recent changes in coding and related issues
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APA SLC 2005APA SLC 2005
Recent Changes in Coding and Recent Changes in Coding and Related Issues Related Issues
American Psychological AssociationAmerican Psychological Association State Leadership ConferenceState Leadership Conference
Washington, D.C.Washington, D.C. 03.06.0503.06.05
APA SLC 2005APA SLC 2005
OutlineOutline
Current Procedural TerminologyCurrent Procedural Terminology DocumentationDocumentation Defining TimeDefining Time Relative Value UnitsRelative Value Units Ongoing CPT DevelopmentsOngoing CPT Developments
APA SLC 2005APA SLC 2005
CPT: BackgroundCPT: Background
American Medical AssociationAmerican 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
CMSCMS AMA Under License with CMSAMA Under License with CMS CMS Now Provides Active Input into CPTCMS Now Provides Active Input into CPT
APA SLC 2005APA SLC 2005
CPT: Background/DirectionCPT: Background/Direction
Current System = CPT 5Current System = CPT 5 CategoriesCategories
I= Standard Coding for Professional I= Standard Coding for Professional ServicesServices
II = Performance MeasurementII = Performance Measurement III = Emerging TechnologyIII = Emerging Technology
APA SLC 2005APA SLC 2005
CPT: CompositionCPT: Composition
AMA House of DelegatesAMA House of Delegates 109 Medical Specialties109 Medical Specialties
HCPACHCPAC 11 Societies (e.g., APA)11 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
APA SLC 2005APA SLC 2005
What Is a CPT Code?What Is a CPT Code?
Professional Health Service Provided Professional Health Service Provided Across the Country at Multiple Across the Country at Multiple locationslocations
Many Physicians Perform ServicesMany Physicians Perform Services Clinical Efficacy is Established and Clinical Efficacy is Established and
Documented in Peer-Reviewed Documented in Peer-Reviewed LiteratureLiterature
APA SLC 2005APA SLC 2005
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 Separate SectionsSections = Five Separate Sections PsychiatryPsychiatry BiofeedbackBiofeedback Central Nervous AssessmentCentral Nervous Assessment Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Health & Behavior Assessment & ManagementHealth & Behavior Assessment & Management
APA SLC 2005APA SLC 2005
CPT: Development of a CodeCPT: Development of a Code
InitialInitial Health Care Advisory Committee (non-Health Care Advisory Committee (non-
MDs)MDs) PrimaryPrimary
CPT Work GroupCPT Work Group CPT PanelCPT Panel
Time FrameTime Frame 3-5 to over a decade3-5 to over a decade
APA SLC 2005APA SLC 2005
CPT: PsychiatryCPT: Psychiatry
SectionsSections Interview (90801) vs. Intervention (e.g., Interview (90801) vs. Intervention (e.g.,
908.06)908.06) 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
APA SLC 2005APA SLC 2005
CPT: CNS AssessmentCPT: CNS Assessment
InterviewInterview 9611596115
TestingTesting Psychological = 96100; 96110/11Psychological = 96100; 96110/11 Neuropsychological = 96117Neuropsychological = 96117 Aphasia = 96105Aphasia = 96105 Developmental = 96110/111Developmental = 96110/111
APA SLC 2005APA SLC 2005
CPT: Physical Medicine & CPT: Physical Medicine & RehabilitationRehabilitation
97770 now 9753297770 now 97532 Note: 15 minute incrementsNote: 15 minute increments
APA SLC 2005APA SLC 2005
CPT: Health & Behavior CPT: Health & Behavior Assessment & ManagementAssessment & Management
Purpose: Medical DiagnosisPurpose: Medical Diagnosis Time: 15 Minute IncrementsTime: 15 Minute Increments AssessmentAssessment InterventionIntervention
APA SLC 2005APA SLC 2005
Rationale: GeneralRationale: General
Acute or chronic (health) illness may not Acute or chronic (health) illness may not meet the criteria for a psychiatric meet the criteria for a psychiatric diagnosisdiagnosis
Avoids inappropriate labeling of a patient Avoids inappropriate labeling of a patient as having a mental health disorderas having a mental health disorder
