cpt1 Coding, Billing and Documenting Neurosychological Services: With Special Emphasis on the 2006 Testing Codes Antonio E. Puente Department of Psychology University of North Carolina Wilmington Midwest Neuropsychology Group Chicago, Illinois May 12, 2006

cpt2 Disclaimer The information contained in this extended presentation is not intended to reflect APA, NAN, Division 40, MNG, AMA and/or CMS policy. Further, this presentation is intended to be informative and not meant to imply that it supersedes APA or state ethical guidelines and/or local, state or national regulations and/or laws. Further, Local Coverage Determination and specific health care contracts may supersede the information presented. The information contained herein is meant to provide practitioners as well as health care institutions (e.g., insurance companies) involved in psychological services with the latest information available regarding the issues addressed. This is a living document that can and will be revised as additional information becomes available. The ultimate responsibility of the validity and utility of the information contained herein lies with the individual and/or institution using this information and not with any supporting organization and/or the author of this presentation. Suggestions or changes should be addressed to the author. Thank you… The information contained in this extended presentation is not intended to reflect APA, NAN, Division 40, MNG, AMA and/or CMS policy. Further, this presentation is intended to be informative and not meant to imply that it supersedes APA or state ethical guidelines and/or local, state or national regulations and/or laws. Further, Local Coverage Determination and specific health care contracts may supersede the information presented. The information contained herein is meant to provide practitioners as well as health care institutions (e.g., insurance companies) involved in psychological services with the latest information available regarding the issues addressed. This is a living document that can and will be revised as additional information becomes available. The ultimate responsibility of the validity and utility of the information contained herein lies with the individual and/or institution using this information and not with any supporting organization and/or the author of this presentation. Suggestions or changes should be addressed to the author. Thank you…

cpt3 Outline of Presentation Part I: Coding, Billing and Documentation Part I: Coding, Billing and Documentation Part II: Specific CPT Topics Part II: Specific CPT Topics Part III: Current Problems Part III: Current Problems

cpt4 Part I: Coding, Billing & Documentation Part I: Part I: Medicare Medicare Current Procedural Terminology Current Procedural Terminology Diagnosing Diagnosing Medical Necessity Medical Necessity Documentation Documentation Time Time

cpt5 A. Medicare: Why? The Standard for Universal Health Care: The Standard for Universal Health Care: Coding (what can be done) Coding (what can be done) Value (how much it will be paid) Value (how much it will be paid) Documentation (what needs to be said) Documentation (what needs to be said) Auditing (determination of whether it occurred) Auditing (determination of whether it occurred)

cpt6 Medicare: Local Review Medical Review Policy Medical Review Policy National Policy Sets Overall Model National Policy Sets Overall Model Local Coverage Determination (LCD) Sets Local/Regional Policy- Local Coverage Determination (LCD) Sets Local/Regional Policy- More restrictive than national policy More restrictive than national policy Over-rides national policy Over-rides national policy Changes frequently without warning or publicity Changes frequently without warning or publicity Information best found on respective web pages Information best found on respective web pages

cpt7 B. Current Procedural Terminology (CPT): Overview Background Background Codes & Coding Codes & Coding Existing Codes Existing Codes Model System X Type of Problem Model System X Type of Problem

cpt8 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 CPT Meets a Minimum of 4 Times/Year CPT Meets a Minimum of 4 Times/Year Center for Medicare & Medicaid Services Center for Medicare & Medicaid Services AMA Under License by CMS AMA Under License by CMS CMS Now Provides Active Input into CPT CMS Now Provides Active Input into CPT

cpt9 What Is a CPT Code? A Coding System Developed by AMA in Conjunction with CMS to Describe Professional Services 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 Each Code has a Specific Number and Description as well as a Reimbursable Value Professional Health Service Provided Across the Country at Multiple Locations Professional Health Service Provided Across the Country at Multiple Locations Many “Physicians” or “Qualified Health Professional” Perform Services Many “Physicians” or “Qualified Health Professional” Perform Services Clinical Efficacy is Established and Documented in Peer-Reviewed Literature Clinical Efficacy is Established and Documented in Peer-Reviewed Literature

