1. 2006 nan advanced cpt1 Coding, Billing and Documenting Clinical Neuropsychological Services: An Advanced Presentation Antonio E. Puente University of North Carolina Wilmington National Academy of Neuropsychology October 26, 2006

2. 2006 nan advanced cpt2 Disclaimer The information contained in this extended presentation is not intended to reflect NAN, APA, Division 40, NCPA, AMA, and/or CMS policy. Further, this presentation is intended to be informative and not meant to imply that it supersedes APA or state licensing boards’ ethical guidelines and/or local, state or national regulations and/or laws. Further, Local Coverage Determination and specific health care contracts supersedes 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 NAN, APA, Division 40, NCPA, AMA, and/or CMS policy. Further, this presentation is intended to be informative and not meant to imply that it supersedes APA or state licensing boards’ ethical guidelines and/or local, state or national regulations and/or laws. Further, Local Coverage Determination and specific health care contracts supersedes 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…

3. 2006 nan advanced cpt3 Acknowledgments  North Carolina Psychological Association  American Medical Association (AMA) CPT Staff  American Psychological Association (APA) Practice Directorate (PD)  National Academy of Neuropsychology (NAN)  Division of Clinical Neuropsychology of APA (40)  Center for Medicare & Medicaid Services (CMS) Medical Policy Staff- Medicare Special thanks to theDepartment of Psychology, UNC-Wilmington, James Georgoulakis, Neil Pliskin, Ted Peck and AEP’s Clinical and Research Staff

4. 2006 nan advanced cpt4 Specific Support Provided by Primary Organizations APA = All expenses paid for travel associated with AMA CPT activities APA = All expenses paid for travel associated with AMA CPT activities NAN = (from PAIC budget) applied to UNCW activities NAN = (from PAIC budget) applied to UNCW activities 2006 = $25,000 per year – two course per semester teaching reduction per academic year 2006 = $25,000 per year – two course per semester teaching reduction per academic year UNCW = Time away from university duties (e.g., teaching) plus incidental support such as copying, telephone calls, secretarial and work-study student assistance UNCW = Time away from university duties (e.g., teaching) plus incidental support such as copying, telephone calls, secretarial and work-study student assistance

5. 2006 nan advanced cpt5 Part I: Coding, Billing & Documentation Part I: Part I: A. Medicare A. Medicare B. Current Procedural Terminology B. Current Procedural Terminology C. Diagnosing C. Diagnosing D. Medical Necessity D. Medical Necessity E. Documentation E. Documentation F. Time F. Time G. Technicians G. Technicians H. Supervision H. Supervision

6. 2006 nan advanced cpt6 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) Note: While Medicare sets the standard, there is no point-to-point correspondence with private carriers

7. 2006 nan advanced cpt7 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

8. 2006 nan advanced cpt8 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

9. 2006 nan advanced cpt9 CPT Copyright CPT is Copyrighted by the American Medical Association CPT is Copyrighted by the American Medical Association CPT Manuals May be Ordered from the AMA at 1.800.621.8335 CPT Manuals May be Ordered from the AMA at 1.800.621.8335

10. 2006 nan advanced cpt10 Psychiatry: Interviewing Interviewing Interviewing 90801 90801 One time per illness incident or bout One time per illness incident or bout Un-timed Un-timed Comprehensive analysis of records, observations as well as structured and/or unstructured clinical interview Comprehensive analysis of records, observations as well as structured and/or unstructured clinical interview

11. 2006 nan advanced cpt11 Psychiatric: Intervention Therapy Therapy 20 minutes = 90804 20 minutes = 90804 45-50 minutes = 90806* 45-50 minutes = 90806* 80-90 minutes = 90808 80-90 minutes = 90808 * = most typical

12. 2006 nan advanced cpt12 Rationale for CPT Changes: CNS Assessment Codes Avoidance of Continuation of Reimbursement Heavily Based on Practice Expense Avoidance of Continuation of Reimbursement Heavily Based on Practice Expense Greater Clarification of Activities Including Interviewing and Testing by Professional, Technician and/or Computer Greater Clarification of Activities Including Interviewing and Testing by Professional, Technician and/or Computer Recognition of Cognitive Work Recognition of Cognitive Work Great Clarity of What Actual is Happening Great Clarity of What Actual is Happening Differentiation of Professional, Technical and (non-assisted) Computer Testing Differentiation of Professional, Technical and (non-assisted) Computer Testing Most Importantly, a Mandate from CMS Most Importantly, a Mandate from CMS

