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cptcpt 11
Interfacing Science, Politics and Economics:Interfacing Science, Politics and Economics:How Medicare and the AMA Affect How Medicare and the AMA Affect
the Practice of Psychologythe Practice of Psychology
University of GeorgiaUniversity of Georgia02.24.0602.24.06
Antonio E. PuenteAntonio E. PuenteUniversity of North Carolina WilmingtonUniversity of North Carolina Wilmington
cptcpt 22
AcknowledgmentsAcknowledgments North Carolina Psychological AssociationNorth Carolina Psychological Association Practice Directorate of the American Psychological Association (APA)Practice Directorate of the American Psychological Association (APA) American Medical Association (AMA) CPT StaffAmerican Medical Association (AMA) CPT Staff National Academy of Neuropsychology (NAN)National Academy of Neuropsychology (NAN) Department of Psychology, UNC-WilmingtonDepartment of Psychology, UNC-Wilmington
Division of Clinical Neuropsychology- APADivision of Clinical Neuropsychology- APA Center for Medicare & Medicaid Services Medical Policy Staff- MedicareCenter for Medicare & Medicaid Services Medical Policy Staff- Medicare Inter-Divisional Health Care Committee- APAInter-Divisional Health Care Committee- APA
Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted Peck; AEP Research Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted Peck; AEP Research Team and Clinical Staff)Team and Clinical Staff)
cptcpt 33
Specific Support Provided by Primary Specific Support Provided by Primary OrganizationsOrganizations
APA = All expenses paid for travel associated with CPT APA = All expenses paid for travel associated with CPT activitiesactivities
NAN = (from PAIO budget) applied to UNCW activitiesNAN = (from PAIO budget) applied to UNCW activities 2002-2004 = $10,000 per year – one course for two semesters teaching 2002-2004 = $10,000 per year – one course for two semesters teaching
reductionreduction 2005 = $5,000 per year – one course for one semester teaching 2005 = $5,000 per year – one course for one semester teaching
reductionreduction 2006 = $25,000 per year – in negotiation2006 = $25,000 per year – in negotiation
UNCW = Time away from university duties (e.g., teaching) UNCW = Time away from university duties (e.g., teaching) plus incidental support such as copying, telephone calls, and plus incidental support such as copying, telephone calls, and secretarial and work-study student assistancesecretarial and work-study student assistance
cptcpt 44
BackgroundBackground(1988 – present)(1988 – present)
North Carolina Psychological Association (e)North Carolina Psychological Association (e) APA’s Policy & Planning Board; Div. 40 (e)APA’s Policy & Planning Board; Div. 40 (e) American Medical Association’s Current American Medical Association’s Current
Procedural Terminology Committee (IV/V) (a)Procedural Terminology Committee (IV/V) (a) Health Care Finance Administration’s Working Health Care Finance Administration’s Working
Group for Mental Health Policy (a)Group for Mental Health Policy (a) Center for Medicare/Medicaid Services’ Center for Medicare/Medicaid Services’
Medicare Coverage Advisory Committee (fa)Medicare Coverage Advisory Committee (fa) Consultant with the North Carolina Medicaid Consultant with the North Carolina Medicaid
Office;North Carolina Blue Cross/Blue Shield Office;North Carolina Blue Cross/Blue Shield (a)(a)
NAN’s Professional Affairs & Information Office NAN’s Professional Affairs & Information Office (a)(a)
((legend; a = appointment, fa = federal appointment, e = election)legend; a = appointment, fa = federal appointment, e = election)
cptcpt 55
Primary Goal & General Primary Goal & General Outcome Outcome
of CPT Work (AEP)of CPT Work (AEP) GoalGoal
Parity with PhysiciansParity with Physicians Expansion of Scope of Diagnostic ServicesExpansion of Scope of Diagnostic Services
OutcomeOutcome Intended/Anticipated/HopedIntended/Anticipated/Hoped
Similar reimbursement as physician servicesSimilar reimbursement as physician services General increase in the scope of practice General increase in the scope of practice Greater inclusion into health care systemGreater inclusion into health care system
Less AnticipatedLess Anticipated Transparency Transparency AccountabilityAccountability UniformityUniformity
cptcpt 66
Primary Goals of PresentationPrimary Goals of Presentation
Understand the Role of Medicare in Understand the Role of Medicare in Setting Standards for PsychologySetting Standards for Psychology
Understand the AMA Current Understand the AMA Current Procedural Terminology (CPT) for Procedural Terminology (CPT) for Coding of Professional ServicesCoding of Professional Services
Explain Potential Problems & Explain Potential Problems & Trajectory for 2006 and BeyondTrajectory for 2006 and Beyond
cptcpt 77
Outline of PresentationOutline of Presentation
I. MedicareI. Medicare II. Current Procedural Terminology II. Current Procedural Terminology III. Problems & Possible SolutionsIII. Problems & Possible Solutions IV. Predictions for the FutureIV. Predictions for the Future V. ResourcesV. Resources
cptcpt 88
I. Medicare: WhyI. Medicare: Why
TheThe Standard for Universal Health Standard for Universal Health Care: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 Auditing (determination of whether it
occurred)occurred)
cptcpt 99
Medicare: Immediate Medicare: Immediate ImpactImpact
As a Consequence, the Benchmark As a Consequence, the Benchmark for:for: All Commercial Carriers (e.g., HMOs)All Commercial Carriers (e.g., HMOs) As well as;As well as;
Workers CompensationWorkers Compensation Forensic ApplicationsForensic Applications Related Applications (e.g., industrial, sports)Related Applications (e.g., industrial, sports)
cptcpt 1010
Medicare: Long-term ImpactMedicare: Long-term Impact
By 2015, Medicare will represent By 2015, Medicare will represent approximately 50% of all health care approximately 50% of all health care payments in the United Statespayments in the United States
Most likely, in the next decade a national Most likely, in the next decade a national (US) health insurance will be established(US) health insurance will be established
One possible model will be to introduce One possible model will be to introduce Medicare to younger citizens will be in Medicare to younger citizens will be in age increments (e.g., 60-64, then 50-59, age increments (e.g., 60-64, then 50-59, etc)etc)
Hence, Medicare will come to set the Hence, Medicare will come to set the standard for all of health carestandard for all of health care
cptcpt 1111
Medicare: OverviewMedicare: Overview
Centers for Medicare and Medicaid Centers for Medicare and Medicaid ServicesServices
BenefitsBenefits Part A (Hospital)Part A (Hospital) Part B (Supplementary)Part B (Supplementary) Part C (Medicare+ Choice)Part C (Medicare+ Choice) New Pharmaceutical BenefitNew Pharmaceutical Benefit
cptcpt 1212
Medicare: Local ReviewMedicare: Local Review
Local Medical Review Policy (LMRP)Local Medical Review Policy (LMRP) National Policy Sets Overall ModelNational Policy Sets Overall Model LMRP Sets Local/Regional Policy-LMRP Sets Local/Regional Policy-
More restrictive than national policyMore restrictive than national policy Over-rides national policyOver-rides national policy Changes frequently without warning or Changes frequently without warning or
publicitypublicity Information best found on respective web Information best found on respective web
pagespages
cptcpt 1313
II. Current Procedural II. Current Procedural Terminology (CPT): Terminology (CPT):
OverviewOverview BackgroundBackground Codes & CodingCodes & Coding Existing CodesExisting Codes Model System X Type of ProblemModel System X Type of Problem Medical NecessityMedical Necessity DocumentingDocumenting TimeTime
cptcpt 1414
CPT: BackgroundCPT: Background
AmericanAmerican Medical Association Medical Association Developed by Surgeons (& Physicians) Developed by Surgeons (& Physicians)
in 1966 for Billing Purposesin 1966 for Billing Purposes 7,500+ Discrete Codes7,500+ Discrete Codes CPT Meets a Minimum of 4 Times/YearCPT Meets a Minimum of 4 Times/Year
Center for Medicare & Medicaid Center for Medicare & Medicaid ServicesServices AMA Under License by CMSAMA Under License by CMS CMS Now Provides Active Input into CPTCMS Now Provides Active Input into CPT
cptcpt 1515
CPT: Background/DirectionCPT: Background/Direction
Current System = CPT 5Current System = CPT 5 CategoriesCategories
I= Standard Coding for Professional I= Standard Coding for Professional ServicesServices
Codes of interestCodes of interest II = Performance MeasurementII = Performance Measurement
Starting to emerge; will be the future of CPTStarting to emerge; will be the future of CPT III = Emerging TechnologyIII = Emerging Technology
New technology and procedures New technology and procedures
cptcpt 1616
CPT: CompositionCPT: Composition
AMA House of DelegatesAMA House of Delegates 109 Medical Specialties109 Medical Specialties
HCPACHCPAC 11 Allied Health Societies (e.g., APA)11 Allied Health Societies (e.g., APA)
CPT Editorial PanelCPT Editorial Panel 17 Voting Members17 Voting Members
11 Appointed by AMA Board11 Appointed by AMA Board 1 each from BC/BS, AHA, HIAA, CMS1 each from BC/BS, AHA, HIAA, CMS 2 HCPAC 2 HCPAC
cptcpt 1717
CPT: TheoryCPT: Theory
Order of Value - PersonnelOrder of Value - Personnel Surgeons, Physicians, Doctorate Level Surgeons, Physicians, Doctorate Level
Allied Health, Non-Doctorate Level Allied Allied Health, Non-Doctorate Level Allied HealthHealth
Order of Value - CostsOrder of Value - Costs Cognitive Work, Expense, MalpracticeCognitive Work, Expense, Malpractice
cptcpt 1818
What Is a CPT Code?What Is a CPT Code?