cpt10 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 Primary Separate Sections Sections = Five Primary Separate Sections Psychiatry (e.g., mental health) Psychiatry (e.g., mental health) Biofeedback Biofeedback Central Nervous System Assessment (testing) Central Nervous System Assessment (testing) Physical Medicine & Rehabilitation Physical Medicine & Rehabilitation Health & Behavior Assessment & Management (h.p.) Health & Behavior Assessment & Management (h.p.) Evaluation and Management Evaluation and Management

cpt11 CPT: Psychiatry Sections (or Categories) Sections (or Categories) Interview (90801) vs. Intervention (e.g., 90806) Interview (90801) vs. Intervention (e.g., 90806) These codes are one unit These codes are one unit 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

cpt12 CPT: CNS Assessment Psychological Testing (e.g., 5 units) Psychological Testing (e.g., 5 units) Three New Codes Three New Codes New Numbers & Descriptors New Numbers & Descriptors Neurobehavioral Status Exam (e.g., 2 units) Neurobehavioral Status Exam (e.g., 2 units) New Number & Revised Descriptor New Number & Revised Descriptor Neuropsychological Testing (e.g., 10 units) Neuropsychological Testing (e.g., 10 units) Three New Codes Three New Codes New Numbers & Descriptors New Numbers & Descriptors

cpt13 Psychological Testing: By Professional –Psychological Testing –Psychological Testing 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) 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”)

cpt14 Psychological Testing: By Technician Psychological Testing Psychological Testing 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 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

cpt15 Psychological Testing: By Computer Psychological Testing Psychological Testing Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, (e.g., MMPI) administered by a computer, with qualified health professional interpretation and the report Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, (e.g., MMPI) administered by a computer, with qualified health professional interpretation and the report

cpt16 Neurobehavioral Status Exam Neurobehavioral status exam 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 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”)

cpt17 Neuropsychological Testing- By Professional Neuropsychological testing Neuropsychological testing (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 (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”)

cpt18 Neuropsychological Testing: By Technician Neuropsychological testing Neuropsychological testing (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 (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

cpt19 Neuropsychological Testing- By Computer Neuropsychological testing Neuropsychological testing (e.g., WCST) administered by a computer with qualified health care professional interpretation and the report (e.g., WCST) administered by a computer with qualified health care professional interpretation and the report

cpt20 CPT: Physical Medicine & Rehabilitation now now Note: 15 minute increments (round up or down) Note: 15 minute increments (round up or down)

cpt21 CPT: Health & Behavior Assessment & Management (CPT Assistant, 03.04) (CPT Assistant, 08.05, 15, #6, 10) Purpose: Medical Diagnosis Purpose: Medical Diagnosis Time: 15 Minute Increments Time: 15 Minute Increments Assessment Assessment Intervention Intervention

cpt22 Overview of H & B Codes Codes Effective as (with ongoing revisions of language) Codes Effective as (with ongoing revisions of language) Assessment (e.g., 4 units) Assessment (e.g., 4 units) Intervention (e.g., up to a total of 48 units) Intervention (e.g., up to a total of 48 units) Established Medical Illness or Diagnosis Established Medical Illness or Diagnosis Focus on Biopsychosocial Factors Focus on Biopsychosocial Factors

cpt23 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

cpt24 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) (limited acceptability) (limited acceptability) family (without the patient present; not being reimbursed ) family (without the patient present; not being reimbursed )

cpt25 CPT: Model System Psychiatric Psychiatric Neurological Neurological Non-Neurological Medical Non-Neurological Medical

cpt26 CPT Model Rationale for CPT Code: Rationale for CPT Code: Choose Code that Best Describes the Service Choose Code that Best Describes the Service Match the Interview with the Testing with the Intervention Code with the Diagnosis Match the Interview with the Testing with the Intervention Code with the Diagnosis Goal = Uniformity and Fluency Goal = Uniformity and Fluency

