Cpt1 Interfacing Science, Politics and Economics: How Medicare and the AMA Affect the Practice of Psychology University of Georgia 02.24.06 Antonio E.

cptcpt 11

Interfacing Science, Politics and Economics:Interfacing Science, Politics and Economics:How Medicare and the AMA Affect How Medicare and the AMA Affect

the Practice of Psychologythe Practice of Psychology

University of GeorgiaUniversity of Georgia02.24.0602.24.06

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

cptcpt 22

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

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

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

cptcpt 33

Specific Support Provided by Primary Specific Support Provided by Primary OrganizationsOrganizations

APA = All expenses paid for travel associated with CPT APA = All expenses paid for travel associated with CPT activitiesactivities

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

reductionreduction 2005 = $5,000 per year – one course for one semester teaching 2005 = $5,000 per year – one course for one semester teaching

reductionreduction 2006 = $25,000 per year – in negotiation2006 = $25,000 per year – in negotiation

UNCW = Time away from university duties (e.g., teaching) UNCW = Time away from university duties (e.g., teaching) plus incidental support such as copying, telephone calls, and plus incidental support such as copying, telephone calls, and secretarial and work-study student assistancesecretarial and work-study student assistance

cptcpt 44

BackgroundBackground(1988 – present)(1988 – present)

North Carolina Psychological Association (e)North Carolina Psychological Association (e) APA’s Policy & Planning Board; Div. 40 (e)APA’s Policy & Planning Board; Div. 40 (e) American Medical Association’s Current American Medical Association’s Current

Procedural Terminology Committee (IV/V) (a)Procedural Terminology Committee (IV/V) (a) Health Care Finance Administration’s Working Health Care Finance Administration’s Working

Group for Mental Health Policy (a)Group for Mental Health Policy (a) Center for Medicare/Medicaid Services’ Center for Medicare/Medicaid Services’

Medicare Coverage Advisory Committee (fa)Medicare Coverage Advisory Committee (fa) Consultant with the North Carolina Medicaid Consultant with the North Carolina Medicaid

Office;North Carolina Blue Cross/Blue Shield Office;North Carolina Blue Cross/Blue Shield (a)(a)

NAN’s Professional Affairs & Information Office NAN’s Professional Affairs & Information Office (a)(a)

((legend; a = appointment, fa = federal appointment, e = election)legend; a = appointment, fa = federal appointment, e = election)

cptcpt 55

Primary Goal & General Primary Goal & General Outcome Outcome

of CPT Work (AEP)of CPT Work (AEP) GoalGoal

Parity with PhysiciansParity with Physicians Expansion of Scope of Diagnostic ServicesExpansion of Scope of Diagnostic Services

OutcomeOutcome Intended/Anticipated/HopedIntended/Anticipated/Hoped

Similar reimbursement as physician servicesSimilar reimbursement as physician services General increase in the scope of practice General increase in the scope of practice Greater inclusion into health care systemGreater inclusion into health care system

Less AnticipatedLess Anticipated Transparency Transparency AccountabilityAccountability UniformityUniformity

cptcpt 66

Primary Goals of PresentationPrimary Goals of Presentation

Understand the Role of Medicare in Understand the Role of Medicare in Setting Standards for PsychologySetting Standards for Psychology

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

Explain Potential Problems & Explain Potential Problems & Trajectory for 2006 and BeyondTrajectory for 2006 and Beyond

cptcpt 77

Outline of PresentationOutline of Presentation

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

cptcpt 88

I. Medicare: WhyI. Medicare: Why

TheThe Standard for Universal Health Standard for Universal Health Care:Care: Coding (what can be done)Coding (what can be done) Value (how much it will be paid)Value (how much it will be paid) Documentation (what needs to be said)Documentation (what needs to be said) Auditing (determination of whether it Auditing (determination of whether it

occurred)occurred)

cptcpt 99

Medicare: Immediate Medicare: Immediate ImpactImpact

As a Consequence, the Benchmark As a Consequence, the Benchmark for:for: All Commercial Carriers (e.g., HMOs)All Commercial Carriers (e.g., HMOs) As well as;As well as;

Workers CompensationWorkers Compensation Forensic ApplicationsForensic Applications Related Applications (e.g., industrial, sports)Related Applications (e.g., industrial, sports)

cptcpt 1010

Medicare: Long-term ImpactMedicare: Long-term Impact

By 2015, Medicare will represent By 2015, Medicare will represent approximately 50% of all health care approximately 50% of all health care payments in the United Statespayments in the United States

Most likely, in the next decade a national Most likely, in the next decade a national (US) health insurance will be established(US) health insurance will be established

One possible model will be to introduce One possible model will be to introduce Medicare to younger citizens will be in Medicare to younger citizens will be in age increments (e.g., 60-64, then 50-59, age increments (e.g., 60-64, then 50-59, etc)etc)

Hence, Medicare will come to set the Hence, Medicare will come to set the standard for all of health carestandard for all of health care

cptcpt 1111

Medicare: OverviewMedicare: Overview

Centers for Medicare and Medicaid Centers for Medicare and Medicaid ServicesServices

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

cptcpt 1212

Medicare: Local ReviewMedicare: Local Review

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

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

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

pagespages

cptcpt 1313

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

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

cptcpt 1414

CPT: BackgroundCPT: Background

AmericanAmerican Medical Association Medical Association Developed by Surgeons (& Physicians) Developed by Surgeons (& Physicians)

in 1966 for Billing Purposesin 1966 for Billing Purposes 7,500+ Discrete Codes7,500+ Discrete Codes CPT Meets a Minimum of 4 Times/YearCPT Meets a Minimum of 4 Times/Year

Center for Medicare & Medicaid Center for Medicare & Medicaid ServicesServices AMA Under License by CMSAMA Under License by CMS CMS Now Provides Active Input into CPTCMS Now Provides Active Input into CPT

cptcpt 1515

CPT: Background/DirectionCPT: Background/Direction

Current System = CPT 5Current System = CPT 5 CategoriesCategories

I= Standard Coding for Professional I= Standard Coding for Professional ServicesServices

Codes of interestCodes of interest II = Performance MeasurementII = Performance Measurement

Starting to emerge; will be the future of CPTStarting to emerge; will be the future of CPT III = Emerging TechnologyIII = Emerging Technology

New technology and procedures New technology and procedures

cptcpt 1616

CPT: CompositionCPT: Composition

AMA House of DelegatesAMA House of Delegates 109 Medical Specialties109 Medical Specialties

HCPACHCPAC 11 Allied Health Societies (e.g., APA)11 Allied Health Societies (e.g., APA)

CPT Editorial PanelCPT Editorial Panel 17 Voting Members17 Voting Members

11 Appointed by AMA Board11 Appointed by AMA Board 1 each from BC/BS, AHA, HIAA, CMS1 each from BC/BS, AHA, HIAA, CMS 2 HCPAC 2 HCPAC

cptcpt 1717

CPT: TheoryCPT: Theory

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

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

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

cptcpt 1818

What Is a CPT Code?What Is a CPT Code?

