Making a Living in Professional Psychology: Coding, Billing and Documenting Psychological Services Antonio E. Puente University of North Carolina Wilmington Florida Institute of Technology April 14, 2006 cpt NCPA/DIPP 2006

Acknowledgments North Carolina Psychological Association Practice Directorate of the American Psychological Association (APA) American Medical Association (AMA) CPT Staff National Academy of Neuropsychology (NAN) Division of Clinical Neuropsychology- APA Center for Medicare & Medicaid Services Medical Policy Staff- Medicare Inter-Divisional Health Care Committee- APA Department of Psychology, UNC-Wilmington Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted Peck; AEP Research Team and Clinical Staff) cpt

Specific Support Provided by Primary Organizations APA = All expenses paid for travel associated with CPT activities NAN = (from PAIO budget) applied to UNCW activities 2002-2004 = $10,000 per year – one course for two semesters teaching reduction 2005 = $5,000 per year – one course for one semester teaching reduction 2006 = $25,000 per year – in negotiation UNCW = Time away from university duties (e.g., teaching) plus incidental support such as copying, telephone calls, and secretarial and work-study student assistance cpt

Background (1988 – present) North Carolina Psychological Association (e) APA’s Policy & Planning Board; Div. 40 (e) American Medical Association’s Current Procedural Terminology Committee (IV/V) (a) Health Care Finance Administration’s Working Group for Mental Health Policy (a) Center for Medicare/Medicaid Services’ Medicare Coverage Advisory Committee (fa) Consultant with the North Carolina Medicaid Office;North Carolina Blue Cross/Blue Shield (a) NAN’s Professional Affairs & Information Office (a) (legend; a = appointment, fa = federal appointment, e = election) cpt

Primary Goal & General Outcome of CPT Work Goal (20 year plan) Parity with Physicians Expansion of Scope of Services Outcome (presently) Intended/Anticipated/Hoped Similar reimbursement as physician services General increase in the scope of practice Greater inclusion into health care system Less Anticipated Transparency Accountability Uniformity Potential impact on certain practice patterns cpt

Primary Goals of Presentation Understand the Role of Medicare in Setting Standards for Psychology Understand the AMA Current Procedural Terminology (CPT) for Coding of Professional Services Introduce the New Testing and Interview Codes Suggest a Model System for Coding Explain the Concept of Medical Necessity Provide Suggestions for Documentation Define Time Explain Reimbursement Practices Address Supervision and Incident to Explain the Concept of Fraud Versus Errors Address Current and Potential Problems Provide Trajectory for 2006 and Beyond cpt

Outline of Presentation Part I: Coding, Billing and Documentation (Introductory) Part II: Specific Issues with CPT (Intermediate) Part III: Projections; Questions & Answers (Advanced) cpt

Part I: Coding, Billing & Documentation (Introductory) Medicare Current Procedural Terminology Diagnosing Medical Necessity Documentation Time Site of Service cpt

A. Medicare: Why? The Standard for Universal Health Care: Coding (what can be done) Value (how much it will be paid) Documentation (what needs to be said) Auditing (determination of whether it occurred) cpt

Medicare: Immediate Impact As a Consequence, the Benchmark for: All Commercial Carriers (e.g., HMOs) As well as; Workers Compensation Forensic Applications Related Applications (e.g., industrial, sports) cpt

Medicare: Long-term Impact By 2015, Medicare will represent approximately 50% of all health care payments in the United States Eventually, a national (US) health insurance will be established One possible model will be to introduce Medicare to younger citizens will be in age increments (e.g., 60-64, then 50-59, etc) Hence, Medicare will come to set the standard for all of health care cpt

Medicare: Overview Centers for Medicare and Medicaid Services Benefits Part A (Hospital) Part B (Supplementary) Part C (Medicare+ Choice) Part D (Pharmaceutical) cpt

Medicare: Local Review Medical Review Policy National Policy Sets Overall Model Local Coverage Determination (LCD) Sets Local/Regional Policy- More restrictive than national policy Over-rides national policy Changes frequently without warning or publicity Information best found on respective web pages cpt

B. Current Procedural Terminology (CPT): Overview Background Codes & Coding Existing Codes Model System X Type of Problem cpt

CPT: Background American Medical Association Developed by Surgeons (& Physicians) in 1966 for Billing Purposes 7,500+ Discrete Codes CPT Meets a Minimum of 4 Times/Year Center for Medicare & Medicaid Services AMA Under License by CMS CMS Now Provides Active Input into CPT cpt