A Coding System Developed by AMA in A Coding System Developed by AMA in Conjunction with CMS Conjunction with CMS
Each Code has a Specific Description and a Each Code has a Specific Description and a Reimbursable ValueReimbursable Value
Professional Health Service Provided Professional Health Service Provided Across the Country at Multiple LocationsAcross the Country at Multiple Locations
Many “Physicians” or “Qualified Health Many “Physicians” or “Qualified Health Professional” Perform ServicesProfessional” Perform Services
Clinical Efficacy is Established and Clinical Efficacy is Established and Documented in Peer-Reviewed LiteratureDocumented in Peer-Reviewed Literature
cptcpt 1919
Abbreviated CPT GlossaryAbbreviated CPT Glossary
CPTCPT Current Procedure Terminology = professional service codeCurrent Procedure Terminology = professional service code
Qualified Health ProfessionalQualified Health Professional Who has the contract with the insurance carrierWho has the contract with the insurance carrier Defined by training, state and federal statutes/laws/regulationsDefined by training, state and federal statutes/laws/regulations
TechnicianTechnician Anybody elseAnybody else
Facility vs Non-facilityFacility vs Non-facility Non-facility = all settings other than a hospital or skilled Non-facility = all settings other than a hospital or skilled
nursing facilitynursing facility UnitsUnits
Time based factor which is applied as a multiplier to the RVUs Time based factor which is applied as a multiplier to the RVUs agreed to by AMA CPT and CMSagreed to by AMA CPT and CMS
Face-to-faceFace-to-face In front of the patientIn front of the patient
cptcpt 2020
CPT: Applicable CodesCPT: Applicable Codes
Total Possible Codes = Approximately Total Possible Codes = Approximately 7,5007,500
Possible Codes for Psychology = Possible Codes for Psychology = Approximately 40 to 60Approximately 40 to 60
Sections = Five Primary Separate SectionsSections = Five Primary Separate Sections PsychiatryPsychiatry BiofeedbackBiofeedback Central Nervous AssessmentCentral Nervous Assessment Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Health & Behavior Assessment & ManagementHealth & Behavior Assessment & Management Possibility of Evaluation and Management Possibility of Evaluation and Management
cptcpt 2121
CPT: Development of a CodeCPT: Development of a Code
InitialInitial Health Care Advisory Committee (non-MDs)Health Care Advisory Committee (non-MDs)
PrimaryPrimary CPT Work Group (selected organizations)CPT Work Group (selected organizations) CPT Panel (all specialties)CPT Panel (all specialties)
Time FrameTime Frame 3-5 years to well over a decade3-5 years to well over a decade
cptcpt 2222
CPT: PsychiatryCPT: Psychiatry
Sections (or Categories)Sections (or Categories) Interview (90801) vs. Intervention (e.g., 908.06)Interview (90801) vs. Intervention (e.g., 908.06) These codes are one unitThese codes are one unit Office vs. InpatientOffice vs. Inpatient Regular vs. Evaluation & ManagementRegular vs. Evaluation & Management OtherOther
Types of InterventionsTypes of Interventions Insight, Behavior Modifying, and/or Supportive Insight, Behavior Modifying, and/or Supportive
vs. Interactivevs. Interactive
cptcpt 2323
CPT Changes:CPT Changes:CNS Assessment Codes CNS Assessment Codes
TimetableTimetable Activity x DateActivity x Date
Codes Without Cognitive Work Obtained, 1994Codes Without Cognitive Work Obtained, 1994 Initial Request for Practice Expense by APA, Summer, 2002Initial Request for Practice Expense by APA, Summer, 2002 APA Appeared Before AMA RUC, September, 2003APA Appeared Before AMA RUC, September, 2003 Initial Decision by AMA CPT Panel, November 7, 2004Initial Decision by AMA CPT Panel, November 7, 2004 Call for Other Societies to Participate, November 19, 2004Call for Other Societies to Participate, November 19, 2004 Final Decision by AMA CPT Panel, December 1, 2004Final Decision by AMA CPT Panel, December 1, 2004 Submission of CPT Codes to AMA RUC Committee immediately Submission of CPT Codes to AMA RUC Committee immediately
thereafterthereafter Review by AMA RUC Research Subcommittee in January, 2005Review by AMA RUC Research Subcommittee in January, 2005 Review by AMA RUC Panel in February 3-6, 2005Review by AMA RUC Panel in February 3-6, 2005 Survey of Codes, second & third week of February, 2005Survey of Codes, second & third week of February, 2005 Analysis of surveys, March, 2005Analysis of surveys, March, 2005 Presentation to RUC Committee in April, 2005Presentation to RUC Committee in April, 2005 Inclusion in the 2006 Physician Fee Schedule on January 1, 2006Inclusion in the 2006 Physician Fee Schedule on January 1, 2006 CPT Assistant article early 2006CPT Assistant article early 2006
cptcpt 2424
CPT: CNS AssessmentCPT: CNS AssessmentEffective 01.01.06 Effective 01.01.06 (no grace (no grace
period)period) Psychological Testing (e.g., 5 units)Psychological Testing (e.g., 5 units)
Three New CodesThree New Codes New Numbers & DescriptorsNew Numbers & Descriptors
Neurobehavioral Status Exam (e.g., 2 Neurobehavioral Status Exam (e.g., 2 units)units) New Number & Revised DescriptorNew Number & Revised Descriptor
Neuropsychological Testing (e.g., 10 units)Neuropsychological Testing (e.g., 10 units) Three New CodesThree New Codes New Numbers & DescriptorsNew Numbers & Descriptors
cptcpt 2525
Psychological Testing:Psychological Testing:By ProfessionalBy Professional
9610196101 –Psychological Testing –Psychological Testing Psychodiagnostic assessment of Psychodiagnostic assessment of
emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology, e.g., personality and psychopathology, e.g., MMPI, Rorschach, WAIS (per hour of MMPI, Rorschach, WAIS (per hour of psychologist’s orpsychologist’s or physician’sphysician’s time, time, both face-to-face time with the patient both face-to-face time with the patient and time interpreting test results and and time interpreting test results and preparing the report)preparing the report)
cptcpt 2626
Psychological Testing:Psychological Testing:By TechnicianBy Technician
9610296102- Psychological Testing- Psychological Testing Psychodiagnostic assessment of Psychodiagnostic assessment of
emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology (e.g., personality and psychopathology (e.g., MMPI, Rorschach, WAIS) with MMPI, Rorschach, WAIS) with qualified qualified health care professionalhealth care professional interpretation interpretation and report, administered by and report, administered by techniciantechnician, , per hour of technician time, face-to-faceper hour of technician time, face-to-face
cptcpt 2727
Psychological Testing:Psychological Testing:By ComputerBy Computer
96103 96103 - Psychological Testing- Psychological Testing Psychodiagnostic assessment of Psychodiagnostic assessment of
emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology, (e.g., personality and psychopathology, (e.g., MMPI) administered by a MMPI) administered by a computercomputer, , with with qualified health professionalqualified health professional interpretation and the reportinterpretation and the report
cptcpt 2828
Neurobehavioral Status Neurobehavioral Status ExamExam
9611696116 - Neurobehavioral status exam - Neurobehavioral status exam Clinical assessment of thinking, reasoning Clinical assessment of thinking, reasoning