13. 2006 nan advanced cpt13 CPT: CNS Assessment Effective 01.01.06 (no grace period) 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

14. 2006 nan advanced cpt14 Psychological Testing: By Professional 96101 –Psychological Testing 96101 –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)

15. 2006 nan advanced cpt15 Psychological Testing: By Technician 96102- Psychological Testing 96102- 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

16. 2006 nan advanced cpt16 Psychological Testing: By Computer 96103 - Psychological Testing 96103 - 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

17. 2006 nan advanced cpt17 Neurobehavioral Status Exam 96116 - Neurobehavioral status exam 96116 - 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

18. 2006 nan advanced cpt18 Neuropsychological Testing- By Professional 96118 - Neuropsychological testing 96118 - 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

19. 2006 nan advanced cpt19 Neuropsychological Testing: By Technician 96119 - Neuropsychological testing 96119 - 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

20. 2006 nan advanced cpt20 Neuropsychological Testing- By Computer 96120 - Neuropsychological testing 96120 - 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

21. 2006 nan advanced cpt21 CNS Assessment Examples Neurobehavioral Status with Neuropsychological Testing Neurobehavioral Status with Neuropsychological Testing Interview by the Professional Interview by the Professional Testing by Testing by Professional, and/or Professional, and/or Technician, and/or Technician, and/or Computer. Computer. Interpretation & Report Writing by Qualified Health Professional Interpretation & Report Writing by Qualified Health Professional A Technician or Computer Code are “Typically” Billed Together with a Professional Code Assuming that Different Services are Being Provided (since the final product should be a comprehensive/integrative report) A Technician or Computer Code are “Typically” Billed Together with a Professional Code Assuming that Different Services are Being Provided (since the final product should be a comprehensive/integrative report)

22. 2006 nan advanced cpt22 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

23. 2006 nan advanced cpt23 H & B: Rationale Acute or Chronic Health Illness Acute or Chronic Health Illness Not Applicable to Psychiatric Illness Not Applicable to Psychiatric Illness However, Both Could be Treated Simultaneously But Not Within the Same Session However, Both Could be Treated Simultaneously But Not Within the Same Session

24. 2006 nan advanced cpt24 Health & Behavior Assessment Codes 96150 96150 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 96151 96151 re-assessment re-assessment

25. 2006 nan advanced cpt25 Health & Behavior Intervention Codes 96152 96152 Health and behavior intervention Health and behavior intervention each 15 minutes each 15 minutes face-to-face face-to-face individual individual 96153 96153 group (2 or more patients) group (2 or more patients) 96154 96154 family (with the patient present) family (with the patient present) 96155 (limited acceptability) 96155 (limited acceptability) family (without the patient present; not being reimbursed ) family (without the patient present; not being reimbursed )

26. 2006 nan advanced cpt26 New Code: fMRI 96020- Functional Brain Mapping 96020- Functional Brain Mapping Neurofunctional test selection and administration during non-invasive imaging functional brain mapping with test administered entirely by a physician or psychologist with review of test results and report Neurofunctional test selection and administration during non-invasive imaging functional brain mapping with test administered entirely by a physician or psychologist with review of test results and report

27. 2006 nan advanced cpt27 CPT: Model System Psychiatric Psychiatric Neurological Neurological Non-Neurological Medical Non-Neurological Medical

28. 2006 nan advanced cpt28 CPT Model Rationale for a Specific CPT Code: Rationale for a Specific 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

29. 2006 nan advanced cpt29 CPT: Psychiatric Model (Children & Adult) Interview Interview 90801- adult 90801- adult 90802- child 90802- child Testing Testing 96101-03 96101-03 Also, 96111 for children Also, 96111 for children Intervention Intervention e.g., 90806- adult e.g., 90806- adult e.g., 90820-child e.g., 90820-child

30. 2006 nan advanced cpt30 CPT: Neurological Model (Children & Adult) Interview Interview 96116 96116 Testing Testing 96118/19/20 96118/19/20 Intervention Intervention 97532 97532