CPT: Composition AMA House of Delegates HCPAC CPT Editorial Panel 109 Medical Specialties HCPAC 11 Allied Health Societies (e.g., APA) CPT Editorial Panel 17 Voting Members 11 Appointed by AMA Board 1 each from BC/BS, AHA, HIAA, CMS 2 HCPAC cpt

What Is a CPT Code? A Coding System Developed by AMA in Conjunction with CMS to Describe Professional Services Each Code has a Specific Number and Description as well as a Reimbursable Value Professional Health Service Provided Across the Country at Multiple Locations Many “Physicians” or “Qualified Health Professional” Perform Services Clinical Efficacy is Established and Documented in Peer-Reviewed Literature cpt

CPT: Applicable Codes Total Possible Codes = Approximately 7,500 Possible Codes for Psychology = Approximately 40 to 60 Sections = Five Primary Separate Sections Psychiatry (e.g., mental health) Biofeedback Central Nervous System Assessment (testing) Physical Medicine & Rehabilitation Health & Behavior Assessment & Management (h.p.) Evaluation and Management cpt

CPT: Development of a Code Initial Health Care Advisory Committee (non-MDs) Primary CPT Work Group (selected organizations) CPT Panel (all specialties) Time Frame 3-5 years to well over a decade cpt

CPT: Psychiatry Sections (or Categories) Types of Interventions Interview (90801) vs. Intervention (e.g., 90806) These codes are one unit Office vs. Inpatient Regular vs. Evaluation & Management Other Types of Interventions Insight, Behavior Modifying, and/or Supportive vs. Interactive cpt

Psychiatric Codes Interviewing 90801 One time per illness incident or bout Untimed Comprehensive analysis of records, observations as well as structured and/or unstructured clinical interview cpt

Psychiatric Codes Therapy 20 minutes = 90804 45-50 minutes = 90806 cpt

CPT Changes: CNS Assessment Codes Timetable Activity x Date Codes Without Cognitive Work Obtained, 1994 Initial Request for Practice Expense by APA, Summer, 2002 APA Appeared Before AMA RUC, September, 2003 Initial Decision by AMA CPT Panel, November 7, 2004 Call for Other Societies to Participate, November 19, 2004 Final Decision by AMA CPT Panel, December 1, 2004 Submission of CPT Codes to AMA RUC Committee immediately thereafter Review by AMA RUC Research Subcommittee in January, 2005 Review by AMA RUC Panel in February 3-6, 2005 Survey of Codes, second & third week of February, 2005 Analysis of surveys, March, 2005 Presentation to RUC Committee in April, 2005 Inclusion in the 2006 Physician Fee Schedule on January 1, 2006 CPT Assistant article April, 2006 cpt

CPT: CNS Assessment Effective 01.01.06 (no grace period) Psychological Testing (e.g., 5 units) Three New Codes New Numbers & Descriptors Neurobehavioral Status Exam (e.g., 2 units) New Number & Revised Descriptor Neuropsychological Testing (e.g., 10 units) cpt

Psychological Testing: By Professional Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS (per hour of psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report) (note: “psychologist’s or physician’s” will probably be changed to “qualified health professional”) cpt

Psychological Testing: By Technician Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology (e.g., MMPI, Rorschach, WAIS) with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face cpt

Psychological Testing: By Computer Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, (e.g., MMPI) administered by a computer, with qualified health professional interpretation and the report cpt

Neurobehavioral Status Exam Clinical assessment of thinking, reasoning and judgment ( e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual-spatial abilities) per hour of psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report (note: “psychologist’s or physician’s” will probably be changed to “qualified health professional”) cpt

Neuropsychological Testing- By Professional (e.g., Halstead-Reitan Neuropsychological, WMS, Wisconsin Card Sorting) per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report (note: “psychologist’s or physician’s” will probably be changed to “qualified health professional”) cpt

Neuropsychological Testing: By Technician (e.g., Halstead-Reitan Neuropsychological, WMS, Wisconsin Card Sorting) with qualified health care professional interpretation and report, administered by a technician per hour of technician time, face-to-face cpt

Neuropsychological Testing- By Computer (e.g., WCST) administered by a computer with qualified health care professional interpretation and the report cpt

CNS Assessment Examples Neurobehavioral Status with Neuropsychological Testing Interview by the Professional Testing by Professional, and/or Technician, and/or Computer. Interpretation & Report Writing by Qualified Health Professional A Technician or Computer Code are Typically Billed Together with a Professional Code (since the final product should be a comprehensive/integrative report) cpt

CPT: Physical Medicine & Rehabilitation 97770 now 97532 Note: 15 minute increments cpt

CPT: Cognitive Rehabilitation Application Rationale Allied Health & Physical Medicine Code Acceptability GN – Speech Therapists GO – Occupational Therapists GP – Physical Therapists AH – Mental Health (not applicable) cpt