cpt27 CPT: Psychiatric Model (Children & Adult) Interview Interview adult adult child child Testing Testing Also, for children Also, for children Intervention Intervention e.g., adult e.g., adult e.g., child e.g., child

cpt28 CPT: Neurological Model (Children & Adult) Interview Interview Testing Testing 96118/19/ /19/20 Intervention Intervention

cpt29 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)

cpt30 C. 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 – 9 CM (physical diagnosis coding) ICD – 9 CM (physical diagnosis coding)

cpt31 D. CPT: Medical Necessity Scientific & Clinical Necessity Vs Insurance Necessity Scientific & Clinical Necessity Vs Insurance Necessity Insurance Necessity = CPT x DX formulary Insurance Necessity = CPT x DX formulary Necessity Can Only be Proven with Documentation Necessity Can Only be Proven with Documentation Screening or Regularly Scheduled Evaluations Do Not Meet Criteria for Necessity Screening or Regularly Scheduled Evaluations Do Not Meet Criteria for Necessity Will Results Affect Outcome of Patient? Will Results Affect Outcome of Patient?

cpt32 E. CPT: Documenting Purpose Purpose General Principles General Principles

cpt33 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

cpt34 Documentation: Basic Information Across Codes Date Date Time, if applicable Time, if applicable Identity of Observer (technician ?) Identity of Observer (technician ?) Reason for Service Reason for Service Status Status Procedure Procedure Results/Finding Results/Finding Impression/Diagnoses Impression/Diagnoses Disposition Disposition

cpt35 Documentation: Assessment Reason for Service Reason for Service Dates (amount of service time; total Vs. actual) Dates (amount of service time; total Vs. actual) Identity of Tester (technician?) Identity of Tester (technician?) Tests and Protocols (included editions) Tests and Protocols (included editions) Narrative of Results Narrative of Results Impression Impression Disposition Disposition

cpt36 Documentation: Intervention Reason for Service Reason for Service Status of Patient Status of Patient Intervention Performed Intervention Performed Results Obtained Results Obtained Impression or Diagnosis (es) Impression or Diagnosis (es) Disposition Disposition Time Time

cpt37 E. Time Time is Broadly Defined as What the Professional Does Time is Broadly Defined as What the Professional Does For Intervention – Time is face-to-face For Intervention – Time is face-to-face For Assessment - Time could be either face-to-face or professional time For Assessment - Time could be either face-to-face or professional time

cpt38 Time: Testing Quantifying Time Quantifying Time Round up or down to nearest increment Round up or down to nearest increment Actual time vs. Elapsed time? Actual time vs. Elapsed time? Time Does Not Include Time Does Not Include Patient completing tests, scales, forms, etc. Patient completing tests, scales, 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.

cpt39 Part II: Specific CPT Topics Reimbursement Reimbursement Supervision & Incident to Supervision & Incident to Technicians Technicians Time Time Coverage & Payment Coverage & Payment Fraud & Abuse Fraud & Abuse

cpt40 A. 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)

cpt41 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. $ ) Conversion Factor (approx. $ )

cpt42 RVU Components Percentages Physician Work=52% Physician Work=52% Practice Expense=44% Practice Expense=44% Liability= 4% 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 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

cpt43 CPT x RVU Pre 2006

cpt44 National Work RVU/Estimated $ 2006 Values op=outpatient, ip=inpatient, est=estimate rvu = work Code # OP RVU IP RVU OP $ est IN $est

cpt45 B. Supervision ( Federal Register, 69, #150, August 5, 2004, page 47553) 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 as defined by Medicare) Applicable Only to “clinical psychologists” (and not “independent” psychologists as defined by Medicare) 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

cpt46 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

cpt47 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 Probably Limited Future to Incident to Due to Inclusion of New Testing Codes Probably Limited Future to Incident to Due to Inclusion of New Testing Codes