31. 2006 nan advanced cpt31 CPT: Non-Neurological Medical Model (Children & Adult) Interview & Assessment Interview & Assessment 96150 (initial) 96150 (initial) 96151 (re-evaluation) 96151 (re-evaluation) Intervention Intervention 96152 (individual) 96152 (individual) 96153 (group) 96153 (group) 96154 (family with patient) 96154 (family with patient)

32. 2006 nan advanced cpt32 Modifiers (from Appendix A in CPT book; see oig reports) Examples Examples 22 = reduced service 22 = reduced service 25 = additional payment for an E & M code as a specific procedure code (problematic) 25 = additional payment for an E & M code as a specific procedure code (problematic) 51 = multiple procedures 51 = multiple procedures 52 = reduced services 52 = reduced services 59 = when two procedures occur on same day 59 = when two procedures occur on same day GN, GO, AH, etc. = local carrier specific GN, GO, AH, etc. = local carrier specific Problems Problems Incomplete support for modifier from 15 to 35% of documentation results in paybacks Incomplete support for modifier from 15 to 35% of documentation results in paybacks

33. 2006 nan advanced cpt33 National Work RVU/Estimated $ 2006 Values op=outpatient, ip=inpatient, est.=estimate rvu = work Code # OP RVU IP RVU OP $ est IN $est 961012.562.54 97.02 97.02 96.26 96.26 961021.170.68 44.34 44.34 25.77 25.77 961030.740.70 28.04 28.04 26.53 26.53 961162.872.68108.77101.57 961183.432.67129.99101.19 961191.750.92 66.32 66.32 34.87 34.87 961201.270.70 48.13 48.13 26.53 26.53

34. 2006 nan advanced cpt34 C. CPT: Diagnosing Limited Formulary Limited Formulary 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) www.cdc.gov/nchs/about/otheract/icd9 www.cdc.gov/nchs/about/otheract/icd9

35. 2006 nan advanced cpt35 D. CPT: Medical Necessity Scientific & Clinical Necessity Scientific & Clinical Necessity Local Medical Review or Carrier Definitions of Necessity Local Medical Review or Carrier Definitions of Necessity Necessity = CPT x DX formulary Necessity = CPT x DX formulary Necessity Dictates Type and Level of Service Necessity Dictates Type and Level of Service Screening or Regularly Scheduled Evaluations Do Not Meet Criteria for Necessity Screening or Regularly Scheduled Evaluations Do Not Meet Criteria for Necessity Will New Information or Outcome Be Obtained as a Function of the Activity? Will New Information or Outcome Be Obtained as a Function of the Activity?

36. 2006 nan advanced cpt36 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” “Services which are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member” Re-evaluation should only occur when there is a potential change in; Re-evaluation should only occur when there is a potential change in; Diagnosis Diagnosis Symptoms Symptoms

37. 2006 nan advanced cpt37 E. CPT: Documenting General Principles General Principles Assessment Assessment Intervention Intervention

38. 2006 nan advanced cpt38 Documentation: Basic Information Across Codes Date Date Time, if applicable (total time Vs. actual time) Time, if applicable (total time Vs. actual time) 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

39. 2006 nan advanced cpt39 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

40. 2006 nan advanced cpt40 Documentation: Intervention Reason for Service Reason for Service Status of Patient Status of Patient Intervention Performed Intervention Performed Results Obtained Results Obtained Impression(s) or Diagnosis (es) Impression(s) or Diagnosis (es) Disposition Disposition Time Time

41. 2006 nan advanced cpt41 Documentation: CPT X Report Each CPT Code Should Generate a Separate Report (or at least a separate section; titles should reflect the code that is being billed such as “psychological testing) Each CPT Code Should Generate a Separate Report (or at least a separate section; titles should reflect the code that is being billed such as “psychological testing) Alternatively, Clearly Label/Title Sections of the Report to Match Codes Used Alternatively, Clearly Label/Title Sections of the Report to Match Codes Used

42. 2006 nan advanced cpt42 Documentation: Suggestions Consider Having a Multi-level System of Documentation; Consider Having a Multi-level System of Documentation; Raw data (e.g., test protocols) Raw data (e.g., test protocols) Internal routing sheets documenting such information as start/stop time, dates, etc. (a master sheet could track technician as well as professional time) Internal routing sheets documenting such information as start/stop time, dates, etc. (a master sheet could track technician as well as professional time) Final report Final report