CPT: Health & Behavior Assessment & Management (CPT Assistant, 03 CPT: Health & Behavior Assessment & Management (CPT Assistant, 03.04) (CPT Assistant, 08.05, 15, #6, 10) Purpose: Medical Diagnosis Time: 15 Minute Increments Assessment Intervention cpt

Overview of H & B Codes Codes Effective as 01.01.2002 (with ongoing revisions of language) Assessment (e.g., 4 units) Intervention (e.g., up to a total of 48 units) Established Medical Illness or Diagnosis Focus on Biopsychosocial Factors cpt

H & B: Rationale Acute or Chronic Health Illness Not Applicable to Psychiatric Illness However, Both Could be Treated Simultaneously But Not Within the Same Session cpt

H & B: Examples of Service Symptom Management & Expression Patient Adherence to Medical Treatment Health Promoting Behaviors Overall Adjustment to Medical Illness cpt

Health & Behavior Assessment Codes 96150 Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires) each 15 minutes face-to-face with the patient initial assessment 96151 re-assessment cpt

H & B: Assessment Explanation Identification of Psychological, Behavioral, Emotional, Cognitive and/or Social Factors In the Prevention, Treatment and/or Management of Physical Health Problems Focus on Biopsychosocial and not Mental Health Factors cpt

H & B: Assessment Examples Health-Focused Clinical Interview Behavioral Observations Psychophysiological Monitoring Health-Oriented Questionnaires cpt

Health & Behavior Intervention Codes 96152 Health and behavior intervention each 15 minutes face-to-face individual 96153 group (2 or more patients) 96154 family (with the patient present) 96155 (limited acceptability) family (without the patient present; not being reimbursed) cpt

H & B: Intervention Explanation Modification of Psychological, Behavioral, Emotional, Cognitive and/or Social Factors Affecting Physiological Functioning, Disease Status, Health and/or Well-Being Focus = Improvement of Health with Cognitive, Behavioral, Social and/or Psychophysiological Procedures cpt

H & B: Intervention Examples Cognitive Behavioral Social Psychophysiological cpt

H & B: Diagnoses Associated with an Acute or Chronic Medical Illness Not Applicable to Psychiatric Diagnoses cpt

CPT: Model System Psychiatric Neurological Non-Neurological Medical

CPT Model Rationale for CPT Code: Choose Code that Best Describes the Service Match the Interview with the Testing with the Intervention Code with the Diagnosis Goal = Uniformity and Fluency cpt

CPT: Psychiatric Model (Children & Adult) Interview 90801- adult 90802- child Testing 96101-03 Also, 96111 for children Intervention e.g., 90806- adult e.g., 90820-child cpt

CPT: Neurological Model (Children & Adult) Interview 96116 Testing 96118/19/20 Intervention 97532 cpt

CPT: Non-Neurological Medical Model (Children & Adult) Interview & Assessment 96150 (initial) 96151 (re-evaluation) Intervention 96152 (individual) 96153 (group) 96154 (family with patient) cpt

C. CPT: Diagnosing Psychiatric Neurological & Non-Neurological Medical DSM The problem with DSM and neuropsych testing of developmentally-related neurological problems Neurological & Non-Neurological Medical ICD – 9 CM (physical diagnosis coding) www.cdc.gov/nchs/about/otheract/icd9 cpt

D. CPT: Medical Necessity Scientific & Clinical Necessity Local Medical Review or Carrier Definitions of Necessity Necessity = CPT x DX formulary Necessity Dictates Type and Level of Service Necessity Can Only be Proven with Documentation Screening or Regularly Scheduled Evaluations Do Not Meet Criteria for Necessity Will Results Affect Outcome of Patient? Will New Information Be Obtained as a Function of the Activity? cpt

Medically Reasonable and Necessary Section 1862 (a)(1) 1963 42, C.F.R., 411.15 (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” Re-evaluation should only occur when there is a potential change in; Diagnosis Symptoms cpt

E. CPT: Documenting Purpose Payer Requirements General Principles History Examination Decision Making cpt

Documentation: Purpose Medical Necessity Evaluate and Plan for Treatment Communication and Continuity of Care Claims Review and Payment Research and Education cpt

Documentation: General Principles Rationale for Service Assessment, Progress, Impression, or Diagnosis Plan for Care Date and Identity of Observer Also Legible Timely Confidential cpt

Documentation: Basic Information Across Codes Date Time, if applicable Identity of Observer (technician ?) Reason for Service Status Procedure Results/Finding Impression/Diagnoses Disposition Stand Alone cpt