A Coding System Developed by AMA in A Coding System Developed by AMA in Conjunction with CMS Conjunction with CMS

Each Code has a Specific Description and a Each Code has a Specific Description and a Reimbursable ValueReimbursable Value

Professional Health Service Provided Professional Health Service Provided Across the Country at Multiple LocationsAcross the Country at Multiple Locations

Many “Physicians” or “Qualified Health Many “Physicians” or “Qualified Health Professional” Perform ServicesProfessional” Perform Services

Clinical Efficacy is Established and Clinical Efficacy is Established and Documented in Peer-Reviewed LiteratureDocumented in Peer-Reviewed Literature

cptcpt 1919

Abbreviated CPT GlossaryAbbreviated CPT Glossary

CPTCPT Current Procedure Terminology = professional service codeCurrent Procedure Terminology = professional service code

Qualified Health ProfessionalQualified Health Professional Who has the contract with the insurance carrierWho has the contract with the insurance carrier Defined by training, state and federal statutes/laws/regulationsDefined by training, state and federal statutes/laws/regulations

TechnicianTechnician Anybody elseAnybody else

Facility vs Non-facilityFacility vs Non-facility Non-facility = all settings other than a hospital or skilled Non-facility = all settings other than a hospital or skilled

nursing facilitynursing facility UnitsUnits

Time based factor which is applied as a multiplier to the RVUs Time based factor which is applied as a multiplier to the RVUs agreed to by AMA CPT and CMSagreed to by AMA CPT and CMS

Face-to-faceFace-to-face In front of the patientIn front of the patient

cptcpt 2020

CPT: Applicable CodesCPT: Applicable Codes

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

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

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

cptcpt 2121

CPT: Development of a CodeCPT: Development of a Code

InitialInitial Health Care Advisory Committee (non-MDs)Health Care Advisory Committee (non-MDs)

PrimaryPrimary CPT Work Group (selected organizations)CPT Work Group (selected organizations) CPT Panel (all specialties)CPT Panel (all specialties)

Time FrameTime Frame 3-5 years to well over a decade3-5 years to well over a decade

cptcpt 2222

CPT: PsychiatryCPT: Psychiatry

Sections (or Categories)Sections (or Categories) Interview (90801) vs. Intervention (e.g., 908.06)Interview (90801) vs. Intervention (e.g., 908.06) These codes are one unitThese codes are one unit Office vs. InpatientOffice vs. Inpatient Regular vs. Evaluation & ManagementRegular vs. Evaluation & Management OtherOther

Types of InterventionsTypes of Interventions Insight, Behavior Modifying, and/or Supportive Insight, Behavior Modifying, and/or Supportive

vs. Interactivevs. Interactive

cptcpt 2323

CPT Changes:CPT Changes:CNS Assessment Codes CNS Assessment Codes

TimetableTimetable Activity x DateActivity x Date

Codes Without Cognitive Work Obtained, 1994Codes Without Cognitive Work Obtained, 1994 Initial Request for Practice Expense by APA, Summer, 2002Initial Request for Practice Expense by APA, Summer, 2002 APA Appeared Before AMA RUC, September, 2003APA Appeared Before AMA RUC, September, 2003 Initial Decision by AMA CPT Panel, November 7, 2004Initial Decision by AMA CPT Panel, November 7, 2004 Call for Other Societies to Participate, November 19, 2004Call for Other Societies to Participate, November 19, 2004 Final Decision by AMA CPT Panel, December 1, 2004Final Decision by AMA CPT Panel, December 1, 2004 Submission of CPT Codes to AMA RUC Committee immediately Submission of CPT Codes to AMA RUC Committee immediately

thereafterthereafter Review by AMA RUC Research Subcommittee in January, 2005Review by AMA RUC Research Subcommittee in January, 2005 Review by AMA RUC Panel in February 3-6, 2005Review by AMA RUC Panel in February 3-6, 2005 Survey of Codes, second & third week of February, 2005Survey of Codes, second & third week of February, 2005 Analysis of surveys, March, 2005Analysis of surveys, March, 2005 Presentation to RUC Committee in April, 2005Presentation to RUC Committee in April, 2005 Inclusion in the 2006 Physician Fee Schedule on January 1, 2006Inclusion in the 2006 Physician Fee Schedule on January 1, 2006 CPT Assistant article early 2006CPT Assistant article early 2006

cptcpt 2424

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

period)period) Psychological Testing (e.g., 5 units)Psychological Testing (e.g., 5 units)

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

Neurobehavioral Status Exam (e.g., 2 Neurobehavioral Status Exam (e.g., 2 units)units) New Number & Revised DescriptorNew Number & Revised Descriptor

Neuropsychological Testing (e.g., 10 units)Neuropsychological Testing (e.g., 10 units) Three New CodesThree New Codes New Numbers & DescriptorsNew Numbers & Descriptors

cptcpt 2525

Psychological Testing:Psychological Testing:By ProfessionalBy Professional

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

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

cptcpt 2626

Psychological Testing:Psychological Testing:By TechnicianBy Technician

9610296102- Psychological Testing- Psychological Testing Psychodiagnostic assessment of Psychodiagnostic assessment of

emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology (e.g., personality and psychopathology (e.g., MMPI, Rorschach, WAIS) with MMPI, Rorschach, WAIS) with qualified qualified health care professionalhealth care professional interpretation interpretation and report, administered by and report, administered by techniciantechnician, , per hour of technician time, face-to-faceper hour of technician time, face-to-face

cptcpt 2727

Psychological Testing:Psychological Testing:By ComputerBy Computer

96103 96103 - Psychological Testing- Psychological Testing Psychodiagnostic assessment of Psychodiagnostic assessment of

emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology, (e.g., personality and psychopathology, (e.g., MMPI) administered by a MMPI) administered by a computercomputer, , with with qualified health professionalqualified health professional interpretation and the reportinterpretation and the report

cptcpt 2828

Neurobehavioral Status Neurobehavioral Status ExamExam

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

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

cptcpt 2929

Neuropsychological Testing-Neuropsychological Testing-By ProfessionalBy Professional