43. 2006 nan advanced cpt43 F. CPT: 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

44. 2006 nan advanced cpt44 Time Defining Defining Professional (not patient) Time Including: Professional (not patient) Time Including: pre, intra & post-clinical service activities pre, intra & post-clinical service activities Interview & Assessment Codes Interview & Assessment Codes Use 15 or 60 minute increments, as applicable Use 15 or 60 minute increments, as applicable Intervention Codes Intervention Codes Use 15, 30, 60 or 90 minute increments, as applicable Use 15, 30, 60 or 90 minute increments, as applicable

45. 2006 nan advanced cpt45 Time (continued) Communicating further with others Communicating further with others Follow-up with patient, family, and/or others Follow-up with patient, family, and/or others Arranging for ancillary and/or other services Arranging for ancillary and/or other services

46. 2006 nan advanced cpt46 “Missed” Time Section 20.3.1. Billing for Services That Were Not Provided” is Fraud Billing for Services That Were Not Provided” is Fraud The Patient Possibly Could be Billed for Missed Appointment (not for missed service) The Patient Possibly Could be Billed for Missed Appointment (not for missed service)

47. 2006 nan advanced cpt47 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 For Timed Codes (in physical medicine): The Beginning and Ending Time Should be Documented Time Should be Documented Along with the Treatment Description Time Should be Documented Along with the Treatment Description

48. 2006 nan advanced cpt48 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.

49. 2006 nan advanced cpt49 G. CPT: 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 www.napnet.org www.napnet.org 40 & NAN Position Paper 40 & 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

50. 2006 nan advanced cpt50 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

51. 2006 nan advanced cpt51 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

52. 2006 nan advanced cpt52 Federal Government’s Definition of a Technician DM & S Supplement, MP-5, Part I DM & S Supplement, MP-5, Part I Authority: 38 U.S.C. 4105 Authority: 38 U.S.C. 4105 Appendix 17A Change 43 Appendix 17A Change 43 Psychology Technician GS-181-5/7/9 Psychology Technician GS-181-5/7/9 Definition Definition Bachelor’s degree from accredited college/university with a major in appropriate social or biological sciences (+ 12 psy hours) Bachelor’s degree from accredited college/university with a major in appropriate social or biological sciences (+ 12 psy hours)

53. 2006 nan advanced cpt53 NAN’s Definition of Technician Approved by NAN Board of Directors 08.2006 Approved by NAN Board of Directors 08.2006 Archives of Clinical Neuropsychology- Archives of Clinical Neuropsychology- in press in press

54. 2006 nan advanced cpt54 NAN’s Definition of a Technician Function- administration & scoring of tests Function- administration & scoring of tests Responsibility- supervisor Responsibility- supervisor Education- minimum, bachelor’s level Education- minimum, bachelor’s level Training- include ethics, neuropsy, psychopath, testing Training- include ethics, neuropsy, psychopath, testing Confidentiality- APA ethics, HIPAA… Confidentiality- APA ethics, HIPAA… Emergencies- contingencies must be in place Emergencies- contingencies must be in place Cultural Sensitivity- must be considered Cultural Sensitivity- must be considered Supervision- general (Medicare) level Supervision- general (Medicare) level Contract- must be in place Contract- must be in place Liability Insurance- must be in place Liability Insurance- must be in place

55. 2006 nan advanced cpt55 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

56. 2006 nan advanced cpt56 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

57. 2006 nan advanced cpt57 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

58. 2006 nan advanced cpt58 H. CPT: 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 services in rural areas May increase services in rural areas

59. 2006 nan advanced cpt59 Supervision Program Memorandum Carriers Department of Health and Human Services- HCFA Transmittal b-01-28; April 19, 2001 Levels of Supervision Levels of Supervision General General Furnished under overall direction and control, presence is not required Furnished under overall direction and control, presence is not required Direct Direct Must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure Must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure Personal Personal Must be in attendance in the room during the performance of the procedure Must be in attendance in the room during the performance of the procedure

60. 2006 nan advanced cpt60 Level of Supervision 42 CFR 410.32 According to Medicare published guidelines as of July, 2006; According to Medicare published guidelines as of July, 2006; General- activity is directed and supervised by the doctoral level provider but the provider does not need to be in office suite General- activity is directed and supervised by the doctoral level provider but the provider does not need to be in office suite

