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cptcpt 11
Making a Living in Professional Making a Living in Professional Psychology:Psychology:
Coding, Billing and Documenting Coding, Billing and Documenting Psychological ServicesPsychological Services
Antonio E. PuenteAntonio E. PuenteUniversity of North Carolina WilmingtonUniversity of North Carolina Wilmington
Florida Institute of TechnologyFlorida Institute of TechnologyApril 14, 2006April 14, 2006
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) Division of Clinical Neuropsychology- APADivision of Clinical Neuropsychology- APA Center for Medicare & Medicaid Services Medical Policy Staff- Center for Medicare & Medicaid Services Medical Policy Staff-
MedicareMedicare Inter-Divisional Health Care Committee- APAInter-Divisional Health Care Committee- APA Department of Psychology, UNC-WilmingtonDepartment of Psychology, UNC-Wilmington
Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted Peck; AEP Research Team and Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted Peck; AEP Research Team and Clinical Staff)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 2002-2004 = $10,000 per year – one course for two semesters
teaching reductionteaching reduction 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, plus incidental support such as copying, telephone calls, and secretarial and work-study student assistanceand secretarial 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 Workof CPT Work Goal (20 year plan)Goal (20 year plan)
Parity with PhysiciansParity with Physicians Expansion of Scope of ServicesExpansion of Scope of Services
Outcome (presently)Outcome (presently) 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 Potential impact on certain practice patternsPotential impact on certain practice patterns
cptcpt 66
Primary Goals of PresentationPrimary Goals of Presentation
Understand the Role of Medicare in Setting Understand the Role of Medicare in Setting Standards for PsychologyStandards for Psychology
Understand the AMA Current Procedural Terminology Understand the AMA Current Procedural Terminology (CPT) for Coding of Professional Services(CPT) for Coding of Professional Services
Introduce the New Testing and Interview CodesIntroduce the New Testing and Interview Codes Suggest a Model System for Coding Suggest a Model System for Coding Explain the Concept of Medical NecessityExplain the Concept of Medical Necessity Provide Suggestions for DocumentationProvide Suggestions for Documentation Define TimeDefine Time Explain Reimbursement PracticesExplain Reimbursement Practices Address Supervision and Incident toAddress Supervision and Incident to Explain the Concept of Fraud Versus ErrorsExplain the Concept of Fraud Versus Errors Address Current and Potential Problems Address Current and Potential Problems Provide Trajectory for 2006 and BeyondProvide Trajectory for 2006 and Beyond
cptcpt 77
Outline of PresentationOutline of Presentation
Part I: Coding, Billing and Part I: Coding, Billing and Documentation Documentation (Introductory)(Introductory)
Part II: Specific Issues with CPT Part II: Specific Issues with CPT (Intermediate)(Intermediate)
Part III: Projections; Questions & Part III: Projections; Questions & Answers Answers (Advanced)(Advanced)
cptcpt 88
Part I: Coding, Billing & Part I: Coding, Billing & DocumentationDocumentation(Introductory)(Introductory)
Part I:Part I: MedicareMedicare Current Procedural TerminologyCurrent Procedural Terminology DiagnosingDiagnosing Medical NecessityMedical Necessity Documentation Documentation TimeTime Site of Service Site of Service
cptcpt 99
A. Medicare: Why?A. 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 1010
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 1111
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
Eventually, a national (US) health Eventually, a national (US) health insurance will be establishedinsurance 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 1212
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) Part D (Pharmaceutical)Part D (Pharmaceutical)
cptcpt 1313
Medicare: Local ReviewMedicare: Local Review
Medical Review Policy Medical Review Policy National Policy Sets Overall ModelNational Policy Sets Overall Model Local Coverage Determination (LCD) Sets Local Coverage Determination (LCD) Sets