and judgment ( e.g., acquired knowledge, and judgment ( e.g., acquired knowledge, attention, language, memory, planning attention, language, memory, planning and problem solving, and visual-spatial and problem solving, and visual-spatial abilities) per hour of abilities) per hour of psychologist’s or psychologist’s or physician’sphysician’s time, both face-to-face time time, both face-to-face time with the patient and time interpreting with the patient and time interpreting test results and preparing the reporttest results and preparing the report
cptcpt 2929
Neuropsychological Testing-Neuropsychological Testing-By ProfessionalBy Professional
9611896118 - Neuropsychological testing - Neuropsychological testing (e.g., Halstead-Reitan (e.g., Halstead-Reitan
Neuropsychological, WMS, Wisconsin Neuropsychological, WMS, Wisconsin Card Sorting) per hour of the Card Sorting) per hour of the psychologist’s or physician’spsychologist’s or physician’s time, time, both face-to-face time with the patient both face-to-face time with the patient and time interpreting test results and and time interpreting test results and preparing the reportpreparing the report
cptcpt 3030
Neuropsychological Testing:Neuropsychological Testing:By TechnicianBy Technician
96119 96119 - Neuropsychological testing - Neuropsychological testing (e.g., Halstead-Reitan (e.g., Halstead-Reitan
Neuropsychological, WMS, Wisconsin Neuropsychological, WMS, Wisconsin Card Sorting) with Card Sorting) with qualified health care qualified health care professionalprofessional interpretation and report, interpretation and report, administered by a administered by a techniciantechnician per hour per hour of technician time, face-to-faceof technician time, face-to-face
cptcpt 3131
Neuropsychological Testing-Neuropsychological Testing-By ComputerBy Computer
9612096120 - Neuropsychological testing - Neuropsychological testing (e.g., WCST) administered by a (e.g., WCST) administered by a
computercomputer with with qualified health care qualified health care professionalprofessional interpretation and the interpretation and the reportreport
cptcpt 3232
CNS Assessment ExamplesCNS Assessment Examples
Neurobehavioral Status with Neuropsychological TestingNeurobehavioral Status with Neuropsychological Testing Interview by the ProfessionalInterview by the Professional Testing byTesting by
Professional, and/orProfessional, and/or Technician, and/orTechnician, and/or Computer.Computer.
Interpretation & Report Writing by Qualified Health Interpretation & Report Writing by Qualified Health ProfessionalProfessional
A Technician or Computer Code are Typically Billed A Technician or Computer Code are Typically Billed Together with a Professional Code (since the final Together with a Professional Code (since the final product should be a product should be a comprehensive/integrative comprehensive/integrative report)report)
cptcpt 3333
CPT: Physical Medicine & CPT: Physical Medicine & RehabilitationRehabilitation
97770 now 9753297770 now 97532 Note: 15 minute incrementsNote: 15 minute increments
cptcpt 3434
CPT: Cognitive CPT: Cognitive RehabilitationRehabilitation
Application RationaleApplication Rationale Allied Health & Physical Medicine CodeAllied Health & Physical Medicine Code
AcceptabilityAcceptability GN – Speech TherapistsGN – Speech Therapists GO – Occupational TherapistsGO – Occupational Therapists GP – Physical TherapistsGP – Physical Therapists AH – Mental Health (not applicable)AH – Mental Health (not applicable)
cptcpt 3535
CPT: Health & Behavior CPT: Health & Behavior Assessment & ManagementAssessment & Management
((CPT AssistantCPT Assistant, 03.04), 03.04)((CPT AssistantCPT Assistant, 08.05, , 08.05, 1515, #6, 10), #6, 10)
Purpose: Medical DiagnosisPurpose: Medical Diagnosis Time: 15 Minute IncrementsTime: 15 Minute Increments AssessmentAssessment InterventionIntervention
cptcpt 3636
History of H & B CodesHistory of H & B Codes
Inter-divisional Health Care Committee of APA Inter-divisional Health Care Committee of APA (22, 38, 40, 54; Glueckauf, chair)(22, 38, 40, 54; Glueckauf, chair)
Convened in 1995 by APA PD (Phelps)Convened in 1995 by APA PD (Phelps) First draft 09.11.98; Working draft 07.01.00First draft 09.11.98; Working draft 07.01.00 First AMA presentation 11.06.98; Final 08.08.00 First AMA presentation 11.06.98; Final 08.08.00
(Ft. Lauderdale, Chicago, Denver, San Francisco, (Ft. Lauderdale, Chicago, Denver, San Francisco, Washington, Chicago, Chicago)Washington, Chicago, Chicago)
First survey 01.31.01; Final survey 04.26.01First survey 01.31.01; Final survey 04.26.01 Revisions to language – Revisions to language –
First preamble 03.02First preamble 03.02 Last preamble 11.04Last preamble 11.04
cptcpt 3737
Overview of H & B CodesOverview of H & B Codes
Codes Effective as 01.01.2002 Codes Effective as 01.01.2002 (with ongoing (with ongoing revisions of language)revisions of language)
Assessment (e.g., 4 units)Assessment (e.g., 4 units) Intervention (e.g., up to a total of 48 units)Intervention (e.g., up to a total of 48 units)
Established Medical Illness or Established Medical Illness or DiagnosisDiagnosis
Focus on Biopsychosocial FactorsFocus on Biopsychosocial Factors
cptcpt 3838
Health & Behavior Health & Behavior Assessment CodesAssessment Codes
9615096150 Health and behavior assessment (e.g., Health and behavior assessment (e.g.,
health-focused clinical interview, health-focused clinical interview, behavioral observations, behavioral observations, psychophysiological monitoring, health-psychophysiological monitoring, health-oriented questionnaires)oriented questionnaires)
each 15 minuteseach 15 minutes face-to-face with the patientface-to-face with the patient initial assessmentinitial assessment
9615196151 re-assessmentre-assessment
cptcpt 3939
H & B: Assessment H & B: Assessment ExplanationExplanation
Identification of Psychological, Identification of Psychological, Behavioral, Emotional, Cognitive Behavioral, Emotional, Cognitive and/or Social Factorsand/or Social Factors
In the Prevention, Treatment and/or In the Prevention, Treatment and/or Management of Physical Health Management of Physical Health ProblemsProblems
Focus on Biopsychosocial and not Focus on Biopsychosocial and not Mental Health FactorsMental Health Factors
cptcpt 4040
H & B: Assessment H & B: Assessment ExamplesExamples
Health-Focused Clinical InterviewHealth-Focused Clinical Interview Behavioral ObservationsBehavioral Observations Psychophysiological MonitoringPsychophysiological Monitoring Health-Oriented QuestionnairesHealth-Oriented Questionnaires
cptcpt 4141
Health & Behavior Health & Behavior Intervention CodesIntervention Codes
9615296152 Health and behavior interventionHealth and behavior intervention each 15 minuteseach 15 minutes face-to-faceface-to-face individualindividual
9615396153 group (2 or more patients)group (2 or more patients)
9615496154 family (with the patient present)family (with the patient present)
96155 (limited acceptability)96155 (limited acceptability) family (without the patient present; not being family (without the patient present; not being
reimbursedreimbursed))
cptcpt 4242
H & B: Intervention H & B: Intervention ExamplesExamples
CognitiveCognitive BehavioralBehavioral Social Social PsychophysiologicalPsychophysiological
cptcpt 4343
H & B: DiagnosesH & B: Diagnoses
Associated with an Acute or Chronic Associated with an Acute or Chronic Medical IllnessMedical Illness
Not Applicable to Psychiatric Not Applicable to Psychiatric DiagnosesDiagnoses
cptcpt 4444
CPT: Model SystemCPT: Model System
PsychiatricPsychiatric NeurologicalNeurological Non-Neurological MedicalNon-Neurological Medical
cptcpt 4545
CPT ModelCPT Model
Rationale for CPT Code:Rationale for CPT Code: Choose Code that Best Describes the Choose Code that Best Describes the