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

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

cptcpt 3030

Neuropsychological Testing:Neuropsychological Testing:By TechnicianBy Technician

96119 96119 - Neuropsychological testing - Neuropsychological testing (e.g., Halstead-Reitan (e.g., Halstead-Reitan

Neuropsychological, WMS, Wisconsin Neuropsychological, WMS, Wisconsin Card Sorting) with Card Sorting) with qualified health care qualified health care professionalprofessional interpretation and report, interpretation and report, administered by a administered by a techniciantechnician per hour per hour of technician time, face-to-faceof technician time, face-to-face

cptcpt 3131

Neuropsychological Testing-Neuropsychological Testing-By ComputerBy Computer

9612096120 - Neuropsychological testing - Neuropsychological testing (e.g., WCST) administered by a (e.g., WCST) administered by a

computercomputer with with qualified health care qualified health care professionalprofessional interpretation and the interpretation and the reportreport

cptcpt 3232

CNS Assessment ExamplesCNS Assessment Examples

Neurobehavioral Status with Neuropsychological TestingNeurobehavioral Status with Neuropsychological Testing Interview by the ProfessionalInterview by the Professional Testing byTesting by

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

Interpretation & Report Writing by Qualified Health Interpretation & Report Writing by Qualified Health ProfessionalProfessional

A Technician or Computer Code are Typically Billed A Technician or Computer Code are Typically Billed Together with a Professional Code (since the final Together with a Professional Code (since the final product should be a product should be a comprehensive/integrative comprehensive/integrative report)report)

cptcpt 3333

CPT: Physical Medicine & CPT: Physical Medicine & RehabilitationRehabilitation

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

cptcpt 3434

CPT: Cognitive CPT: Cognitive RehabilitationRehabilitation

Application RationaleApplication Rationale Allied Health & Physical Medicine CodeAllied Health & Physical Medicine Code

AcceptabilityAcceptability GN – Speech TherapistsGN – Speech Therapists GO – Occupational TherapistsGO – Occupational Therapists GP – Physical TherapistsGP – Physical Therapists AH – Mental Health (not applicable)AH – Mental Health (not applicable)

cptcpt 3535

CPT: Health & Behavior CPT: Health & Behavior Assessment & ManagementAssessment & Management

((CPT AssistantCPT Assistant, 03.04), 03.04)((CPT AssistantCPT Assistant, 08.05, , 08.05, 1515, #6, 10), #6, 10)

Purpose: Medical DiagnosisPurpose: Medical Diagnosis Time: 15 Minute IncrementsTime: 15 Minute Increments AssessmentAssessment InterventionIntervention

cptcpt 3636

History of H & B CodesHistory of H & B Codes

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

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

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

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

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

cptcpt 3737

Overview of H & B CodesOverview of H & B Codes

Codes Effective as 01.01.2002 Codes Effective as 01.01.2002 (with ongoing (with ongoing revisions of language)revisions of language)

Assessment (e.g., 4 units)Assessment (e.g., 4 units) Intervention (e.g., up to a total of 48 units)Intervention (e.g., up to a total of 48 units)

Established Medical Illness or Established Medical Illness or DiagnosisDiagnosis

Focus on Biopsychosocial FactorsFocus on Biopsychosocial Factors

cptcpt 3838

Health & Behavior Health & Behavior Assessment CodesAssessment Codes

9615096150 Health and behavior assessment (e.g., Health and behavior assessment (e.g.,

health-focused clinical interview, health-focused clinical interview, behavioral observations, behavioral observations, psychophysiological monitoring, health-psychophysiological monitoring, health-oriented questionnaires)oriented questionnaires)

each 15 minuteseach 15 minutes face-to-face with the patientface-to-face with the patient initial assessmentinitial assessment

9615196151 re-assessmentre-assessment

cptcpt 3939

H & B: Assessment H & B: Assessment ExplanationExplanation

Identification of Psychological, Identification of Psychological, Behavioral, Emotional, Cognitive Behavioral, Emotional, Cognitive and/or Social Factorsand/or Social Factors

In the Prevention, Treatment and/or In the Prevention, Treatment and/or Management of Physical Health Management of Physical Health ProblemsProblems

Focus on Biopsychosocial and not Focus on Biopsychosocial and not Mental Health FactorsMental Health Factors

cptcpt 4040

H & B: Assessment H & B: Assessment ExamplesExamples

Health-Focused Clinical InterviewHealth-Focused Clinical Interview Behavioral ObservationsBehavioral Observations Psychophysiological MonitoringPsychophysiological Monitoring Health-Oriented QuestionnairesHealth-Oriented Questionnaires

cptcpt 4141

Health & Behavior Health & Behavior Intervention CodesIntervention Codes

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

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

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

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

reimbursedreimbursed))

cptcpt 4242

H & B: Intervention H & B: Intervention ExamplesExamples

CognitiveCognitive BehavioralBehavioral Social Social PsychophysiologicalPsychophysiological

cptcpt 4343

H & B: DiagnosesH & B: Diagnoses

Associated with an Acute or Chronic Associated with an Acute or Chronic Medical IllnessMedical Illness

Not Applicable to Psychiatric Not Applicable to Psychiatric DiagnosesDiagnoses

cptcpt 4444

CPT: Model SystemCPT: Model System

PsychiatricPsychiatric NeurologicalNeurological Non-Neurological MedicalNon-Neurological Medical

cptcpt 4545

CPT ModelCPT Model

Rationale for CPT Code:Rationale for CPT Code: Choose Code that Best Describes the Choose Code that Best Describes the

