antonio e. puente department of psychology university of north carolina at wilmington 28403-3297
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Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of a 10 year of progress report
Antonio E. PuenteDepartment of PsychologyUniversity of North Carolina at Wilmington 28403-3297Tel 910.962.3812, Fax 910.962.7010, e-mail Puente@uncwil.edu; web “clinicalneuropsychology.com”
Massachusetts Neuropsychological SocietyBoston, MA, December 5, 2000
Outline of PresentationHistory/Background of InvolvementProcedural CodingReimbursementDocumentationAuditingRelated IssuesFuture Trends
Purpose of My Involvement with Coding & MedicareShort Term
ReimbursementLong Term
Why the Focus on Medicare Bring Some Standardization to the Field Expand the Scope and Value of Clinical
Neuropsychology Parity with Other Doctoral Level Health Providers
in Health Care Shape Psychology Towards a Biological Model
History/BackgroundNorth Carolina Psychological Association
Blue-Cross Blue ShieldAmerican Psychological Association
Chair or Member of Approx.a Dozen Committees/Boards, (e.g., Neuropsychology)
Division 40 Board- 1987 to present Two Terms on APA’s Council of
Representatives (1994 to present) Policy and Planning Board
History/Background (continued)American Medical Association
CPT- 4 CPT- 5
Health Care Financing Administration Model Mental Health Policy Workgroup Medicare Coverage Advisory Committee
Procedural CodingDefining CodingHistory of CodingCoding
Defining CodingDescription of Professional Service
RenderedPurpose of Coding
Archival/Research Reimbursement
Coding Systems SNOMED WHO / ICD AMA / CPT
History of CPT CodingFirst Developed in 1966Currently Using the 4th EditionThe 5th Edition Will be Used in 2002A Total of 7,500 CodesAMA Developed and Owns the CPTUnder Contract with the HCFA
Overview of CodingTotal Possible Codes = 60+# Of Typically Reimbursed Codes = 5
interview, testing, & psychotherapy# Of Codes Sometimes Reimbursed = 35
family/group therapy biofeedback
# Of Codes Rarely Reimbursed = 20+ evaluation and management report evaluation and writing
Overview of Coding: An evolution of codingPsychiatryNeurologyPhysical Medicine & Rehabilitation“Evaluation & Management”
Overview of Coding (cont.)Psychiatry
Interview (90801) Psychotherapy (90804 - 90857)
Types of Psychotherapy (regular vs interactive)# of “Patients” (individual vs group vs family)Locations of Intervention (in vs outpatient)Evaluation & Management vs RegularLength of Time (30, 60, 90)
BiofeedbackRegular vs Psychophysiological (90901 vs 90875)
Overview of Coding (cont.)Central Nervous System
Assessments/Test 96100 = Psychological Testing 96105 = Aphasia Testing 96110/1 = Developmental Testing 96115 = Neurobehavioral Status
Exam 96177 = Neuropsychological Testing
Overview of Coding (cont.)Physical Medicine
97770 = Cognitive Skills Development Look for New/split Codes in the Near
Future
Overview of Coding (cont.)Health & Behavior
909X1 assessment (15 minutes) 909X2 re-assessment 909X3 intervention- individual 909X4 intervention- group 909X5 intervention- family 909X6 intervention- family w/o pt. NOTE: these codes need to be valued...
Coding OverviewCoding Categories
Psychiatry Neurology; CNS/Assessment Physical Medicine “Evaluation & Management”
Procedures Assessment Intervention
Overview of Coding (cont.)Diagnosing
If Problem is Psychiatric = DSM If Problem is Neurological = ICD
Matching Dx with CPT DSM = 90801, 96100, 90806 ICD = 96115, 96117, 97770
ReimbursementHistoryDefining RBRVSFormulaDefining TimeDefining SiteDefining NecessityDefining and Applying “Incident to”
History of ReimbursementCost plus ReimbursementProspective Payment (PPS) &
Diagnostic Related Groups (DRGs)Customary. Prevailing, &
Reasonable(CPR)Resource Based Relative Value System
(RBRVS)Prospective Payment System
RBRVSMajor Components
Physician Work Resource Value Unit Practice Expense Resource Value Unit Malpractice Component Resource Value Unit
Conversion FactorAdoption of the RBRVS
Medicare Blue Cross/Blue Shield- 87% Managed Care- 55%
Reimbursement FormulaProcedural CodeTimeDiagnosisSite of ServiceProviderFormula
Code X Time X Dx X Site X Provider
Reimbursement DifficultiesPhysician Work ValuePhd/PsyD/EdD vs MDLocation Defined
Common Reasons for Lack of ReimbursementClerical ErrorsService Is Not CoveredNo Prior Authorization ObtainedExceeded Allocated Time LimitsInvalid or Incorrect Dx CodeCPT and Dx Do Not Match
Defining TimeDefining Time
Professional (not patient) ActivityInterview vs Assessment Codes
Hourly Increments Includes Pre and Post-clinical Service
Intervention Codes 15, 30, 60, & 90 Face-to-face Contact No Pre or Post-clinical Service Time Included
Testing Time DefinedPreparing to Test PatientReviewing of RecordsSelection of TestsScoring of TestsReviewing of ResultsInterpretation of ResultsPreparation and Report Writing
DocumentationPurposeGeneral GuidelinesSpecific DocumentationTrendsSuggestions
Purpose of DocumentationEvaluate and Plan for TreatmentCommunication and Continuity of
CareClaims Review and PaymentResearch and Education
General Principles of DocumentationComplete and LegibleReason/Rationale for the EncounterAssessment, Impression, or
Diagnosi/esPlan for CareDate and Identity of Observer
Documentation HistoryChief ComplaintHistory of Present Illness (HPI)Review of SystemsPast, Family, and/or Social History
Documentation of Chief ComplaintConcise Statement Describing the
Symptom, Problem, Condition, Diagnosis, Physician Recommended Return, or other Factor that is the Reason for the Encounter.