Service Service Match the Interview with the Testing Match the Interview with the Testing
with the Intervention Code with the with the Intervention Code with the DiagnosisDiagnosis
Goal = Uniformity and FluencyGoal = Uniformity and Fluency
cptcpt 4646
CPT: Psychiatric ModelCPT: Psychiatric Model(Children & Adult)(Children & Adult)
InterviewInterview 90801- adult90801- adult 90802- child90802- child
TestingTesting 96101-0396101-03 Also, 96111 for childrenAlso, 96111 for children
InterventionIntervention e.g., 90806- adulte.g., 90806- adult e.g., 90820-childe.g., 90820-child
cptcpt 4747
CPT: Neurological ModelCPT: Neurological Model(Children & Adult)(Children & Adult)
InterviewInterview 9611696116
TestingTesting 96118/19/2096118/19/20
InterventionIntervention 9753297532
cptcpt 4848
CPT: Non-Neurological CPT: Non-Neurological Medical ModelMedical Model
(Children & Adult)(Children & Adult)
Interview & AssessmentInterview & Assessment 96150 (initial)96150 (initial) 96151 (re-evaluation)96151 (re-evaluation)
InterventionIntervention 96152 (individual)96152 (individual) 96153 (group)96153 (group) 96154 (family with patient)96154 (family with patient) 96155 (family without patient)96155 (family without patient)
cptcpt 4949
CPT: Correct Coding InitiativeCPT: Correct Coding Initiative
PurposePurpose Used to evaluate submissions when Used to evaluate submissions when
provider bills more than one service for provider bills more than one service for the same beneficiary and same date of the same beneficiary and same date of serviceservice
Example; psychotherapy and testingExample; psychotherapy and testing ActivationActivation
Automatic editsAutomatic edits
cptcpt 5050
CPT: DiagnosingCPT: Diagnosing
PsychiatricPsychiatric DSMDSM
The problem with DSM and neuropsych The problem with DSM and neuropsych testing of developmentally-related testing of developmentally-related neurological problemsneurological problems
Neurological & Non-Neurological Neurological & Non-Neurological MedicalMedical ICD – 9 CM (physical diagnosis coding)ICD – 9 CM (physical diagnosis coding) www.cdc.gov/nchs/about/otheract/icd9www.cdc.gov/nchs/about/otheract/icd9
cptcpt 5151
Medically Reasonable and Medically Reasonable and NecessaryNecessary
Section 1862 (a)(1) 1963Section 1862 (a)(1) 196342, C.F.R., 411.15 (k)42, C.F.R., 411.15 (k)
““Services which are reasonable and necessary Services which are reasonable and necessary for the diagnosis and treatment of illness or for the diagnosis and treatment of illness or injury or to improve the functioning of a injury or to improve the functioning of a malformed body member”malformed body member”
Re-evaluation should only occur when there is a Re-evaluation should only occur when there is a potential change in;potential change in; DiagnosisDiagnosis SymptomsSymptoms
cptcpt 5252
CPT: DocumentingCPT: Documenting
PurposePurpose Payer RequirementsPayer Requirements General PrinciplesGeneral Principles HistoryHistory ExaminationExamination Decision MakingDecision Making
cptcpt 5353
Documentation: PurposeDocumentation: Purpose
Medical NecessityMedical Necessity Evaluate and Plan for TreatmentEvaluate and Plan for Treatment Communication and Continuity of Communication and Continuity of
CareCare Claims Review and PaymentClaims Review and Payment Research and EducationResearch and Education
cptcpt 5454
Documentation: General Documentation: General PrinciplesPrinciples
Rationale for ServiceRationale for Service Complete and LegibleComplete and Legible Reason/Rationale for ServiceReason/Rationale for Service Assessment, Progress, Impression, or Assessment, Progress, Impression, or
DiagnosisDiagnosis Plan for CarePlan for Care Date and Identity of ObserveDate and Identity of Observe TimelyTimely ConfidentialConfidential
cptcpt 5555
Documentation: Basic Documentation: Basic Information Across CodesInformation Across Codes
DateDate Time, if applicableTime, if applicable Identify of Observer (technician ?)Identify of Observer (technician ?) Reason for ServiceReason for Service StatusStatus ProcedureProcedure Results/FindingResults/Finding Impression/DiagnosesImpression/Diagnoses DispositionDisposition Stand AloneStand Alone
cptcpt 5656
Documentation:Documentation: Chief Complaint Chief Complaint
Concise Statement Describing the Concise Statement Describing the Symptom, Problem, Condition, & Symptom, Problem, Condition, & DiagnosisDiagnosis
Foundation for Medical NecessityFoundation for Medical Necessity Must be Complete & ExhaustiveMust be Complete & Exhaustive
cptcpt 5757
Documentation: Documentation: Present IllnessPresent Illness
SymptomsSymptoms Location, Quality, Severity, Duration, Location, Quality, Severity, Duration,
timing, Context, Modifying Factors timing, Context, Modifying Factors Associated SignsAssociated Signs
Follow-upFollow-up Changes in ConditionChanges in Condition ComplianceCompliance
cptcpt 5858
Documentation: HistoryDocumentation: History
PastPast Family Family SocialSocial Medical/PsychologicalMedical/Psychological
cptcpt 5959
Documentation: AssessmentDocumentation: Assessment
Reason for ServiceReason for Service Dates (amount of service time?)Dates (amount of service time?) Identity of TesterIdentity of Tester Tests and Protocols (included editions)Tests and Protocols (included editions) Narrative of ResultsNarrative of Results ImpressionImpression DispositionDisposition
cptcpt 6060
Documentation: Documentation: InterventionIntervention
Reason for ServiceReason for Service Status of PatientStatus of Patient Intervention PerformedIntervention Performed Results ObtainedResults Obtained Impression or Diagnosis (es)Impression or Diagnosis (es) DispositionDisposition TimeTime
cptcpt 6161
CPT X ReportCPT X Report
Each CPT Code Should Generate a Each CPT Code Should Generate a Separate ReportSeparate Report
Alternatively, Clearly Label/Title Alternatively, Clearly Label/Title Sections of the Report to Match Sections of the Report to Match Codes UsedCodes Used
cptcpt 6262
Documentation:Documentation:SuggestionsSuggestions
Avoid Handwritten NotesAvoid Handwritten Notes Do Not Use Red InkDo Not Use Red Ink Avoid Color PaperAvoid Color Paper Document On and After Every Document On and After Every
Encounter, Every Procedure, Every Encounter, Every Procedure, Every PatientPatient
Review Changes Whenever ApplicableReview Changes Whenever Applicable Avoid Standard Phrases & ProtocolsAvoid Standard Phrases & Protocols
cptcpt 6363
TimeTime
DefiningDefining Professional (not patient) Time Including:Professional (not patient) Time Including:
pre, intra & post-clinical service activitiespre, intra & post-clinical service activities Interview & Assessment CodesInterview & Assessment Codes
Use 15 or 60 minute increments, as applicableUse 15 or 60 minute increments, as applicable Intervention CodesIntervention Codes
Use 15, 30, 60 or 90 minute increments, as Use 15, 30, 60 or 90 minute increments, as applicableapplicable
cptcpt 6464
Time: DefinitionTime: Definition
AMA Definition of TimeAMA Definition of Time
Physicians also spend time during work, Physicians also spend time during work, before, or after the face-to-face time with before, or after the face-to-face time with the patient, performing such tasks as the patient, performing such tasks as reviewing records & tests, arranging for reviewing records & tests, arranging for services & communicating further with services & communicating further with other professionals & the patient through other professionals & the patient through written reports & telephone contact.written reports & telephone contact.
