Coding Billing and Documenting Clinical Neuropsychological Services An
Coding, Billing and Documenting Clinical Neuropsychological Services: An Introductory Presentation Antonio E. Puente University of North Carolina Wilmington National Academy of Neuropsychology October 27, 2006 nan introductory cpt 1
Disclaimer n 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… 2006 nan introductory cpt 2
Acknowledgments q q q 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 the. Department of Psychology, UNC-Wilmington, James Georgoulakis, Neil Pliskin, Ted Peck and AEP’s Clinical and Research Staff 2006 nan introductory cpt 3
Specific Support Provided by Primary Organizations n n APA = All expenses paid for travel associated with AMA CPT activities NAN = (from PAIC budget) applied to UNCW activities n n 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 2006 nan introductory cpt 4
Part I: Coding, Billing & Documentation n Part I: n A. Medicare n B. Current Procedural Terminology n n n C. Diagnosing D. Medical Necessity E. Documentation F. Time G. Technicians H. Supervision 2006 nan introductory cpt 5
A. Medicare: Why? n The Standard for Universal Health Care: Coding (what can be done) n Value (how much it will be paid) n Documentation (what needs to be said) n Auditing (determination of whether it occurred) n 2006 nan introductory cpt 6
Medicare: Immediate Impact n As a Consequence, the Benchmark for: All Commercial Carriers (e. g. , HMOs) n As well as; n Workers Compensation n Forensic Applications n Related Applications (e. g. , industrial, sports) n 2006 nan introductory cpt 7
Medicare: Long-term Impact n n By 2015, Medicare will represent approximately 50% of all health care payments in the United States Eventually, a national (US) health insurance will be established One possible model will be to introduce Medicare to younger citizens will be in age increments (e. g. , 60 -64, then 50 -59, etc) Hence, Medicare will come to set the standard for all of health care 2006 nan introductory cpt 8
Medicare: Overview n n Centers for Medicare and Medicaid Services Benefits Part A (Hospital) n Part B (Supplementary) n Part C (Medicare+ Choice) n Part D (Pharmaceutical) n 2006 nan introductory cpt 9
Medicare: Local Review n Medical Review Policy National Policy Sets Overall Model n Local Coverage Determination (LCD) Sets Local/Regional Policyn n n More restrictive than national policy Over-rides national policy Changes frequently without warning or publicity Information best found on respective web pages 2006 nan introductory cpt 10
B. Current Procedural Terminology (CPT): Overview n n Background Codes & Coding Existing Codes Model System X Type of Problem 2006 nan introductory cpt 11
CPT Copyright n n CPT is Copyrighted by the American Medical Association CPT Manuals May be Ordered from the AMA at 1. 800. 621. 8335 2006 nan introductory cpt 12
CPT: Background n American Medical Association Developed by Surgeons (& Physicians) in 1966 for Billing Purposes n 7, 500+ Discrete Codes n CPT Meets a Minimum of 3 Times/Year n n Center for Medicare & Medicaid Services AMA Under License by CMS n CMS Now Provides Active Input into CPT n 2006 nan introductory cpt 13
CPT: Theory n Order of Value - Personnel n n Surgeons, Physicians, Doctorate Level Allied Health, Non-Doctorate Level Allied Health Order of Value - Costs Cognitive Work, Expense, Malpractice n X a Geographic Location Factor n 2006 nan introductory cpt 14
What Is a CPT Code? n n n A Coding System Developed by AMA in Conjunction with CMS to Describe Professional Services Each Code has a Specific Number and Description as well as a Reimbursable Value Professional Health Service Provided Across the Country at Multiple Locations Many “Physicians” or “Qualified Health Professional” Perform Services Clinical Efficacy is Established and Documented in Peer-Reviewed Literature 2006 nan introductory cpt 15
CPT: Applicable Codes n n n Total Possible Codes = Approximately 7, 500 Possible Codes for Psychology = Approximately 40 to 60 Sections = Five Primary Separate Sections n n n Psychiatry (e. g. , mental health) Biofeedback Central Nervous System Assessment (testing) Physical Medicine & Rehabilitation Health & Behavior Assessment & Management (h. p. ) Evaluation and Management 2006 nan introductory cpt 16