Documentation: Chief Complaint Concise Statement Describing the Symptom, Problem, Condition, & Diagnosis Foundation for Medical Necessity Must be Complete & Exhaustive cpt

Documentation: Present Illness Symptoms Location, Quality, Severity, Duration, timing, Context, Modifying Factors Associated Signs Follow-up Changes in Condition Compliance cpt

Documentation: History Past Family Social Medical/Psychological cpt

Documentation: Assessment Reason for Service Dates (amount of service time?) Identity of Tester (technician) Tests and Protocols (included editions) Narrative of Results Impression Disposition cpt

Documentation: Intervention Reason for Service Status of Patient Intervention Performed Results Obtained Impression or Diagnosis (es) Disposition Time cpt

CPT X Report Each CPT Code Should Generate a Separate Report Alternatively, Clearly Label/Title Sections of the Report to Match Codes Used cpt

Documentation: Suggestions Avoid Handwritten Notes Do Not Use Red Ink Avoid Color Paper Document On and After Every Encounter, Every Procedure, Every Patient Review Changes Whenever Applicable Avoid Standard Phrases & Protocols cpt

Documentation Suggestions (continued) Two Tiered System of Documentation (using HIPPA as Model) Raw data = handwritten and not for distribution psychotherapy notes Report = “typed” notes for more public consumption cpt

E. Time Time is Broadly Defined as What the Professional Does For Intervention – Time is face-to-face For Assessment - Time could be either face-to-face or professional time cpt

Time: Definition 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. cpt

Time: Testing Quantifying Time Time Does Not Include Round up or down to nearest increment Actual time vs. Elapsed time? Time Does Not Include Patient completing tests, scales, forms, etc. Waiting time by patient Typing of reports Non-Professional (e.g., clerical) time Literature searches, learning new techniques, etc. cpt

Time (CPT Assistant, 08. 05, 15, #8, pg. 12) (www. cms. hhs Time (CPT Assistant, 08.05, 15, #8, pg. 12) (www.cms.hhs.gov/providers/therapy) For Timed Codes (in physical medicine): The Beginning and Ending Time Should be Documented Time Should be Documented Along with the Treatment Description cpt

Time: Physical Medicine Codes (effective 07.01.05) Physical Medicine Codes are in 15’ Increments Multiple Units Can Be Billed on a Date of Service for Same or Different Procedures “A substantial amount portion of 15 minutes must be spent in performing the pre, intra, and post-service work…” cpt

Time: Defining 15 Minutes (from CPT Assistant, 08.05, 11-12) (www.cms.hhs.gov/manuals/104_claims/clm104c05.pdf) Defining 15 Minute Increments Units Amount of Minutes 1 >08; <23 2 >22; <38 3 >38; <53 4 >53; <68 5 >68; <83 6 >83; <98 7 >98; <113 8 >113;<128 Over 2 hours similar pattern as above cpt

Part II: Specific Issues with CPT (Intermediate) Reimbursement Supervision & Incident to Technicians Time Coverage & Payment Fraud & Abuse UPIN # cpt

A. Reimbursement History Cost Plus Prospective Payment System (PPS) Diagnostic Related Groups (DRGs) Customary, Prevailing & Reasonable (CPR) Resource Based Relative Value System (RBRVS) Note: On average, insurance companies will pay approximate 75% of its income) cpt

Relative Value Units: Overview Components Units Values Current Problems cpt

RVU: Components Physician Work Resource Value Practice Expense Resource Value Malpractice Geographic Conversion Factor (approx. $37.8975 02.2005) cpt

RVU Components Percentages Physician Work = 52% Practice Expense = 44% Liability = 4% NOTE: Within 5-10 years, another major component will be performance; in other words, not only the work must be performed but some results should occur as a function of the service cpt

Defining Physician Work Clinical Work Mental Effort and Judgment Technical Skill/Physical Effort Psychological Stress cpt

Defining Practice Expense Constitutes 43% of Medicare Payments Components of Practice Expense Clinical non-physician labor (43 categories) RN/LPN/MTA = $.37/minute ( $37,440/year) Medical disposable supplies (842 items) Equipment (553 items) cpt

RVU: Values Psychotherapy: Psych/NP Testing: Health & Behavior Prior Value =1.86 New Value = 2.65 Psych/NP Testing: Work value= 0 Hsiao study recommendation = 2.2 New Value = undetermined Health & Behavior .25 (per 15 minutes increments) cpt

RVU: Acceptance Medicare (100% since 01.01.92) Medicaid = 100% Private Payors = 74% and increasing to 95% Blue Cross/Blue Shield = 87% Managed Care = 69% Other = 44% New Trends: RVUs as a Model for All Insurance Companies RVUs as a Basis for Compensation Formulas cpt

