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Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of a 10 year of progress report Antonio E. Puente Department of Psychology.

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Presentation on theme: "Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of a 10 year of progress report Antonio E. Puente Department of Psychology."— Presentation transcript:

1 Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of a 10 year of progress report Antonio E. Puente Department of Psychology University of North Carolina at Wilmington Tel , Fax , web “” Massachusetts Neuropsychological Society Boston, MA, December 5, 2000

2 Outline of Presentation
History/Background of Involvement Procedural Coding Reimbursement Documentation Auditing Related Issues Future Trends

3 Purpose of My Involvement with Coding & Medicare
Short Term Reimbursement Long Term Why the Focus on Medicare Bring Some Standardization to the Field Expand the Scope and Value of Clinical Neuropsychology Parity with Other Doctoral Level Health Providers in Health Care Shape Psychology Towards a Biological Model

4 History/Background North Carolina Psychological Association
Blue-Cross Blue Shield American Psychological Association Chair or Member of Approx.a Dozen Committees/Boards, (e.g., Neuropsychology) Division 40 Board to present Two Terms on APA’s Council of Representatives (1994 to present) Policy and Planning Board

5 History/Background (continued)
American Medical Association CPT- 4 CPT- 5 Health Care Financing Administration Model Mental Health Policy Workgroup Medicare Coverage Advisory Committee

6 Procedural Coding Defining Coding History of Coding Coding

7 Defining Coding Description of Professional Service Rendered
Purpose of Coding Archival/Research Reimbursement Coding Systems SNOMED WHO / ICD AMA / CPT

8 History of CPT Coding First Developed in 1966
Currently Using the 4th Edition The 5th Edition Will be Used in 2002 A Total of 7,500 Codes AMA Developed and Owns the CPT Under Contract with the HCFA

9 Overview of Coding Total Possible Codes = 60+
# Of Typically Reimbursed Codes = 5 interview, testing, & psychotherapy # Of Codes Sometimes Reimbursed = 35 family/group therapy biofeedback # Of Codes Rarely Reimbursed = 20+ evaluation and management report evaluation and writing

10 Overview of Coding: An evolution of coding
Psychiatry Neurology Physical Medicine & Rehabilitation “Evaluation & Management”

11 Overview of Coding (cont.)
Psychiatry Interview (90801) Psychotherapy ( ) Types of Psychotherapy (regular vs interactive) # of “Patients” (individual vs group vs family) Locations of Intervention (in vs outpatient) Evaluation & Management vs Regular Length of Time (30, 60, 90) Biofeedback Regular vs Psychophysiological (90901 vs 90875)

12 Overview of Coding (cont.)
Central Nervous System Assessments/Test = Psychological Testing = Aphasia Testing 96110/1 = Developmental Testing = Neurobehavioral Status Exam = Neuropsychological Testing

13 Overview of Coding (cont.)
Physical Medicine = Cognitive Skills Development Look for New/split Codes in the Near Future

14 Overview of Coding (cont.)
Health & Behavior 909X1 assessment (15 minutes) 909X2 re-assessment 909X3 intervention- individual 909X4 intervention- group 909X5 intervention- family 909X6 intervention- family w/o pt. NOTE: these codes need to be valued...

15 Coding Overview Coding Categories Procedures Psychiatry
Neurology; CNS/Assessment Physical Medicine “Evaluation & Management” Procedures Assessment Intervention

16 Overview of Coding (cont.)
Diagnosing If Problem is Psychiatric = DSM If Problem is Neurological = ICD Matching Dx with CPT DSM = , 96100, 90806 ICD = , 96117, 97770

17 Reimbursement History Defining RBRVS Formula Defining Time
Defining Site Defining Necessity Defining and Applying “Incident to”

18 History of Reimbursement
Cost plus Reimbursement Prospective Payment (PPS) & Diagnostic Related Groups (DRGs) Customary. Prevailing, & Reasonable(CPR) Resource Based Relative Value System (RBRVS) Prospective Payment System

19 RBRVS Major Components Conversion Factor Adoption of the RBRVS
Physician Work Resource Value Unit Practice Expense Resource Value Unit Malpractice Component Resource Value Unit Conversion Factor Adoption of the RBRVS Medicare Blue Cross/Blue Shield- 87% Managed Care- 55%

20 Reimbursement Formula
Procedural Code Time Diagnosis Site of Service Provider Formula Code X Time X Dx X Site X Provider

21 Reimbursement Difficulties
Physician Work Value Phd/PsyD/EdD vs MD Location Defined

22 Common Reasons for Lack of Reimbursement
Clerical Errors Service Is Not Covered No Prior Authorization Obtained Exceeded Allocated Time Limits Invalid or Incorrect Dx Code CPT and Dx Do Not Match

23 Defining Time Defining Time Interview vs Assessment Codes
Professional (not patient) Activity Interview vs Assessment Codes Hourly Increments Includes Pre and Post-clinical Service Intervention Codes 15, 30, 60, & 90 Face-to-face Contact No Pre or Post-clinical Service Time Included

24 Testing Time Defined Preparing to Test Patient Reviewing of Records
Selection of Tests Scoring of Tests Reviewing of Results Interpretation of Results Preparation and Report Writing

25 Documentation Purpose General Guidelines Specific Documentation Trends

26 Purpose of Documentation
Evaluate and Plan for Treatment Communication and Continuity of Care Claims Review and Payment Research and Education

27 General Principles of Documentation
Complete and Legible Reason/Rationale for the Encounter Assessment, Impression, or Diagnosi/es Plan for Care Date and Identity of Observer

28 Documentation History
Chief Complaint History of Present Illness (HPI) Review of Systems Past, Family, and/or Social History

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

30 Documentation of Present Illness
Chronological 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. For Symptoms: Location, Quality, Severity, Duration, Timing, Context, Modifying Factors Including Medications, Associated Signs, Symptoms, etc. For Follow up: Changes in Condition Since Last Visit, Compliance with Treatment, etc.

