contact information

NCPA/DIPP 2006NCPA/DIPP 2006 11

Coding, Billing and Documenting Coding, Billing and Documenting Professional Psychological Services:Professional Psychological Services:With Special Emphasis on the 2006 With Special Emphasis on the 2006

Testing CodesTesting Codes

Antonio E. PuenteAntonio E. PuenteUniversity of North Carolina WilmingtonUniversity of North Carolina Wilmington

North Carolina Psychological AssociationNorth Carolina Psychological AssociationDivision of Professional PracticeDivision of Professional Practice

Chapel Hill, North Carolina 02.03.06Chapel Hill, North Carolina 02.03.06


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


DisclaimerDisclaimer

The information contained in this extended presentation The information contained in this extended presentation is not intended to reflect either NCPA, APA nor NAN is not intended to reflect either NCPA, APA nor NAN policy. Further, this presentation is intended to be policy. Further, this presentation is intended to be informative and not meant to imply that it supersedes informative and not meant to imply that it supersedes APA or state ethical guidelines and/or local, state or APA or state ethical guidelines and/or local, state or national regulations and/or laws. Further, LMRP and national regulations and/or laws. Further, LMRP and specific health care contracts may supersede the specific health care contracts may supersede the information presented. The information contained herein information presented. The information contained herein is meant to provide practitioners as well as health care is meant to provide practitioners as well as health care institutions (e.g., insurance companies) involved in institutions (e.g., insurance companies) involved in psychology with the latest information available psychology with the latest information available regarding the issues addressed. This is a living regarding the issues addressed. This is a living document that can and will be revised as additional document that can and will be revised as additional information becomes available. Suggestions or changes information becomes available. Suggestions or changes should be addressed to the author. Thank you…should be addressed to the author. Thank you…


AcknowledgmentsAcknowledgments North Carolina Psychological AssociationNorth Carolina Psychological Association Practice Directorate of the American Psychological Association (APA)Practice Directorate of the American Psychological Association (APA) American Medical Association (AMA) CPT StaffAmerican Medical Association (AMA) CPT Staff National Academy of Neuropsychology (NAN)National Academy of Neuropsychology (NAN) Department of Psychology, UNC-WilmingtonDepartment of Psychology, UNC-Wilmington

Division of Clinical Neuropsychology- APADivision of Clinical Neuropsychology- APA Center for Medicare & Medicaid ServicesMedical Policy Staff- MedicareCenter for Medicare & Medicaid ServicesMedical Policy Staff- Medicare Inter-Divisional Health Care Committee- APAInter-Divisional Health Care Committee- APA

Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted Peck; Research Team Selected Individuals (e.g., Jim Georgoulakis; Neil Pliskin, Ted Peck; Research Team and Clinical Staff)and Clinical Staff)


Specific Support Provided by Primary Specific Support Provided by Primary OrganizationsOrganizations

APA = All expenses paid for travel associated with APA = All expenses paid for travel associated with CPT activitiesCPT activities

NAN = (from PAIO budget) applied to UNCW NAN = (from PAIO budget) applied to UNCW activitiesactivities 2002-2004 = $10,000 per year – one course for two 2002-2004 = $10,000 per year – one course for two

semesters teaching reductionsemesters teaching reduction 2005 = $5,000 per year – one course for one semester 2005 = $5,000 per year – one course for one semester

teaching reductionteaching reduction 2006 = $25,000 per year – in negotiation2006 = $25,000 per year – in negotiation

UNCW = Time off plus incidentals such as copying, UNCW = Time off plus incidentals such as copying, telephone calls, and secretarial supporttelephone calls, and secretarial support


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)


Primary Goals of PresentationPrimary Goals of Presentation

Understand the Role of Medicare in Setting Understand the Role of Medicare in Setting Standards for NeuropsychologyStandards for Neuropsychology

Understand the AMA Current Procedural Understand the AMA Current Procedural Terminology (CPT) for Coding of Professional Terminology (CPT) for Coding of Professional ServicesServices

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 Provide Suggestions for DocumentationProvide Suggestions for Documentation Explain the Concept of Fraud Versus ErrorsExplain the Concept of Fraud Versus Errors Explain Potential Problems & Trajectory for 2006Explain Potential Problems & Trajectory for 2006


Outline of PresentationOutline of Presentation

I. MedicareI. Medicare II. Current Procedural Terminology II. Current Procedural Terminology III. Problems & Possible SolutionsIII. Problems & Possible Solutions IV. Predictions for the FutureIV. Predictions for the Future V. ResourcesV. Resources