2006 RVU Changes (CPT Assistant, January, 2006, 16, 1) 283 RVU Changes Submitted Medicare Accepted 97% Professional Liability to Change to 1.00 Geographic Index is Revised Every 3 yrs. cpt

CPT x RVU Pre 2006 cpt

National Work RVU/Estimated $ 2006 Values op=outpatient, ip=inpatient, est=estimate rvu = work Code # OP RVU IP RVU OP $ est IN $est 96101 2.56 2.54 92.61 91.89 96102 1.17 0.68 42.33 24.60 96103 0.74 0.70 26.77 25.32 96116 2.87 2.68 103.83 96.95 96118 3.43 2.67 124.09 96.59 96119 1.75 0.92 63.31 33.28 96120 1.27 45.94 cpt

B. Supervision ( Federal Register, 69, #150, August 5, 2004, page 47553) Hold Doctoral Degree in Psychology Licensed or Certified as a Psychologist Applicable Only to “clinical psychologists” (and not “independent” psychologists as defined by Medicare) Rationale Allows for higher level of expertise to supervise Could relieve burden on physicians and facilities May increase service in rural areas Recommended Supervision Level = General cpt

Supervision Supervision 1.General = overall direction 2.Direct = present in office suite 3.Personal = in actual room 4.Psychological = when supervised by a psychologist cpt

Supervision Program Memorandum Carriers Department of Health and Human Services- HCFA Transmittal b-01-28; April 19, 2001 Levels of Supervision General Furnished under overall direction and control, presence is not required Direct Must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure Personal Must be in attendance in the room during the performance of the procedure cpt

Incident to Rationale for Incident to Definition of Physician Extender Congress intended to provide coverage for services not typically covered elsewhere Definition of Physician Extender How Limitations Definition of In vs. Outpatient Geographic Vs Financial Probably Limited Future to Incident to Due to Inclusion of New Testing Codes cpt

Defining Incident to Definition Commonly furnished service Integral, though incidental to psychologist Performed under direct supervision Either furnished without charge or as part of the psychologist’s charge The employee meets the contractual requirement sent by CMS (e.g., 1099) cpt

More Incident to When is “Incident to” Acceptable: Testing - Definite Cognitive Rehabilitation; Biofeedback - Probably Psychotherapy – CMS does not have a national policy prohibiting psychotherapy as a incident to but it has supported local carriers when they took the position that psychotherapy should not be incident to cpt NCPA/DIPP 2006

Incident to & Site of Service Outpatient vs. Inpatient Geographical Location- Separate Corporate Entities- Separate Billing Service- Separate Chart Information & Location- Separate cpt

Incident to versus Independent Service When Does Incident to Become Independent Service Appearance of No Supervision Clinical Decisions are Made by Staff Ratio of Physician to Staff Time Becomes Disproportionate Distance Difficulties Supervision Difficulties cpt

Difficulties with Incident to The “Physician” Must Evaluate and/or Treat the Patient First No Clear Guidelines Regarding Reasonable Mix of Physician to Extender Activities What are the Limits of the Extender? cpt

Difference Between Supervision and “Incident to” Applies to whether and how a “physician” oversees the work of ancillary personnel A clinical concept Can occur at any level of supervision (from general to personal) “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 cpt

The Future of Incident to vs. Supervision Intervention Technical Interventions such as biofeedback and cognitive rehabilitation Testing None , if technical codes accepted If not, presumably it can continue Supervision Regardless, some form of supervision required if a technician is used cpt

C. Defining a Technician What is the Minimum Level of Training Required for a Technician? National Association of Psychometrists NAN Position Paper Level of Education- Probably a minimum of Bachelors Level of Training Level of Supervision cpt

Defining a Technician (Federal Register, Vol. 66, #149, page 40382) Requirement Employee (e.g., 1099); “employees, leased employees, or independent contractor” Most common is independent contractor “We do not believe that the nature of the employment relationship is critical for purposes of payment to the services of physician…as long as…(the personnel) is under the required level of supervision.” Common Practice Independent Contractor cpt

Defining a Technician HCFA/CMS Line 25 This is the line that identifies in a common insurance form who is the “qualified health provider” that is responsible for and completing the service Anybody else, from high school to post-doctoral fellow, is, for all practical purposes, a technician Extern, Intern, Postdoctoral Fellow, Technician cpt

Acceptance of Technicians Medicare Outside of North Central & California, yes Some states require specific modifiers (e.g., North Carolina, use the “AH” modifier) Private Carriers Magellan, United Health… – yes Others (e.g., Value Options) – under consideration cpt