Service Service Match the Interview with the Testing Match the Interview with the Testing

with the Intervention Code with the with the Intervention Code with the DiagnosisDiagnosis

Goal = Uniformity and FluencyGoal = Uniformity and Fluency

cptcpt 4646

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

InterviewInterview 90801- adult90801- adult 90802- child90802- child

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

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

cptcpt 4747

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

InterviewInterview 9611696116

TestingTesting 96118/19/2096118/19/20

InterventionIntervention 9753297532

cptcpt 4848

CPT: Non-Neurological CPT: Non-Neurological Medical ModelMedical Model

(Children & Adult)(Children & Adult)

Interview & AssessmentInterview & Assessment 96150 (initial)96150 (initial) 96151 (re-evaluation)96151 (re-evaluation)

InterventionIntervention 96152 (individual)96152 (individual) 96153 (group)96153 (group) 96154 (family with patient)96154 (family with patient) 96155 (family without patient)96155 (family without patient)

cptcpt 4949

CPT: Correct Coding InitiativeCPT: Correct Coding Initiative

PurposePurpose Used to evaluate submissions when Used to evaluate submissions when

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

Example; psychotherapy and testingExample; psychotherapy and testing ActivationActivation

Automatic editsAutomatic edits

cptcpt 5050

CPT: DiagnosingCPT: Diagnosing

PsychiatricPsychiatric DSMDSM

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

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

cptcpt 5151

Medically Reasonable and Medically Reasonable and NecessaryNecessary

Section 1862 (a)(1) 1963Section 1862 (a)(1) 196342, C.F.R., 411.15 (k)42, C.F.R., 411.15 (k)

““Services which are reasonable and necessary Services which are reasonable and necessary for the diagnosis and treatment of illness or for the diagnosis and treatment of illness or injury or to improve the functioning of a injury or to improve the functioning of a malformed body member”malformed body member”

Re-evaluation should only occur when there is a Re-evaluation should only occur when there is a potential change in;potential change in; DiagnosisDiagnosis SymptomsSymptoms

cptcpt 5252

CPT: DocumentingCPT: Documenting

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

cptcpt 5353

Documentation: PurposeDocumentation: Purpose

Medical NecessityMedical Necessity Evaluate and Plan for TreatmentEvaluate and Plan for Treatment Communication and Continuity of Communication and Continuity of

CareCare Claims Review and PaymentClaims Review and Payment Research and EducationResearch and Education

cptcpt 5454

Documentation: General Documentation: General PrinciplesPrinciples

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

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

cptcpt 5555

Documentation: Basic Documentation: Basic Information Across CodesInformation Across Codes

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

cptcpt 5656

Documentation:Documentation: Chief Complaint Chief Complaint

Concise Statement Describing the Concise Statement Describing the Symptom, Problem, Condition, & Symptom, Problem, Condition, & DiagnosisDiagnosis

Foundation for Medical NecessityFoundation for Medical Necessity Must be Complete & ExhaustiveMust be Complete & Exhaustive

cptcpt 5757

Documentation: Documentation: Present IllnessPresent Illness

SymptomsSymptoms Location, Quality, Severity, Duration, Location, Quality, Severity, Duration,

timing, Context, Modifying Factors timing, Context, Modifying Factors Associated SignsAssociated Signs

Follow-upFollow-up Changes in ConditionChanges in Condition ComplianceCompliance

cptcpt 5858

Documentation: HistoryDocumentation: History

PastPast Family Family SocialSocial Medical/PsychologicalMedical/Psychological

cptcpt 5959

Documentation: AssessmentDocumentation: Assessment

Reason for ServiceReason for Service Dates (amount of service time?)Dates (amount of service time?) Identity of TesterIdentity of Tester Tests and Protocols (included editions)Tests and Protocols (included editions) Narrative of ResultsNarrative of Results ImpressionImpression DispositionDisposition

cptcpt 6060

Documentation: Documentation: InterventionIntervention

Reason for ServiceReason for Service Status of PatientStatus of Patient Intervention PerformedIntervention Performed Results ObtainedResults Obtained Impression or Diagnosis (es)Impression or Diagnosis (es) DispositionDisposition TimeTime

cptcpt 6161

CPT X ReportCPT X Report

Each CPT Code Should Generate a Each CPT Code Should Generate a Separate ReportSeparate Report

Alternatively, Clearly Label/Title Alternatively, Clearly Label/Title Sections of the Report to Match Sections of the Report to Match Codes UsedCodes Used

cptcpt 6262

Documentation:Documentation:SuggestionsSuggestions

Avoid Handwritten NotesAvoid Handwritten Notes Do Not Use Red InkDo Not Use Red Ink Avoid Color PaperAvoid Color Paper Document On and After Every Document On and After Every

Encounter, Every Procedure, Every Encounter, Every Procedure, Every PatientPatient

Review Changes Whenever ApplicableReview Changes Whenever Applicable Avoid Standard Phrases & ProtocolsAvoid Standard Phrases & Protocols

cptcpt 6363

TimeTime

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

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

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

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

cptcpt 6464

Time: DefinitionTime: Definition

AMA Definition of TimeAMA Definition of Time

Physicians also spend time during work, Physicians also spend time during work, before, or after the face-to-face time with before, or after the face-to-face time with the patient, performing such tasks as the patient, performing such tasks as reviewing records & tests, arranging for reviewing records & tests, arranging for services & communicating further with services & communicating further with other professionals & the patient through other professionals & the patient through written reports & telephone contact.written reports & telephone contact.

cptcpt 6565

Time (continued)Time (continued)

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

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

servicesservices

cptcpt 6666

Time: TestingTime: Testing

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

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

etc.etc.

cptcpt 6767

Time: Defining 15 MinutesTime: Defining 15 Minutes(from CPT Assistant, 08.05, 11-12)(from CPT Assistant, 08.05, 11-12)

((www.cms.hhs.gov/manuals/104_claims/clm104c05.www.cms.hhs.gov/manuals/104_claims/clm104c05.pdf)pdf)

Defining 15 Minute IncrementsDefining 15 Minute Increments UnitsUnits Amount of MinutesAmount of Minutes