I. Medicare: WhyI. Medicare: Why

TheThe Standard for Universal Health Care: Standard for Universal Health 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 occurred)Auditing (determination of whether it occurred)

As a Consequence, the Benchmark for:As a Consequence, the Benchmark for: Workers CompensationWorkers Compensation Forensic WorkForensic Work Sports & Industrial ApplicationsSports & Industrial Applications


Medicare: OverviewMedicare: Overview

Centers for Medicare and Medicaid Centers for Medicare and Medicaid ServicesServices

BenefitsBenefits Part A (Hospital)Part A (Hospital) Part B (Supplementary)Part B (Supplementary) Part C (Medicare+ Choice)Part C (Medicare+ Choice) New Pharmaceutical BenefitNew Pharmaceutical Benefit


Medicare: Local ReviewMedicare: Local Review

Local Medical Review Policy (LMRP)Local Medical Review Policy (LMRP) National Policy Sets Overall ModelNational Policy Sets Overall Model LMRP Sets Local/Regional Policy-LMRP Sets Local/Regional Policy-

More restrictive than national policyMore restrictive than national policy Over-rides national policyOver-rides national policy Changes frequently without warning or Changes frequently without warning or

publicitypublicity Information best found on respective web Information best found on respective web

pagespages


III. Current Procedural III. Current Procedural Terminology (CPT): Terminology (CPT):

OverviewOverview BackgroundBackground Codes & CodingCodes & Coding Existing CodesExisting Codes Model System X Type of ProblemModel System X Type of Problem Medical NecessityMedical Necessity DocumentingDocumenting TimeTime


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


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


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


CPT: TheoryCPT: Theory

Order of Value - PersonnelOrder of Value - Personnel Surgeons, Physicians, Doctorate Level Surgeons, Physicians, Doctorate Level

Allied Health, Non-Doctorate Level Allied Allied Health, Non-Doctorate Level Allied HealthHealth

Order of Value - CostsOrder of Value - Costs Cognitive Work, Expense, MalpracticeCognitive Work, Expense, Malpractice


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 AMA Conjunction with AMA

Each Code has a Reimbursable ValueEach Code has a Reimbursable Value Professional Health Service Provided Professional Health Service Provided

Across the Country at Multiple LocationsAcross the Country at Multiple Locations Many “Physicians” or “Qualified Health Many “Physicians” or “Qualified Health

Professional” Perform ServicesProfessional” Perform Services Clinical Efficacy is Established and Clinical Efficacy is Established and

Documented in Peer-Reviewed LiteratureDocumented in Peer-Reviewed Literature


CPT: Applicable CodesCPT: Applicable Codes

Total Possible Codes = Approximately Total Possible Codes = Approximately 7,5007,500

Possible Codes for Psychology = Possible Codes for Psychology = Approximately 40 to 60Approximately 40 to 60

Sections = Five Primary Separate SectionsSections = Five Primary Separate Sections PsychiatryPsychiatry BiofeedbackBiofeedback Central Nervous AssessmentCentral Nervous Assessment Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Health & Behavior Assessment & ManagementHealth & Behavior Assessment & Management Possibility of Evaluation and Management Possibility of Evaluation and Management


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


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


CPT: CNS AssessmentCPT: CNS AssessmentUntil 12.31.05Until 12.31.05

InterviewInterview 9611596115

TestingTesting Psychological = 96100; 96110/11Psychological = 96100; 96110/11 Neuropsychological = 96117Neuropsychological = 96117 Aphasia = 96105Aphasia = 96105 Developmental = 96110/111Developmental = 96110/111


Rationale for CPT Changes:Rationale for CPT Changes:CNS Assessment CodesCNS Assessment Codes

Rationale for ChangesRationale for Changes Avoidance of Continuation of Reimbursement Avoidance of Continuation of Reimbursement

Strictly Based on Practice Expense Strictly Based on Practice Expense Potential catastrophe in terms of reimbursementPotential catastrophe in terms of reimbursement Recognition of cognitive work for testing codesRecognition of cognitive work for testing codes

Greater Clarity of Professional and Non-Greater Clarity of Professional and Non-Professional ActivitiesProfessional Activities

Differentiation of professional, technical and Differentiation of professional, technical and computer activitycomputer activity

Accounting/auditing, research, and salary purposesAccounting/auditing, research, and salary purposes Recognition of “Physician” WorkRecognition of “Physician” Work

Ending over a 10 year struggleEnding over a 10 year struggle


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: CNS AssessmentCPT: CNS AssessmentEffective 01.01.06 Effective 01.01.06 (no grace (no grace

period)period) Psychological TestingPsychological Testing

Three New CodesThree New Codes New Numbers & DescriptorsNew Numbers & Descriptors