cptcpt 6565
Time (continued)Time (continued)
Communicating further with othersCommunicating further with others Follow-up with patient, family, and/or Follow-up with patient, family, and/or
othersothers Arranging for ancillary and/or other Arranging for ancillary and/or other
servicesservices
cptcpt 6666
Time: TestingTime: Testing
Quantifying TimeQuantifying Time Round up or down to nearest incrementRound up or down to nearest increment
Time Does Not IncludeTime Does Not Include Patient completing tests, scales, forms, etc.Patient completing tests, scales, forms, etc. Waiting time by patientWaiting time by patient Typing of reportsTyping of reports Non-Professional (e.g., clerical) timeNon-Professional (e.g., clerical) time Literature searches, learning new techniques, Literature searches, learning new techniques,
etc.etc.
cptcpt 6767
Time: Defining 15 MinutesTime: Defining 15 Minutes(from CPT Assistant, 08.05, 11-12)(from CPT Assistant, 08.05, 11-12)
((www.cms.hhs.gov/manuals/104_claims/clm104c05.www.cms.hhs.gov/manuals/104_claims/clm104c05.pdf)pdf)
Defining 15 Minute IncrementsDefining 15 Minute Increments UnitsUnits Amount of MinutesAmount of Minutes
11 >08; <23>08; <23 22 >22; <38>22; <38 33 >38; <53>38; <53 44 >53; <68>53; <68 55 >68; <83>68; <83 66 >83; <98>83; <98 77 >98; <113>98; <113 88 >113;<128>113;<128 Over 2 hoursOver 2 hours similar pattern as abovesimilar pattern as above
cptcpt 6868
Reimbursement HistoryReimbursement History
Cost Plus Cost Plus Prospective Payment System (PPS)Prospective Payment System (PPS) Diagnostic Related Groups (DRGs)Diagnostic Related Groups (DRGs) Customary, Prevailing & Reasonable Customary, Prevailing & Reasonable
(CPR)(CPR) Resource Based Relative Value System Resource Based Relative Value System
(RBRVS)(RBRVS) Note: On average, insurance companies Note: On average, insurance companies
will pay approximate 75% of its income)will pay approximate 75% of its income)
cptcpt 6969
Relative Value Units: OverviewRelative Value Units: Overview
ComponentsComponents UnitsUnits ValuesValues Current ProblemsCurrent Problems
cptcpt 7070
RVU: ComponentsRVU: Components
Physician Work Resource ValuePhysician Work Resource Value Practice Expense Resource ValuePractice Expense Resource Value MalpracticeMalpractice GeographicGeographic Conversion Factor (approx. $37.8975 Conversion Factor (approx. $37.8975
02.2005)02.2005)
cptcpt 7171
RVU Components PercentagesRVU Components Percentages
Physician WorkPhysician Work == 52%52% Practice ExpensePractice Expense == 44%44% LiabilityLiability = 4%= 4%
NOTE: Within 5-10 years, another major NOTE: Within 5-10 years, another major component will be performance; in other component will be performance; in other words, not only the work must be words, not only the work must be performed but some results should occur performed but some results should occur as a function of the serviceas a function of the service
cptcpt 7272
Defining Physician WorkDefining Physician Work
Clinical WorkClinical Work Mental Effort and JudgmentMental Effort and Judgment Technical Skill/Physical EffortTechnical Skill/Physical Effort Psychological StressPsychological Stress
cptcpt 7373
Estimate of Psychologists’ Estimate of Psychologists’ ValueValue
AudiologistAudiologist .52.52 DieticianDietician .43.43 RNRN .42.42 Speech PathologistSpeech Pathologist .55.55
PsychologistPsychologist .82.82
cptcpt 7474
Defining Practice ExpenseDefining Practice Expense
Constitutes 43% of Medicare Constitutes 43% of Medicare PaymentsPayments
Components of Practice ExpenseComponents of Practice Expense Clinical non-physician labor (43 Clinical non-physician labor (43
categories)categories) RN/LPN/MTA = $.37/minute ( $37,440/year)RN/LPN/MTA = $.37/minute ( $37,440/year)
Medical disposable supplies (842 items)Medical disposable supplies (842 items) Equipment (553 items)Equipment (553 items)
cptcpt 7575
RVU: ValuesRVU: Values
Psychotherapy:Psychotherapy: Prior Value =1.86Prior Value =1.86 New Value = 2.65New Value = 2.65
Psych/NP Testing: Psych/NP Testing: Work value= 0Work value= 0 Hsiao study recommendation = 2.2Hsiao study recommendation = 2.2 New Value = undeterminedNew Value = undetermined
Health & BehaviorHealth & Behavior .25 (per 15 minutes increments).25 (per 15 minutes increments)
cptcpt 7676
RVU: AcceptanceRVU: Acceptance
Medicare (100% since 01.01.92)Medicare (100% since 01.01.92) Medicaid = 100%Medicaid = 100% Private Payors = 74% and increasing to Private Payors = 74% and increasing to
95%95% Blue Cross/Blue Shield = 87%Blue Cross/Blue Shield = 87% Managed Care = 69%Managed Care = 69%
Other = 44%Other = 44% New Trends: New Trends:
RVUs as a Model for All Insurance CompaniesRVUs as a Model for All Insurance Companies RVUs as a Basis for Compensation FormulasRVUs as a Basis for Compensation Formulas
cptcpt 7777
CPT x RVU CPT x RVU Pre 2006Pre 2006
CPTCode
WorkValue
PracticeExpense
MalpracticeExpense
TotalRVU
MutuallyExclusive
90801 2.80 1.14 0.06 4.00 90802, 90846, 90847,90853, 99291, 99292
90806 1.86 0.75 0.04 2.65 90801 (?)
96100 0 1.67 0.15 1.82 96110, 96 115
96115 0 1.67 0.15 1.82 - // -
96117 0 1.67 0.15 1.82 96110, 96111
96150 0.5 0.2 0.02 0.72 96151, 96152, 96153,96154, 96155
96152 0.46 0.18 0.02 0.66 96150, 96151, 96153,96154, 96155
cptcpt 7878
National RVU 2006 ValuesNational RVU 2006 Valuesop=outpatient, ip=inpatient, est=estimateop=outpatient, ip=inpatient, est=estimate
Code #Code # OP RVUOP RVU IP RVUIP RVU OP $ estOP $ est IN IN $est$est
9610196101 2.562.56 2.542.54 92.6192.61 91.8991.89
9610296102 1.171.17 0.680.68 42.3342.33 24.6024.60
9610396103 0.740.74 0.700.70 26.7726.77 25.3225.32
9611696116 2.872.87 2.682.68 103.83103.83 96.9596.95
9611896118 3.433.43 2.672.67 124.09124.09 96.5996.59
9611996119 1.751.75 0.920.92 63.3163.31 33.2833.28
9612096120 1.271.27 0.700.70 45.9445.94 25.3225.32
cptcpt 7979
III. ProblemsIII. Problems
Supervision vs Incident toSupervision vs Incident to TechniciansTechnicians TimeTime PaymentPayment Fraud & AbuseFraud & Abuse
cptcpt 8080
SupervisionSupervision( ( Federal Register, Federal Register, 6969, #150, August 5, 2004, page 47553), #150, August 5, 2004, page 47553)
Hold Doctoral Degree in PsychologyHold Doctoral Degree in Psychology Licensed or Certified as a PsychologistLicensed or Certified as a Psychologist Applicable Only to “clinical psychologists” Applicable Only to “clinical psychologists”
(and not “independent” psychologists (and not “independent” psychologists (e.g., Ed. (e.g., Ed.
