Coding Documenting and Billing Auditing Neuropsychological Services revision
Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of a 10 year of progress report Antonio E. Puente Department of Psychology University of North Carolina at Wilmington 28403 -3297 Tel 910. 962. 3812, Fax 910. 962. 7010, e-mail Puente@uncwil. edu; web “clinicalneuropsychology. com” Massachusetts Neuropsychological Society Boston, MA, December 5, 2000
Outline of Presentation z. History/Background of Involvement z. Procedural Coding z. Reimbursement z. Documentation z. Auditing z. Related Issues z. Future Trends
Purpose of My Involvement with Coding & Medicare z. Short Term y. Reimbursement z. Long Term y. Why the Focus on Medicare y. Bring Some Standardization to the Field y. Expand the Scope and Value of Clinical Neuropsychology y. Parity with Other Doctoral Level Health Providers in Health Care y. Shape Psychology Towards a Biological Model
History/Background z. North Carolina Psychological Association y. Blue-Cross Blue Shield z. American Psychological Association y. Chair or Member of Approx. a Dozen Committees/Boards, (e. g. , Neuropsychology) y. Division 40 Board- 1987 to present y. Two Terms on APA’s Council of Representatives (1994 to present) y. Policy and Planning Board
History/Background (continued) z. American Medical Association y. CPT- 4 y. CPT- 5 z. Health Care Financing Administration y. Model Mental Health Policy Workgroup y. Medicare Coverage Advisory Committee
Procedural Coding z. Defining Coding z. History of Coding z. Coding
Defining Coding z. Description of Professional Service Rendered z. Purpose of Coding y. Archival/Research y. Reimbursement z. Coding Systems y. SNOMED y. WHO / ICD y. AMA / CPT
History of CPT Coding z. First Developed in 1966 z. Currently Using the 4 th Edition z. The 5 th Edition Will be Used in 2002 z. A Total of 7, 500 Codes z. AMA Developed and Owns the CPT z. Under Contract with the HCFA
Overview of Coding z. Total Possible Codes = 60+ z# Of Typically Reimbursed Codes = 5 yinterview, testing, & psychotherapy z# Of Codes Sometimes Reimbursed = 35 yfamily/group therapy ybiofeedback z# Of Codes Rarely Reimbursed = 20+ yevaluation and management yreport evaluation and writing
Overview of Coding: An evolution of coding z. Psychiatry z. Neurology z. Physical Medicine & Rehabilitation z“Evaluation & Management”
Overview of Coding (cont. ) z. Psychiatry y. Interview (90801) y. Psychotherapy (90804 - 90857) x. Types of Psychotherapy (regular vs interactive) x# of “Patients” (individual vs group vs family) x. Locations of Intervention (in vs outpatient) x. Evaluation & Management vs Regular x. Length of Time (30, 60, 90) y. Biofeedback x. Regular vs Psychophysiological (90901 vs 90875)
Overview of Coding (cont. ) z. Central Nervous System Assessments/Test y 96100 y 96105 y 96110/1 y 96115 y 96177 = = = Psychological Testing Aphasia Testing Developmental Testing Neurobehavioral Status Exam Neuropsychological Testing
Overview of Coding (cont. ) z. Physical Medicine y 97770 = Cognitive Skills Development y Look for New/split Codes in the Near Future
Overview of Coding (cont. ) z. Health & Behavior y 909 X 1 y 909 X 2 y 909 X 3 y 909 X 4 y 909 X 5 y 909 X 6 y. NOTE: assessment (15 minutes) re-assessment intervention- individual intervention- group intervention- family w/o pt. these codes need to be valued. . .