Neurobehavioral Status ExamNeurobehavioral Status Exam New Number & Revised DescriptorNew Number & Revised Descriptor

Neuropsychological TestingNeuropsychological Testing Three New CodesThree New Codes New Numbers & DescriptorsNew Numbers & Descriptors


Psychological Testing:Psychological Testing:By ProfessionalBy Professional

9610196101 –Psychological Testing –Psychological Testing Psychodiagnostic assessment of Psychodiagnostic assessment of

emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology, e.g., personality and psychopathology, e.g., MMPI, Rorschach, WAIS (per hour of MMPI, Rorschach, WAIS (per hour of psychologist’s orpsychologist’s or physician’sphysician’s time, time, both face-to-face time with the patient both face-to-face time with the patient and time interpreting test results and and time interpreting test results and preparing the report)preparing the report)


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


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


Neurobehavioral Status Neurobehavioral Status ExamExam

9611696116 - Neurobehavioral status exam - Neurobehavioral status exam Clinical assessment of thinking, reasoning Clinical assessment of thinking, reasoning

and judgment ( e.g., acquired knowledge, and judgment ( e.g., acquired knowledge, attention, language, memory, planning attention, language, memory, planning and problem solving, and visual-spatial and problem solving, and visual-spatial abilities) per hour of abilities) per hour of psychologist’s or psychologist’s or physician’sphysician’s time, both face-to-face time time, both face-to-face time with the patient and time interpreting with the patient and time interpreting test results and preparing the reporttest results and preparing the report


Neuropsychological Testing-Neuropsychological Testing-By ProfessionalBy Professional

9611896118 - Neuropsychological testing - Neuropsychological testing (e.g., Halstead-Reitan (e.g., Halstead-Reitan

Neuropsychological, WMS, Wisconsin Neuropsychological, WMS, Wisconsin Card Sorting) per hour of the Card Sorting) per hour of the psychologist’s or physician’spsychologist’s or physician’s time, time, both face-to-face time with the patient both face-to-face time with the patient and time interpreting test results and and time interpreting test results and preparing the reportpreparing the report


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


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


CNS Assessment ExamplesCNS Assessment Examples

Neurobehavioral Status with Neurobehavioral Status with Neuropsychological TestingNeuropsychological Testing Interview by ProfessionalInterview by Professional Testing byTesting by

Professional, and/orProfessional, and/or Technician, and/orTechnician, and/or Computer.Computer.

Interpretation & Report Writing by Interpretation & Report Writing by Qualified Health ProfessionalQualified Health Professional


CPT: Physical Medicine & CPT: Physical Medicine & RehabilitationRehabilitation

97770 now 9753297770 now 97532 Note: 15 minute incrementsNote: 15 minute increments


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)


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


History of H & B CodesHistory of H & B Codes

Inter-divisional Health Care Committee of APA Inter-divisional Health Care Committee of APA (22, 38, 40, 54; Glueckauf, chair)(22, 38, 40, 54; Glueckauf, chair)

Convened in 1995 by APA PD (Phelps)Convened in 1995 by APA PD (Phelps) First draft 09.11.98; Working draft 07.01.00First draft 09.11.98; Working draft 07.01.00 First AMA presentation 11.06.98; Final 08.08.00 First AMA presentation 11.06.98; Final 08.08.00

(Ft. Lauderdale, Chicago, Denver, San Fransisco, (Ft. Lauderdale, Chicago, Denver, San Fransisco, Washington, Chicago, Chicago)Washington, Chicago, Chicago)

First survey 01.31.01; Final survey 04.26.01First survey 01.31.01; Final survey 04.26.01 Revisions to language – Revisions to language –

First preamble 03.02First preamble 03.02 Last preamble 11.04Last preamble 11.04


Overview of H & B CodesOverview of H & B Codes

Codes Effective as 01.01.2002Codes Effective as 01.01.2002 AssessmentAssessment InterventionIntervention

Established Medical Illness or Established Medical Illness or DiagnosisDiagnosis

Focus on Biopsychosocial FactorsFocus on Biopsychosocial Factors


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

SimultaneouslySimultaneously


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


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


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


H & B: Assessment H & B: Assessment ExamplesExamples

Health-Focused Clinical InterviewHealth-Focused Clinical Interview Behavioral ObservationsBehavioral Observations Psychophysiological MonitoringPsychophysiological Monitoring Health-Oriented QuestionnnairesHealth-Oriented Questionnnaires