Psych.Psych.)) RationaleRationale
Allows for higher level of expertise to superviseAllows for higher level of expertise to supervise Could relieve burden on physicians and facilitiesCould relieve burden on physicians and facilities May increase service in rural areasMay increase service in rural areas
Recommended Supervision Level = GeneralRecommended Supervision Level = General
cptcpt 8181
SupervisionSupervision
SupervisionSupervision 1.General = overall direction1.General = overall direction 2.Direct = present in office suite2.Direct = present in office suite 3.Personal = in actual room3.Personal = in actual room 4.Psychological = when supervised by a 4.Psychological = when supervised by a
psychologistpsychologist
cptcpt 8282
SupervisionSupervisionProgram Memorandum CarriersProgram Memorandum Carriers
Department of Health and Human Services- HCFADepartment of Health and Human Services- HCFATransmittal b-01-28; April 19, 2001Transmittal b-01-28; April 19, 2001
Levels of SupervisionLevels of Supervision GeneralGeneral
Furnished under overall direction and control, Furnished under overall direction and control, presence is not requiredpresence is not required
DirectDirect Must be present in the office suite and immediately Must be present in the office suite and immediately
available to furnish assistance and direction available to furnish assistance and direction throughout the performance of the procedurethroughout the performance of the procedure
PersonalPersonal Must be in attendance in the room during the Must be in attendance in the room during the
performance of the procedureperformance of the procedure
cptcpt 8383
Incident toIncident to Rationale for Incident toRationale for Incident to
Congress intended to provide coverage for Congress intended to provide coverage for services not typically covered elsewhereservices not typically covered elsewhere
Definition of Physician ExtenderDefinition of Physician Extender HowHow LimitationsLimitations
Definition of In vs. OutpatientDefinition of In vs. Outpatient Geographic Vs FinancialGeographic Vs Financial
Probably no Future to Incident toProbably no Future to Incident to
cptcpt 8484
Defining Incident toDefining Incident to
DefinitionDefinition Commonly furnished serviceCommonly furnished service Integral, though incidental to psychologistIntegral, though incidental to psychologist Performed under direct supervisionPerformed under direct supervision Either furnished without charge or as part Either furnished without charge or as part
of the psychologist’s chargeof the psychologist’s charge The employee meets the contractual The employee meets the contractual
requirement sent by CMS (e.g., 1099)requirement sent by CMS (e.g., 1099)
cptcpt 8585
More Incident toMore Incident to
When is “Incident to” Acceptable:When is “Incident to” Acceptable: Testing - DefiniteTesting - Definite Cognitive Rehabilitation; Biofeedback - Cognitive Rehabilitation; Biofeedback -
ProbablyProbably Psychotherapy – CMS is not opposed to Psychotherapy – CMS is not opposed to
incident for this serviceincident for this service
cptcpt 8686
Incident to & Incident to & Site of ServiceSite of Service
Outpatient vs. InpatientOutpatient vs. Inpatient Geographical Location- SeparateGeographical Location- Separate Corporate Entities- SeparateCorporate Entities- Separate Billing Service- SeparateBilling Service- Separate Chart Information & Location- SeparateChart Information & Location- Separate
cptcpt 8787
Incident to versus Incident to versus Independent ServiceIndependent Service
When Does Incident to Become When Does Incident to Become Independent ServiceIndependent Service Appearance of No SupervisionAppearance of No Supervision Clinical Decisions are Made by StaffClinical Decisions are Made by Staff Ratio of Physician to Staff Time Ratio of Physician to Staff Time
Becomes DisproportionateBecomes Disproportionate Distance DifficultiesDistance Difficulties Supervision DifficultiesSupervision Difficulties
cptcpt 8888
Difficulties with Incident toDifficulties with Incident to
The Physician Must Evaluate The Physician Must Evaluate and/or Treat the Patient Firstand/or Treat the Patient First
No Clear Guidelines Regarding No Clear Guidelines Regarding Reasonable Mix of Physician to Reasonable Mix of Physician to Extender?Extender?
What are the Limits of the What are the Limits of the Extender?Extender?
cptcpt 8989
Difference Between Difference Between Supervision and “Incident to”Supervision and “Incident to”
SupervisionSupervision Applies to whether Applies to whether
and how a and how a “physician” oversees “physician” oversees the work of ancillary the work of ancillary personnelpersonnel
A A clinicalclinical concept concept Can occur at any Can occur at any
level of supervision level of supervision (from general to (from general to personal)personal)
““Incident to”Incident to” Applies when billing Applies when billing
for services for services supervised by a supervised by a “physician”“physician”
An An economiceconomic concept concept Can only occur when Can only occur when
supervision is “direct” supervision is “direct” (i.e., in the same office (i.e., in the same office suite)suite)
Note: no “incident to” Note: no “incident to” in inpatient settings in inpatient settings for Medicarefor Medicare
cptcpt 9090
The Future of Incident to vs. The Future of Incident to vs. SupervisionSupervision
Incident toIncident to InterventionIntervention
Technical Interventions such as biofeedback and Technical Interventions such as biofeedback and cognitive rehabilitationcognitive rehabilitation
TestingTesting None , if technical codes acceptedNone , if technical codes accepted If not, presumably it can continueIf not, presumably it can continue
SupervisionSupervision Regardless, some form of supervision required Regardless, some form of supervision required
if a technician is usedif a technician is used
cptcpt 9191
Problem: Defining a Problem: Defining a TechnicianTechnician
What is the Minimum Level of What is the Minimum Level of Training Required for a Technician?Training Required for a Technician? National Association of PsychometristsNational Association of Psychometrists NAN Position PaperNAN Position Paper
Level of Education- Probably a minimum of Level of Education- Probably a minimum of BachelorsBachelors
Level of TrainingLevel of Training Level of SupervisionLevel of Supervision
cptcpt 9292
Defining a TechnicianDefining a Technician(Federal Register, Vol. 66, #149, page (Federal Register, Vol. 66, #149, page
40382)40382) RequirementRequirement
Employee (e.g., 1099); “employees, leased Employee (e.g., 1099); “employees, leased employees, or independent contractor”employees, or independent contractor”
Most common is independent contractorMost common is independent contractor ““We do not believe that the nature of the We do not believe that the nature of the
employment relationship is critical for purposes employment relationship is critical for purposes of payment to the services of physician…as of payment to the services of physician…as long as…(the personnel) is under the required long as…(the personnel) is under the required level of supervision.”level of supervision.”
Common PracticeCommon Practice Independent ContractorIndependent Contractor
cptcpt 9393
Defining a TechnicianDefining a Technician
HCFA/CMS Line 25HCFA/CMS Line 25 This is the line that identifies in a common This is the line that identifies in a common
insurance form who is the “qualified health insurance form who is the “qualified health provider” that is responsible for and completing provider” that is responsible for and completing the servicethe service
Anybody else, from high school to post-doctoral Anybody else, from high school to post-doctoral fellow, is, for all practical purposes, a technicianfellow, is, for all practical purposes, a technician
Extern, Intern, Postdoctoral Fellow, Extern, Intern, Postdoctoral Fellow, TechnicianTechnician
cptcpt 9494
Acceptance of TechniciansAcceptance of Technicians
MedicareMedicare Outside of North Central & California, yesOutside of North Central & California, yes Some states require specific modifiers Some states require specific modifiers
(e.g., North Carolina, use the “AH” (e.g., North Carolina, use the “AH” modifier)modifier)
Private CarriersPrivate Carriers Magellan, United Health… – yesMagellan, United Health… – yes Others (e.g., Value Options) – under Others (e.g., Value Options) – under