31 Review of Systems Psychiatric Neurological Other

32 Documentation of History
Past History Family History Social History

33 Specific Documentation Suggestions: Psychiatric Interview
Name, Date, Observer, Dx/Impression Mental Status Exam Language, Thought Processes, Insight, Judgment, Reliability, Reasoning, Perceptions, Suicidality, Violence, Mood & Affect, Orientation, Memory, Attention, Intelligence

34 Specific Documentation Suggestions: Neurobehavioral Status Exam
Name, Date, Observer, Dx/Impression Variables Attention, Memory, Visuo-Spatial, Lanague, Planning

35 Specific Documentation Suggestions: Testing
Name, Date, Observer, Dx/Impression Names of Tests Interpretation of Tests Results Disposition Time

36 Documentation Suggestions
Avoid Handwritten Notes Do Not Use Red Ink Document on Every Encounter, Every Procedure, and Every Patient Re-Cap Status, Whenever Possible, At Least Change From Session to Session Document Soon After Procedure

37 Trends Issues of Confidentiality Over-Diagnosing Over-Documenting

38 Auditing Fraud & Abuse vs Erroneous Self-Auditing Suggestions
Risk Situations Development of an Internal Auditing System

39 Fraud vs Error Fraud = Intentional, Pattern Erroneous = Clerical, etc.

40 Self-Auditing Suggestions
Written Policies Compliance Officer Training & Education Lines of Communication Should Exist Internal Monitoring & Auditing Enforce Standards Alter as Necessary

41 Risk Areas for Fraud Coding & Billing Reasonable & Necessary Services
Documentation Improper Inducements

42 Fraudulent Claims Flags
Upcoding Excessive or Unnecessary Visits to ACF Outpatient Service 72 Hrs. Post-Discharge CPT Code Usage Shift High Percentage of the Same Codes Use of Similar Time for Testing Across Pts. Medical Necessity (dx; interpretation)

43 Defining Necessity “reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member” All services must “stand alone” Acute and emergency services more like to be considered necessary

44 Evaluating Effectiveness
Adequacy of Evidence Bias External Validity Size of Effect From Not Effective to Breakthrough

45 Evaluating Effectiveness (continued)
Organized Approaches to Evaluation of Scientific Evidence American College of Physicians Agency for Health Care Policy and Research BC/BS Technology Evaluation Center American College of Cardiology American College of Urology

46 Additional Issues Incident to Graduate Medical Education
in vs outpatient technical vs professional component performing vs billing Graduate Medical Education allied health vs medical interns vs postdoctoral fellows CPT I, II, & III I = standard codes II = performance measures III = emerging technology

47 Future Trends Surveys; Practice, Ongoing & New Codes
Health Care Finance Administration Committee for the Advance of Professional Practice Practice Directorate of the APA General Trends Future of Clinical Neuropsychology Resources

48 Surveys Rationale for Surveys Support Required
All Decisions are Empirical Reasonably Large Ns Adequate Data Support Required If Asked, Participate Two Ongoing; NAN/Division 40 Practice Survey Re-evaluation of “Cognitive Rehabilitation”

49 Health Care Financing Administration
Problems Definition of Physician (Social Security Practice Act of 1989) Doctoral vs Non-Doctoral Providers Directions Physician Work Value Practice Expense Matching of CPT with Reimbursement

50 Committee for the Advancement of Professional Practice
Observers Joe Fishburn (NAN), Ida Sue Baron (Div 40) Attitude Division 40; NAN Gift Positive, Receptive Additional Staff Member for Medicare Program

51 General Trends Fraud, Abuse, & Effects of Regulations
Clinical Neuropsychology Standardizing & Expanding Into Non-Traditional Areas “Boutique” vs “Industrial” Neuropsych. Psychometrics as Clinical Neuropsychology Assessment & Rehabilitation Neuropsychology’s “Technical” Pipeline Establishment of “Grassroots Network”

52 Future of Clinical Neuropsychology: A Holiday Wish List
More (normative?) Data & A Few Theories Measurement of the Cultural & Subjective Less Focus on Conserving the Medicare Trust Fund & Stockholder Profits by Focusing on the Aged & Disabled Appreciating that Brain is Inside a Person Which is Inside a System (Value?) Conscilience

53 Resources Web Sites Publications APA Medicare Handbook (PP; 2000)
neuropsych;, government;, personal; Publications APA Medicare Handbook (PP; 2000) NAN Bulletin (1994, 1997, 1998, 2000) Journal of Psychopathology & Behavioral Assessment (1987) Professional Psychology (with Camara & Nathan, 2000)

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