Local/Regional Policy-Local/Regional Policy- More restrictive than national policyMore restrictive than national policy Over-rides national policyOver-rides national policy Changes frequently without warning or publicityChanges frequently without warning or publicity Information best found on respective web pagesInformation best found on respective web pages
cptcpt 1414
B. Current Procedural B. 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
cptcpt 1515
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 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
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 to Describe Conjunction with CMS to Describe Professional Services Professional Services
Each Code has a Specific Number and Each Code has a Specific Number and Description as well as a Reimbursable ValueDescription as well as a Reimbursable Value
Professional Health Service Provided Across Professional Health Service Provided Across the Country at Multiple Locationsthe 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 1818
CPT: Applicable CodesCPT: Applicable Codes
Total Possible Codes = Approximately 7,500Total Possible Codes = Approximately 7,500 Possible Codes for Psychology = Possible Codes for Psychology =
Approximately 40 to 60Approximately 40 to 60 Sections = Five Primary Separate SectionsSections = Five Primary Separate Sections
Psychiatry (e.g., mental health)Psychiatry (e.g., mental health) BiofeedbackBiofeedback Central Nervous System Assessment (testing)Central Nervous System Assessment (testing) Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Health & Behavior Assessment & Management Health & Behavior Assessment & Management
(h.p.)(h.p.) Evaluation and Management Evaluation and Management
cptcpt 1919
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 2020
CPT: PsychiatryCPT: Psychiatry
Sections (or Categories)Sections (or Categories) Interview (Interview (9080190801) vs. Intervention (e.g., ) vs. Intervention (e.g., 9080690806)) 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 2121
Psychiatric CodesPsychiatric Codes
InterviewingInterviewing 9080190801 One time per illness incident or boutOne time per illness incident or bout UntimedUntimed Comprehensive analysis of records, Comprehensive analysis of records,
observations as well as structured observations as well as structured and/or unstructured clinical interviewand/or unstructured clinical interview
cptcpt 2222
Psychiatric CodesPsychiatric Codes
TherapyTherapy 20 minutes = 9080420 minutes = 90804 45-50 minutes = 9080645-50 minutes = 90806 80-90 minutes = 9080880-90 minutes = 90808
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 April, 2006CPT Assistant article April, 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, both time, both face-to-face time with the patient and face-to-face time with the patient and time interpreting test results and time interpreting test results and preparing the report)preparing the report)(note: “psychologist’s or physician’s” will (note: “psychologist’s or physician’s” will probably be changed to “qualified health probably be changed to “qualified health professional”)professional”)
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 and Clinical assessment of thinking, reasoning and
judgment ( e.g., acquired knowledge, judgment ( e.g., acquired knowledge, attention, language, memory, planning and attention, language, memory, planning and problem solving, and visual-spatial abilities) problem solving, and visual-spatial abilities) per hour of per hour of psychologist’s or physician’spsychologist’s or physician’s time, both face-to-face time with the patient time, 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
(note: “psychologist’s or physician’s” will (note: “psychologist’s or physician’s” will probably be changed to “qualified health probably be changed to “qualified health professional”)professional”)
cptcpt 2929
Neuropsychological Testing-Neuropsychological Testing-By ProfessionalBy Professional
9611896118 - Neuropsychological testing - Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological, (e.g., Halstead-Reitan Neuropsychological,
WMS, Wisconsin Card Sorting) per hour of the WMS, Wisconsin Card Sorting) per hour of the psychologist’s or physician’spsychologist’s or physician’s time, both time, both face-to-face time with the patient and time face-to-face time with the patient and time interpreting test results and preparing the interpreting test results and preparing the reportreport