cpt48 Defining Incident to Defining Incident to Definition Definition Commonly furnished service Commonly furnished service Integral, though incidental to psychologist Integral, though incidental to psychologist Performed under direct supervision Performed under direct supervision Either furnished without charge or as part of the psychologist’s charge Either furnished without charge or as part of the psychologist’s charge The employee meets the contractual requirement sent by CMS (e.g., 1099) The employee meets the contractual requirement sent by CMS (e.g., 1099)

cpt49 More Incident to When is “Incident to” Acceptable: When is “Incident to” Acceptable: Testing - Definite Testing - Definite Cognitive Rehabilitation; Biofeedback - Probably 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 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

cpt50 Incident to & Site of Service Incident to & Site of Service Outpatient vs. Inpatient Outpatient vs. Inpatient Geographical Location- Separate Geographical Location- Separate Corporate Entities- Separate Corporate Entities- Separate Billing Service- Separate Billing Service- Separate Chart Information & Location- Separate Chart Information & Location- Separate

cpt51 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

cpt52 Difficulties with Incident to The “Physician” Must Evaluate and/or Treat the Patient First The “Physician” Must Evaluate and/or Treat the Patient First No Clear Guidelines Regarding Reasonable Mix of Physician to Extender Activities No Clear Guidelines Regarding Reasonable Mix of Physician to Extender Activities What are the Limits of the Extender? What are the Limits of the Extender?

cpt53 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

cpt54 The Future of Incident to vs. Supervision Incident to Incident to Intervention Intervention Technical Interventions such as biofeedback and cognitive rehabilitation Technical Interventions such as biofeedback and cognitive rehabilitation Testing Testing None, if technical codes accepted None, if technical codes accepted If not, presumably it can continue If not, presumably it can continue Supervision Supervision Regardless, some form of supervision required if a technician is used Regardless, some form of supervision required if a technician is used

cpt55 C. Defining a Technician What is the Minimum Level of Training Required for a Technician? What is the Minimum Level of Training Required for a Technician? National Association of Psychometrists National Association of Psychometrists Division 40 Position Paper Division 40 Position Paper NAN Position Paper NAN Position Paper Level of Education- Probably a minimum of Bachelors Level of Education- Probably a minimum of Bachelors Level of Training Level of Training Level of Supervision Level of Supervision

cpt56 Defining a Technician (Federal Register, Vol. 66, #149, page 40382) Requirement Requirement Employee (e.g., 1099); “employees, leased employees, or independent contractor” Employee (e.g., 1099); “employees, leased employees, or independent contractor” Most common is 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.” “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 Common Practice Independent Contractor Independent Contractor

cpt57 Defining a Technician HCFA/CMS Line 25 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 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 Anybody else, from high school to post-doctoral fellow, is, for all practical purposes, a technician Extern, Intern, Postdoctoral Fellow, Technician Extern, Intern, Postdoctoral Fellow, Technician

cpt58 Acceptance of Technicians Medicare Medicare Outside of North Central & California, yes Outside of North Central & California, yes Some states require specific modifiers (e.g., North Carolina, use the “AH” modifier) Some states require specific modifiers (e.g., North Carolina, use the “AH” modifier) Private Carriers Private Carriers Magellan, United Health… – yes Magellan, United Health… – yes Others (e.g., Value Options) – under consideration Others (e.g., Value Options) – under consideration

cpt59 Uses of Technicians The Qualified Health Provider must; The Qualified Health Provider must; See the patient first See the patient first Supervise the activity Supervise the activity Interpret and write the note/report Interpret and write the note/report Engaged in an ongoing capacity Engaged in an ongoing capacity NOTE: Pattern similar to medical providers NOTE: Pattern similar to medical providers

cpt60 Use of Technician Use of Technician Technicians in a “Facility” Technicians in a “Facility” A “facility” in essentially an inpatient setting 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 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 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

cpt61 Use of Technicians Practice Expense & Practice Implications Practice Expense & Practice Implications Each tech code has.51 work value Each tech code has.51 work value This means that the provider is engaged in the work This means that the provider is engaged in the work That engagement would include; That engagement would include; Selection of tests Selection of tests Determination of testing protocol Determination of testing protocol Supervision of testing Supervision of testing Interpretation of individual tests Interpretation of individual tests Reporting on individual tests Reporting on individual tests

