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Quadrant Biosciences: Economics and Reimbursement Training

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1 Quadrant Biosciences: Economics and Reimbursement Training
5/28/2018 Quadrant Biosciences: Economics and Reimbursement Training 1 1 1

2 Terminology and descriptions Review of CPT codes for billing
Reimbursement 5/28/2018 Terminology and descriptions Review of CPT codes for billing Review typical diagnosis codes Documentation Q&A Review common testing and billing scenarios for ImPACT 2 2 2

3 Economics Economics HCP & Physicians
5/28/2018 Economics HCP & Physicians Institutions, Sports Clubs, Schools 3 3 3

4 CMS = Centers for Medicare & Medicaid Services
Terminology 5/28/2018 CMS = Centers for Medicare & Medicaid Services CPT= Current Procedural Terminology codes ICD-10 = International Statistical Classification of Diseases and Related Health Problems RVU= Relative Value Units Face to Face= Time spent with the patient Facility/Non-facility = Hospital or skilled nursing home vs all others ImPACT Webinar, April 28, 2010 4 4 4

5 CMS -Centers for Medicare & Medicaid Services
5/28/2018 Design, pass and over see diagnoses and billing regulations for Medicare and Medicaid Most insurance companies follow CMS but regional variations do occur ImPACT Webinar, April 28, 2010 5 5 5

6 CPT –Current Procedural Terminology
5/28/2018 Developed, copy protected and published by the American Medical Association (AMA) But mandated by CMS and HIPPA Used to report the procedures and services being submitted for payment Over 7,500 CPT codes 40-60 for psychologists ImPACT Webinar, April 28, 2010 6 6 6

7 International Statistical Classification of Diseases
ICD-10 5/28/2018 International Statistical Classification of Diseases The coding of diseases, symptoms and problems by The World Health Organization ICD 10 Has ≈155,000 codes Grouped by systems Codes are mental health/psychiatric dx Codes are neurological disorders Codes are a mix of other dx intracranial injury including concussion (850) ImPACT Webinar, April 28, 2010 7 7 7

8 Potential Diagnostic Codes (potential)1
ICD-10 5/28/2018 Potential Diagnostic Codes (potential)1 Z Personal history of traumatic brain injury Z Encounter for examination for participation in sport Z Encounter for routine child health examination with abnormal findings Karff Diana, “Public school evaluation head incidents.doc”, March 6, 8 8 8

9 RVU –Relative Value Unit
5/28/2018 A common scale used to determine the value of the procedure Each CPT code has a RVU Part of the equation used in determining reimbursement fee ImPACT Webinar, April 28, 2010 9 9 9

10 RVU –Relative Value Unit
5/28/2018 Based upon (in order of complexity): Type of Provider: Surgeon, Physician, Psychologist, mid-level provider and technician (52%) Difficulty of the healthcare provider’s work including time, complexity, mental effort, judgment and stress Expenses of healthcare provider for that procedure (44%) Regional variations Malpractice insurance for that procedure (4%) Direct and indirect costs ImPACT Webinar, April 28, 2010 10 10 10

11 CMS – CPT Q&A 5/28/2018 Do Current Procedural Terminology (CPT) codes for psychological and neuropsychological tests include tests performed by technicians and computers? Yes. Effective January 1, 2006, CPT codes for psychological and neuropsychological tests include tests performed by technicians and computers (CPT codes 96102, 96103, and 96120) in addition to tests performed by physicians, clinical psychologists (CPs), independently practicing psychologists (IPPs) and other qualified nonphysician practitioners (NPPs). The payment amounts for tests performed by a technician or a computer are adjusted depending upon whether the service was performed in a facility or non-facility setting. CMS.GOV, 11 11 11

12 CMS – CPT Q&A 5/28/2018 What are the supervision requirements for diagnostic psychological and neuropsychological tests? For diagnostic psychological and neuropsychological tests ( ), there is a regulatory exception that allows either a clinical psychologist (CP) or a physician to provide the required general supervision for diagnostic psychological and neuropsychological tests. Moreover, nonphysician practitioners (NPPs) such as nurse practitioners (NPs), clinical nurse specialists (CNSs), and physician assistants (PAs) who personally perform diagnostic psychological and neuropsychological tests are excluded from the supervision requirements for diagnostic tests. However, they must meet the collaboration and physician supervision practice requirements under their respective benefits. CMS.GOV, 12 12 12