CPT: Psychiatry n Sections (or Categories) n n n Interview (90801) vs. Intervention (e. g. , 90806) These codes are one unit (time = un-timed to varied) Office vs. Inpatient Regular vs. Evaluation & Management Other Types of Interventions n Insight, Behavior Modifying, and/or Supportive vs. Interactive 2006 nan introductory cpt 17
Psychiatric Codes n Interviewing n 90801 One time per illness incident or bout n Un-timed n Comprehensive analysis of records, observations as well as structured and/or unstructured clinical interview n 2006 nan introductory cpt 18
Psychiatric Codes n Therapy 20 minutes = 90804 n 45 -50 minutes = 90806* n 80 -90 minutes = 90808 n * = most typical 2006 nan introductory cpt 19
CPT: CNS Assessment Until 12. 31. 05 n Interview n n 96115 Testing Psychological = 96100; 96110/11 n Neuropsychological = 96117 n Aphasia = 96105 n Developmental = 96110/111 n 2006 nan introductory cpt 20
Rationale for CPT Changes: CNS Assessment Codes n n n Avoidance of Continuation of Reimbursement Heavily Based on Practice Expense Greater Clarification of Activities Including Interviewing and Testing by Professional, Technician and/or Computer Recognition of Cognitive Work Great Clarity of What Actual is Happening Differentiation of Professional, Technical and (non-assisted) Computer Testing Most Importantly, a Mandate from CMS 2006 nan introductory cpt 21
CPT: CNS Assessment Effective 01. 06 (no grace period) n Psychological Testing (e. g. , 5 units) n n n Neurobehavioral Status Exam (e. g. , 2 units) n n Three New Codes New Numbers & Descriptors New Number & Revised Descriptor Neuropsychological Testing (e. g. , 10 units) n n Three New Codes New Numbers & Descriptors 2006 nan introductory cpt 22
Psychological Testing: By Professional n 96101 –Psychological Testing n 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) 2006 nan introductory cpt 23
Psychological Testing: By Technician n 96102 - Psychological Testing n 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, faceto-face 2006 nan introductory cpt 24
Psychological Testing: By Computer n 96103 - Psychological Testing n Psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, (e. g. , MMPI) administered by a computer, with qualified health professional interpretation and the report 2006 nan introductory cpt 25
Neurobehavioral Status Exam n 96116 - Neurobehavioral status exam n 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 2006 nan introductory cpt 26
Neuropsychological Testing. By Professional n 96118 - Neuropsychological testing n (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 2006 nan introductory cpt 27
Neuropsychological Testing: By Technician n 96119 - Neuropsychological testing n (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 2006 nan introductory cpt 28
Neuropsychological Testing. By Computer n 96120 - Neuropsychological testing n (e. g. , WCST) administered by a computer with qualified health care professional interpretation and the report 2006 nan introductory cpt 29
CNS Assessment Examples n Neurobehavioral Status with Neuropsychological Testing n Interview by the Professional n Testing by n Professional, and/or n Technician, and/or n Computer. n Interpretation & Report Writing by Qualified Health Professional n A Technician or Computer Code are Typically Billed Together with a Professional Code Assuming that Different Services are Provided (since the final product should be a comprehensive/integrative 2006 nan introductory cpt 30 report)
CPT: Cognitive Rehabilitation n Application Rationale n n Allied Health & Physical Medicine Code Acceptability GN – Speech Therapists n GO – Occupational Therapists n GP – Physical Therapists n AH – Mental Health (not applicable) n 2006 nan introductory cpt 31
CPT: Health & Behavior Assessment & Management (CPT Assistant, 03. 04) (CPT Assistant, 08. 05, 15, #6, 10) n n Purpose: Medical Diagnosis Time: 15 Minute Increments Assessment Intervention 2006 nan introductory cpt 32
H & B: Rationale n n n Acute or Chronic Health Illness Not Applicable to Psychiatric Illness However, Both Could be Treated Simultaneously But Not Within the Same Session 2006 nan introductory cpt 33
Health & Behavior Assessment Codes n 96150 n Health and behavior assessment (e. g. , healthfocused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires) each 15 minutes face-to-face with the patient initial assessment n re-assessment n n 96151 2006 nan introductory cpt 34