Documentation of Present IllnessChronological Description of the
Development of the Patient’s Present Illness from the First Sign and/or Symptom or from the Previous Encounter to the Present. For Symptoms: Location, Quality, Severity,
Duration, Timing, Context, Modifying Factors Including Medications, Associated Signs, Symptoms, etc.
For Follow up: Changes in Condition Since Last Visit, Compliance with Treatment, etc.
Review of SystemsPsychiatricNeurologicalOther
Documentation of HistoryPast HistoryFamily HistorySocial History
Specific Documentation Suggestions: Psychiatric Interview
Name, Date, Observer, Dx/Impression
Mental Status Exam Language, Thought Processes, Insight,
Judgment, Reliability, Reasoning, Perceptions, Suicidality, Violence, Mood & Affect, Orientation, Memory, Attention, Intelligence
Specific Documentation Suggestions: Neurobehavioral Status ExamName, Date, Observer,
Dx/ImpressionVariables
Attention, Memory, Visuo-Spatial, Lanague, Planning
Specific Documentation Suggestions: TestingName, Date, Observer,
Dx/ImpressionNames of TestsInterpretation of Tests ResultsDispositionTime
Documentation SuggestionsAvoid Handwritten NotesDo Not Use Red InkDocument on Every Encounter, Every
Procedure, and Every PatientRe-Cap Status, Whenever Possible, At
Least Change From Session to SessionDocument Soon After Procedure
TrendsIssues of ConfidentialityOver-DiagnosingOver-Documenting
AuditingFraud & Abuse vs ErroneousSelf-Auditing SuggestionsRisk SituationsDevelopment of an Internal Auditing
System
Fraud vs ErrorFraud = Intentional, Pattern
Erroneous = Clerical, etc.
Self-Auditing SuggestionsWritten PoliciesCompliance OfficerTraining & Education Lines of Communication Should ExistInternal Monitoring & AuditingEnforce Standards Alter as Necessary
Risk Areas for FraudCoding & BillingReasonable & Necessary ServicesDocumentationImproper Inducements
Fraudulent Claims FlagsUpcodingExcessive or Unnecessary Visits to ACFOutpatient Service 72 Hrs. Post-DischargeCPT Code Usage ShiftHigh Percentage of the Same CodesUse of Similar Time for Testing Across Pts.Medical Necessity (dx; interpretation)
Defining Necessity“reasonable and necessary for the
diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member”
All services must “stand alone”Acute and emergency services more
like to be considered necessary
Evaluating EffectivenessAdequacy of Evidence
Bias External Validity
Size of Effect From Not Effective to Breakthrough
Evaluating Effectiveness (continued)Organized Approaches to Evaluation
of Scientific Evidence American College of Physicians Agency for Health Care Policy and
Research BC/BS Technology Evaluation Center American College of Cardiology American College of Urology
Additional IssuesIncident to
in vs outpatient technical vs professional component performing vs billing
Graduate Medical Education allied health vs medical interns vs postdoctoral fellows
CPT I, II, & III I = standard codes II = performance measures III = emerging technology
Future TrendsSurveys; Practice, Ongoing & New CodesHealth Care Finance AdministrationCommittee for the Advance of
Professional Practice Practice Directorate of the APAGeneral TrendsFuture of Clinical NeuropsychologyResources
SurveysRationale for Surveys
All Decisions are Empirical Reasonably Large Ns Adequate Data
Support Required If Asked, Participate Two Ongoing;
NAN/Division 40 Practice SurveyRe-evaluation of “Cognitive Rehabilitation”
Health Care Financing AdministrationProblems
Definition of Physician (Social Security Practice Act of 1989)
Doctoral vs Non-Doctoral ProvidersDirections
Physician Work Value Practice Expense Matching of CPT with Reimbursement
Committee for the Advancement of Professional Practice
Observers Joe Fishburn (NAN), Ida Sue Baron (Div
40)Attitude
Division 40; NAN Gift Positive, Receptive Additional Staff Member for Medicare
Program
General TrendsFraud, Abuse, & Effects of RegulationsClinical Neuropsychology Standardizing &
Expanding Into Non-Traditional Areas“Boutique” vs “Industrial” Neuropsych.Psychometrics as Clinical
NeuropsychologyAssessment & Rehabilitation
Neuropsychology’s “Technical” PipelineEstablishment of “Grassroots Network”
Future of Clinical Neuropsychology: A Holiday Wish ListMore (normative?) Data & A Few TheoriesMeasurement of the Cultural & SubjectiveLess Focus on Conserving the Medicare
Trust Fund & Stockholder Profits by Focusing on the Aged & Disabled
Appreciating that Brain is Inside a Person Which is Inside a System (Value?)
Conscilience
ResourcesWeb Sites
neuropsych; NANonline.org, Div40.org government; HCFA.gov, NIH.gov personal; clinicalneuropsychology.com
Publications APA Medicare Handbook (PP; 2000) NAN Bulletin (1994, 1997, 1998, 2000) Journal of Psychopathology & Behavioral Assessment
(1987) Professional Psychology (with Camara & Nathan,
2000)
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