13 CMS – CPT Q&A 5/28/2018 Are expenses for diagnostic psychological and neuropsychological tests subject to the payment limitation for outpatient mental health treatment services? In most cases, expenses for diagnostic psychological tests and neuropsychological tests are not subject to the payment limitation on certain outpatient mental health treatment services. The outpatient mental health treatment limitation (the limitation) is the payment limitation on treatment services for mental, psychoneurotic and personality disorders as authorized under the Social Security Act. However, the limitation does apply to diagnostic psychological and neuropsychological tests when these tests are performed to evaluate a patient’s progress during treatment rather than to establish or confirm the patient’s diagnosis. CMS.GOV, 13 13 13

14 CMS – CPT Q&A 5/28/2018 Can more than one CPT code for psychological or neuropsychological testing be billed on the same date of service for the same patient? Yes. If several different, clinically appropriate tests are administered on the same date to the same patient (whether by a physician/psychologist, technician or by computer), then the appropriate testing codes for psychological testing or neuropsychological testing can be billed together. More than one code can also be billed when several distinct tests are administered to the same patient on the same date of service via technician (96102/96119) or computer (96103/96120), and the physician/psychologist needs to integrate the separate interpretations and written reports for each of these tests into a comprehensive report. CMS.GOV, 14 14 14

15 CMS – CPT Q&A 5/28/2018 Can more than one CPT code for psychological or neuropsychological testing be billed together on the same date of service for the same patient if all of the testing is administered by a technician and/or computer? Yes. The technician-administered code (96102/96119) is billed based on the number of hours that the technician spends face-to-face with the patient. The computer-administered testing code (96103/96120) is billed once regardless of the time spent completing the tests. Note, however, that when testing is administered by a technician or a computer, the time that the physician/psychologist spends interpreting and reporting the results of each individual test is already included in each of these codes. CMS.GOV, 15 15 15

16 CMS – CPT Q&A 5/28/2018 Should I bill the CPT code for computer-administered psychological (96103) or neuropsychological testing (96120) if my patient takes a paper-and-pencil test, and I use a computer to score it? The computer codes (96103 and 96120) can only be billed when a computer is used to administer tests. The codes cannot be billed if the computer is used only to score tests. For paper-and-pencil tests, the physician/psychologist should bill appropriately for any other service provided. CMS.GOV, 16 16 16

17 CPT Codes Associated with a Post-Event Exam utilizing ClearEdge®
5/28/2018 Non-Facility New Patient New Patient Exam Level 3 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. RVU New Patient Exam Level 4 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. RVU Neuropsychological testing Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. RVU 96119 Neuropsychological testing Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face to face. RVU 2.26 Physical performance test or measurement Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes RVU Choose One Choose One Motion Intelligence Reimbursement Guide, Jan 17 17

18 CPT Codes Associated with a Post-Event Exam utilizing ClearEdge®
5/28/2018 Facility In-Hospital New Patient New Patient Exam Level 3 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. RVU New Patient Exam Level 4 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. RVU Neuropsychological testing Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. RVU 96119 Neuropsychological testing Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face to face. RVU 0.67 Physical performance test or measurement Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes RVU n/a Choose One Choose One Motion Intelligence Reimbursement Guide, Jan 18 18

19 CPT Codes Associated with a Post-Event Exam utilizing ClearEdge®
5/28/2018 Non-Facility Existing Patient Existing Patient Exam Level 3 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. RVU Existing Patient Exam Level 4 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. RVU Neuropsychological testing Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. RVU 96119 Neuropsychological testing Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face to face. RVU 2.26 Physical performance test or measurement Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes RVU Choose One Choose One Motion Intelligence Reimbursement Guide, Jan 19 19

20 CPT Codes Associated with a Post-Event Exam utilizing ClearEdge®
5/28/2018 Facility In-Hospital Existing Patient Existing Patient Exam Level 3 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. RVU Existing Patient Exam Level 4 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. RVU Neuropsychological testing Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. RVU 96119 Neuropsychological testing Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face to face. RVU 0.67 Physical performance test or measurement Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes RVU n/a Choose One Choose One Motion Intelligence Reimbursement Guide, Jan 20 20