11 >08; <23>08; <23 22 >22; <38>22; <38 33 >38; <53>38; <53 44 >53; <68>53; <68 55 >68; <83>68; <83 66 >83; <98>83; <98 77 >98; <113>98; <113 88 >113;<128>113;<128 Over 2 hoursOver 2 hours similar pattern as abovesimilar pattern as above

cptcpt 6868

Reimbursement HistoryReimbursement History

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

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

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

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

cptcpt 6969

Relative Value Units: OverviewRelative Value Units: Overview

ComponentsComponents UnitsUnits ValuesValues Current ProblemsCurrent Problems

cptcpt 7070

RVU: ComponentsRVU: Components

Physician Work Resource ValuePhysician Work Resource Value Practice Expense Resource ValuePractice Expense Resource Value MalpracticeMalpractice GeographicGeographic Conversion Factor (approx. $37.8975 Conversion Factor (approx. $37.8975

02.2005)02.2005)

cptcpt 7171

RVU Components PercentagesRVU Components Percentages

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

NOTE: Within 5-10 years, another major NOTE: Within 5-10 years, another major component will be performance; in other component will be performance; in other words, not only the work must be words, not only the work must be performed but some results should occur performed but some results should occur as a function of the serviceas a function of the service

cptcpt 7272

Defining Physician WorkDefining Physician Work

Clinical WorkClinical Work Mental Effort and JudgmentMental Effort and Judgment Technical Skill/Physical EffortTechnical Skill/Physical Effort Psychological StressPsychological Stress

cptcpt 7373

Estimate of Psychologists’ Estimate of Psychologists’ ValueValue

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

PsychologistPsychologist .82.82

cptcpt 7474

Defining Practice ExpenseDefining Practice Expense

Constitutes 43% of Medicare Constitutes 43% of Medicare PaymentsPayments

Components of Practice ExpenseComponents of Practice Expense Clinical non-physician labor (43 Clinical non-physician labor (43

categories)categories) RN/LPN/MTA = $.37/minute ( $37,440/year)RN/LPN/MTA = $.37/minute ( $37,440/year)

Medical disposable supplies (842 items)Medical disposable supplies (842 items) Equipment (553 items)Equipment (553 items)

cptcpt 7575

RVU: ValuesRVU: Values

Psychotherapy:Psychotherapy: Prior Value =1.86Prior Value =1.86 New Value = 2.65New Value = 2.65

Psych/NP Testing: Psych/NP Testing: Work value= 0Work value= 0 Hsiao study recommendation = 2.2Hsiao study recommendation = 2.2 New Value = undeterminedNew Value = undetermined

Health & BehaviorHealth & Behavior .25 (per 15 minutes increments).25 (per 15 minutes increments)

cptcpt 7676

RVU: AcceptanceRVU: Acceptance

Medicare (100% since 01.01.92)Medicare (100% since 01.01.92) Medicaid = 100%Medicaid = 100% Private Payors = 74% and increasing to Private Payors = 74% and increasing to

95%95% Blue Cross/Blue Shield = 87%Blue Cross/Blue Shield = 87% Managed Care = 69%Managed Care = 69%

Other = 44%Other = 44% New Trends: New Trends:

RVUs as a Model for All Insurance CompaniesRVUs as a Model for All Insurance Companies RVUs as a Basis for Compensation FormulasRVUs as a Basis for Compensation Formulas

cptcpt 7777

CPT x RVU CPT x RVU Pre 2006Pre 2006

CPTCode

WorkValue

PracticeExpense

MalpracticeExpense

TotalRVU

MutuallyExclusive

90801 2.80 1.14 0.06 4.00 90802, 90846, 90847,90853, 99291, 99292

90806 1.86 0.75 0.04 2.65 90801 (?)

96100 0 1.67 0.15 1.82 96110, 96 115

96115 0 1.67 0.15 1.82 - // -

96117 0 1.67 0.15 1.82 96110, 96111

96150 0.5 0.2 0.02 0.72 96151, 96152, 96153,96154, 96155

96152 0.46 0.18 0.02 0.66 96150, 96151, 96153,96154, 96155

cptcpt 7878

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

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

9610196101 2.562.56 2.542.54 92.6192.61 91.8991.89

9610296102 1.171.17 0.680.68 42.3342.33 24.6024.60

9610396103 0.740.74 0.700.70 26.7726.77 25.3225.32

9611696116 2.872.87 2.682.68 103.83103.83 96.9596.95

9611896118 3.433.43 2.672.67 124.09124.09 96.5996.59

9611996119 1.751.75 0.920.92 63.3163.31 33.2833.28

9612096120 1.271.27 0.700.70 45.9445.94 25.3225.32

cptcpt 7979

III. ProblemsIII. Problems

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

cptcpt 8080

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

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

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

Psych.Psych.)) RationaleRationale

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

Recommended Supervision Level = GeneralRecommended Supervision Level = General

cptcpt 8181

SupervisionSupervision

SupervisionSupervision 1.General = overall direction1.General = overall direction 2.Direct = present in office suite2.Direct = present in office suite 3.Personal = in actual room3.Personal = in actual room 4.Psychological = when supervised by a 4.Psychological = when supervised by a

psychologistpsychologist

cptcpt 8282

SupervisionSupervisionProgram Memorandum CarriersProgram Memorandum Carriers

Department of Health and Human Services- HCFADepartment of Health and Human Services- HCFATransmittal b-01-28; April 19, 2001Transmittal b-01-28; April 19, 2001

Levels of SupervisionLevels of Supervision GeneralGeneral

Furnished under overall direction and control, Furnished under overall direction and control, presence is not requiredpresence is not required

DirectDirect Must be present in the office suite and immediately Must be present in the office suite and immediately

available to furnish assistance and direction available to furnish assistance and direction throughout the performance of the procedurethroughout the performance of the procedure

PersonalPersonal Must be in attendance in the room during the Must be in attendance in the room during the

performance of the procedureperformance of the procedure

cptcpt 8383

Incident toIncident to Rationale for Incident toRationale for Incident to

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

Definition of Physician ExtenderDefinition of Physician Extender HowHow LimitationsLimitations