Health & Behavior Intervention Codes n 96152 n Health and behavior intervention each 15 minutes face-to-face individual n group (2 or more patients) n n n 96153 96154 family (with the patient present) 96155 (limited acceptability) n family (without the patient present; not being reimbursed ) n n 2006 nan introductory cpt 35
CPT: Model System n n n Psychiatric Neurological Non-Neurological Medical 2006 nan introductory cpt 36
CPT Model n Rationale for a Specific CPT Code: Choose Code that Best Describes the Service n Match the Interview with the Testing with the Intervention Code with the Diagnosis n Goal = Uniformity and Fluency n 2006 nan introductory cpt 37
CPT: Psychiatric Model (Children & Adult) n Interview n n n Testing n n n 90801 - adult 90802 - child 96101 -03 Also, 96111 for children Intervention n n e. g. , 90806 - adult e. g. , 90820 -child 2006 nan introductory cpt 38
CPT: Neurological Model (Children & Adult) n Interview n n Testing n n 96116 96118/19/20 Intervention n 97532 2006 nan introductory cpt 39
CPT: Non-Neurological Medical Model (Children & Adult) n Interview & Assessment 96150 (initial) n 96151 (re-evaluation) n n Intervention 96152 (individual) n 96153 (group) n 96154 (family with patient) n 2006 nan introductory cpt 40
Modifiers (from Appendix A in CPT book; see oig reports) n Examples n n n n 22 = reduced service 25 = additional payment for an E & M code as a specific procedure code (problematic) 51 = multiple procedures 52 = reduced services 59 = when two procedures occur on same day GN, GO, AH, etc. = local carrier specific Problems n Incomplete support for modifier from 15 to 35% of documentation results in paybacks 2006 nan introductory cpt 41
National Work RVU/Estimated $ 2006 Values op=outpatient, ip=inpatient, est. =estimate rvu = work Code # OP RVU IP RVU OP $ est IN $est 96101 96102 96103 96116 96118 96119 96120 2. 56 1. 17 0. 74 2. 87 3. 43 1. 75 1. 27 2. 54 0. 68 0. 70 2. 68 2. 67 0. 92 0. 70 97. 02 44. 34 28. 04 108. 77 129. 99 66. 32 48. 13 96. 26 25. 77 26. 53 101. 57 101. 19 34. 87 26. 53 2006 nan introductory cpt 42
C. CPT: Diagnosing n Psychiatric n DSM n n The problem with DSM and neuropsych testing of developmentally-related neurological problems Neurological & Non-Neurological Medical ICD – 9 CM (physical diagnosis coding) n www. cdc. gov/nchs/about/otheract/icd 9 n 2006 nan introductory cpt 43
D. CPT: Medical Necessity n n n n Scientific & Clinical Necessity Local Medical Review or Carrier Definitions of Necessity = CPT x DX formulary Necessity Dictates Type and Level of Service Necessity Can Only be Proven with Documentation Screening or Regularly Scheduled Evaluations Do Not Meet Criteria for Necessity Will Results Affect Outcome of Patient? Will New Information Be Obtained as a Function of the Activity? 2006 nan introductory cpt 44
Medically Reasonable and Necessary Section 1862 (a)(1) 1963 42, C. F. R. , 411. 15 (k) n n “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; n n Diagnosis Symptoms 2006 nan introductory cpt 45
E. CPT: Documenting n n Purpose General Principles Assessment Intervention 2006 nan introductory cpt 46
Documentation: Purpose n n n Medical Necessity Evaluate and Plan for Treatment Communication and Continuity of Care Claims Review and Payment Research and Education 2006 nan introductory cpt 47
Documentation: General Principles n n n Rationale for Service Assessment, Progress, Impression, or Diagnosis Plan for Care Date and Identity of Observer Also Legible n Timely n Confidential n 2006 nan introductory cpt 48
Documentation: Basic Information Across Codes n n n n n Date Time, if applicable Identity of Observer (technician ? ) Reason for Service Status Procedure Results/Finding Impression/Diagnoses Disposition Stand Alone 2006 nan introductory cpt 49
Documentation: Assessment n n n n Reason for Service Dates (amount of service time; total Vs. actual) Identity of Tester (technician? ) Tests and Protocols (included editions) Narrative of Results Impression Disposition 2006 nan introductory cpt 50
Documentation: Intervention n n n Reason for Service Status of Patient Intervention Performed Results Obtained Impression(s) or Diagnosis (es) Disposition Time 2006 nan introductory cpt 51
Documentation: CPT X Report n n 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 2006 nan introductory cpt 52