Increases the accuracy of correct coding Increases the accuracy of correct coding of professional servicesof professional services
Increase range of servicesIncrease range of services
APA SLC 2005APA SLC 2005
Overview of CodesOverview of Codes
New SubsectionNew Subsection Six New CodesSix New Codes
AssessmentAssessment InterventionIntervention
Established Medical Illness or Established Medical Illness or DiagnosisDiagnosis
Focus on Biopsychosocial FactorsFocus on Biopsychosocial Factors
APA SLC 2005APA SLC 2005
Health & Behavior Health & Behavior Assessment CodesAssessment Codes
9615096150 Health and behavior assessment (e.g., health-Health and behavior assessment (e.g., health-
focused clinical interview, behavioral focused clinical interview, behavioral observations, psychophysiological monitoring, observations, psychophysiological monitoring, health-oriented questionnaires)health-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
APA SLC 2005APA SLC 2005
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 family (without the patient present; not being family (without the patient present; not being
reimbursed)reimbursed)
APA SLC 2005APA SLC 2005
CPT: Model SystemCPT: Model System
PsychiatricPsychiatric NeurologicalNeurological Non-Neurological MedicalNon-Neurological Medical AlternativesAlternatives
APA SLC 2005APA SLC 2005
CPT ModelCPT Model
Rationale for CPT Code:Rationale for CPT Code: Choose Code that Best Describes the Choose Code that Best Describes the
Service ProvidedService Provided Match the Interview with the Testing Match the Interview with the Testing
with the Intervention Codewith the Intervention Code Match All that With a DiagnosisMatch All that With a Diagnosis Goal = Uniformity and FluencyGoal = Uniformity and Fluency
APA SLC 2005APA SLC 2005
CPT: Psychiatric ModelCPT: Psychiatric Model(Children & Adult)(Children & Adult)
InterviewInterview 90801- adult90801- adult 90802- child90802- child
TestingTesting 96100- adult96100- adult 96110/11- child96110/11- child
InterventionIntervention e.g., 90806- adulte.g., 90806- adult e.g., 90820-childe.g., 90820-child
APA SLC 2005APA SLC 2005
CPT: Neurological ModelCPT: Neurological Model(Children & Adult)(Children & Adult)
InterviewInterview 9611596115
TestingTesting 9611796117
InterventionIntervention 9753297532
APA SLC 2005APA SLC 2005
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)
APA SLC 2005APA SLC 2005
Recent CPT ChangesRecent CPT Changes
Biofeedback (90911)Biofeedback (90911) Minor editorial changes in biofeedback Minor editorial changes in biofeedback
trainingtraining
APA SLC 2005APA SLC 2005
Recent CPT ChangesRecent CPT Changes
Developmental Testing CodesDevelopmental Testing Codes ApplicabilityApplicability
ChildrenChildren BackgroundBackground
Part of Central Nervous System family of codesPart of Central Nervous System family of codes Hence, no work value (& lower reimbursement rate)Hence, no work value (& lower reimbursement rate) Recently “re-surveyed” by pediatriciansRecently “re-surveyed” by pediatricians
Specific ChangesSpecific Changes 96110 96110
Continues to have no work valueContinues to have no work value Use for completion of forms (Connors; by parents)Use for completion of forms (Connors; by parents)
96111 96111 Has physician work value Has physician work value Assessment of child’s social, emotional, etc status (WJ)Assessment of child’s social, emotional, etc status (WJ)
APA SLC 2005APA SLC 2005
Recent CPT Changes :Recent CPT Changes :Health & Behavior Assessment Health & Behavior Assessment
CodesCodes Brief HistoryBrief History
Inter-divisional Health Care Committee (22, 38, 40, 54; Glueckauf)Inter-divisional Health Care Committee (22, 38, 40, 54; Glueckauf) Convened in 1995 by APA Practice Directorate (Phelps)Convened in 1995 by APA Practice Directorate (Phelps) DraftsDrafts
First Draft - September 11, 1998; Final Working Draft – July 1, 2000First Draft - September 11, 1998; Final Working Draft – July 1, 2000 PresentationsPresentations