Health & Behavior Health & Behavior Intervention CodesIntervention Codes

9615296152 Health and behavior interventionHealth and behavior intervention each 15 minuteseach 15 minutes face-to-faceface-to-face individualindividual

9615396153 group (2 or more patients)group (2 or more patients)

9615496154 family (with the patient present)family (with the patient present)

96155 (limited acceptability)96155 (limited acceptability) family (without the patient present; not being family (without the patient present; not being

reimbursedreimbursed))


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


H & B: Intervention H & B: Intervention ExamplesExamples

CognitiveCognitive BehavioralBehavioral Social Social PsychophysiologicalPsychophysiological


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


CPT: Model SystemCPT: Model System

PsychiatricPsychiatric NeurologicalNeurological Non-Neurological MedicalNon-Neurological Medical


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


CPT: Psychiatric ModelCPT: Psychiatric Model(Children & Adult)(Children & Adult)

InterviewInterview 90801- adult90801- adult 90802- child90802- child

TestingTesting 96101-0396101-03 Also, 96111 for childrenAlso, 96111 for children

InterventionIntervention e.g., 90806- adulte.g., 90806- adult e.g., 90820-childe.g., 90820-child


CPT: Neurological ModelCPT: Neurological Model(Children & Adult)(Children & Adult)

InterviewInterview 9611696116

TestingTesting 96118/19/2096118/19/20

InterventionIntervention 9753297532


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)


Alternative CPT CodesAlternative CPT Codes(probably reimbursable)(probably reimbursable)

Developmental Testing CodesDevelopmental Testing Codes Target Target

ChildrenChildren Applicable CodesApplicable Codes

96110 - Brief96110 - Brief 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 - Extended96111 - Extended Has physician work value Has physician work value Assessment of child’s social, emotional status (WJ)Assessment of child’s social, emotional status (WJ)


Alternative CPT CodesAlternative CPT Codes(probably not reimbursable)(probably not reimbursable)

99050 – Office, outside regular office hrs.99050 – Office, outside regular office hrs. 99052 - Service provided btw. 10pm-8am99052 - Service provided btw. 10pm-8am 99054 – Service provided on Sun/holidays99054 – Service provided on Sun/holidays 0074T – Online service0074T – Online service 90825 – Review of records90825 – Review of records 0074T – Online evaluation and 0074T – Online evaluation and

managementmanagement Evaluation and management codesEvaluation and management codes


CPT: Correct Coding InitiativeCPT: Correct Coding Initiative

PurposePurpose Used to evaluate submissions when Used to evaluate submissions when

provider bills more than one service for provider bills more than one service for the same beneficiary and same date of the same beneficiary and same date of serviceservice

Example; psychotherapy and testingExample; psychotherapy and testing ActivationActivation

Automatic editsAutomatic edits


Currently Debated Issues Currently Debated Issues Associated with CCIAssociated with CCI

90801 and 9611590801 and 96115 Reasoning-Reasoning-

Similar to MedicineSimilar to Medicine Cannot perform two procedures for same Cannot perform two procedures for same

illness and be reimbursed for bothillness and be reimbursed for both Reimbursed for most complexReimbursed for most complex

H & M and Psychiatric DiagnosesH & M and Psychiatric Diagnoses Psychiatric Procedures nor Diagnoses Psychiatric Procedures nor Diagnoses

can be used at the same timecan be used at the same time


CPT: DiagnosingCPT: Diagnosing

PsychiatricPsychiatric DSMDSM

The problem with DSM and neuropsych The problem with DSM and neuropsych testing of developmentally-related testing of developmentally-related neurological problemsneurological problems

Neurological & Non-Neurological Neurological & Non-Neurological MedicalMedical ICD – 9 CM (physical diagnosis coding)ICD – 9 CM (physical diagnosis coding) www.cdc.gov/nchs/about/otheract/icd9www.cdc.gov/nchs/about/otheract/icd9


CPT: Medical NecessityCPT: 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 DXNecessity = CPT x DX 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 Do Screening or Regularly Scheduled Evaluations Do

Not Meet Criteria for NecessityNot Meet Criteria for Necessity Will Results Affect Outcome of Patient?Will Results Affect Outcome of Patient? Will New Information Be Obtained?Will New Information Be Obtained?