Uses of Technicians The Qualified Health Provider must; See the patient first Supervise the activity Interpret and write the note/report Engaged in an ongoing capacity NOTE: Pattern similar to medical providers cpt

Use of Technician Technicians in a “Facility” A “facility” in essentially an inpatient setting If a technician is an employee of a private provider but the service is provided in an inpatient setting, the inpatient fee would be used If a technician is an employee of a a facility, there is some question as to whether they could be supervised by a provider who is not an employee of the facility cpt

Use of Technicians Practice Expense & Practice Implications Each tech code has .51 work value This means that the provider is engaged in the work That engagement would include; Selection of tests Determination of testing protocol Supervision of testing Interpretation of individual tests Reporting on individual tests cpt

The Problem with Training Medicare Will Pay When: The physician provides the service alone The physician provides the service in conjunction with the medical student The physician is present in the same room when the student provides the service Possibility of Students as Incident to A Student/Extern/Intern/Postdoc, For All Practical Purposes = a Technician cpt

Medicare Billing Suggestions When to Bill Overall = after documentation is in place Diagnostic Services After the Interview After all testing is completed and a report has been completed Billing should occur only once after testing Therapeutic Services Could occur after each session Should occur at least by the end of the month cpt

Billing Model Components Procedure Completed Number of Units of that Procedure Location or Site Where the Service was Provided Date of Service CPT X # of Units X Dx X Site of Service X Date cpt

E. Office of Inspector General (2005 Orange Book) Identify Nursing Home Residents with Serious Mental Illness (OEI-05-99-00701 Improve Assessments of Mental Illness (OEI-05-99-00700) Eliminate Inappropriate Payments for Mental Health Services cpt

Expenditures & Fraud Projections Current By 2011; 14% 17% ($2.8 trillion) cpt

Fraud: Medicare’s Interpretation of Physician Liability Overpayment From Incorrect Charge Mathematical or Clerical Error Billing for Items Known Not to be Covered Services Provided by Non-qualified Practitioner Inappropriate Documentation cpt

Defining Fraud Fraud Intentional Pattern Error Clerical Dates cpt

Problem: Fraud & Abuse 26 Different Kinds of Fraud Types Psychological Services Have Been Identified as Problematic cpt

Fraud & Office of Inspector General Primary Problems Medical Necessity (approximately $5 billion) Documentation Psychotherapy (oig.hhs/gov/reports/region5/50100068) Individual Group # of Hours Who Does the Therapy Psychological Testing cpt

Fraud (continued) Nursing Homes Children Identification Overuse of Services Children cpt

Fraud: OIG’s May 2001 Study (OEI-03-99-00130) Overall Payments in 1998 = $1.2 billion (62% outpatient = $718 million) Inappropriate Outpatient Mental Health “Particularly Problematic” due to Medically unnecessary Billed incorrectly Rendered by unqualified providers Undocumented or poorly documented cpt

OIG Report (continued) Provider Not Qualified = 11% Medically Unnecessary = 23% Billed Incorrectly = 41% Insufficient Documentation = 65% cpt

Fraud (cont.) Estimated Pattern of Fraud Analysis For-profit Medical Centers For-profit Medical Clinics Non-profit Medical Centers Non-profit Medical Clinics Nursing Homes Group Practices Individual Practices Research Grants and, if applicable, Clinical Trials cpt

Fraud: (can go back 10 years) Initial Review (14 points of submitted claims) Legibility Coverage Matching dates Signature Subsequent Review (occurs if over 5-6 items are failed in initial review) Does the service affect a potential change in medical condition? cpt

Fraud: CERT Program (www.oig.hhs.gov) Comprehensive Error Rate Testing Program National Contractor-specific Service-specific Reviews both denied and accepted claims An initial written request is followed by 4 letters and 3 phone calls followed by an overpayment demand letter and interpreted as services non-rendered cpt

Fraud: New Information The Good Enough or Common Sense Approach If Medicare Audit Occurs then an Increased Likelihood of Medicaid Audit Practice Situations That Increase Potential Audits; Skilled Nursing Facilities Statistical Outliers Testing States with Increased Audit Activity; TX, CA, FL, PR cpt

Fraud: 2006 Red Book Section 1862(a)(1)(A) of the Social Security Practice Act requires all services to be reasonable and necessary for the diagnosis or treatment of an illness or injury. Claim errors have exceed 34% cpt

Fraud: Red Book (continued) Problem Areas Acute Hospital outpatient Services ($224) Partial Hospitalization ($180) Psychiatric Hospital outpatient ($57) Nursing Home ($30) General Mental Health ($185) Beneficiaries who are unable to benefit from psychotherapy services Note: in millions (total for 2005 - $676,000,000) cpt