First Presentation to AMA November 6, 1998 ; Final Presentation – August 8, First Presentation to AMA November 6, 1998 ; Final Presentation – August 8, 20002000
7 total presentations- Ft. Lauderdale, Chicago, Denver, San Francisco, 7 total presentations- Ft. Lauderdale, Chicago, Denver, San Francisco, Washington, DC, Chicago, ChicagoWashington, DC, Chicago, Chicago
SurveysSurveys First Survey January 31, 2001; Final Survey April 26, 2001First Survey January 31, 2001; Final Survey April 26, 2001
Revisions to LanguageRevisions to Language First Preamble revision – March, 2002; Last Preamble revision – November, First Preamble revision – March, 2002; Last Preamble revision – November,
20042004 ApplicabilityApplicability
When behavioral, cognitive, emotional, and/or psychological techniques When behavioral, cognitive, emotional, and/or psychological techniques are used to assess and/or treat health (medical not psychiatric) are used to assess and/or treat health (medical not psychiatric) problemsproblems
APA SLC 2005APA SLC 2005
Recent CPT Changes:Recent CPT Changes:Health & Behavior Assessment Health & Behavior Assessment
CodesCodes AcceptabilityAcceptability
All Medicare carriers (minus Florida’s)All Medicare carriers (minus Florida’s) Some Medicaid programs (e.g., Colorado, Vermont)Some Medicaid programs (e.g., Colorado, Vermont) Some private insurers (BC/BS in NC, DC; Nationwide) Some private insurers (BC/BS in NC, DC; Nationwide)
ChangesChanges PreamblePreamble ClarificationClarification
Not a preventive medicine codeNot a preventive medicine code Patient can have a history or presence of mental illnessPatient can have a history or presence of mental illness
Future ExpectationFuture Expectation No further changesNo further changes Increased carrier acceptance, especially if providers educate carriersIncreased carrier acceptance, especially if providers educate carriers
Final Verification AnticipatedFinal Verification Anticipated December 1, 2004December 1, 2004 Applicability starting January 1, 2005Applicability starting January 1, 2005
APA SLC 2005APA SLC 2005
Develiping CPT Changes:Develiping CPT Changes:CNS Assessment CodesCNS Assessment Codes
Neurobehavioral Status ExamNeurobehavioral Status Exam Re-write (different language; same concept)Re-write (different language; same concept) Addition of “Physician” Work ValueAddition of “Physician” Work Value
Psychological TestingPsychological Testing Expansion of existing codeExpansion of existing code Addition of “Physician” Work ValueAddition of “Physician” Work Value
Neuropsychological TestingNeuropsychological Testing Expansion of existing codeExpansion of existing code Addition of “Physician” Work ValueAddition of “Physician” Work Value
APA SLC 2005APA SLC 2005
Probable CPT Changes:Probable CPT Changes:CNS Assessment CodesCNS Assessment Codes
Net EffectNet Effect Avoidance of Continuation of Reimbursement Strictly Avoidance of Continuation of Reimbursement Strictly
Based on Practice Expense Based on Practice Expense Potential catastrophe in terms of reimbursementPotential catastrophe in terms of reimbursement Potential reimbursement rates in the vicinity of $40/hrPotential reimbursement rates in the vicinity of $40/hr
Greater Clarity of Professional and Non-Professional Greater Clarity of Professional and Non-Professional ActivitiesActivities
Differentiation of professional, technical and computer Differentiation of professional, technical and computer activityactivity
Accounting/auditing, research, and salary purposesAccounting/auditing, research, and salary purposes Recognition of “Physician” WorkRecognition of “Physician” Work
Ending a 10 year struggleEnding a 10 year struggle Possibly, Increased ReimbursementPossibly, Increased Reimbursement
APA SLC 2005APA SLC 2005
ProPro2828bable CPT Changes:bable CPT Changes:CNS Assessment CodesCNS Assessment Codes
Timetable (activity x date)Timetable (activity x date) 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 Submission of CPT Codes to AMA RUC Committee