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


CPT: DocumentingCPT: Documenting

PurposePurpose Payer RequirementsPayer Requirements General PrinciplesGeneral Principles HistoryHistory ExaminationExamination Decision MakingDecision Making


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


Documentation: Payer Documentation: Payer RequirementsRequirements

Site of ServiceSite of Service Medical Necessity for Service Medical Necessity for Service

ProvidedProvided Appropriate Reporting of ActivityAppropriate Reporting of Activity


Documentation: General Documentation: General PrinciplesPrinciples

Rationale for ServiceRationale for Service Complete and LegibleComplete and Legible Reason/Rationale for ServiceReason/Rationale for Service Assessment, Progress, Impression, or Assessment, Progress, Impression, or

DiagnosisDiagnosis Plan for CarePlan for Care Date and Identity of ObserveDate and Identity of Observe TimelyTimely ConfidentialConfidential


Documentation: Basic Documentation: Basic Information Across CodesInformation Across Codes

DateDate Time, if applicableTime, if applicable Identify of Observer (technician ?)Identify of Observer (technician ?) Reason for ServiceReason for Service StatusStatus ProcedureProcedure Results/FindingResults/Finding Impression/DiagnosesImpression/Diagnoses DispositionDisposition Stand AloneStand Alone


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


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


Documentation: HistoryDocumentation: History

PastPast Family Family SocialSocial Medical/PsychologicalMedical/Psychological


Documentation: AssessmentDocumentation: Assessment

Reason for ServiceReason for Service Dates (amount of service time?)Dates (amount of service time?) Tests and Protocols (included Tests and Protocols (included

editions)editions) Narrative of ResultsNarrative of Results ImpressionImpression DispositionDisposition


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


Documentation: TimeDocumentation: Time((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


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


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


TimeTime

DefiningDefining Professional (not patient) Time Including:Professional (not patient) Time Including:

pre, intra & post-clinical service activitiespre, intra & post-clinical service activities Interview & Assessment CodesInterview & Assessment Codes

Use 15 or 60 minute increments, as applicableUse 15 or 60 minute increments, as applicable Intervention CodesIntervention Codes

Use 15, 30, 60 or 90 minute increments, as Use 15, 30, 60 or 90 minute increments, as applicableapplicable


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.


Time (continued)Time (continued)

Communicating further with othersCommunicating further with others Follow-up with patient, family, and/or Follow-up with patient, family, and/or

othersothers Arranging for ancillary and/or other Arranging for ancillary and/or other

servicesservices


Time: TestingTime: Testing

Quantifying TimeQuantifying Time Round up or down to nearest incrementRound up or down to nearest increment

Time Does Not IncludeTime Does Not Include Patient completing tests, scales, forms, etc.Patient completing tests, scales, forms, etc. Waiting time by patientWaiting time by patient Typing of reportsTyping of reports Non-Professional (e.g., clerical) timeNon-Professional (e.g., clerical) time Literature searches, learning new techniques, Literature searches, learning new techniques,

etc.etc.


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…”


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


Reimbursement HistoryReimbursement History

Cost Plus Cost Plus Prospective Payment System (PPS)Prospective Payment System (PPS) Diagnostic Related Groups (DRGs)Diagnostic Related Groups (DRGs) Customary, Prevailing & Reasonable Customary, Prevailing & Reasonable

(CPR)(CPR) Resource Based Relative Value System Resource Based Relative Value System

(RBRVS)(RBRVS) Note: On average, insurance companies Note: On average, insurance companies

will pay approximate 75% of its income)will pay approximate 75% of its income)


Relative Value Units: OverviewRelative Value Units: Overview

ComponentsComponents UnitsUnits ValuesValues Current ProblemsCurrent Problems


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)


RVU Components PercentagesRVU Components Percentages

Physician WorkPhysician Work == 52%52% Practice ExpensePractice Expense == 44%44% LiabilityLiability = 4%= 4%


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


Estimate of Psychologists’ Estimate of Psychologists’ ValueValue

AudiologistAudiologist .52.52 DieticianDietician .43.43 RNRN .42.42 Speech PathologistSpeech Pathologist .55.55

PsychologistPsychologist .82.82


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)


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)


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


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.


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


National RVU 2006 ValuesNational RVU 2006 Valuesop=outpatient, ip=inpatient, est=estimateop=outpatient, ip=inpatient, est=estimate

Code #Code # OP RVUOP RVU IP RVUIP RVU OP $ estOP $ est IN IN $est$est

9610196101 2.562.56 2.542.54 92.6192.61 91.8991.89

9610296102 1.171.17 0.680.68 42.3342.33 24.6024.60

9610396103 0.740.74 0.700.70 26.7726.77 25.3225.32

9611696116 2.872.87 2.682.68 103.83103.83 96.9596.95

9611896118 3.433.43 2.672.67 124.09124.09 96.5996.59

9611996119 1.751.75 0.920.92 63.3163.31 33.2833.28

9612096120 1.271.27 0.700.70 45.9445.94 25.3225.32


CIGNA Medicare Part BCIGNA Medicare Part B2006 Fee Schedule 2006 Fee Schedule

(participating provider)(participating provider)