61. 2006 nan advanced cpt61 Part II: Summary, Resources & Questions/Answers Summary of Present Problems Summary of Present Problems Continuing Concerns With Fraud Continuing Concerns With Fraud National Provider Identification Number National Provider Identification Number CMS National Directive CMS National Directive National Correct Coding Initiative National Correct Coding Initiative Contact Information Contact Information Questions & Answers Questions & Answers

62. 2006 nan advanced cpt62 Fraud & Abuse http://oig.hhs.gov/publications/docs/mfcu/ MFCU%202004-5.pdf http://oig.hhs.gov/publications/docs/mfcu/ MFCU%202004-5.pdf

63. 2006 nan advanced cpt63 National Provider Identification Number Required by May 23, 2007 Required by May 23, 2007 General Codes General Codes Psychologist Psychologist Neuropsychologist Neuropsychologist APA Advises to Choose Both APA Advises to Choose Both A Committee of AMA with Little External Output A Committee of AMA with Little External Output

64. 2006 nan advanced cpt64 CMS National Directive: Summary of September, 2006 Statement Title Title Pub 100-02 Medicare Benefit Policy Pub 100-02 Medicare Benefit Policy Transmittal 55 Transmittal 55 Dates Dates Issued September 29, 2006 Issued September 29, 2006 Effective Date: January 1, 2006 Effective Date: January 1, 2006 Implementation Date: December 28, 2006 Implementation Date: December 28, 2006

65. 2006 nan advanced cpt65 CMS National Directive: Summary of September, 2006 Statement 5204.1 5204.1 “Carriers and fiscal intermediaries shall pay for medically necessary diagnostic psychological and neuropsychological tests…” “Carriers and fiscal intermediaries shall pay for medically necessary diagnostic psychological and neuropsychological tests…” 5204.2 5204.2 “Contractors need not search their files to either retract payment for claims already paid or to retroactively pay claims to 01.01.06. However, contractors shall adjust claims brought to their attention”. “Contractors need not search their files to either retract payment for claims already paid or to retroactively pay claims to 01.01.06. However, contractors shall adjust claims brought to their attention”.

66. 2006 nan advanced cpt66 CMS National Directive: Summary of September, 2006 Statement “When diagnostic psychological tests are performed by a psychologists who is not practicing independently, but is on the staff of an institution, agency or clinic, that entity bills for the psychological tests.” “When diagnostic psychological tests are performed by a psychologists who is not practicing independently, but is on the staff of an institution, agency or clinic, that entity bills for the psychological tests.”

67. 2006 nan advanced cpt67 CMS National Directive: Summary of September, 2006 Statement Independent is defined as: Independent is defined as: “Free of professional control..” “Free of professional control..” “The persons they treat are their own patients” “The persons they treat are their own patients” “They have the right to bill directly…” “They have the right to bill directly…” For those psychologists practicing in an office located in an institution; For those psychologists practicing in an office located in an institution; The office is confined to a seperately-identified part of the facility which is used solely as the psychologist’s office The office is confined to a seperately-identified part of the facility which is used solely as the psychologist’s office The psychologists conducts a private practice…services are rendered to patients in and outside of the institution The psychologists conducts a private practice…services are rendered to patients in and outside of the institution

68. 2006 nan advanced cpt68 CMS National Directive: Summary of September, 2006 Statement “CPT … test codes 96101/96118 should not be paid when billed for the same tests or services performed under the…test codes 96102/103/96119/120.” “CPT … test codes 96101/96118 should not be paid when billed for the same tests or services performed under the…test codes 96102/103/96119/120.” “Medicare does not pay for services represented by CPT codes 96102 and 96119 when performed by a student or a trainee.” “Medicare does not pay for services represented by CPT codes 96102 and 96119 when performed by a student or a trainee.”