F. Unique Physician Identification Number (UPIN) Historical UPIN # Box 17 a CMS (insurance) 1500 form Present National Provide Identification Number cpt

National Provider Identification Number (CMS memo, 45 CFR Part 16c) Basic Information 10 Position numeric & individual number No specific information about provider Managed by CMS’s Provider System Dates of Implementation May 23, 2005 – Apply May 23, 2007 – Most entities will use May 23, 2008 – All entities will use Applicability Federal plans – immediately State plans – this year Other health plans- as soon as feasible cpt

Part III: Summary, Trajectories, Resources & Questions/Answers Summary of Present Problems Trajectories Resources Questions & Answers cpt

A. Present Problems Commercial Carriers Medical vs. Mental Health vs. No Coverage Upper limits on # of hours/evaluation Limited test formularies Specific time per test “Phantom benefits”- carrier states a service is covered but no authorization is possible cpt

Summary of Present Problems with New Codes- Carrier-Based Code Acceptance- Use of new codes at all If 96101/96118 accepted, technical and computer codes not being accepted Overall interpretation of codes (EOBs are still out) Code Payment- Lower than expected RVU % by private carriers Medicare carriers not paying- too high of a value placed by AMA and CMS Human error in interpreting code submission (manuals/software) “Congressional action pending” Technicians Current and operational definition Acceptance by carriers & licensing boards (e.g., NY) cpt

Summary of Present Problems with New Codes- Provider-Based General Understanding & Usage Specific Code Usage- Mixing of psychiatric with neuropsychological procedures as well as mixing of diagnostic codes Time (estimates, rounding) Professional having to see the patient at all Professional having to interpret and write the evaluation Misunderstanding of potential difference between computerized testing and computer code (interactive computerized testing with tech or professional is coded as such) and computerized testing (non-interactive is coded as a computer code) cpt

Summary of Present Problems with Codes- Provider-Based (continued) Technicians Training programs (externs, interns and postdoctoral fellows) Essentially no difference between a bachelor’s level technician and a postdoctoral fellow Difference between training and providing professional services “Limited” interpretation of scoring (away from the patient) Difference among psychometricians and psychometrists as well as technicians Psychometricians = doctoral level scientist involved in testing issue Technicians = any provider that does not have a contract with the insurance carrier Psychometrists= typically a certified technician (e.g., NAP) cpt

Summary of Present Problems with Testing Codes- Potential Concerns Qualifications Who can perform neuropsychological services? CMS/AMA delegates that restriction to states licensing boards and carriers Technicians Could no acceptance of technical code = incident to? Understanding that scoring time is built in the code value One could score while the patient is being tested, easier for adults than for children but information about the observation has to occur Tests Time estimates (HMOs) for test administration & interpretation Documentation of start/stop times Listing of actual tests for documentation Formulary (both in terms of tests as well as time allocated) cpt

Summary of Present Problems with Testing Codes- Potential Concerns Documentation Inclusion of #s along with narratives in documentation Matching of documentation with carrier requirements Inclusion of Actual Time Inclusion of name of technician Masters Level Practitioners Will they be viewed as “qualified health practitioners? cpt

B. Future Perspectives: 2003 Predictions Paradigms Industrial vs. Boutique/Niche Clinical vs. Forensic Mental Health vs. Health Existing vs. Developing cpt

2004 Predictions Federal Technical – Health Electronic Records by 2008 Performance Based Payment Traditionally = Fee for service provided Anticipated = Fee for performance/results obtained Economic Overall, Positive cpt

2004 (Continued) Increased Probability of Audits Psychological and Neuropsychological Testing Individual Practitioners Skilled Nursing Facilities In Institutions, supervision and “incident to” Primary Issues of Concern Medical Necessity Documentation cpt

2004 (Continued) Institutionally Based Professional Institutionally Based Limitations secondary to “incident to” Difficulties in gaining access to GME funds Practitioner Based Increase in audits Shifting in practice patterns Practice Parameter Based Difficulties with battery-based approaches to diagnostics Expansion and alterations of reimbursement practices Significant expansion of types of services and clients served cpt

2005 Medicare Institutional Individual Practice 4.3-4.6% decrease over next 6 years (compared to 1.5% increase each over the last 3 years; AAP Advance, Summer, 2005) Institutional Further defining of supervision & incident to Significantly limited access to funds (e.g., GME) Individual Increased focus on business issues Technician based practice will increase Continued emphasizes on expanding non-health care services (e.g., forensic) Practice Diagnostic work will continue being emphasized (e.g.,fMRI) Pay-for-Performance or P4P (5-10% differences; Medicare Payment Advisory Commission, 09.15.05) WellPoint, WellChoice, HealthNet, MVP Health Care, Blue Cross of California and 32 states (105 programs in mid 2005) cpt