Documentation: Suggestions n Consider Having a Multi-level System of Documentation; Raw data (e. g. , test protocols) n Internal routing sheets documenting such information as start/stop time, dates, etc. (a master sheet could track technician as well as professional time) n Final report n 2006 nan introductory cpt 53
F. CPT: Time n n n Time is Broadly Defined as What the Professional Does For Intervention – Time is face-to-face For Assessment - Time could be either face-to-face or professional time 2006 nan introductory cpt 54
Time n n Defining Professional (not patient) Time Including: n n Interview & Assessment Codes n n pre, intra & post-clinical service activities Use 15 or 60 minute increments, as applicable Intervention Codes n Use 15, 30, 60 or 90 minute increments, as applicable 2006 nan introductory cpt 55
Time (continued) n n n Communicating further with others Follow-up with patient, family, and/or others Arranging for ancillary and/or other services 2006 nan introductory cpt 56
“Missed” Time Section 20. 3. 1. n n Billing for Services That Were Not Provided” is Fraud The Patient Possibly Could be Billed for Missed Appointment (not for missed service) 2006 nan introductory cpt 57
Time (CPT Assistant, 08. 05, 15, #8, pg. 12) (www. cms. hhs. gov/providers/therapy) n n For Timed Codes (in physical medicine): The Beginning and Ending Time Should be Documented Along with the Treatment Description 2006 nan introductory cpt 58
Time: Testing n Quantifying Time n n n Round up or down to nearest increment Actual time vs. Elapsed time? Time Does Not Include n n n Patient completing tests, scales, forms, etc. Waiting time by patient Typing of reports Non-Professional (e. g. , clerical) time Literature searches, learning new techniques, etc. 2006 nan introductory cpt 59
G. CPT: Defining a Technician n What is the Minimum Level of Training Required for a Technician? National Association of Psychometrists n 40 & NAN Position Paper n Level of Education- Probably a minimum of Bachelors n Level of Training n Level of Supervision n 2006 nan introductory cpt 60
Defining a Technician (Federal Register, Vol. 66, #149, page 40382) n Requirement n n Employee (e. g. , 1099); “employees, leased employees, or independent contractor” Most common is independent contractor “We do not believe that the nature of the employment relationship is critical for purposes of payment to the services of physician…as long as…(the personnel) is under the required level of supervision. ” Common Practice n Independent Contractor 2006 nan introductory cpt 61
Defining a Technician n HCFA/CMS Line 25 n n n This is the line that identifies in a common insurance form who is the “qualified health provider” that is responsible for and completing the service Anybody else, from high school to post-doctoral fellow, is, for all practical purposes, a technician Extern, Intern, Postdoctoral Fellow, Technician 2006 nan introductory cpt 62
NAN’s Definition of Technician n n Approved by NAN Board of Directors 08. 2006 Archives of Clinical Neuropsychologyn in press 2006 nan introductory cpt 63
NAN’s Definition of a Technician n n Function- administration & scoring of tests Responsibility- supervisor Education- minimum, bachelor’s level Training- include ethics, neuropsy, psychopath, testing Confidentiality- APA ethics, HIPAA… Emergencies- contingencies must be in place Cultural Sensitivity- must be considered Supervision- general (Medicare) level Contract- must be in place Liability Insurance- must be in place 2006 nan introductory cpt 64
Use of Technicians n Practice Expense & Practice Implications n n n Each tech code has. 51 work value This means that the provider is engaged in the work That engagement would include; n n n Selection of tests Determination of testing protocol Supervision of testing Interpretation of individual tests Reporting on individual tests 2006 nan introductory cpt 65
Uses of Technicians n The Qualified Health Provider must; See the patient first n Supervise the activity n Interpret and write the note/report n Engaged in an ongoing capacity n n NOTE: Pattern similar to medical providers 2006 nan introductory cpt 66