(note: “psychologist’s or physician’s” will (note: “psychologist’s or physician’s” will probably be changed to “qualified health probably be changed to “qualified health professional”)professional”)
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 Neurobehavioral Status with Neuropsychological TestingTesting 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
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 3737
H & B: RationaleH & B: Rationale
Acute or Chronic Health IllnessAcute or Chronic Health Illness Not Applicable to Psychiatric IllnessNot Applicable to Psychiatric Illness However, Both Could be Treated However, Both Could be Treated
Simultaneously But Not Within the Simultaneously But Not Within the Same SessionSame Session
cptcpt 3838
H & B: Examples of ServiceH & B: Examples of Service
Symptom Management & ExpressionSymptom Management & Expression Patient Adherence to Medical Patient Adherence to Medical
TreatmentTreatment Health Promoting BehaviorsHealth Promoting Behaviors Overall Adjustment to Medical IllnessOverall Adjustment to Medical Illness
cptcpt 3939
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 4040
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 4141
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 4242
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)
9615596155 (limited acceptability)(limited acceptability) family (without the patient present; not being family (without the patient present; not being
reimbursedreimbursed))
cptcpt 4343
H & B: Intervention H & B: Intervention ExplanationExplanation
Modification of Psychological, Behavioral, Modification of Psychological, Behavioral, Emotional, Cognitive and/or Social Emotional, Cognitive and/or Social FactorsFactors
Affecting Physiological Functioning, Affecting Physiological Functioning, Disease Status, Health and/or Well-BeingDisease Status, Health and/or Well-Being
Focus = Improvement of Health with Focus = Improvement of Health with Cognitive, Behavioral, Social and/or Cognitive, Behavioral, Social and/or Psychophysiological ProceduresPsychophysiological Procedures
cptcpt 4444
H & B: Intervention H & B: Intervention ExamplesExamples
CognitiveCognitive BehavioralBehavioral Social Social PsychophysiologicalPsychophysiological
cptcpt 4545
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 4646
CPT: Model SystemCPT: Model System
PsychiatricPsychiatric NeurologicalNeurological Non-Neurological MedicalNon-Neurological Medical
cptcpt 4747
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 4848
CPT: Psychiatric ModelCPT: Psychiatric Model(Children & Adult)(Children & Adult)
InterviewInterview 9080190801- adult- adult 9080290802- child- child
TestingTesting 96101-0396101-03 Also, Also, 9611196111 for childrenfor children
InterventionIntervention e.g., e.g., 9080690806- adult- adult e.g., e.g., 9082090820-child-child
cptcpt 4949
CPT: Neurological ModelCPT: Neurological Model(Children & Adult)(Children & Adult)
InterviewInterview 9611696116
TestingTesting 96118/19/2096118/19/20
InterventionIntervention 9753297532
cptcpt 5050
CPT: Non-Neurological CPT: Non-Neurological Medical ModelMedical Model
(Children & Adult)(Children & Adult)
Interview & AssessmentInterview & Assessment 96150 96150 (initial)(initial) 9615196151 (re-evaluation) (re-evaluation)
InterventionIntervention 9615296152 (individual) (individual) 9615396153 (group) (group) 9615496154 (family with patient) (family with patient)
cptcpt 5151
C. CPT: DiagnosingC. CPT: 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 5252
D. CPT: Medical NecessityD. CPT: Medical Necessity
Scientific & Clinical NecessityScientific & Clinical Necessity Local Medical Review or Carrier Definitions of Local Medical Review or Carrier Definitions of
NecessityNecessity Necessity = CPT x DX formularyNecessity = CPT x DX formulary Necessity Dictates Type and Level of ServiceNecessity Dictates Type and Level of Service Necessity Can Only be Proven with Necessity Can Only be Proven with
DocumentationDocumentation Screening or Regularly Scheduled Evaluations Screening or Regularly Scheduled Evaluations
Do Not Meet Criteria for NecessityDo Not Meet Criteria for Necessity Will Results Affect Outcome of Patient?Will Results Affect Outcome of Patient? Will New Information Be Obtained as a Will New Information Be Obtained as a
Function of the Activity?Function of the Activity?
