 2004 Problem: Qualification of Technician What is the Minimum Level of Training Required for a Technician? What is the Minimum Level of Training Required for a Technician? Bachelors vs. Masters Bachelors vs. Masters Student vs. Staff Student vs. Staff

NAN 2004 Problem: Payment Origins of the Problem Origins of the Problem Balanced Budget Act of 1997 Balanced Budget Act of 1997 Employers Cost for Health Care in 2002 = $5,000 per employee Employers Cost for Health Care in 2002 = $5,000 per employee What Should Your Code Be Payed at? What Should Your Code Be Payed at? State Legislation State Legislation

NAN 2004 Problem: Payment Problems Refilling Refilling 51% require refilling of original forms 51% require refilling of original forms But, up to 60% do not follow up But, up to 60% do not follow up Errors Errors 54% = plan administrator 54% = plan administrator 17% = provider 17% = provider 29% = member 29% = member

NAN 2004 Problem: Payment Use of HMOs & Third Party Use of HMOs & Third Party Shift in Practice Patterns by Psychiatry (14% increase) Shift in Practice Patterns by Psychiatry (14% increase) Exclusion of MSW, etc. (Increase) Exclusion of MSW, etc. (Increase) Worst Hit Are Psychologists (2% decrease) Worst Hit Are Psychologists (2% decrease) Compensation Compensation Gross Charges Gross Charges Adjusted Charges Adjusted Charges RVUs RVUs Receivables Receivables

NAN 2004 Problem: Payment of Health & Behavior Codes Medicare Almost all Resolved Medicare Almost all Resolved Non-Medicare Resolving Non-Medicare Resolving

NAN 2004 Medicare Questions Cannot Impose a Limitation on a Medicare Patient That is Not Imposed on Other Pts. Cannot Impose a Limitation on a Medicare Patient That is Not Imposed on Other Pts. Non-Covered Services Can Be Charged if Patient Knows and Agrees Ahead of Time Non-Covered Services Can Be Charged if Patient Knows and Agrees Ahead of Time Records Should be Retained, state law or; Records Should be Retained, state law or; Adult- 5 years post service Adult- 5 years post service Children- until 21 Children- until 21 Billing Billing In Continuing Cases- End of month In Continuing Cases- End of month Otherwise- At end of service Otherwise- At end of service

NAN 2004 Problem: Expenditures & Fraud Projections Projections Current Current 14% 14% By 2011; By 2011; 17% ($2.8 trillion) 17% ($2.8 trillion)

NAN 2004 Fraud: Medicares Interpretation of Physician Liability Overpayment From Incorrect Charge Overpayment From Incorrect Charge 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 Mathematical or Clerical Error Mathematical or Clerical Error Inappropriate Documentation Inappropriate Documentation

NAN 2004 Defining Fraud Fraud Fraud Intentional Intentional Pattern Pattern Error Error Clerical Clerical Dates Dates

NAN 2004 Problem: Fraud & Abuse 26 Different Kinds of Fraud Types 26 Different Kinds of Fraud Types Mental Health Profiled Mental Health Profiled Estimates of Less Than 10% Recovered Estimates of Less Than 10% Recovered Psychotherapy Estimates/Day = 9.67 hours Psychotherapy Estimates/Day = 9.67 hours Review Likely if Over 12 Hours Per Day Review Likely if Over 12 Hours Per Day Problems with Fraud Methodology Problems with Fraud Methodology Primarily in how the research was done Primarily in how the research was done Also, in the application of sampling Also, in the application of sampling

NAN 2004 Problem: 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

NAN 2004 Problem: Fraud & The (Red) Book Contractor Operations Contractor Operations Strengthen Regional Offices Oversight Strengthen Regional Offices Oversight Improve Evaluation of Fraud Unit Improve Evaluation of Fraud Unit Prevent Duplicate Payments for Same Service Prevent Duplicate Payments for Same Service Hospital Operations Hospital Operations Identify Patterns of Aberrant Overpayment Identify Patterns of Aberrant Overpayment Improve External Review of Psychiatric Hospitals Improve External Review of Psychiatric Hospitals Nursing Homes Nursing Homes Mental Illness Mental Illness

NAN 2004 Problem: The Medicare Book (continued) Physicians/Allied Health Professionals Physicians/Allied Health Professionals Improve Oversight of Rural Health Clinics Improve Oversight of Rural Health Clinics Eliminate Inappropriate Payments for Mental Health Services Eliminate Inappropriate Payments for Mental Health Services Yet, Improve Medicaid Mental Health Programs Yet, Improve Medicaid Mental Health Programs

NAN 2004 Problem: Fraud (cont.) Nursing Homes Nursing Homes Identification Identification Overuse of Services Overuse of Services Children Children Experience Experience Corporation Audit Corporation Audit Company Audit Company Audit Personal Audit Personal Audit Consultant for Companies & Individuals Consultant for Companies & Individuals

NAN 2004 Problem: 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 (Current & Widespread) Individual Practices (Current & Widespread)

NAN 2004 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?