Use of Technician n Technicians in a “Facility” n n n A “facility” in essentially an inpatient setting If a technician is an employee of a private provider but the service is provided in an inpatient setting, the inpatient fee would be used If a technician is an employee of a a facility, there is some question as to whether they could be supervised by a provider who is not an employee of the facility 2006 nan introductory cpt 67
H. CPT: Supervision ( Federal Register, 69, #150, August 5, 2004, page 47553) n n Hold Doctoral Degree in Psychology Licensed or Certified as a Psychologist Applicable Only to “clinical psychologists” (and not “independent” psychologists as defined by Medicare) Rationale n n n Allows for higher level of expertise to supervise Could relieve burden on physicians and facilities May increase services in rural areas 2006 nan introductory cpt 68
Supervision n Supervision 1. General = overall direction n 2. Direct = present in office suite n 3. Personal = in actual room n 4. Psychological = when supervised by a psychologist n 2006 nan introductory cpt 69
Supervision Program Memorandum Carriers Department of Health and Human Services- HCFA Transmittal b-01 -28; April 19, 2001 n Levels of Supervision n General n n Direct n n Furnished under overall direction and control, presence is not required Must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure Personal n Must be in attendance in the room during the performance of the procedure 2006 nan introductory cpt 70
Level of Supervision 42 CFR 410. 32 n According to Medicare published guidelines as of July, 2006; n General- activity is directed and supervised by the doctoral level provider but the provider does not need to be in office suite 2006 nan introductory cpt 71
Part II: Summary, Resources & Questions/Answers n n n Summary of Present Problems Contact Information Questions & Answers 2006 nan introductory cpt 72
Summary of Problems: Carrier-Based n Commercial Carriers Medical vs. Mental Health vs. No Coverage n The Simultaneous Use of Two or More Testing Codes n For Managed Care, an Extremely Conservative Interpretation of Information Available (e. g. , APA Toolkit) May Result in an Unintended and Highly Restrictive Interpretation of the Use of Codes n 2006 nan introductory cpt 73
Summary of Problems: Provider-Based n n General Understanding & Usage Specific Code Usagen n n Mixing of psychiatric with neuropsychological procedures as well as mixing of diagnostic codes Time (estimates, rounding) Professional having to see the patient at all Professional having to interpret and write the evaluation Misunderstanding of potential difference between computerized testing and computer code (interactive computerized testing with tech or professional is coded as such) and computerized testing (non-interactive is coded as a computer code) 2006 nan introductory cpt 74
Summary of Present: Provider-Based (continued) n Technicians n n Training programs (externs, interns and postdoctoral fellows) Essentially no difference between a bachelor’s level technician and a postdoctoral fellow Difference between training and providing professional services “Limited” interpretation of scoring (away from the patient) 2006 nan introductory cpt 75
The Future n Personal Approach n n n Short Term n n Stay Informed Stay Flexible Volatility and significant change Long Term n n Stability Possible 14% cut resulting in zero to minimal overall increases 2006 nan introductory cpt 76
Resources n Organizations n n n Websites n n n NAN (PAIC; 804. 285. 2555) APA (40, Practice Directorate; 800. 374. 2723) AAP AMA www. nanonline. org www. apa. org NAN Digital Video n n Contains 3 hour video with multiple resources Over 74 total hits per week 2006 nan introductory cpt 77
Contact Information n Websites n Univ = www. uncw. edu/people/puente Practice = www. clinicalneuropsychology. us n NAN = www. nanonline. org/paio n n E-mail n n n University = puente@uncw. edu Practice = puente@clinicalneuropsychology. us Telephone n n University = 910. 962. 3812 Practice = 910. 509. 9371 2006 nan introductory cpt 78
Q&A n Friday, October 27, 2006; 7: 45 – 8: 45 am n n Ted Peck, Ph. D. , PAIC Via Telephonen n Randy Phelps, Ph. D. , Associate Director, APA PD Diane Pedulla, J. D. , Legal and Regulatory Affairs Kimberly Moore, Medicare Staff Officer Saturday, October 28, 2006; 8: 45 – 9: 45 am n Ted Peck, Ph. D. , PAIC 2006 nan introductory cpt 79
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