cptcpt 5353
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 5454
E. CPT: DocumentingE. CPT: Documenting
PurposePurpose Payer RequirementsPayer Requirements General PrinciplesGeneral Principles HistoryHistory ExaminationExamination Decision MakingDecision Making
cptcpt 5555
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 5656
Documentation: General Documentation: General PrinciplesPrinciples
Rationale for ServiceRationale for Service Assessment, Progress, Impression, or Assessment, Progress, Impression, or
DiagnosisDiagnosis Plan for CarePlan for Care Date and Identity of ObserverDate and Identity of Observer AlsoAlso
LegibleLegible TimelyTimely ConfidentialConfidential
cptcpt 5757
Documentation: Basic Documentation: Basic Information Across CodesInformation Across Codes
DateDate Time, if applicableTime, if applicable Identity of Observer (technician ?)Identity of Observer (technician ?) Reason for ServiceReason for Service StatusStatus ProcedureProcedure Results/FindingResults/Finding Impression/DiagnosesImpression/Diagnoses DispositionDisposition Stand AloneStand Alone
cptcpt 5858
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 5959
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 6060
Documentation: HistoryDocumentation: History
PastPast Family Family SocialSocial Medical/PsychologicalMedical/Psychological
cptcpt 6161
Documentation: AssessmentDocumentation: Assessment
Reason for ServiceReason for Service Dates (amount of service time?)Dates (amount of service time?) Identity of Tester (technician)Identity of Tester (technician) Tests and Protocols (included editions)Tests and Protocols (included editions) Narrative of ResultsNarrative of Results ImpressionImpression DispositionDisposition
cptcpt 6262
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 6363
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 6464
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 6565
Documentation Suggestions Documentation Suggestions (continued)(continued)
Two Tiered System of Documentation Two Tiered System of Documentation (using HIPPA as Model)(using HIPPA as Model) Raw data = handwritten and not for Raw data = handwritten and not for
distribution psychotherapy notesdistribution psychotherapy notes Report = “typed” notes for more public Report = “typed” notes for more public
consumptionconsumption
cptcpt 6666
E. TimeE. Time
Time is Broadly Defined as What the Time is Broadly Defined as What the Professional DoesProfessional Does
For Intervention – Time is face-to-For Intervention – Time is face-to-faceface
For Assessment - Time could be For Assessment - Time could be either face-to-face or professional either face-to-face or professional timetime
cptcpt 6767
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 6868
Time: TestingTime: Testing
Quantifying TimeQuantifying Time Round up or down to nearest incrementRound up or down to nearest increment Actual time vs. Elapsed time?Actual time vs. Elapsed time?
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, etc.Literature searches, learning new techniques, etc.
cptcpt 6969
TimeTime((CPT AssistantCPT Assistant, 08.05, , 08.05, 1515, #8, pg. 12), #8, pg. 12)(www.cms.hhs.gov/providers/therapy)(www.cms.hhs.gov/providers/therapy)
For Timed Codes (in physical For Timed Codes (in physical medicine): The Beginning and Ending medicine): The Beginning and Ending Time Should be DocumentedTime Should be Documented
Time Should be Documented Along Time Should be Documented Along with the Treatment Descriptionwith the Treatment Description
cptcpt 7070
Time: Physical Medicine CodesTime: Physical Medicine Codes(effective 07.01.05)(effective 07.01.05)
Physical Medicine Codes are in 15’ Physical Medicine Codes are in 15’ IncrementsIncrements
Multiple Units Can Be Billed on a Date Multiple Units Can Be Billed on a Date of Service for Same or Different of Service for Same or Different ProceduresProcedures
““A substantial amount portion of 15 A substantial amount portion of 15 minutes must be spent in performing minutes must be spent in performing the pre, intra, and post-service work…”the pre, intra, and post-service work…”
cptcpt 7171
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 7272
Part II: Specific IssuesPart II: Specific Issueswith CPT (Intermediate)with CPT (Intermediate)
ReimbursementReimbursement Supervision & Incident to Supervision & Incident to TechniciansTechnicians TimeTime Coverage & PaymentCoverage & Payment Fraud & AbuseFraud & Abuse UPIN #UPIN #
cptcpt 7373
A. Reimbursement HistoryA. Reimbursement 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 7474
Relative Value Units: OverviewRelative Value Units: Overview
ComponentsComponents UnitsUnits ValuesValues Current ProblemsCurrent Problems
cptcpt 7575
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 7676
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 7777
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 7878
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 7979
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 8080
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 8181
2006 RVU Changes2006 RVU Changes((CPT AssistantCPT Assistant, January, 2006, , January, 2006, 1616, 1), 1)
283 RVU Changes Submitted283 RVU Changes Submitted Medicare Accepted 97%Medicare Accepted 97% Professional Liability to Change to Professional Liability to Change to
1.001.00 Geographic Index is Revised Every 3 Geographic Index is Revised Every 3
yrs.yrs.