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

Probably no Future to Incident toProbably no Future to Incident to

cptcpt 8484

Defining Incident toDefining Incident to

DefinitionDefinition Commonly furnished serviceCommonly furnished service Integral, though incidental to psychologistIntegral, though incidental to psychologist Performed under direct supervisionPerformed under direct supervision Either furnished without charge or as part Either furnished without charge or as part

of the psychologist’s chargeof the psychologist’s charge The employee meets the contractual The employee meets the contractual

requirement sent by CMS (e.g., 1099)requirement sent by CMS (e.g., 1099)

cptcpt 8585

More Incident toMore Incident to

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

ProbablyProbably Psychotherapy – CMS is not opposed to Psychotherapy – CMS is not opposed to

incident for this serviceincident for this service

cptcpt 8686

Incident to & Incident to & Site of ServiceSite of Service

Outpatient vs. InpatientOutpatient vs. Inpatient Geographical Location- SeparateGeographical Location- Separate Corporate Entities- SeparateCorporate Entities- Separate Billing Service- SeparateBilling Service- Separate Chart Information & Location- SeparateChart Information & Location- Separate

cptcpt 8787

Incident to versus Incident to versus Independent ServiceIndependent Service

When Does Incident to Become When Does Incident to Become Independent ServiceIndependent Service Appearance of No SupervisionAppearance of No Supervision Clinical Decisions are Made by StaffClinical Decisions are Made by Staff Ratio of Physician to Staff Time Ratio of Physician to Staff Time

Becomes DisproportionateBecomes Disproportionate Distance DifficultiesDistance Difficulties Supervision DifficultiesSupervision Difficulties

cptcpt 8888

Difficulties with Incident toDifficulties with Incident to

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

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

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

cptcpt 8989

Difference Between Difference Between Supervision and “Incident to”Supervision and “Incident to”

SupervisionSupervision Applies to whether Applies to whether

and how a and how a “physician” oversees “physician” oversees the work of ancillary the work of ancillary personnelpersonnel

A A clinicalclinical concept concept Can occur at any Can occur at any

level of supervision level of supervision (from general to (from general to personal)personal)

““Incident to”Incident to” Applies when billing Applies when billing

for services for services supervised by a supervised by a “physician”“physician”

An An economiceconomic concept concept Can only occur when Can only occur when

supervision is “direct” supervision is “direct” (i.e., in the same office (i.e., in the same office suite)suite)

Note: no “incident to” Note: no “incident to” in inpatient settings in inpatient settings for Medicarefor Medicare

cptcpt 9090

The Future of Incident to vs. The Future of Incident to vs. SupervisionSupervision

Incident toIncident to InterventionIntervention

Technical Interventions such as biofeedback and Technical Interventions such as biofeedback and cognitive rehabilitationcognitive rehabilitation

TestingTesting None , if technical codes acceptedNone , if technical codes accepted If not, presumably it can continueIf not, presumably it can continue

SupervisionSupervision Regardless, some form of supervision required Regardless, some form of supervision required

if a technician is usedif a technician is used

cptcpt 9191

Problem: Defining a Problem: Defining a TechnicianTechnician

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

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

Level of TrainingLevel of Training Level of SupervisionLevel of Supervision

cptcpt 9292

Defining a TechnicianDefining a Technician(Federal Register, Vol. 66, #149, page (Federal Register, Vol. 66, #149, page

40382)40382) RequirementRequirement

Employee (e.g., 1099); “employees, leased Employee (e.g., 1099); “employees, leased employees, or independent contractor”employees, or independent contractor”

Most common is independent contractorMost common is independent contractor ““We do not believe that the nature of the We do not believe that the nature of the

employment relationship is critical for purposes employment relationship is critical for purposes of payment to the services of physician…as of payment to the services of physician…as long as…(the personnel) is under the required long as…(the personnel) is under the required level of supervision.”level of supervision.”

Common PracticeCommon Practice Independent ContractorIndependent Contractor

cptcpt 9393

Defining a TechnicianDefining a Technician

HCFA/CMS Line 25HCFA/CMS Line 25 This is the line that identifies in a common This is the line that identifies in a common

insurance form who is the “qualified health insurance form who is the “qualified health provider” that is responsible for and completing provider” that is responsible for and completing the servicethe service

Anybody else, from high school to post-doctoral Anybody else, from high school to post-doctoral fellow, is, for all practical purposes, a technicianfellow, is, for all practical purposes, a technician

Extern, Intern, Postdoctoral Fellow, Extern, Intern, Postdoctoral Fellow, TechnicianTechnician

cptcpt 9494

Acceptance of TechniciansAcceptance of Technicians

MedicareMedicare Outside of North Central & California, yesOutside of North Central & California, yes Some states require specific modifiers Some states require specific modifiers

(e.g., North Carolina, use the “AH” (e.g., North Carolina, use the “AH” modifier)modifier)

Private CarriersPrivate Carriers Magellan, United Health… – yesMagellan, United Health… – yes Others (e.g., Value Options) – under Others (e.g., Value Options) – under

considerationconsideration

cptcpt 9595

Uses of TechniciansUses of Technicians

The Qualified Health Provider must;The Qualified Health Provider must; See the patient firstSee the patient first Supervise the activitySupervise the activity Interpret and write the note/reportInterpret and write the note/report Engaged in an ongoing capacityEngaged in an ongoing capacity

NOTE: Pattern similar to medical NOTE: Pattern similar to medical providersproviders

cptcpt 9696

Use of TechnicianUse of Technician

Technicians in a “Facility”Technicians in a “Facility” A “facility” in essentially an inpatient settingA “facility” in essentially an inpatient setting If a technician is an employee of a private If a technician is an employee of a private

provider but the service is provided in an provider but the service is provided in an inpatient setting, the inpatient fee would be inpatient setting, the inpatient fee would be usedused

If a technician is an employee of a a facility, If a technician is an employee of a a facility, there is some question as to whether they there is some question as to whether they could be supervised by a provider who is not could be supervised by a provider who is not an employee of the facilityan employee of the facility

cptcpt 9797

Use of TechniciansUse of Technicians

Practice Expense & Practice ImplicationsPractice Expense & Practice Implications Each tech code has .51 work valueEach tech code has .51 work value This means that the provider is engaged in the This means that the provider is engaged in the

workwork That engagement would include;That engagement would include;