Code #Code # OP $OP $ IP $IP $

9610196101 90.0890.08 89.4289.42

9610296102 40.2940.29 23.0923.09

9610396103 25.9025.90 24.5724.57

9611696116 99.0899.08 92.7692.76

9611896118 117.72117.72 92.4292.42

9611996119 58.0158.01 30.3930.39

9612096120 43.5443.54 24.5724.57


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


Unique Physician Identification Unique Physician Identification Number (UPIN)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


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

DatesDates 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


Place of ServicePlace of Service ## LocationLocation

1111 Doctor’s OfficeDoctor’s Office

1212 Patient’s HomePatient’s Home

2121 Inpatient HospitalInpatient Hospital

2222 Outpatient HospitalOutpatient Hospital

3131 Skilled Nursing Skilled Nursing FacilityFacility

3232 Nursing FacilityNursing Facility

3333 Custodial Care Custodial Care FacilityFacility

5656 Psychiatric Psychiatric ResidentialResidential

6161 Inpatient Inpatient RehabilitationRehabilitation


IV. Continuing ProblemsIV. Continuing Problems

Supervision vs Incident toSupervision vs Incident to TechniciansTechnicians TimeTime PaymentPayment Fraud & AbuseFraud & Abuse


SupervisionSupervision( ( Federal Register, Federal Register, 6969, #150, August 5, 2004, page 47553), #150, August 5, 2004, page 47553)

Hold Doctoral Degree in PsychologyHold Doctoral Degree in Psychology Licensed or Certified as a PsychologistLicensed or Certified as a Psychologist Applicable Only to “clinical psychologists” Applicable Only to “clinical psychologists”

(and not “independent” psychologists (and not “independent” psychologists (e.g., Ed. (e.g., Ed.

Psych.Psych.)) RationaleRationale

Allows for higher level of expertise to superviseAllows for higher level of expertise to supervise Could relieve burden on physicians and facilitiesCould relieve burden on physicians and facilities May increase service in rural areasMay increase service in rural areas

Recommended Supervision Level = GeneralRecommended Supervision Level = General


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


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


Problem: Incident toProblem: Incident to Rationale for Incident toRationale for Incident to

Congress intended to provide coverage for Congress intended to provide coverage for services not typically covered elsewhereservices not typically covered elsewhere

Definition of Physician ExtenderDefinition of Physician Extender HowHow LimitationsLimitations

Definition of In vs. OutpatientDefinition of In vs. Outpatient Geographic Vs FinancialGeographic Vs Financial

Probably no Future to Incident toProbably no Future to Incident to


Problem: Defining Incident Problem: Defining Incident toto

DefinitionDefinition Commonly furnished serviceCommonly furnished service Integral, though incidental to Integral, though incidental to

psychologistpsychologist Performed under direct supervisionPerformed under direct supervision Either furnished without charge or as Either furnished without charge or as

part of the psychologist’s chargepart of the psychologist’s charge


Problem: More Incident toProblem: More Incident to

When is “Incident to” Acceptable:When is “Incident to” Acceptable: Testing - DefiniteTesting - Definite Cognitive Rehabilitation; Biofeedback - Cognitive Rehabilitation; Biofeedback -

ProbablyProbably Psychotherapy – Uncertain to Probably Psychotherapy – Uncertain to Probably

NotNot


Problem: Incident to & Problem: 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


Problem: Problem: 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


Problems:Problems:Difficulties with Incident toDifficulties with Incident to

The Physician Must Evaluate The Physician Must Evaluate and/or Treat the Patient Firstand/or Treat the Patient First

No Clear Guidelines Regarding No Clear Guidelines Regarding Reasonable Mix of Physician to Reasonable Mix of Physician to Extender?Extender?

What are the Limits of the What are the Limits of the Extender?Extender?


