Coding Documenting Billing Auditing Psychological Services a 10

Coding, Documenting, Billing & Auditing Psychological Services: 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” North Carolina Psychological Association Raleigh, NC, March 3, 2000

Disclaimer z. This workshop presents a list of recommendation for obtaining reimbursement for and documenting professional psychological services. These recommendations are based on the author’s work with the AMA-CPT Panel (4 th and 5 th editions) as well as HCFA’s Medical Directors’ Workgroup and the Medicare Coverage Advisory Committee.

Disclaimer (continued) z. These suggestions are being constantly revised and serve as general guidelines. Legal and third-party state and federal regulations may vary relative to these recommendations.

Acknowledgements z. North Carolina Psychological Association z. American Psychological Association y. Practice Directorate y. Division of Clinical Neuropsychology z. National Academy of Neuropsychology z. University of North Carolina at Wilmington

Outline of Presentation z. History/Background of Involvement z. Diagnoses z. Procedural Coding z. Time, Site of Service, Provider z. Reimbursement z. Documentation z. Auditing z. Related Issues z. Medicare z. Tests

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 and Psychology 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. NCPA & NCPF President y. Blue-Cross Blue Shield z. American Psychological Association y. Chair or Member of Approximately a Dozen Committees/Boards, (e. g. , CE, BCA) y. Division 40 Board- 1987 to present y. Two Terms on APA’s Council of Representatives- Div. 40 (1994 to present) y. Policy and Planning Board

History/Background (continued) z. American Medical Association y. CPT- 4 y. CPT- 5 z APA’s Practice Directorate z Blue Cross/Blue Shield of North Carolina z. Health Care Financing Administration y. Model Mental Health Policy Workgroup y. Medicare Coverage Advisory Committee

Medicare: Overview z. Benefits y. Part A (Hospital) y. Part B (Supplementary) y. Part C (Medicare + Choice) z. HCFA Vs. Local Carrier

Medicare: Local Medical Review Policy z. Development of Local Policy z. Restrictive

Reimbursement Model z. Diagnoses z. Procedural Code z. Time z. Site of Service z. Provider z. Formula y. Dx X Code X Time X Site X Provider

Procedural Coding z. Defining Coding z. History of Coding z. Coding

Diagnoses z. System (World Health Organization) y. DSM= 290 -319 y. ICD = all other diagnoses z. Referral Diagnosis y. Referral versus Final Diagnoses y. Rule-Out Diagnoses z. Multiple Diagnoses y. Advisable for Medically Necessary y. First Diagnosis is Most Important

Defining Coding z. Description of Professional Service Rendered z. Purpose of Coding y. Reimbursement y. Archival/Research y. Performance Assessment z. Current 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

CPT & HCFA z. Federal Register, August 17, 2000 y. Health Insurance Reform: Standards for Electronic Transactions y. The CPT is the standard code set for reporting physician and other health care services

Developing Codes z. Member/Society Generated Idea z. APA Practice Directorate z. Health Care Professionals Advisory Committee z. Integration with Specialty Groups within American Medical Association/Workgroup z. Formal Panel Presentation z. Relative Value of Code z. Time Frame (3 -6 years)

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 assessment (15 minutes) y 909 X 2 re-assessment y 909 X 3 intervention- individual y 909 X 4 intervention- group y 909 X 5 intervention- family y 909 X 6 intervention- family w/o pt. y. NOTE: codes have been valued and will be available for use in 01. 2002

Coding Modifiers z. Acceptability y. Medicare = 95% y. Others = Approximately 80% z. Modifiers y 22 y 51 y 52 y 53 = = Unusual or More Extensive Service Multiple Procedures Reduced Service Discontinued Service

New Category II Codes: Performance Measurement z. Purpose y. Reduction of detailed chart review y. Provide performance measurement z. Use y. Alphanumeric identifier with a letter in the last field y. Evidenced-based measurement that address conditions of high prevalence, risk or cost with established health outcomes

New Category III Codes: Emerging Technology z. Purpose y. Collect data and assess efficacy of new procedures z. Use y. Alphanumeric identifier z. Example y 0018 T y. Repetitive Transcranial Magnetic Stimulation y. Delivery of high power, focal magnetic pulses for direct stimulation of cortical neurons

Next Set of Codes z. Splitting of the Neuropsychological (and possibly, later) the Testing Codes y. Rationale x 5 Year Re-evaluation x. Lack of Cognitive Component y. Approach x. Integration with HCFA x. Involvement of NAN, 40 x. Group Survey Testing

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. Prospective Payment System z. Defining RBRVS z. Reimbursement Difficulties

Overview of the 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: Purpose & History z. Purpose: To Provide Equitable Payment for Medical Services z. History y. Phase I: Initial 12 physician specialties y. Phase II: Psychiatry y. Phase III: Psychology

RBRVS: Overview z. Major Components y. Physician Work Resource Value Unit y. Practice Expense Resource Value Unit y. Malpractice Component Resource Value Unit y. Geographical Practice Cost Index

RBRVS: Conversion Factor z. Dollar Value That Is Utilized to Convert the Resource Value Units and Geographic Practice Cost Indexes Into a Payment

RBRVS: Adoption z. Medicare z. Blue Cross/Blue Shield = 87% z. Managed Care = 69% z. Medicaid = 55% z. Other = 44%

Prospective Payment System z. Standard Scenario y. Included in inpatient bundled service z. Alternative Scenario y. Bill under own provider number z. Inpatient versus Patient

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

Time z. Defining Time y. Professional (not patient) Activity z. AMA Definition y. Physicians also spend time during work, before, or after the face-to-face time with the patient, performing such tasks as reviewing records and tests, arranging for services and communicating further with other professional and the patient through written reports and telephone contact

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

Testing Time Defined (continued) z. Communicating Further With Others z. Follow-up With Patient, Family, and/or Others z. Arranging for Ancillary and/or Other Services

Intervention Time Defined z. All Time is Bundled in the Allocated Time y 90806 = 45 minutes of total time y 97770 = 15 minutes of total time

Time X Code z. Interview & Assessment y. Hourly Increments z. Intervention y 15 y 30 y 45 y 90?