Selection of testsSelection of tests Determination of testing protocolDetermination of testing protocol Supervision of testingSupervision of testing Interpretation of individual testsInterpretation of individual tests Reporting on individual testsReporting on individual tests

cptcpt 9898

PaymentPayment

MedicareMedicare Proposed 4.4% cut reversed 02.01.06Proposed 4.4% cut reversed 02.01.06 No changes from 2005 fee scheduleNo changes from 2005 fee schedule

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

cptcpt 9999

National Coverage PolicyNational Coverage Policy

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

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

cptcpt 100100

CMS Determination of CMS Determination of CoverageCoverage

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

provider)provider) Coverage without ConditionsCoverage without Conditions

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

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

cptcpt 101101

Billing ModelBilling Model

ComponentsComponents Procedure CompletedProcedure Completed Number of Units of that ProcedureNumber of Units of that Procedure Location or Site Where the Service was Location or Site Where the Service was

ProvidedProvided Date of ServiceDate of Service

CPT CPT XX # of Units # of Units X X Dx Dx XX Site of Site of Service Service XX Date Date

cptcpt 102102

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

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

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

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

cptcpt 103103

Expenditures & FraudExpenditures & Fraud

ProjectionsProjections CurrentCurrent

14%14% By 2011;By 2011;

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

cptcpt 104104

Fraud: Medicare’s Fraud: Medicare’s Interpretation of Physician Interpretation of Physician

LiabilityLiability Overpayment From Incorrect ChargeOverpayment From Incorrect Charge Mathematical or Clerical ErrorMathematical or Clerical Error Billing for Items Known Not to be Billing for Items Known Not to be

CoveredCovered Services Provided by Non-qualified Services Provided by Non-qualified

PractitionerPractitioner Inappropriate DocumentationInappropriate Documentation

cptcpt 105105

Defining FraudDefining Fraud

FraudFraud IntentionalIntentional PatternPattern

ErrorError ClericalClerical DatesDates

cptcpt 106106

Problem: Fraud & AbuseProblem: Fraud & Abuse

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

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

cptcpt 107107

Fraud & Office of Inspector Fraud & Office of Inspector GeneralGeneral

Primary ProblemsPrimary Problems Medical Necessity (approximately $5 billion)Medical Necessity (approximately $5 billion) DocumentationDocumentation

Psychotherapy Psychotherapy (oig.hhs/gov/reports/region5/50100068)(oig.hhs/gov/reports/region5/50100068) IndividualIndividual GroupGroup # of Hours# of Hours Who Does the TherapyWho Does the Therapy

Psychological TestingPsychological Testing # of Hours# of Hours DocumentationDocumentation

cptcpt 108108

Fraud: OIG’s May 2001 Fraud: OIG’s May 2001 StudyStudy

(OEI-03-99-00130)(OEI-03-99-00130) Overall Payments in 1998 = $1.2 billionOverall Payments in 1998 = $1.2 billion

(62% outpatient = $718 million)(62% outpatient = $718 million) Inappropriate Outpatient Mental HealthInappropriate Outpatient Mental Health ““Particularly Problematic” due to Particularly Problematic” due to

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

cptcpt 109109

OIG Report (continued)OIG Report (continued)

Provider Not QualifiedProvider Not Qualified = 11%= 11% Medically Unnecessary Medically Unnecessary = =

23%23% Billed IncorrectlyBilled Incorrectly = 41%= 41% Insufficient DocumentationInsufficient Documentation = =

65%65%

cptcpt 110110

V. Future PerspectivesV. Future Perspectives: : 2003 Predictions2003 Predictions

ParadigmsParadigms Industrial vs. Boutique/NicheIndustrial vs. Boutique/Niche Clinical vs. ForensicClinical vs. Forensic Mental Health vs. HealthMental Health vs. Health Existing vs. Developing Existing vs. Developing

cptcpt 111111

2004 Predictions2004 Predictions

Federal Federal Technical – Health Electronic Records by 2008Technical – Health Electronic Records by 2008 Performance Based PaymentPerformance Based Payment

Traditionally = Fee for service providedTraditionally = Fee for service provided Anticipated = Fee for performance/results Anticipated = Fee for performance/results

obtainedobtained EconomicEconomic

Overall, PositiveOverall, Positive

cptcpt 112112

2004 (Continued)2004 (Continued)

Increased Probability of AuditsIncreased Probability of Audits Psychological and Neuropsychological Psychological and Neuropsychological

TestingTesting Individual PractitionersIndividual Practitioners Skilled Nursing FacilitiesSkilled Nursing Facilities In Institutions, supervision and “incident to”In Institutions, supervision and “incident to”

Primary Issues of ConcernPrimary Issues of Concern Medical NecessityMedical Necessity DocumentationDocumentation

cptcpt 113113

2004 (Continued)2004 (Continued)

ProfessionalProfessional Institutionally BasedInstitutionally Based

Limitations secondary to “incident to”Limitations secondary to “incident to” Difficulties in gaining access to GME fundsDifficulties in gaining access to GME funds

Practitioner BasedPractitioner Based Increase in auditsIncrease in audits Shifting in practice patterns Shifting in practice patterns

Practice Parameter BasedPractice Parameter Based Difficulties with battery-based approaches to diagnosticsDifficulties with battery-based approaches to diagnostics Expansion and alterations of reimbursement practicesExpansion and alterations of reimbursement practices Significant expansion of types of services and clients servedSignificant expansion of types of services and clients served

cptcpt 114114

20052005

MedicareMedicare 4.3-4.6% decrease over next 6 years (compared to 1.5% increase each 4.3-4.6% decrease over next 6 years (compared to 1.5% increase each

over the last 3 years; over the last 3 years; AAP AdvanceAAP Advance, Summer, 2005), Summer, 2005) InstitutionalInstitutional

Further defining of supervision & incident toFurther defining of supervision & incident to Significantly limited access to funds (e.g., GME)Significantly limited access to funds (e.g., GME)

IndividualIndividual Increased focus on business issuesIncreased focus on business issues Technician based practice will increaseTechnician based practice will increase Continued emphasizes on expanding non-health care services (e.g., Continued emphasizes on expanding non-health care services (e.g.,

forensic)forensic) PracticePractice

Diagnostic work will continue being emphasized (e.g.,fMRI)Diagnostic work will continue being emphasized (e.g.,fMRI) Pay-for-Performance or P4P (5-10% differences; Medicare Payment Pay-for-Performance or P4P (5-10% differences; Medicare Payment