69. 2006 nan advanced cpt69 Correct Coding Initiative: September, 2006 Statement Introduced in March 30, 2006 for Comment; Effective 10.01.06 Introduced in March 30, 2006 for Comment; Effective 10.01.06 When 96118, 96119 and/or 961120 occur together, a modifier must be used; When 96118, 96119 and/or 961120 occur together, a modifier must be used; Most appropriate code is probably 59 (possibly 51) Most appropriate code is probably 59 (possibly 51) Model used is radiology (when more than one service is provided by the same provider to the same patient) Model used is radiology (when more than one service is provided by the same provider to the same patient)

70. 2006 nan advanced cpt70 Use of Modifiers Routine in Medicine, Especially Radiology (since their common use of technicians) Routine in Medicine, Especially Radiology (since their common use of technicians) Describes That More Than One Procedure Was Provide to the Same Patient on the Same Day Describes That More Than One Procedure Was Provide to the Same Patient on the Same Day Should not Increase Time to Reimbursement or Audit Probability Nor Decrease Reimbursement Should not Increase Time to Reimbursement or Audit Probability Nor Decrease Reimbursement

71. 2006 nan advanced cpt71 AMA CPT Assistant Publications Q & A Appeared September, 2006 Q & A Appeared September, 2006 Full Length Article Last Approved 10.02.06 & to be Published in November, 2006 Full Length Article Last Approved 10.02.06 & to be Published in November, 2006 A Comprehensive Review of the Information Previously Presented A Comprehensive Review of the Information Previously Presented Approved by the AMA CPT Editorial Panel Approved by the AMA CPT Editorial Panel Allows for the Use of All Codes Simultaneously or Alone Allows for the Use of All Codes Simultaneously or Alone A Follow-up Q & A to Appear in December, 2006 A Follow-up Q & A to Appear in December, 2006

72. 2006 nan advanced cpt72 APA’s Official Statement on Testing Codes “APA is Going to Work With Outside Counsel to Analyze This Situation and Obtain Recommendations on the Best Way to Proceed with CMS” “APA is Going to Work With Outside Counsel to Analyze This Situation and Obtain Recommendations on the Best Way to Proceed with CMS” “Psychologists Should Read the CMS Documents Carefully and be Alert for Any New Information Issued by Their Local Carriers” “Psychologists Should Read the CMS Documents Carefully and be Alert for Any New Information Issued by Their Local Carriers”

73. 2006 nan advanced cpt73 Potential Solutions Not Accept Medicare Patients (if so, you may want to contact your local representative and/or congressmen) Not Accept Medicare Patients (if so, you may want to contact your local representative and/or congressmen) Take a Conservative Approach Take a Conservative Approach Interface with Individual Carriers to Develop Specific Understanding and Procedures Interface with Individual Carriers to Develop Specific Understanding and Procedures Use of Modifiers Use of Modifiers The final decision on how to code rests on the individual and/or their institution’s assessment of carrier contract as well as their understanding of the current policy situation

74. 2006 nan advanced cpt74 Ongoing Activities CMS CMS Conference Call With CCI Workgroup- late October, 2006 (Niles Rosen, M.D.) Conference Call With CCI Workgroup- late October, 2006 (Niles Rosen, M.D.) Direct Interfacing with Director of Medical Director’s Workgroup (Dick Whitten, M.D.) Direct Interfacing with Director of Medical Director’s Workgroup (Dick Whitten, M.D.) AMA AMA CPT Assistant Article (November, 2006) CPT Assistant Article (November, 2006) CPT Assistant Q & A (December, 2006) CPT Assistant Q & A (December, 2006) CPT Manual- preamble, footnote? CPT Manual- preamble, footnote? Request Presentation at 2007 AMA CPT Meeting Request Presentation at 2007 AMA CPT Meeting Consider Changing the Language in the CPT Manual Consider Changing the Language in the CPT Manual Insertion of the words – “limited” or “minimal” or “single test” interpretation Insertion of the words – “limited” or “minimal” or “single test” interpretation Deletion of the words – “with interpretation and report” Deletion of the words – “with interpretation and report” APA APA Weekly Conference Calls with Psychological Test Work Group Weekly Conference Calls with Psychological Test Work Group Development of Case Vignettes Along with All Possible Clinical Permutations Development of Case Vignettes Along with All Possible Clinical Permutations Presentation at the State Leadership Conference Presentation at the State Leadership Conference

75. 2006 nan advanced cpt75 Keeping Abreast Individual Carrier Websites Individual Carrier Websites APA APA Practitioner’s Toolbox Practitioner’s Toolbox E-Mail Blasts E-Mail Blasts 40 40 Practice Committee (Pliskin) Practice Committee (Pliskin) NAN NAN Website Website E-Mail Blasts E-Mail Blasts PAIC (Peck & Puente) PAIC (Peck & Puente)