cpt62 The Problem with Training Medicare Will Pay When: Medicare Will Pay When: The physician provides the service alone The physician provides the service alone The physician provides the service in conjunction with the medical student 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 The physician is present in the same room when the student provides the service Possibility of Students as Incident to Possibility of Students as Incident to A Student/Extern/Intern/Postdoc, For All Practical Purposes = a Technician A Student/Extern/Intern/Postdoc, For All Practical Purposes = a Technician

cpt63 D. Coverage & Payment Origins of the Problem Origins of the Problem Balanced Budget Act of 1997 Balanced Budget Act of 1997 Employer’s Cost for Health Care in 2002 = $5,000 per employee Employer’s 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

cpt64 CMS Determination of Coverage Coverage Types Coverage Types Coverage with Conditions (specific DX, facility or provider) Coverage with Conditions (specific DX, facility or provider) Coverage without Conditions Coverage without Conditions Data Reviewed Data Reviewed Benefit Benefit Risks Vs. Benefits Risks Vs. Benefits Available Clinical Studies Available Clinical Studies Databases Databases Longitudinal or cohort studies Longitudinal or cohort studies Prospective studies Prospective studies Randomized clinical trials Randomized clinical trials

cpt65 Billing Model Components Components Procedure Completed Procedure Completed Number of Units of that Procedure Number of Units of that Procedure Location or Site Where the Service was Provided Location or Site Where the Service was Provided Date of Service Date of Service CPT X # of Units X Dx X Site of Service X Date CPT X # of Units X Dx X Site of Service X Date

cpt66 E. Office of Inspector General (2005 Orange Book) Identify Nursing Home Residents with Serious Mental Illness (OEI ) Identify Nursing Home Residents with Serious Mental Illness (OEI ) Improve Assessments of Mental Illness (OEI ) Improve Assessments of Mental Illness (OEI ) Eliminate Inappropriate Payments for Mental Health Services Eliminate Inappropriate Payments for Mental Health Services

cpt67 Fraud: Medicare’s Interpretation of Physician Liability Overpayment From Incorrect Charge Overpayment From Incorrect Charge Mathematical or Clerical Error Mathematical or Clerical Error 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 Inappropriate Documentation Inappropriate Documentation

cpt68 Defining Fraud Fraud Fraud Intentional Intentional Pattern Pattern Error Error Clerical Clerical Dates Dates

cpt69 OIG Report (continued) Provider Not Qualified= 11% Provider Not Qualified= 11% Medically Unnecessary = 23% Medically Unnecessary = 23% Billed Incorrectly= 41% Billed Incorrectly= 41% Insufficient Documentation= 65% Insufficient Documentation= 65%

cpt70 Fraud: New Information The Good Enough or Common Sense Approach The Good Enough or Common Sense Approach If Medicare Audit Occurs then an Increased Likelihood of Medicaid Audit If Medicare Audit Occurs then an Increased Likelihood of Medicaid Audit Practice Situations That Increase Potential Audits; Practice Situations That Increase Potential Audits; Skilled Nursing Facilities Skilled Nursing Facilities Statistical Outliers Statistical Outliers Testing Testing States with Increased Audit Activity; States with Increased Audit Activity; TX, CA, FL, PR TX, CA, FL, PR

cpt71 Part III: Summary, Trajectories, Resources & Questions/Answers Summary of Present Problems Summary of Present Problems Trajectories Trajectories Resources Resources Questions & Answers Questions & Answers

cpt72 A. Present Problems Carrier-Based Carrier-Based Provider-Based Provider-Based Potential Problems Potential Problems