Coding Overview z. Coding Categories y. Psychiatry y. Neurology; CNS/Assessment y. Physical Medicine y“Evaluation & Management” z. Procedures y. Assessment y. Intervention
Overview of Coding (cont. ) z. Diagnosing y. If Problem is Psychiatric = DSM y. If Problem is Neurological = ICD z. Matching Dx with CPT y. DSM y. ICD = 90801, 96100, 90806 = 96115, 96117, 97770
Reimbursement z. History z. Defining z. Formula z. Defining RBRVS Time Site Necessity and Applying “Incident to”
History of Reimbursement z. Cost plus Reimbursement z. Prospective Payment (PPS) & Diagnostic Related Groups (DRGs) z. Customary. Prevailing, & Reasonable(CPR) z. Resource Based Relative Value System (RBRVS) z. Prospective Payment System
RBRVS z. Major Components y. Physician Work Resource Value Unit y. Practice Expense Resource Value Unit y. Malpractice Component Resource Value Unit z. Conversion Factor z. Adoption of the RBRVS y. Medicare y. Blue Cross/Blue Shield- 87% y. Managed Care- 55%
Reimbursement Formula z. Procedural Code z. Time z. Diagnosis z. Site of Service z. Provider z. Formula y. Code X Time X Dx X Site X Provider
Reimbursement Difficulties z. Physician Work Value z. Phd/Psy. D/Ed. D vs MD z. Location Defined
Common Reasons for Lack of Reimbursement z. Clerical Errors z. Service Is Not Covered z. No Prior Authorization Obtained z. Exceeded Allocated Time Limits z. Invalid or Incorrect Dx Code z. CPT and Dx Do Not Match
Defining Time z. Defining Time y. Professional (not patient) Activity z. Interview vs Assessment Codes y. Hourly Increments y. Includes Pre and Post-clinical Service z. Intervention Codes y 15, 30, 60, & 90 y. Face-to-face Contact y. No Pre or Post-clinical Service Time Included
Testing Time Defined z. Preparing to Test Patient z. Reviewing of Records z. Selection of Tests z. Scoring of Tests z. Reviewing of Results z. Interpretation of Results z. Preparation and Report Writing
Documentation z. Purpose z. General Guidelines z. Specific Documentation z. Trends z. Suggestions
Purpose of Documentation z. Evaluate and Plan for Treatment z. Communication and Continuity of Care z. Claims Review and Payment z. Research and Education
General Principles of Documentation z. Complete and Legible z. Reason/Rationale for the Encounter z. Assessment, Impression, or Diagnosi/es z. Plan for Care z. Date and Identity of Observer
Documentation History z. Chief Complaint z. History of Present Illness (HPI) z. Review of Systems z. Past, Family, and/or Social History
Documentation of Chief Complaint z. Concise Statement Describing the Symptom, Problem, Condition, Diagnosis, Physician Recommended Return, or other Factor that is the Reason for the Encounter.
Documentation of Present Illness z. Chronological Description of the Development of the Patient’s Present Illness from the First Sign and/or Symptom or from the Previous Encounter to the Present. y. For Symptoms: Location, Quality, Severity, Duration, Timing, Context, Modifying Factors Including Medications, Associated Signs, Symptoms, etc. y. For Follow up: Changes in Condition Since Last Visit, Compliance with Treatment, etc.
Review of Systems z. Psychiatric z. Neurological z. Other
Documentation of History z. Past History z. Family History z. Social History
Specific Documentation Suggestions: Psychiatric Interview z. Name, Date, Observer, Dx/Impression z. Mental Status Exam y. Language, Thought Processes, Insight, Judgment, Reliability, Reasoning, Perceptions, Suicidality, Violence, Mood & Affect, Orientation, Memory, Attention, Intelligence
Specific Documentation Suggestions: Neurobehavioral Status Exam z. Name, Date, Observer, Dx/Impression z. Variables y. Attention, Memory, Visuo-Spatial, Lanague, Planning
Specific Documentation Suggestions: Testing z. Name, Date, Observer, Dx/Impression z. Names of Tests z. Interpretation of Tests Results z. Disposition z. Time
Documentation Suggestions z. Avoid Handwritten Notes z. Do Not Use Red Ink z. Document on Every Encounter, Every Procedure, and Every Patient z. Re-Cap Status, Whenever Possible, At Least Change From Session to Session z. Document Soon After Procedure
Trends z. Issues of Confidentiality z. Over-Diagnosing z. Over-Documenting
Auditing z. Fraud & Abuse vs Erroneous z. Self-Auditing Suggestions z. Risk Situations z. Development of an Internal Auditing System
Fraud vs Error z. Fraud = Intentional, Pattern z. Erroneous = Clerical, etc.