cptcpt 8282
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 8383
National Work National Work RVU/Estimated $ 2006 RVU/Estimated $ 2006
ValuesValuesop=outpatient, ip=inpatient, est=estimate rvu = op=outpatient, ip=inpatient, est=estimate rvu =
workworkCode #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 8484
B. SupervisionB. Supervision( ( 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 as (and not “independent” psychologists as defined by Medicare)defined by Medicare)
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 8585
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 8686
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 8787
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 Limited Future to Incident to Due Probably Limited Future to Incident to Due to Inclusion of New Testing Codesto Inclusion of New Testing Codes
cptcpt 8888
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 8989
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 does not have a Psychotherapy – CMS does not have a
national policy prohibiting national policy prohibiting psychotherapy as a incident to but it has psychotherapy as a incident to but it has supported local carriers when they took supported local carriers when they took the position that psychotherapy should the position that psychotherapy should not be incident tonot be incident to
cptcpt 9090
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 9191
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 9292
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 ActivitiesExtender Activities
What are the Limits of the What are the Limits of the Extender?Extender?
cptcpt 9393
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 9494
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 9595
C. Defining a TechnicianC. Defining a Technician
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 9696
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 9797
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 9898
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 9999
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 100100
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 101101
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 102102
The Problem with TrainingThe Problem with Training
Medicare Will Pay When:Medicare Will Pay When: The physician provides the service aloneThe physician provides the service alone The physician provides the service in The physician provides the service in
conjunction with the medical studentconjunction with the medical student The physician is present in the same room The physician is present in the same room
when the student provides the servicewhen the student provides the service Possibility of Students as Incident toPossibility of Students as Incident to A Student/Extern/Intern/Postdoc, For All A Student/Extern/Intern/Postdoc, For All
Practical Purposes = a TechnicianPractical Purposes = a Technician
cptcpt 103103
Medicare Billing Medicare Billing SuggestionsSuggestions
When to BillWhen to Bill Overall = after documentation is in placeOverall = after documentation is in place Diagnostic ServicesDiagnostic Services
After the InterviewAfter the Interview After all testing is completed aAfter all testing is completed andnd a report has been a report has been
completedcompleted Billing should occur only once after testingBilling should occur only once after testing
Therapeutic ServicesTherapeutic Services Could occur after each sessionCould occur after each session Should occur at least by the end of the monthShould occur at least by the end of the month
cptcpt 104104
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 105105
E. Office of Inspector General E. Office of Inspector General (2005 Orange Book)(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 106106
Expenditures & FraudExpenditures & Fraud
ProjectionsProjections CurrentCurrent
14%14% By 2011;By 2011;
17% ($2.8 trillion)17% ($2.8 trillion)
cptcpt 107107
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 108108
Defining FraudDefining Fraud
FraudFraud IntentionalIntentional PatternPattern
ErrorError ClericalClerical DatesDates
cptcpt 109109
Problem: Fraud & AbuseProblem: Fraud & Abuse
26 Different Kinds of Fraud Types26 Different Kinds of Fraud Types Psychological Services Have Been Psychological Services Have Been
Identified as ProblematicIdentified as Problematic
cptcpt 110110
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 111111
Fraud (continued)Fraud (continued)
Nursing HomesNursing Homes Identification Identification Overuse of ServicesOveruse of Services
ChildrenChildren
cptcpt 112112
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 113113
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 114114
Fraud (cont.)Fraud (cont.)