Quantifying Time z. Rounding y. Round up or down to nearest increment z. Time Does Not Include; y. Patient completing tests, forms, etc. y. Waiting time by patient y. Type of reports y. Non-professional time y. Literature searches, learning new techniques, etc.

Site of Service z. Inpatient y. Physical location y. Billing and business relations y. Origin of the patient y. Skilled and assisted nursing fascilities z. Outpatient y. By definition, anything that is not inpatient

Provider z. Doctorate y. Medicare: Ph. D/Psy. D/Ed. D = MD y. Non-Medicare: 0 -50% less than MD z. Non-Doctorate y. Social Security y. The special case of North Carolina

Medical Necessity z. Definition y. Reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member z. Stand Alone y. Each activity must stand alone y. Point-to-point correspondence between symptoms and procedures z. Likely Types y. Acute and emergency

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. Definition y. Clinical assessment of thinking, reasoning and judgment z. Variables y. Attention, Memory, Visuo-Spatial, Language, Planning y. Acquired knowledge, attention, memory, visual spatial abilities, language functioning,

Specific Documentation Suggestions: Testing z. Name, Date, Observer, Dx/Impression z. Names of Tests z. Interpretation of Tests Results z. Disposition z. Time

Defining Psychotherapy z. Purpose y. Resolving problems or alleviating of emotional disturbances, or changing maladaptive patterns of behavior, or encouraging personal growth and development z. Approaches y. Development of insight or affective understanding, the use of behavior modifying techniques, the use of supportive interactions, the use of cognitive discussion of reality ythe use of physical aids or non-verbal techs.

Specific Documentation Suggestion: Psychotherapy z. Basic Elements y. Date y. Reason for Service y. Intervention y. Results y. Impression y. Disposition y. Identity y. Time

Specific Documentation Suggestion: Cog. Rehab. z. Basic Elements y. Date y. Reason for Service y. Training activity y. Results y. Identity of Observer y. 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 z. Limited Interventions & Diagnostic Procedure

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)

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

Related Issues z. Graduate Medical Education yallied health vs medical yinterns vs postdoctoral fellows

Related Issues z. Incident to y. Definition xtechnical services that are an extension of the professional service(s) xinpatient as inpatient y. Billing xappropriate to provide technical services anywhere xnot appropriate to bill technical services inpatient

Tests z. Purpose z. Funding z. Sample z. Results Summary

Tests: Purpose z. Which Tests Are Being Used z. How Long Does Each Test Take z. Address More Carefully Pre, During, and Post-Testing Time

Tests: Sample z. Clinical y. APA z. Neuropsychological y. NAN y. Total Possible Sample = 2700 y. Total Sampled = 1200 y. Total Used = 447

Tests: Time Spent Testing z. Hours z 0 -4 z 5 -9 z 10 -14 z 15 -20 z>20 % 21 11 16 19 33

Tests: Types z. Type of Testing z. Adaptive z. Aphasia z. Behavioral Med z. Developmental z. Intellectual z. Neurobehavioral z. Neuropsychological z. Personality % 43 46 28 27 79 51 95 79

Tests: Time X Test z. Type Admin z. Adaptive 74 z. Aphasia 61 z. Beh Med 110 z. Develop 113 z. IQ 122 z. Neurobeh 80 z. Neuropsy 304 Score 32 24 35 36 34 26 79 Interpret 48 39 58 59 61 47 135

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 Psychology 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. Three Ongoing; x. NAN/Division 40 Practice Survey x. Re-evaluation of “Cognitive Rehabilitation” x. Splitting of Testing Codes

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 z. Attitude y. Positive, Receptive y. New Full-time Staff Member for Medicare Program (American College of Surgeons)

General Trends z. Fraud, Abuse, & Effects of Regulations z. Standardizing & Expanding Into Non. Traditional Areas z“Boutique” Vs “Industrial” Psychology z. Psychometrics as Clinical Psychology z. Assessment & Rehabilitation z. Psychology’s “Technical” Pipeline z. Establishment of “Grassroots Network”

Future of Professional Psychology 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)

Resources (continued) z. Initial Intake Forms z. Patient Service Forms z. Coding Sheet z. Billing Forms z. Medicare/Cigna Information Including Local Medical Review Revision Policy z. Blue Cross/Blue Shield Information z. Cigna Behavioral Health Forms & Example z. Workers Compensation Forms

Resources (continued) z. CPT Process z. New Health and Behavior Assessment and Intervention Codes z. Existing CPT Codes z. Psychological Test Usage in Professional Psychology (Camara, Nathan & Puente, 2000)