immediately thereafterimmediately thereafter Review by AMA RUC Research Subcommittee in January, Review by AMA RUC Research Subcommittee in January,
20052005 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 Hopeful inclusion in the 2006 Physician Fee Schedule for Hopeful inclusion in the 2006 Physician Fee Schedule for
January 1, 2006January 1, 2006
APA SLC 2005APA SLC 2005
CPT X ReportCPT X Report
Each CPT Code Should Generate a Each CPT Code Should Generate a Separate ReportSeparate Report
Alternative Clearly Label/Title Alternative Clearly Label/Title Sections of the Report to Match Sections of the Report to Match Codes UsedCodes Used
APA SLC 2005APA SLC 2005
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
APA SLC 2005APA SLC 2005
TimeTime
DefiningDefining Professional (not patient) Time Professional (not patient) Time
Including:Including: pre, intra & post-clinical service activitiespre, intra & post-clinical service activities
Interview & Assessment CodesInterview & Assessment Codes Use 15 minute incrementsUse 15 minute increments
Intervention CodesIntervention Codes Use 15 minute incrementsUse 15 minute increments
APA SLC 2005APA SLC 2005
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.
APA SLC 2005APA SLC 2005
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, forms, etc.Patient completing tests, 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.
APA SLC 2005APA SLC 2005
Relative Value Units: OverviewRelative Value Units: Overview
ComponentsComponents UnitsUnits ValuesValues Current ProblemsCurrent Problems
APA SLC 2005APA SLC 2005
RVU: ComponentsRVU: Components
Physician Work Resource ValuePhysician Work Resource Value Practice Expense Resource ValuePractice Expense Resource Value MalpracticeMalpractice GeographicGeographic Conversion Factor (approx. $34)Conversion Factor (approx. $34)
APA SLC 2005APA SLC 2005
RVU Components PercentagesRVU Components Percentages
Physician WorkPhysician Work == 52%52% Practice ExpensePractice Expense == 44%44% LiabilityLiability = 4%= 4%
APA SLC 2005APA SLC 2005
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
APA SLC 2005APA SLC 2005
Estimate of Psychologists’ Estimate of Psychologists’ ValueValue
AudiologistAudiologist .52.52 DieticianDietician .43.43 RNRN .42.42 Speech PathologistSpeech Pathologist .55.55
PsychologistPsychologist .82.82
APA SLC 2005APA SLC 2005
Defining Practice ExpenseDefining Practice Expense
Medical SuppliesMedical Supplies Expendable medical equipment (e.g., Expendable medical equipment (e.g.,
forms)forms) Medical EquipmentMedical Equipment
Durable medical equipment (e.g., tests)Durable medical equipment (e.g., tests) Professional Support StaffProfessional Support Staff
e.g., timee.g., time
APA SLC 2005APA SLC 2005
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)
APA SLC 2005APA SLC 2005
RVU: AcceptanceRVU: Acceptance
Medicare (100% since 01.01.92)Medicare (100% since 01.01.92) Medicaid 100%Medicaid 100% Private Payors 74%Private Payors 74%
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
APA SLC 2005APA SLC 2005
CPT x RVUCPT x RVUCPTCode
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
APA SLC 2005APA SLC 2005
Medicare RatesMedicare Rates
TypeType DeductibleDeductible Co-Co-PaymentPayment
Part APart A $912$912 0-$456 (days)0-$456 (days)
Part BPart B $110$110 Health – 20%Health – 20%
Psych- 50%Psych- 50%
Note: Premiums are $78.20/monthNote: Premiums are $78.20/month
APA SLC 2005APA SLC 2005
Problem:SupervisionProblem:Supervision
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
APA SLC 2005APA SLC 2005
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
APA SLC 2005APA SLC 2005
Problem: Incident toProblem: Incident to Rationale for Incident toRationale for Incident to
Congress intended to provide coverage for services Congress intended to provide coverage for services not typically covered elsewherenot 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
Why No Incident to (DRG)Why No Incident to (DRG) Solution Available for Some Training ProgramsSolution Available for Some Training Programs Probably no Future to Incident toProbably no Future to Incident to