Estimated Pattern of Fraud AnalysisEstimated Pattern of Fraud Analysis For-profit Medical CentersFor-profit Medical Centers For-profit Medical ClinicsFor-profit Medical Clinics Non-profit Medical CentersNon-profit Medical Centers Non-profit Medical ClinicsNon-profit Medical Clinics Nursing HomesNursing Homes Group PracticesGroup Practices Individual Practices Individual Practices Research Grants and, if applicable, Clinical TrialsResearch Grants and, if applicable, Clinical Trials
cptcpt 115115
Fraud: (can go back 10 Fraud: (can go back 10 years)years)
Initial Review (14 points of submitted Initial Review (14 points of submitted claims)claims) LegibilityLegibility CoverageCoverage Matching datesMatching dates SignatureSignature
Subsequent Review (occurs if over 5-6 Subsequent Review (occurs if over 5-6 items are failed in initial review)items are failed in initial review) Does the service affect a potential change in Does the service affect a potential change in
medical condition?medical condition?
cptcpt 116116
Fraud: CERT ProgramFraud: CERT Program(www.oig.hhs.gov)(www.oig.hhs.gov)
Comprehensive Error Rate Testing Comprehensive Error Rate Testing ProgramProgram NationalNational Contractor-specificContractor-specific Service-specificService-specific Reviews both denied and accepted claimsReviews both denied and accepted claims An initial written request is followed by 4 An initial written request is followed by 4
letters and 3 phone calls followed by an letters and 3 phone calls followed by an overpayment demand letter and interpreted as overpayment demand letter and interpreted as services non-renderedservices non-rendered
cptcpt 117117
Fraud: New InformationFraud: New Information
The Good Enough or Common Sense The Good Enough or Common Sense ApproachApproach
If Medicare Audit Occurs then an Increased If Medicare Audit Occurs then an Increased Likelihood of Medicaid AuditLikelihood of Medicaid Audit
Practice Situations That Increase Potential Practice Situations That Increase Potential Audits;Audits; Skilled Nursing FacilitiesSkilled Nursing Facilities Statistical OutliersStatistical Outliers TestingTesting
States with Increased Audit Activity;States with Increased Audit Activity; TX, CA, FL, PRTX, CA, FL, PR
cptcpt 118118
Fraud: 2006 Red BookFraud: 2006 Red Book
Section 1862(a)(1)(A) of the Social Section 1862(a)(1)(A) of the Social Security Practice Act requires all Security Practice Act requires all services to be reasonable and services to be reasonable and necessary for the diagnosis or necessary for the diagnosis or treatment of an illness or injury.treatment of an illness or injury.
Claim errors have exceed 34%Claim errors have exceed 34%
cptcpt 119119
Fraud: Red Book (continued)Fraud: Red Book (continued)
Problem AreasProblem Areas Acute Hospital outpatient Services ($224)Acute Hospital outpatient Services ($224) Partial Hospitalization ($180)Partial Hospitalization ($180) Psychiatric Hospital outpatient ($57)Psychiatric Hospital outpatient ($57) Nursing Home ($30)Nursing Home ($30) General Mental Health ($185)General Mental Health ($185)
Beneficiaries who are unable to benefit from Beneficiaries who are unable to benefit from psychotherapy servicespsychotherapy services
Note: in millions (total for 2005 - $676,000,000)Note: in millions (total for 2005 - $676,000,000)
cptcpt 120120
F. Unique Physician F. Unique Physician Identification Number (UPIN)Identification Number (UPIN)
HistoricalHistorical UPIN #UPIN # Box 17 a CMS (insurance) 1500 formBox 17 a CMS (insurance) 1500 form
PresentPresent National Provide Identification NumberNational Provide Identification Number
cptcpt 121121
National Provider IdentificationNational Provider IdentificationNumber Number (CMS memo, 45 CFR Part 16c)(CMS memo, 45 CFR Part 16c)
Basic InformationBasic Information 10 Position numeric & individual number10 Position numeric & individual number No specific information about providerNo specific information about provider Managed by CMS’s Provider SystemManaged by CMS’s Provider System
Dates of ImplementationDates of Implementation May 23, 2005 – ApplyMay 23, 2005 – Apply May 23, 2007 – Most entities will useMay 23, 2007 – Most entities will use May 23, 2008 – All entities will useMay 23, 2008 – All entities will use
ApplicabilityApplicability Federal plans – immediatelyFederal plans – immediately State plans – this yearState plans – this year Other health plans- as soon as feasibleOther health plans- as soon as feasible
cptcpt 122122
Part III: Part III: Summary, Trajectories, Summary, Trajectories,
Resources & Resources & Questions/AnswersQuestions/Answers