cpt73 Summary of Present Problems with New Codes- Carrier-Based Code Acceptance- Code Acceptance- If 96101/96118 accepted, technical and computer codes not being accepted If 96101/96118 accepted, technical and computer codes not being accepted Overall interpretation of codes Overall interpretation of codes Limited Formulary (tests & hours/tests) Limited Formulary (tests & hours/tests) Code Payment- Code Payment- Lower than expected RVU % by private carriers Lower than expected RVU % by private carriers Medicare carriers not paying Medicare carriers not paying Human error in interpreting code submission (manuals/software) Human error in interpreting code submission (manuals/software) Technicians Technicians Current and operational definition Current and operational definition Acceptance by carriers & licensing boards Acceptance by carriers & licensing boards

cpt74 Summary of Present Problems with New Codes- Provider-Based General Understanding & Usage General Understanding & Usage Specific Code Usage- Specific Code Usage- Mixing of psychiatric with neuropsychological procedures as well as mixing of diagnostic codes Mixing of psychiatric with neuropsychological procedures as well as mixing of diagnostic codes Time (estimates, rounding) Time (estimates, rounding) Professional having to see the patient at all Professional having to see the patient at all Professional having to interpret and write the evaluation 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) 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)

cpt75 Summary of Present Problems with Codes- Provider-Based (continued) Technicians Technicians Training programs (externs, interns and postdoctoral fellows) Training programs (externs, interns and postdoctoral fellows) Essentially no difference between a bachelor’s level technician and a postdoctoral fellow Essentially no difference between a bachelor’s level technician and a postdoctoral fellow Difference between training and providing professional services Difference between training and providing professional services “Limited” interpretation of scoring (away from the patient) “Limited” interpretation of scoring (away from the patient)

cpt76 Summary of Present Problems with Testing Codes- Potential Concerns Qualifications Qualifications Who can perform neuropsychological services? Who can perform neuropsychological services? CMS/AMA delegates that restriction to states licensing boards and carriers CMS/AMA delegates that restriction to states licensing boards and carriers Technicians Technicians Could no acceptance of technical code = incident to? Could no acceptance of technical code = incident to? Understanding that scoring time is built in the code value 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 One could score while the patient is being tested, easier for adults than for children but information about the observation has to occur Tests Tests Time estimates (HMOs) for test administration & interpretation Time estimates (HMOs) for test administration & interpretation Listing of actual tests for documentation Listing of actual tests for documentation

cpt77 Summary of Present Problems with Testing Codes- Potential Concerns Documentation Documentation Inclusion of #s along with narratives in documentation Inclusion of #s along with narratives in documentation Matching of documentation with carrier requirements Matching of documentation with carrier requirements Inclusion of actual time Inclusion of actual time Inclusion of name of technician Inclusion of name of technician

cpt78 B. Projections: 2006 Early Portions of 2006 = Confusion in Use & Reimbursement of Codes Early Portions of 2006 = Confusion in Use & Reimbursement of Codes The Use of Technicians The Use of Technicians Insurance Carriers Acceptance of Codes Insurance Carriers Acceptance of Codes Decreased Revenue Stream Decreased Revenue Stream Middle Portions of 2006 = Increased Stabilization in Use & Reimbursement of Codes Middle Portions of 2006 = Increased Stabilization in Use & Reimbursement of Codes Later Portion of 2006 = Potential Increase in Overall Reimbursement Later Portion of 2006 = Potential Increase in Overall Reimbursement By 2007 = Likely and Stable Increase in Reimbursement Patterns By 2007 = Likely and Stable Increase in Reimbursement Patterns By 2010 = Addition of Performance to Work as a Factor for Reimbursement By 2010 = Addition of Performance to Work as a Factor for Reimbursement

cpt79 C. Resources Telephone Numbers Telephone Numbers APA Practice Directorate’s Government Relations Office; APA Practice Directorate’s Government Relations Office; AMA CPT Office; AMA CPT Office; Medicare National Coverage Determinations; Medicare National Coverage Determinations;

cpt80 Contact Information Websites Websites Univ = Univ = Practice = Practice = NAN = NAN = 40 = 40 = University = University = Practice = Practice = Telephone Telephone University = University = Practice = Practice =