Advisory Commission, 09.15.05)Advisory Commission, 09.15.05) WellPoint, WellChoice, HealthNet, MVP Health Care, Blue Cross of California WellPoint, WellChoice, HealthNet, MVP Health Care, Blue Cross of California

and 32 states (105 programs in mid 2005)and 32 states (105 programs in mid 2005)

cptcpt 115115

20052005

Issues to be AddressedIssues to be Addressed Information disseminationInformation dissemination

ColleaguesColleagues Third-party insurers/payorsThird-party insurers/payors

Potential mix of “old” and “new” testing codes for 2006Potential mix of “old” and “new” testing codes for 2006 Typical use of combination of codesTypical use of combination of codes Technician qualifications and trainingTechnician qualifications and training Use of computerized tests Vs. tests that are Use of computerized tests Vs. tests that are

computerized but interactivecomputerized but interactive Appropriate documentationAppropriate documentation

Technician identificationTechnician identification Time for testing and therapyTime for testing and therapy

cptcpt 116116

20062006

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

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

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

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

By 2010 = Addition of Performance to Work as a By 2010 = Addition of Performance to Work as a Factor for ReimbursementFactor for Reimbursement

cptcpt 117117

Beyond 2006Beyond 2006(CMS)(CMS)

Health Care Spending & GDPHealth Care Spending & GDP 1960 =1960 = 5.0% 5.0% 1970 =1970 = 7.0% 7.0% 1990 =1990 = 9.0%9.0% 2002 = 2002 = 15.4%15.4% 2004 = 2004 = 16.0%16.0% 2005 = 2005 = 16.2%16.2% 20010=20010= 18.0%18.0% 2015 =2015 = 20.0% ( or 4 trillion $) 20.0% ( or 4 trillion $) Final =Final = 33.3%33.3%

cptcpt 118118

What Does the American Public What Does the American Public Want?Want?

Life Expectancy #1Life Expectancy #1 Life Value = approximately $5 millionLife Value = approximately $5 million Expected Expenditure on Health Care= will Expected Expenditure on Health Care= will

finally settle at about 1/3 of earned incomefinally settle at about 1/3 of earned income To be Competitive, Industry and Business will To be Competitive, Industry and Business will

Shift Cost of Health Care to Consumers and the Shift Cost of Health Care to Consumers and the GovernmentGovernment

Government Will, In Turn, Cost Share with the Government Will, In Turn, Cost Share with the ConsumerConsumer

They Will, However, Set the Standard for Health They Will, However, Set the Standard for Health Care Care

cptcpt 119119

Mechanisms to Keep Mechanisms to Keep InformedInformed

APA Practice Website (www.apa.org)APA Practice Website (www.apa.org) NAN Website (NAN Website (www.nanonline.orgwww.nanonline.org))

Support these continuing efforts by Support these continuing efforts by joining, APA, 40 and NANjoining, APA, 40 and NAN

cptcpt 120120

V. ResourcesV. Resources

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

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

cptcpt 121121

Resources Resources (continued)(continued)

Payment/CoveragePayment/Coverage www.myhealthscore.com/consumer/phyoutcptsearch.htmwww.myhealthscore.com/consumer/phyoutcptsearch.htm www.cms.hhs.gov/statistics/feeforservice/defailt.aspwww.cms.hhs.gov/statistics/feeforservice/defailt.asp (covered services) (covered services) www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=167www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=167 (non-covered) (non-covered) www.apa.org/pi/aging/lmrp/toolkit/homepage.htmlwww.apa.org/pi/aging/lmrp/toolkit/homepage.html (apa lmrp) (apa lmrp) www.cms.hhs.gov/providers/mr/lmrp/aspwww.cms.hhs.gov/providers/mr/lmrp/asp (medicare lmrp) (medicare lmrp) www.quickfacts.census.gov/qfdwww.quickfacts.census.gov/qfd (census x type of procedure data) (census x type of procedure data)

LMRP Reconsideration ProcessLMRP Reconsideration Process www.cms.gov/manuals/pm_trans/R28PIM.pdfwww.cms.gov/manuals/pm_trans/R28PIM.pdf

Compliance Web SitesCompliance Web Sites www.oig.hhs.gov (office of inspector general)www.oig.hhs.gov (office of inspector general) www.cms.hhs.gov/manualswww.cms.hhs.gov/manuals (medicare) (medicare) www.uscode.house.gov/usc.htmwww.uscode.house.gov/usc.htm (united states codes) (united states codes) www.apa.orgwww.apa.org (psychologists & hipaa) (psychologists & hipaa) www.cms.hhs.gov/hipaawww.cms.hhs.gov/hipaa. (hipaa). (hipaa) www.hcca-info.orgwww.hcca-info.org (health care compliance assoc.) (health care compliance assoc.)

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Resources Resources (continued)(continued)

ICDICD www.who.int/icd/vol1htm2003/fr-icd.htmwww.who.int/icd/vol1htm2003/fr-icd.htm (who) (who) www.cdc.gov/nchas/about/otheract/icd9/abticdwww.cdc.gov/nchas/about/otheract/icd9/abticd

9.htm9.htm (ccd) (ccd)

Coding Web SitesCoding Web Sites www.catalog.ama-assn.org/Catalog/cpt/cptwww.catalog.ama-assn.org/Catalog/cpt/cpt

_search.jsp_search.jsp (ama cpt) (ama cpt)

www.aapcnatl.orgwww.aapcnatl.org (academy of coders) (academy of coders) www.ntis.gov/product/correct-codingwww.ntis.gov/product/correct-coding

(coding edits)(coding edits)

cptcpt 123123

Contact InformationContact Information

WebsitesWebsites Univ = Univ = www.uncw.edu/people/puentewww.uncw.edu/people/puente Practice = Practice = www.clinicalneuropsychology.uswww.clinicalneuropsychology.us NAN = www.nanonline.org/paioNAN = www.nanonline.org/paio

E-mailE-mail University = pUniversity = [email protected]@uncw.edu Practice = [email protected] = [email protected]

TelephoneTelephone University = 910.962.3812University = 910.962.3812 Practice = 910.509.9371Practice = 910.509.9371