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


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


Problem: Defining a Problem: Defining a TechnicianTechnician

What is the Minimum Level of What is the Minimum Level of Training Required for a Technician?Training Required for a Technician? National Association of PsychometristsNational Association of Psychometrists NAN Position PaperNAN Position Paper

Level of Education- Probably a minimum of Level of Education- Probably a minimum of BachelorsBachelors

Level of TrainingLevel of Training Level of SupervisionLevel of Supervision



(Federal Register, Vol. 66, #149, page 40382)(Federal Register, Vol. 66, #149, page 40382)

RequirementRequirement Employee (e.g., 1099)Employee (e.g., 1099)

Common PracticeCommon Practice Independent ContractorIndependent Contractor



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


Problem: Acceptance of Problem: Acceptance of TechniciansTechnicians

MedicareMedicare Outside of North Central & California, Outside of North Central & California,

yesyes In North Carolina, use the “AH” modifierIn North Carolina, use the “AH” modifier

Private CarriersPrivate Carriers Magellan – yesMagellan – yes Others – not accepting the codeOthers – not accepting the code


Problem: Uses of Problem: Uses of TechniciansTechnicians

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


Problem: PaymentProblem: Payment

Origins of the ProblemOrigins of the Problem Balanced Budget Act of 1997Balanced Budget Act of 1997 Employer’s Cost for Health Care in 2002 = Employer’s Cost for Health Care in 2002 =

$5,000 per employee$5,000 per employee What Should Your Code Be Payed at?What Should Your Code Be Payed at?

www.webstore.ama-assn.org-www.webstore.ama-assn.org- State LegislationState Legislation

www.insure.com/health/lawtool.cfmwww.insure.com/health/lawtool.cfm


Problem:Problem:PaymentPayment

MedicareMedicare Pending 4.4% cutPending 4.4% cut

Other CarriersOther Carriers Non-Equitable % of RVU paymentNon-Equitable % of RVU payment


Payment: National Coverage Payment: National Coverage PolicyPolicy

Services That Are Not Reasonable Services That Are Not Reasonable and Necessary for the Diagnosing and Necessary for the Diagnosing and Treatment of an Illness or Injuryand Treatment of an Illness or Injury

Screening Services, in the Absence of Screening Services, in the Absence of Symptoms or History of Disease are Symptoms or History of Disease are DeniedDenied


Payment in Skilled Nursing Payment in Skilled Nursing FacilitiesFacilities

(CMS Manual, Pub. 100-04; #449; 01.21.05;(CMS Manual, Pub. 100-04; #449; 01.21.05;Effective Date 04.01.05)Effective Date 04.01.05)

Healthcare Common Procedure Healthcare Common Procedure Coding System (HCPCS)Coding System (HCPCS) Subject to consolidated billing under Subject to consolidated billing under

SNF Prospective Payment SystemSNF Prospective Payment System Applies to physical, occupational and Applies to physical, occupational and

speech therapy ONLYspeech therapy ONLY


CMS Determination of CMS Determination of CoverageCoverage

Coverage TypesCoverage Types Coverage with Conditions (specific DX, facility or Coverage with Conditions (specific DX, facility or

provider)provider) Coverage without ConditionsCoverage without Conditions

Data ReviewedData Reviewed BenefitBenefit Risks Vs. BenefitsRisks Vs. Benefits Available Clinical StudiesAvailable Clinical Studies

DatabasesDatabases Longitudinal or cohort studiesLongitudinal or cohort studies Prospective studiesProspective studies Randomized clinical trialsRandomized clinical trials


Problem: PaymentProblem: Payment

Evolution of CompensationEvolution of Compensation Gross ChargesGross Charges Adjusted ChargesAdjusted Charges RVUsRVUs ReceivablesReceivables


Medicare QuestionsMedicare Questions

Cannot Impose a Limitation on a Medicare Cannot Impose a Limitation on a Medicare Patient That is Not Imposed on Other Pts.Patient That is Not Imposed on Other Pts.

Non-Covered Services Can Be Charged if Non-Covered Services Can Be Charged if Patient Knows and Agrees Ahead of TimePatient Knows and Agrees Ahead of Time

Records Should be Retained, state law or;Records Should be Retained, state law or; Adult- 5 years post serviceAdult- 5 years post service Children- until 21Children- until 21

BillingBilling In Continuing Cases- End of monthIn Continuing Cases- End of month Otherwise- At end of service Otherwise- At end of service


Problem: Office of Inspector Problem: Office of Inspector General (2005 Orange Book)General (2005 Orange Book)

Identify Nursing Home Residents with Identify Nursing Home Residents with Serious Mental Illness (OEI-05-99-Serious Mental Illness (OEI-05-99-0070100701

Improve Assessments of Mental Improve Assessments of Mental Illness (OEI-05-99-00700)Illness (OEI-05-99-00700)

Eliminate Inappropriate Payments for Eliminate Inappropriate Payments for Mental Health ServicesMental Health Services


Problem: Expenditures & FraudProblem: Expenditures & Fraud

ProjectionsProjections CurrentCurrent

14%14% By 2011;By 2011;

17% ($2.8 trillion)17% ($2.8 trillion)


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


Defining FraudDefining Fraud

FraudFraud IntentionalIntentional PatternPattern

ErrorError ClericalClerical DatesDates


Problem: Fraud & AbuseProblem: Fraud & Abuse

26 Different Kinds of Fraud Types26 Different Kinds of Fraud Types Psychology Only Professional Group Psychology Only Professional Group

Identified by OIG for Closer Scrutiny Identified by OIG for Closer Scrutiny in 2005-2006in 2005-2006


Problem: FraudProblem: FraudOffice of Inspector GeneralOffice of Inspector General

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


Problem: Fraud (cont.)Problem: Fraud (cont.)