considerationconsideration
cptcpt 9595
Uses of TechniciansUses of Technicians
The Qualified Health Provider must;The Qualified Health Provider must; See the patient firstSee the patient first Supervise the activitySupervise the activity Interpret and write the note/reportInterpret and write the note/report Engaged in an ongoing capacityEngaged in an ongoing capacity
NOTE: Pattern similar to medical NOTE: Pattern similar to medical providersproviders
cptcpt 9696
Use of TechnicianUse of Technician
Technicians in a “Facility”Technicians in a “Facility” A “facility” in essentially an inpatient settingA “facility” in essentially an inpatient setting If a technician is an employee of a private If a technician is an employee of a private
provider but the service is provided in an provider but the service is provided in an inpatient setting, the inpatient fee would be inpatient setting, the inpatient fee would be usedused
If a technician is an employee of a a facility, If a technician is an employee of a a facility, there is some question as to whether they there is some question as to whether they could be supervised by a provider who is not could be supervised by a provider who is not an employee of the facilityan employee of the facility
cptcpt 9797
Use of TechniciansUse of Technicians
Practice Expense & Practice ImplicationsPractice Expense & Practice Implications Each tech code has .51 work valueEach tech code has .51 work value This means that the provider is engaged in the This means that the provider is engaged in the
workwork That engagement would include;That engagement would include;
Selection of testsSelection of tests Determination of testing protocolDetermination of testing protocol Supervision of testingSupervision of testing Interpretation of individual testsInterpretation of individual tests Reporting on individual testsReporting on individual tests
cptcpt 9898
PaymentPayment
MedicareMedicare Proposed 4.4% cut reversed 02.01.06Proposed 4.4% cut reversed 02.01.06 No changes from 2005 fee scheduleNo changes from 2005 fee schedule
Other CarriersOther Carriers Non-Equitable % of RVU paymentNon-Equitable % of RVU payment
cptcpt 9999
National Coverage PolicyNational Coverage Policy
Services That Are Not Reasonable Services That Are Not Reasonable and Necessary for the Diagnosing and Necessary for the Diagnosing and Treatment of an Illness or Injuryand Treatment of an Illness or Injury
Screening Services, in the Absence of Screening Services, in the Absence of Symptoms or History of Disease are Symptoms or History of Disease are DeniedDenied
cptcpt 100100
CMS Determination of CMS Determination of CoverageCoverage
Coverage TypesCoverage Types Coverage with Conditions (specific DX, facility or Coverage with Conditions (specific DX, facility or
provider)provider) Coverage without ConditionsCoverage without Conditions
Data ReviewedData Reviewed BenefitBenefit Risks Vs. BenefitsRisks Vs. Benefits Available Clinical StudiesAvailable Clinical Studies
DatabasesDatabases Longitudinal or cohort studiesLongitudinal or cohort studies Prospective studiesProspective studies Randomized clinical trialsRandomized clinical trials
cptcpt 101101
Billing ModelBilling Model
ComponentsComponents Procedure CompletedProcedure Completed Number of Units of that ProcedureNumber of Units of that Procedure Location or Site Where the Service was Location or Site Where the Service was
ProvidedProvided Date of ServiceDate of Service
CPT CPT XX # of Units # of Units X X Dx Dx XX Site of Site of Service Service XX Date Date
cptcpt 102102
Problem: Office of Inspector Problem: Office of Inspector General (2005 Orange Book)General (2005 Orange Book)
Identify Nursing Home Residents with Identify Nursing Home Residents with Serious Mental Illness (OEI-05-99-Serious Mental Illness (OEI-05-99-0070100701
Improve Assessments of Mental Improve Assessments of Mental Illness (OEI-05-99-00700)Illness (OEI-05-99-00700)
Eliminate Inappropriate Payments for Eliminate Inappropriate Payments for Mental Health ServicesMental Health Services
cptcpt 103103
Expenditures & FraudExpenditures & Fraud
ProjectionsProjections CurrentCurrent
14%14% By 2011;By 2011;
17% ($2.8 trillion)17% ($2.8 trillion)
cptcpt 104104
Fraud: Medicare’s Fraud: Medicare’s Interpretation of Physician Interpretation of Physician
LiabilityLiability Overpayment From Incorrect ChargeOverpayment From Incorrect Charge Mathematical or Clerical ErrorMathematical or Clerical Error Billing for Items Known Not to be Billing for Items Known Not to be
CoveredCovered Services Provided by Non-qualified Services Provided by Non-qualified
PractitionerPractitioner Inappropriate DocumentationInappropriate Documentation
cptcpt 105105
Defining FraudDefining Fraud
FraudFraud IntentionalIntentional PatternPattern
ErrorError ClericalClerical DatesDates
cptcpt 106106
Problem: Fraud & AbuseProblem: Fraud & Abuse
26 Different Kinds of Fraud Types26 Different Kinds of Fraud Types Psychology Only Professional Group Psychology Only Professional Group
Identified by OIG for Closer Scrutiny Identified by OIG for Closer Scrutiny in 2005-2006in 2005-2006
cptcpt 107107
Fraud & Office of Inspector Fraud & Office of Inspector GeneralGeneral
Primary ProblemsPrimary Problems Medical Necessity (approximately $5 billion)Medical Necessity (approximately $5 billion) DocumentationDocumentation
Psychotherapy Psychotherapy (oig.hhs/gov/reports/region5/50100068)(oig.hhs/gov/reports/region5/50100068) IndividualIndividual GroupGroup # of Hours# of Hours Who Does the TherapyWho Does the Therapy
Psychological TestingPsychological Testing # of Hours# of Hours DocumentationDocumentation
cptcpt 108108
Fraud: OIG’s May 2001 Fraud: OIG’s May 2001 StudyStudy
(OEI-03-99-00130)(OEI-03-99-00130) Overall Payments in 1998 = $1.2 billionOverall Payments in 1998 = $1.2 billion
(62% outpatient = $718 million)(62% outpatient = $718 million) Inappropriate Outpatient Mental HealthInappropriate Outpatient Mental Health ““Particularly Problematic” due to Particularly Problematic” due to
Medically unnecessaryMedically unnecessary Billed incorrectlyBilled incorrectly Rendered by unqualified providersRendered by unqualified providers Undocumented or poorly documentedUndocumented or poorly documented
cptcpt 109109
OIG Report (continued)OIG Report (continued)
Provider Not QualifiedProvider Not Qualified = 11%= 11% Medically Unnecessary Medically Unnecessary = =
23%23% Billed IncorrectlyBilled Incorrectly = 41%= 41% Insufficient DocumentationInsufficient Documentation = =
65%65%
cptcpt 110110
V. Future PerspectivesV. Future Perspectives: : 2003 Predictions2003 Predictions
ParadigmsParadigms Industrial vs. Boutique/NicheIndustrial vs. Boutique/Niche Clinical vs. ForensicClinical vs. Forensic Mental Health vs. HealthMental Health vs. Health Existing vs. Developing Existing vs. Developing
cptcpt 111111
2004 Predictions2004 Predictions
Federal Federal Technical – Health Electronic Records by 2008Technical – Health Electronic Records by 2008 Performance Based PaymentPerformance Based Payment
Traditionally = Fee for service providedTraditionally = Fee for service provided Anticipated = Fee for performance/results Anticipated = Fee for performance/results
obtainedobtained EconomicEconomic
Overall, PositiveOverall, Positive
cptcpt 112112
2004 (Continued)2004 (Continued)
Increased Probability of AuditsIncreased Probability of Audits Psychological and Neuropsychological Psychological and Neuropsychological
TestingTesting Individual PractitionersIndividual Practitioners Skilled Nursing FacilitiesSkilled Nursing Facilities In Institutions, supervision and “incident to”In Institutions, supervision and “incident to”
Primary Issues of ConcernPrimary Issues of Concern Medical NecessityMedical Necessity DocumentationDocumentation
cptcpt 113113
2004 (Continued)2004 (Continued)
ProfessionalProfessional Institutionally BasedInstitutionally Based
Limitations secondary to “incident to”Limitations secondary to “incident to” Difficulties in gaining access to GME fundsDifficulties in gaining access to GME funds
Practitioner BasedPractitioner Based Increase in auditsIncrease in audits Shifting in practice patterns Shifting in practice patterns
Practice Parameter BasedPractice Parameter Based Difficulties with battery-based approaches to diagnosticsDifficulties with battery-based approaches to diagnostics Expansion and alterations of reimbursement practicesExpansion and alterations of reimbursement practices Significant expansion of types of services and clients servedSignificant expansion of types of services and clients served