NAN 2004 Problem: Mental vs. Physical Historical vs. Traditional vs. Recent Diagnostic Trends Historical vs. Traditional vs. Recent Diagnostic Trends Recent Insurance Interpretations of Dxs Recent Insurance Interpretations of Dxs Limitations of the DSM Limitations of the DSM The Endless Loop of Mental vs. Physical The Endless Loop of Mental vs. Physical NOTE: Important to realize that LMRP is almost always more restrictive than national guidelines NOTE: Important to realize that LMRP is almost always more restrictive than national guidelines

NAN 2004 Possible Solutions: General Approaches Better Understanding & Application of CPT Better Understanding & Application of CPT More Involvement in Billing More Involvement in Billing Comprehensive Understanding of LMRP Comprehensive Understanding of LMRP More Representation/Involvement with AMA, CMS & Local Medical Review Panels More Representation/Involvement with AMA, CMS & Local Medical Review Panels Meetings with CMS Meetings with CMS Foster Relationship APA Practice and CAPP Foster Relationship APA Practice and CAPP Integration with Division 40 of APA Integration with Division 40 of APA

NAN 2004 News to be Confirmed & Interpreted (CR3016/Pub /Transmittal 4/January 2, 2004) CMS Announced that Psychologists can Opt Not to Participate in the Medicare Program and to Sign Private Agreements with Beneficiaries CMS Announced that Psychologists can Opt Not to Participate in the Medicare Program and to Sign Private Agreements with Beneficiaries

NAN 2004 Future Perspectives: 2003 Income Income Steadier due to decreased changes Steadier due to decreased changes Probable incremental declines, up to % if traditional practice is pursued Probable incremental declines, up to % if traditional practice is pursued If Medicaid dependent (25% or more), then declines could be even higher If Medicaid dependent (25% or more), then declines could be even higher Possible final stabilization by 2005 Possible final stabilization by 2005 Results of election, economy, & new codes Results of election, economy, & new codes

NAN 2004 Future Perspectives 2003 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

NAN 2004 Future Perspectives: 2003 Evolving Paradigm = Continued and Significant Change Evolving Paradigm = Continued and Significant Change Success = Predict, Embrace and Shape Change Success = Predict, Embrace and Shape Change

NAN 2004 Future Perspectives: 2004 Negative Negative Neutral Neutral Positive Positive

NAN 2004 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

NAN 2004 Anticipated General Upcoming Changes Federal (due to results of Presidential election) Federal (due to results of Presidential election) Technical – Health Electronic Records by 2008 Technical – Health Electronic Records by 2008 Legal – Cap of $250,000 for non-economic damages Legal – Cap of $250,000 for non-economic damages Coverage – Goal is to provide slightly increased coverage in terms of additional individuals but not additional services covered Coverage – Goal is to provide slightly increased coverage in terms of additional individuals but not additional services covered 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

NAN 2004 Anticipated General Upcoming Changes Economic Economic Overall, Positive (maybe 3-5% growth) Overall, Positive (maybe 3-5% growth) Clinical Neuropsychology- Clinical Neuropsychology- 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 Increased in Medicare and Major Third Party audits Increased in Medicare and Major Third Party audits Shifting in practice patterns (e.g., hours per evaluation) Shifting in practice patterns (e.g., hours per evaluation) 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

NAN 2004 Summary Overall-Continued and Significant Changes Overall-Continued and Significant Changes Overall, Increase in Recognition, Especially in General Health (vs. mental health) Sectors Overall, Increase in Recognition, Especially in General Health (vs. mental health) Sectors Shifting to Diagnostic and Supervisory Professional Activities over Rehabilitative Shifting to Diagnostic and Supervisory Professional Activities over Rehabilitative Continuing Shifting from Inpatient to Outpatient and from Institutional to Private Practice Stabilization and Increase of Reimbursement Amounts Continuing Shifting from Inpatient to Outpatient and from Institutional to Private Practice Stabilization and Increase of Reimbursement Amounts Reimbursement Practices Will Expand Including Electronic Billing Reimbursement Practices Will Expand Including Electronic Billing Overall Increase, Especially in Traditional Neuropsychology Overall Increase, Especially in Traditional Neuropsychology

NAN 2004 Possible Solutions: Resources General Web Sites General Web Sites (medicare/medicaid) (medicare/medicaid) (health & human services) (health & human services) (inspector general) (inspector general) (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) (staff salaries) (staff salaries)

NAN 2004 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.)