76. 2006 nan advanced cpt76 Summary New Codes New Codes 7 + 1 for a total of 8 new codes 7 + 1 for a total of 8 new codes Allows the use of technicians and fMRI Allows the use of technicians and fMRI Allows for general supervision (used to be direct) Allows for general supervision (used to be direct) Greater Reimbursement Greater Reimbursement 22 to 68% increase over 2005 levels 22 to 68% increase over 2005 levels Problems with the Use of Two Codes Simultaneously with Medicare Problems with the Use of Two Codes Simultaneously with Medicare At worse, return to 2005 levels for now but with supervision and technicians gains At worse, return to 2005 levels for now but with supervision and technicians gains Solutions are evident, just a matter of months Solutions are evident, just a matter of months APA PD, 40, NAN PAIC are working together for this resolution APA PD, 40, NAN PAIC are working together for this resolution

77. 2006 nan advanced cpt77 AMA Contact Information Website Website www.amabookstore.com www.amabookstore.com www.amabookstore.com Link to; Link to; catalog.ama-assn.org/Catalog/cpt/issue_search.jsp catalog.ama-assn.org/Catalog/cpt/issue_search.jsp Telephone Telephone Matt Menning Matt Menning 312.464.5116 312.464.5116

78. 2006 nan advanced cpt78 APA Contact Information American Psychological Association American Psychological Association Russ Newman, J.D., Ph.D. Russ Newman, J.D., Ph.D. Practice Directorate Practice Directorate American Psychological Association American Psychological Association 750 First Street, N.W. 750 First Street, N.W. Washington, D.C. 2002 Washington, D.C. 2002 Association for the Advancement of Psychology Association for the Advancement of Psychology www.aapnet.org www.aapnet.org P.O.Box 38129 P.O.Box 38129 Colorado Springs, Colorado 38129 Colorado Springs, Colorado 38129

79. 2006 nan advanced cpt79 Puente Contact Information Websites Websites Univ = www.uncw.edu/people/puente Univ = www.uncw.edu/people/puentewww.uncw.edu/people/puente Practice = www.clinicalneuropsychology.us Practice = www.clinicalneuropsychology.uswww.clinicalneuropsychology.us NAN = www.nanonline.org/paio NAN = www.nanonline.org/paio E-mail E-mail University = puente@uncw.edu University = puente@uncw.eduuente@uncw.edu Practice = puente@clinicalneuropsychology.us Practice = puente@clinicalneuropsychology.us Telephone Telephone University = 910.962.3812 University = 910.962.3812 Practice = 910.509.9371 Practice = 910.509.9371

80. 2006 nan advanced cpt80 Q & A Friday, October 27, 2006; 7:45 – 8:45 am Friday, October 27, 2006; 7:45 – 8:45 am Ted Peck, Ph.D., PAIC Ted Peck, Ph.D., PAIC Via Telephone- Via Telephone- Randy Phelps, Ph.D., Associate Director, APA PD Randy Phelps, Ph.D., Associate Director, APA PD Diane Pedulla, J.D., Legal and Regulatory Affairs Diane Pedulla, J.D., Legal and Regulatory Affairs Kimberly Moore, Medicare Staff Officer Kimberly Moore, Medicare Staff Officer Saturday, October 28, 2006; 8:45 – 9:45 am Saturday, October 28, 2006; 8:45 – 9:45 am Ted Peck, Ph.D., PAIC Ted Peck, Ph.D., PAIC

81. 2006 nan advanced cpt81 Typical Questions Can I Use 96118 for Interpretation and Report Writing When I Have Used 96119 for Testing? Can I Use 96118 for Interpretation and Report Writing When I Have Used 96119 for Testing? Can I Do This on the Same Day or a Different Day of Service (e.g., under what circumstances are they similar or different services)? Can I Do This on the Same Day or a Different Day of Service (e.g., under what circumstances are they similar or different services)? Should They be Billed on the Day That the Service Occurred or on the Last Day of Service? Should They be Billed on the Day That the Service Occurred or on the Last Day of Service?

82. 2006 nan advanced cpt82 Typical Questions How and When Can I Use a “Student” as a Technician? How and When Can I Use a “Student” as a Technician? What Codes Have a Professional and Which Ones Have a Technical Component? What Codes Have a Professional and Which Ones Have a Technical Component?