Summary of Present Problems Summary of Present Problems TrajectoriesTrajectories ResourcesResources Questions & AnswersQuestions & Answers
cptcpt 123123
A. Present ProblemsA. Present Problems
Commercial CarriersCommercial Carriers Medical vs. Mental Health vs. No CoverageMedical vs. Mental Health vs. No Coverage Upper limits on # of hours/evaluationUpper limits on # of hours/evaluation Limited test formulariesLimited test formularies Specific time per testSpecific time per test ““Phantom benefits”- carrier states a Phantom benefits”- carrier states a
service is covered but no authorization is service is covered but no authorization is possiblepossible
cptcpt 124124
Summary of Present Problems Summary of Present Problems with New Codes- Carrier-Basedwith New Codes- Carrier-Based
Code Acceptance-Code Acceptance- Use of new codes at allUse of new codes at all If 96101/96118 accepted, technical and computer codes not If 96101/96118 accepted, technical and computer codes not
being acceptedbeing accepted Overall interpretation of codes (EOBs are still out)Overall interpretation of codes (EOBs are still out)
Code Payment-Code Payment- Lower than expected RVU % by private carriersLower than expected RVU % by private carriers Medicare carriers not paying- too high of a value placed by Medicare carriers not paying- too high of a value placed by
AMA and CMSAMA and CMS Human error in interpreting code submission Human error in interpreting code submission
(manuals/software)(manuals/software) ““Congressional action pending”Congressional action pending”
TechniciansTechnicians Current and operational definitionCurrent and operational definition Acceptance by carriers & licensing boards (e.g., NY)Acceptance by carriers & licensing boards (e.g., NY)
cptcpt 125125
Summary of Present Problems Summary of Present Problems with New Codes- Provider-with New Codes- Provider-
BasedBased General Understanding & UsageGeneral Understanding & Usage Specific Code Usage-Specific Code Usage-
Mixing of psychiatric with neuropsychological Mixing of psychiatric with neuropsychological procedures as well as mixing of diagnostic codesprocedures as well as mixing of diagnostic codes
Time (estimates, rounding)Time (estimates, rounding) Professional having to see the patient at allProfessional having to see the patient at all Professional having to interpret and write the Professional having to interpret and write the
evaluationevaluation Misunderstanding of potential difference between Misunderstanding of potential difference between
computerized testing and computer code computerized testing and computer code (interactive computerized testing with tech or (interactive computerized testing with tech or professional is coded as such) and computerized professional is coded as such) and computerized testing (non-interactive is coded as a computer testing (non-interactive is coded as a computer code)code)
cptcpt 126126
Summary of Present Problems Summary of Present Problems with Codes- Provider-Based with Codes- Provider-Based
(continued)(continued) TechniciansTechnicians
Training programs (externs, interns and postdoctoral Training programs (externs, interns and postdoctoral fellows)fellows)
Essentially no difference between a bachelor’s level Essentially no difference between a bachelor’s level technician and a postdoctoral fellowtechnician and a postdoctoral fellow
Difference between training and providing professional Difference between training and providing professional servicesservices
““Limited” interpretation of scoring (away from the Limited” interpretation of scoring (away from the patient)patient)
Difference among psychometricians and psychometrists Difference among psychometricians and psychometrists as well as techniciansas well as technicians
Psychometricians = doctoral level scientist involved in Psychometricians = doctoral level scientist involved in testing issuetesting issue
Technicians = any provider that does not have a contract Technicians = any provider that does not have a contract with the insurance carrier with the insurance carrier
Psychometrists= typically a certified technician (e.g., NAP)Psychometrists= typically a certified technician (e.g., NAP)
cptcpt 127127
Summary of Present Problems Summary of Present Problems with Testing Codes- Potential with Testing Codes- Potential
ConcernsConcerns QualificationsQualifications
Who can perform neuropsychological services?Who can perform neuropsychological services? CMS/AMA delegates that restriction to states licensing CMS/AMA delegates that restriction to states licensing
boards and carriersboards and carriers TechniciansTechnicians