cptcpt 114114
20052005
MedicareMedicare 4.3-4.6% decrease over next 6 years (compared to 1.5% increase each 4.3-4.6% decrease over next 6 years (compared to 1.5% increase each
over the last 3 years; over the last 3 years; AAP AdvanceAAP Advance, Summer, 2005), Summer, 2005) InstitutionalInstitutional
Further defining of supervision & incident toFurther defining of supervision & incident to Significantly limited access to funds (e.g., GME)Significantly limited access to funds (e.g., GME)
IndividualIndividual Increased focus on business issuesIncreased focus on business issues Technician based practice will increaseTechnician based practice will increase Continued emphasizes on expanding non-health care services (e.g., Continued emphasizes on expanding non-health care services (e.g.,
forensic)forensic) PracticePractice
Diagnostic work will continue being emphasized (e.g.,fMRI)Diagnostic work will continue being emphasized (e.g.,fMRI) Pay-for-Performance or P4P (5-10% differences; Medicare Payment Pay-for-Performance or P4P (5-10% differences; Medicare Payment
Advisory Commission, 09.15.05)Advisory Commission, 09.15.05) WellPoint, WellChoice, HealthNet, MVP Health Care, Blue Cross of California WellPoint, WellChoice, HealthNet, MVP Health Care, Blue Cross of California
and 32 states (105 programs in mid 2005)and 32 states (105 programs in mid 2005)
cptcpt 115115
20052005
Issues to be AddressedIssues to be Addressed Information disseminationInformation dissemination
ColleaguesColleagues Third-party insurers/payorsThird-party insurers/payors
Potential mix of “old” and “new” testing codes for 2006Potential mix of “old” and “new” testing codes for 2006 Typical use of combination of codesTypical use of combination of codes Technician qualifications and trainingTechnician qualifications and training Use of computerized tests Vs. tests that are Use of computerized tests Vs. tests that are
computerized but interactivecomputerized but interactive Appropriate documentationAppropriate documentation
Technician identificationTechnician identification Time for testing and therapyTime for testing and therapy
cptcpt 116116
20062006
Early Portions of 2006 = Confusion in Use & Early Portions of 2006 = Confusion in Use & Reimbursement of CodesReimbursement of Codes The Use of TechniciansThe Use of Technicians Insurance Carriers Acceptance of CodesInsurance Carriers Acceptance of Codes Decreased Revenue Stream Decreased Revenue Stream
Middle Portions of 2006 = Increased Stabilization in Middle Portions of 2006 = Increased Stabilization in Use & Reimbursement of CodesUse & Reimbursement of Codes
Later Portion of 2006 = Potential Increase in Overall Later Portion of 2006 = Potential Increase in Overall Reimbursement Reimbursement
By 2007 = Likely and Stable Increase in By 2007 = Likely and Stable Increase in Reimbursement PatternsReimbursement Patterns
By 2010 = Addition of Performance to Work as a By 2010 = Addition of Performance to Work as a Factor for ReimbursementFactor for Reimbursement
cptcpt 117117
Beyond 2006Beyond 2006(CMS)(CMS)
Health Care Spending & GDPHealth Care Spending & GDP 1960 =1960 = 5.0% 5.0% 1970 =1970 = 7.0% 7.0% 1990 =1990 = 9.0%9.0% 2002 = 2002 = 15.4%15.4% 2004 = 2004 = 16.0%16.0% 2005 = 2005 = 16.2%16.2% 20010=20010= 18.0%18.0% 2015 =2015 = 20.0% ( or 4 trillion $) 20.0% ( or 4 trillion $) Final =Final = 33.3%33.3%
cptcpt 118118
What Does the American Public What Does the American Public Want?Want?
Life Expectancy #1Life Expectancy #1 Life Value = approximately $5 millionLife Value = approximately $5 million Expected Expenditure on Health Care= will Expected Expenditure on Health Care= will
finally settle at about 1/3 of earned incomefinally settle at about 1/3 of earned income To be Competitive, Industry and Business will To be Competitive, Industry and Business will
Shift Cost of Health Care to Consumers and the Shift Cost of Health Care to Consumers and the GovernmentGovernment
Government Will, In Turn, Cost Share with the Government Will, In Turn, Cost Share with the ConsumerConsumer
They Will, However, Set the Standard for Health They Will, However, Set the Standard for Health Care Care
cptcpt 119119
Mechanisms to Keep Mechanisms to Keep InformedInformed
APA Practice Website (www.apa.org)APA Practice Website (www.apa.org) NAN Website (NAN Website (www.nanonline.orgwww.nanonline.org))
Support these continuing efforts by Support these continuing efforts by joining, APA, 40 and NANjoining, APA, 40 and NAN
cptcpt 120120
V. ResourcesV. Resources
General Web SitesGeneral Web Sites www.apa.orgwww.apa.org www.nanonline.org/paiowww.nanonline.org/paio www.ncpsychology.orgwww.ncpsychology.org www.cms.orgwww.cms.org (medicare/medicaid) (medicare/medicaid) www.hhs.orgwww.hhs.org (health & human services) (health & human services) www.oig.hhs.govwww.oig.hhs.gov (inspector general) (inspector general) www.apa.org/practice/cptwww.apa.org/practice/cpt (apa’s cpt information) (apa’s cpt information) www.ahrq.gov (agency for healthcare research)www.ahrq.gov (agency for healthcare research) www.medpac.govwww.medpac.gov (medical payment advisory comm.) (medical payment advisory comm.) www.whitehouse.gov/fsbr/healthwww.whitehouse.gov/fsbr/health (statistics) (statistics) www.div40.orgwww.div40.org (clinical neuropsychology div of apa) (clinical neuropsychology div of apa) www.napnet.orgwww.napnet.org (national association of (national association of
psychometrists)psychometrists) www.access.gpo.govwww.access.gpo.gov (federal statutes and regulations) (federal statutes and regulations) www.healthcare.group.comwww.healthcare.group.com (staff salaries) (staff salaries)
cptcpt 121121
Resources Resources (continued)(continued)
Payment/CoveragePayment/Coverage www.myhealthscore.com/consumer/phyoutcptsearch.htmwww.myhealthscore.com/consumer/phyoutcptsearch.htm www.cms.hhs.gov/statistics/feeforservice/defailt.aspwww.cms.hhs.gov/statistics/feeforservice/defailt.asp (covered services) (covered services) www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=167www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=167 (non-covered) (non-covered) www.apa.org/pi/aging/lmrp/toolkit/homepage.htmlwww.apa.org/pi/aging/lmrp/toolkit/homepage.html (apa lmrp) (apa lmrp) www.cms.hhs.gov/providers/mr/lmrp/aspwww.cms.hhs.gov/providers/mr/lmrp/asp (medicare lmrp) (medicare lmrp) www.quickfacts.census.gov/qfdwww.quickfacts.census.gov/qfd (census x type of procedure data) (census x type of procedure data)
LMRP Reconsideration ProcessLMRP Reconsideration Process www.cms.gov/manuals/pm_trans/R28PIM.pdfwww.cms.gov/manuals/pm_trans/R28PIM.pdf
Compliance Web SitesCompliance Web Sites www.oig.hhs.gov (office of inspector general)www.oig.hhs.gov (office of inspector general) www.cms.hhs.gov/manualswww.cms.hhs.gov/manuals (medicare) (medicare) www.uscode.house.gov/usc.htmwww.uscode.house.gov/usc.htm (united states codes) (united states codes) www.apa.orgwww.apa.org (psychologists & hipaa) (psychologists & hipaa) www.cms.hhs.gov/hipaawww.cms.hhs.gov/hipaa. (hipaa). (hipaa) www.hcca-info.orgwww.hcca-info.org (health care compliance assoc.) (health care compliance assoc.)
cptcpt 122122
Resources Resources (continued)(continued)
ICDICD www.who.int/icd/vol1htm2003/fr-icd.htmwww.who.int/icd/vol1htm2003/fr-icd.htm (who) (who) www.cdc.gov/nchas/about/otheract/icd9/abticdwww.cdc.gov/nchas/about/otheract/icd9/abticd
9.htm9.htm (ccd) (ccd)
Coding Web SitesCoding Web Sites www.catalog.ama-assn.org/Catalog/cpt/cptwww.catalog.ama-assn.org/Catalog/cpt/cpt
_search.jsp_search.jsp (ama cpt) (ama cpt)
www.aapcnatl.orgwww.aapcnatl.org (academy of coders) (academy of coders) www.ntis.gov/product/correct-codingwww.ntis.gov/product/correct-coding
(coding edits)(coding edits)
cptcpt 123123
Contact InformationContact Information
WebsitesWebsites Univ = Univ = www.uncw.edu/people/puentewww.uncw.edu/people/puente Practice = Practice = www.clinicalneuropsychology.uswww.clinicalneuropsychology.us NAN = www.nanonline.org/paioNAN = www.nanonline.org/paio
E-mailE-mail University = pUniversity = puente@uncw.eduuente@uncw.edu Practice = puente@clinicalneuropsychology.usPractice = puente@clinicalneuropsychology.us
TelephoneTelephone University = 910.962.3812University = 910.962.3812 Practice = 910.509.9371Practice = 910.509.9371
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