21 Reimbursement – Post Event
5/28/2018 Motion Intelligence Reimbursement Guide, Jan 21 21 21

22 ImPACT Billing Guide 5/28/2018 The CPT code is the “professional” code and can only be used by a full licensed psychologist or physician.  It entails all aspects of your evaluation including preparation time, testing time, scoring time, report writing and any other time directly related to your evaluation (e.g., communicating information to a trainer or parent).  There is a separate interview code (96116), however, there is strict time and procedures that must be part of the interview in order to use it (e.g., fully documented mental status examination).  Alternatively, if the interview does not reach the threshold the time can be billed using Both are time based codes where one unit equals one hour of time spent performing the service and the reimbursement is higher for   The general rule is to round to the nearest hour.  If you do 70 minutes of testing you bill for one hour or one unit.  If you tested for 91 minutes you bill for two hours or units. ImPACT Webinar, April 28, 2010 ImPACT Billing FAQs 22 22 22

23 ImPACT Billing Guide 5/28/2018 The CPT code is the “technical” code and is used for face-to-face testing only.  This CPT code is for an individual who performs direct administration of neuropsychological tests that is less than fully licensed at the Ph.D. level.  There is no minimal educational requirement so it would include post-doctoral fellows, interns, and psychometrists (at either the Master’s level or Bachelor’s degrees).  The operative phrase is “face-to- face.” One can only bill for the time the technician actually administers the tests.  Scoring time is not billable, unless the scoring is done in the same room when the patient is completing something else (such as a questionnaire or computerized testing).  While this may seem counter- intuitive (or even a complete contradiction in terms), the technician is still “face-to-face” and as such could bill for time scoring when the patient is completing a form and being supervised by the technician.  Otherwise, non- face-to-face scoring time (for example: when done after the patient has left) is not billable.  Also, any preparation time, interviewing or report writing done by the technician (if they were a psychology intern or post-doctoral fellow, for example) is not billable.  CPT code is a time based code identical to ImPACT Webinar, April 28, 2010 ImPACT Billing FAQs 23 23 23

24 ImPACT Billing Guide 5/28/2018 There is one other neuropsychological testing code, 96120, that is used for any unsupervised computer based testing. It is a one time charge that is not time based. Please note that if the technician or psychologist is in the room while the athlete is testing you would bill the time it took the athlete to complete ImPACT using either or (depending upon who is in the room) rather then the computer code.  You can not bill for both.  It is more financially advantageous to be in the room while the athlete completes ImPACT, as the reimbursement rate is higher. ImPACT Webinar, April 28, 2010 ImPACT Billing FAQs 24 24 24

25 ImPACT Billing Guide 5/28/2018 The reason for the lower reimbursement rates for hospital-based facilities has to do with CMS’s Medicare payments that cover resident training and care of Medicare patients. ImPACT Webinar, April 28, 2010 ImPACT Billing FAQs 25 25 25

26 ImPACT Billing Guide 5/28/2018 The example below is a common scenario for descriptive purposes only. They are not meant to indicate the exact amount of time one needs to spend on a particular case. All cases are different and some can take much longer. Technically this would bill for two (2) units of (rounding to closet hour) and all billed on the last date of service. 2 $ = $248.18 ImPACT Webinar, April 28, 2010 ImPACT Billing FAQs 26 26 26

27 ImPACT Billing Guide 5/28/2018 If in the same example, instead of being in the room while the athlete completed ImPACT, the doctor decided to be in his office doing other work.  This would change the billing to the following:  two hours or units of and one unit of 96118: 2 $ = $ (105 minutes rounds up to 2 units) 96120: 1 $45.84 = $45.94 Total: $294.02 ImPACT Webinar, April 28, 2010 ImPACT Billing FAQs 27 27 27

28 ImPACT Billing Guide – Baseline Testing
5/28/2018 ImPACT Webinar, April 28, 2010 ImPACT Billing FAQs 28 28 28

29 Reimbursement – Base Line
5/28/2018 Office Visit Out of Pocket Only for Diagnostic Test 29 29 29

30 BCBS of Texas – Post-Event
5/28/2018 30 30 30

31 BCBS of Texas – Post-Event
5/28/2018 BCBS of Texas – Post-Event For these two visits Visit 1: 99215 for the first post concussion consult- CPT® represents the high (level 5) office or other outpatient established office patient visit Visit 2: 99213 for the second consult - CPT® represents the middle (level 3) office or other outpatient established office patient visit 96118 for the ImPACT test - Neuropsychological testing (eg, Halstead- Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report 31 31 31

32 Economics - Physicians
5/28/2018 Pediatrician averages 2156 patients 25% are under 5 years of age 1617 potential patients for Concussion testing ClearEdge Survey 27% will pay > $75 437 patients 45% will pay > $50 728 patients 7% will be concussed Requiring an average of two visits 226 visits (tests) 32 32 32

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