Nursing HomesNursing Homes Identification Identification Overuse of ServicesOveruse of Services

ChildrenChildren


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 ““Particulary Problematic” due to Particulary Problematic” due to

Medically unnecessaryMedically unnecessary Billed incorrectlyBilled incorrectly Rendered by unqualified providersRendered by unqualified providers Undocumented or poorly documentedUndocumented or poorly documented


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%


Problem: Fraud (cont.)Problem: 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


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?


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


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

Sensitive Situations for Potential Audits;Sensitive Situations for Potential Audits; Skilled Nursing FacilitiesSkilled Nursing Facilities Statistical OutliersStatistical Outliers TestingTesting

Greater audits in general and in particular;Greater audits in general and in particular; TX, CA, FL, PRTX, CA, FL, PR


Fraud: Voluntary Fraud: Voluntary ComplianceCompliance

(D. Raisin-Waters, APA, 2005)(D. Raisin-Waters, APA, 2005) Address Risk or Problematic Areas Address Risk or Problematic Areas

(e.g., denied claims)(e.g., denied claims) Develop a Compliance Program (with Develop a Compliance Program (with

designated individual, written plan, designated individual, written plan, etc.)etc.)


V. Future PerspectivesV. Future Perspectives: : 20032003

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


Future Perspectives:Future Perspectives:2004 Continued2004 Continued

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


Future Perspectives: Future Perspectives: 2004 Continued2004 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


Future Perspectives:Future Perspectives:2004 Continued2004 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


Future Perspectives:Future Perspectives: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)



Issues to be AddressedIssues to be Addressed Final values for work and practice for testing codesFinal values for work and practice for testing codes 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



Early Portions of 2006 = Confusion in Use & Early Portions of 2006 = Confusion in Use & Reimbursement of CodesReimbursement of Codes The Use of TechsThe Use of Techs Insurance Carriers Acceptance of CodesInsurance Carriers Acceptance of Codes Decreased Revenue Stream Decreased Revenue Stream

Middle Portions of 2006 = Increased Stabilization Middle Portions of 2006 = Increased Stabilization in Use & Reimbursement of Codesin Use & Reimbursement of Codes

Later Portion of 2006 = Potential Increase in Later Portion of 2006 = Potential Increase in Overall Reimbursement Overall Reimbursement

By 2007 = Likely and Stable Increase in By 2007 = Likely and Stable Increase in Reimbursement PatternsReimbursement Patterns


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)) NCPA Website NCPA Website

(www.ncpsychology.org)(www.ncpsychology.org)


V. ResourcesV. Resources

General Web SitesGeneral Web Sites www.apa.orgwww.apa.org www.nanonline.org/paiowww.nanonline.org/paio www.ncpsychology.orgwww.ncpsychology.org www.cms.orgwww.cms.org (medicare/medicaid) (medicare/medicaid) www.hhs.orgwww.hhs.org (health & human services) (health & human services) www.oig.hhs.govwww.oig.hhs.gov (inspector general) (inspector general) www.apa.org/practice/cptwww.apa.org/practice/cpt (apa’s cpt information) (apa’s cpt information) www.ahrq.gov (agency for healthcare research)www.ahrq.gov (agency for healthcare research) www.medpac.govwww.medpac.gov (medical payment advisory comm.) (medical payment advisory comm.) www.whitehouse.gov/fsbr/healthwww.whitehouse.gov/fsbr/health (statistics) (statistics) www.div40.orgwww.div40.org (clinical neuropsychology div of apa) (clinical neuropsychology div of apa) www.napnet.orgwww.napnet.org (national association of (national association of

psychometrists)psychometrists) www.access.gpo.govwww.access.gpo.gov (federal statutes and regulations) (federal statutes and regulations) www.healthcare.group.comwww.healthcare.group.com (staff salaries) (staff salaries)


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)

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.)


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.govwww.ntis.gov/product/correct-coding/product/correct-coding

(coding edits)(coding edits)


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

contact information

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