Self-Auditing Suggestions z. Written Policies z. Compliance Officer z. Training & Education z. Lines of Communication Should Exist z. Internal Monitoring & Auditing z. Enforce Standards z. Alter as Necessary
Risk Areas for Fraud z. Coding & Billing z. Reasonable & Necessary Services z. Documentation z. Improper Inducements
Fraudulent Claims Flags z. Upcoding z. Excessive or Unnecessary Visits to ACF z. Outpatient Service 72 Hrs. Post-Discharge z. CPT Code Usage Shift z. High Percentage of the Same Codes z. Use of Similar Time for Testing Across Pts. z. Medical Necessity (dx; interpretation)
Defining Necessity z“reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member” z. All services must “stand alone” z. Acute and emergency services more like to be considered necessary
Evaluating Effectiveness z. Adequacy of Evidence y. Bias y. External Validity z. Size of Effect y. From Not Effective to Breakthrough
Evaluating Effectiveness (continued) z. Organized Approaches to Evaluation of Scientific Evidence y. American College of Physicians y. Agency for Health Care Policy and Research y. BC/BS Technology Evaluation Center y. American College of Cardiology y. American College of Urology
Additional Issues z. Incident to yin vs outpatient ytechnical vs professional component yperforming vs billing z. Graduate Medical Education yallied health vs medical yinterns vs postdoctoral fellows z. CPT I, II, & III y. I = standard codes y. II = performance measures y. III = emerging technology
Future Trends z. Surveys; Practice, Ongoing & New Codes z. Health Care Finance Administration z. Committee for the Advance of Professional Practice z. Practice Directorate of the APA z. General Trends z. Future of Clinical Neuropsychology z. Resources
Surveys z. Rationale for Surveys y. All Decisions are Empirical y. Reasonably Large Ns y. Adequate Data z. Support Required y. If Asked, Participate y. Two Ongoing; x. NAN/Division 40 Practice Survey x. Re-evaluation of “Cognitive Rehabilitation”
Health Care Financing Administration z. Problems y. Definition of Physician (Social Security Practice Act of 1989) y. Doctoral vs Non-Doctoral Providers z. Directions y. Physician Work Value y. Practice Expense y. Matching of CPT with Reimbursement
Committee for the Advancement of Professional Practice z. Observers y. Joe Fishburn (NAN), Ida Sue Baron (Div 40) z. Attitude y. Division 40; NAN Gift y. Positive, Receptive y. Additional Staff Member for Medicare Program
General Trends z. Fraud, Abuse, & Effects of Regulations z. Clinical Neuropsychology Standardizing & Expanding Into Non-Traditional Areas z“Boutique” vs “Industrial” Neuropsych. z. Psychometrics as Clinical Neuropsychology z. Assessment & Rehabilitation z. Neuropsychology’s “Technical” Pipeline z. Establishment of “Grassroots Network”
Future of Clinical Neuropsychology: A Holiday Wish List z. More (normative? ) Data & A Few Theories z. Measurement of the Cultural & Subjective z. Less Focus on Conserving the Medicare Trust Fund & Stockholder Profits by Focusing on the Aged & Disabled z. Appreciating that Brain is Inside a Person Which is Inside a System (Value? ) z. Conscilience
Resources z. Web Sites yneuropsych; NANonline. org, Div 40. org ygovernment; HCFA. gov, NIH. gov ypersonal; clinicalneuropsychology. com z. Publications y. APA Medicare Handbook (PP; 2000) y. NAN Bulletin (1994, 1997, 1998, 2000) y. Journal of Psychopathology & Behavioral Assessment (1987) y. Professional Psychology (with Camara & Nathan, 2000)
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