APA SLC 2005APA SLC 2005
Problem: More Incident toProblem: More Incident to
When is “Incident to” Acceptable:When is “Incident to” Acceptable: Testing Testing Cognitive Rehabilitation; BiofeedbackCognitive Rehabilitation; Biofeedback PsychotherapyPsychotherapy
DefinitionDefinition Commonly furnished serviceCommonly furnished service Integral, though incidental to psychologistIntegral, though incidental to psychologist Performed under the supervisionPerformed under the supervision Either furnished without charge or as part of Either furnished without charge or as part of
the psychologist’s chargethe psychologist’s charge
APA SLC 2005APA SLC 2005
Difference Between Difference Between Supervision and “Incident to”Supervision and “Incident to”
SupervisionSupervision Applies to whether and Applies to whether and
how a “physician” how a “physician” oversees the work of oversees the work of ancillary personnelancillary personnel
A A clinicalclinical concept concept Can occur at any level Can occur at any level
of supervision (from of supervision (from general to personal)general to personal)
““Incident to”Incident to” Applies when billing for Applies when billing for
services supervised by services supervised by a “physician”a “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” in Note: no “incident to” in inpatient settings for inpatient settings for MedicareMedicare
APA SLC 2005APA SLC 2005
Problem: Face-to-FaceProblem: Face-to-Face
ImplicationsImplications Technical versus Professional Technical versus Professional
ServicesServices Surgery is the Foundation for CPT Surgery is the Foundation for CPT
(and most work is face-to-face)(and most work is face-to-face) Hard to Document & Trace Non-Face-Hard to Document & Trace Non-Face-
to-Face Workto-Face Work
APA SLC 2005APA SLC 2005
Problem: Work ValueProblem: Work Value
Physician Activities (e.g., Physician Activities (e.g., Psychotherapy) Result in Work ValuesPsychotherapy) Result in Work Values
Psychological Based Activities (i.e., Psychological Based Activities (i.e., Testing) Have Testing) Have nono Work Values Work Values
RVUs are Heavily Based on Practice RVUs are Heavily Based on Practice Expenses (which are being reduced)Expenses (which are being reduced)
Net Result = Maybe Up to a Half LowerNet Result = Maybe Up to a Half Lower
APA SLC 2005APA SLC 2005
Problem:Problem:An Artificial Practice An Artificial Practice
ExpenseExpense Five Year ReviewsFive Year Reviews Prior MethodologyPrior Methodology Current MethodologyCurrent Methodology Current Value = approximately 1.5 of 1.75 Current Value = approximately 1.5 of 1.75
is practice expenseis practice expense Deadline for New Practice Expense = 11.04Deadline for New Practice Expense = 11.04
New numbers recently submittedNew numbers recently submitted Expected Value = closer to 50% of total Expected Value = closer to 50% of total
value value at bestat best
APA SLC 2005APA SLC 2005
Continued Expansion of AuditsContinued Expansion of Audits(Office of Inspector General; Red Book)(Office of Inspector General; Red Book)
Increase from Last YearIncrease from Last Year Requested records 124, 379 timesRequested records 124, 379 times Increase activity has resulted in outsourcing of auditing Increase activity has resulted in outsourcing of auditing
servicesservices Major Applicable Areas Major Applicable Areas
Psychological and Neuropsychological TestingPsychological and Neuropsychological Testing 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
APA SLC 2005APA SLC 2005
Resources Resources (continued)(continued)
LMRP Reconsideration ProcessLMRP Reconsideration Process www.cms.gov/manuals/pm_trans/R28PIM.pdfwww.cms.gov/manuals/pm_trans/R28PIM.pdf
Coding Web SitesCoding Web Sites 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)
Compliance Web SitesCompliance Web Sites 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.)
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