2005 Issues to be Addressed Information dissemination Colleagues Third-party insurers/payors Potential mix of “old” and “new” testing codes for 2006 Typical use of combination of codes Technician qualifications and training Use of computerized tests Vs. tests that are computerized but interactive Appropriate documentation Technician identification Time for testing and therapy cpt

2006 Early Portions of 2006 = Confusion in Use & Reimbursement of Codes The Use of Technicians Insurance Carriers Acceptance of Codes Decreased Revenue Stream Middle Portions of 2006 = Increased Stabilization in Use & Reimbursement of Codes Later Portion of 2006 = Potential Increase in Overall Reimbursement By 2007 = Likely and Stable Increase in Reimbursement Patterns By 2010 = Addition of Performance to Work as a Factor for Reimbursement cpt

Pay for Performance (P4P) Initiatives Premise Evidence-based guidelines Outcome more than procedure based Initial Application Dartmouth, Duke & Michigan Final Application 5-10 years cpt

Beyond 2006 (CMS) Health Care Spending & GDP 1960 = 5.0% 1970 = 7.0% 1960 = 5.0% 1970 = 7.0% 1990 = 9.0% 2002 = 15.4% 2004 = 16.0% 2005 = 16.2% 2010= 18.0% 2015 = 20.0% ( or 4 trillion $) Final = 33.3% cpt

Beyond 2006: What Does the American Public Want? Life Expectancy #1 Life Value = approximately $5 million Expected Expenditure on Health Care= will finally settle at about 1/3 of earned income To be Competitive, Industry and Business will Shift Cost of Health Care to Consumers and the Government Government (e.g., Medicare) Will, However, Set the Standard for Health Care cpt

Mechanisms to Keep Informed APA Practice Website (www.apa.org) NAN Website (www.nanonline.org) 40 Website (www.div40.org) Support these continuing efforts by joining APA, NAN, Division 40, SPA as well as your state association cpt

C. Resources General Web Sites www.apa.org www.nanonline.org/paio www.ncpsychology.org www.cms.org (medicare/medicaid) www.hhs.org (health & human services) www.oig.hhs.gov (inspector general) www.apa.org/practice/cpt (apa’s cpt information) www.ahrq.gov (agency for healthcare research) www.medpac.gov (medical payment advisory comm.) www.whitehouse.gov/fsbr/health (statistics) www.div40.org (clinical neuropsychology div of apa) www.napnet.org (national association of psychometrists) www.access.gpo.gov (federal statutes and regulations) www.healthcare.group.com (staff salaries) cpt

Resources (continued) Payment/Coverage www.myhealthscore.com/consumer/phyoutcptsearch.htm www.cms.hhs.gov/statistics/feeforservice/defailt.asp (covered services) www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=167 (non-covered) www.apa.org/pi/aging/lmrp/toolkit/homepage.html (apa lmrp) www.cms.hhs.gov/providers/mr/lmrp/asp (medicare lmrp) www.quickfacts.census.gov/qfd (census x type of procedure data) LMRP Reconsideration Process www.cms.gov/manuals/pm_trans/R28PIM.pdf Compliance Web Sites www.oig.hhs.gov (office of inspector general) www.cms.hhs.gov/manuals (medicare) www.uscode.house.gov/usc.htm (united states codes) www.apa.org (psychologists & hipaa) www.cms.hhs.gov/hipaa. (hipaa) www.hcca-info.org (health care compliance assoc.) cpt

Resources (continued) ICD www.who.int/icd/vol1htm2003/fr-icd.htm (who) www.cdc.gov/nchas/about/otheract/icd9/abticd9.htm (ccd) Coding Web Sites www.catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp (ama cpt) www.aapcnatl.org (academy of coders) www.ntis.gov/product/correct-coding (coding edits) cpt

Resources Telephone Numbers APA Practice Directorate’s Government Relations Office; 202.336.5889 AMA CPT Office; 800.621.8335 Medicare National Coverage Determinations; 410.786.2281 cpt

Contact Information Websites Univ = www.uncw.edu/people/puente Practice = www.clinicalneuropsychology.us NAN = www.nanonline.org/paio E-mail University = puente@uncw.edu Practice = puente@clinicalneuropsychology.us Telephone University = 910.962.3812 Practice = 910.509.9371 cpt NCPA/DIPP 2006