Could no acceptance of technical code = incident to?Could no acceptance of technical code = incident to? Understanding that scoring time is built in the code valueUnderstanding that scoring time is built in the code value One could score while the patient is being tested, easier One could score while the patient is being tested, easier
for adults than for children but information about the for adults than for children but information about the observation has to occurobservation has to occur
Tests Tests Time estimates (HMOs) for test administration & Time estimates (HMOs) for test administration &
interpretationinterpretation Documentation of start/stop timesDocumentation of start/stop times Listing of actual tests for documentationListing of actual tests for documentation Formulary (both in terms of tests as well as time allocated)Formulary (both in terms of tests as well as time allocated)
cptcpt 128128
Summary of Present Problems Summary of Present Problems with Testing Codes- Potential with Testing Codes- Potential
ConcernsConcerns DocumentationDocumentation
Inclusion of #s along with narratives in Inclusion of #s along with narratives in documentationdocumentation
Matching of documentation with carrier Matching of documentation with carrier requirementsrequirements
Inclusion of Actual TimeInclusion of Actual Time Inclusion of name of technicianInclusion of name of technician
Masters Level PractitionersMasters Level Practitioners Will they be viewed as “qualified health Will they be viewed as “qualified health
practitioners?practitioners?
cptcpt 129129
B. Future PerspectivesB. 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 130130
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 131131
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 132132
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 133133
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 134134
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 135135
20062006
Early Portions of 2006Early Portions of 2006 = Confusion in Use & = 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 2006Middle Portions of 2006 = Increased = Increased Stabilization in Use & Reimbursement of CodesStabilization in Use & Reimbursement of Codes
Later Portion of 2006Later Portion of 2006 = Potential Increase in = Potential Increase in Overall Reimbursement Overall Reimbursement
By 2007By 2007 = Likely and Stable Increase in = Likely and Stable Increase in Reimbursement PatternsReimbursement Patterns
By 2010By 2010 = Addition of Performance to Work as a = Addition of Performance to Work as a Factor for ReimbursementFactor for Reimbursement
cptcpt 136136
Pay for Performance (P4P)Pay for Performance (P4P)InitiativesInitiatives
PremisePremise Evidence-based guidelinesEvidence-based guidelines Outcome more than procedure basedOutcome more than procedure based
Initial ApplicationInitial Application Dartmouth, Duke & MichiganDartmouth, Duke & Michigan
Final ApplicationFinal Application 5-10 years5-10 years
cptcpt 137137
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% 2010=2010= 18.0%18.0% 2015 =2015 = 20.0% ( or 4 trillion $) 20.0% ( or 4 trillion $) Final =Final = 33.3%33.3%
cptcpt 138138
Beyond 2006:Beyond 2006: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 Shift Cost of Health Care to Consumers and the Governmentthe Government
Government (e.g., Medicare) Will, However, Government (e.g., Medicare) Will, However, Set the Standard for Health Care Set the Standard for Health Care
cptcpt 139139
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)) 40 Website (www.div40.org)40 Website (www.div40.org)
Support these continuing efforts by Support these continuing efforts by joining APA, NAN, Division 40, SPA as joining APA, NAN, Division 40, SPA as well as your state associationwell as your state association
cptcpt 140140
C. ResourcesC. 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 141141
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 142142
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 143143
ResourcesResources
Telephone NumbersTelephone Numbers APA Practice Directorate’s Government APA Practice Directorate’s Government
Relations Office; 202.336.5889Relations Office; 202.336.5889 AMA CPT Office; 800.621.8335AMA CPT Office; 800.621.8335 Medicare National Coverage Medicare National Coverage
Determinations;Determinations;
410.786.2281410.786.2281
cptcpt 144144
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 = [email protected]@uncw.edu Practice = [email protected] = [email protected]
TelephoneTelephone University = 910.962.3812University = 910.962.3812 Practice = 910.509.9371Practice = 910.509.9371