Cpt1 Making a Living in Professional Psychology: Coding, Billing and Documenting Psychological Services Antonio E. Puente University of North Carolina.

cptcpt 11

Making a Living in Professional Making a Living in Professional Psychology:Psychology:

Coding, Billing and Documenting Coding, Billing and Documenting Psychological ServicesPsychological Services

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

Florida Institute of TechnologyFlorida Institute of TechnologyApril 14, 2006April 14, 2006

cptcpt 22

AcknowledgmentsAcknowledgments

North Carolina Psychological AssociationNorth Carolina Psychological Association Practice Directorate of the American Psychological Association (APA)Practice Directorate of the American Psychological Association (APA) American Medical Association (AMA) CPT StaffAmerican Medical Association (AMA) CPT Staff National Academy of Neuropsychology (NAN)National Academy of Neuropsychology (NAN) Division of Clinical Neuropsychology- APADivision of Clinical Neuropsychology- APA Center for Medicare & Medicaid Services Medical Policy Staff- Center for Medicare & Medicaid Services Medical Policy Staff-

MedicareMedicare Inter-Divisional Health Care Committee- APAInter-Divisional Health Care Committee- APA Department of Psychology, UNC-WilmingtonDepartment of Psychology, UNC-Wilmington

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

cptcpt 33

Specific Support Provided by Primary Specific Support Provided by Primary OrganizationsOrganizations

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

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

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

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

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

cptcpt 44

BackgroundBackground(1988 – present)(1988 – present)

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

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

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

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

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

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

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

cptcpt 55

Primary Goal & General Primary Goal & General Outcome Outcome

of CPT Workof CPT Work Goal (20 year plan)Goal (20 year plan)

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

Outcome (presently)Outcome (presently) Intended/Anticipated/HopedIntended/Anticipated/Hoped

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

Less AnticipatedLess Anticipated Transparency Transparency AccountabilityAccountability UniformityUniformity Potential impact on certain practice patternsPotential impact on certain practice patterns

cptcpt 66

Primary Goals of PresentationPrimary Goals of Presentation

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

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

Introduce the New Testing and Interview CodesIntroduce the New Testing and Interview Codes Suggest a Model System for Coding Suggest a Model System for Coding Explain the Concept of Medical NecessityExplain the Concept of Medical Necessity Provide Suggestions for DocumentationProvide Suggestions for Documentation Define TimeDefine Time Explain Reimbursement PracticesExplain Reimbursement Practices Address Supervision and Incident toAddress Supervision and Incident to Explain the Concept of Fraud Versus ErrorsExplain the Concept of Fraud Versus Errors Address Current and Potential Problems Address Current and Potential Problems Provide Trajectory for 2006 and BeyondProvide Trajectory for 2006 and Beyond

cptcpt 77

Outline of PresentationOutline of Presentation

Part I: Coding, Billing and Part I: Coding, Billing and Documentation Documentation (Introductory)(Introductory)

Part II: Specific Issues with CPT Part II: Specific Issues with CPT (Intermediate)(Intermediate)

Part III: Projections; Questions & Part III: Projections; Questions & Answers Answers (Advanced)(Advanced)

cptcpt 88

Part I: Coding, Billing & Part I: Coding, Billing & DocumentationDocumentation(Introductory)(Introductory)

Part I:Part I: MedicareMedicare Current Procedural TerminologyCurrent Procedural Terminology DiagnosingDiagnosing Medical NecessityMedical Necessity Documentation Documentation TimeTime Site of Service Site of Service

cptcpt 99

A. Medicare: Why?A. Medicare: Why?

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

occurred)occurred)

cptcpt 1010

Medicare: Immediate Medicare: Immediate ImpactImpact

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

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

cptcpt 1111

Medicare: Long-term ImpactMedicare: Long-term Impact

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

Eventually, a national (US) health Eventually, a national (US) health insurance will be establishedinsurance will be established

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

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

cptcpt 1212

Medicare: OverviewMedicare: Overview

Centers for Medicare and Medicaid Centers for Medicare and Medicaid ServicesServices

BenefitsBenefits Part A (Hospital)Part A (Hospital) Part B (Supplementary)Part B (Supplementary) Part C (Medicare+ Choice)Part C (Medicare+ Choice) Part D (Pharmaceutical)Part D (Pharmaceutical)

cptcpt 1313

Medicare: Local ReviewMedicare: Local Review

Medical Review Policy Medical Review Policy National Policy Sets Overall ModelNational Policy Sets Overall Model Local Coverage Determination (LCD) Sets Local Coverage Determination (LCD) Sets

Local/Regional Policy-Local/Regional Policy- More restrictive than national policyMore restrictive than national policy Over-rides national policyOver-rides national policy Changes frequently without warning or publicityChanges frequently without warning or publicity Information best found on respective web pagesInformation best found on respective web pages

cptcpt 1414

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

OverviewOverview

BackgroundBackground Codes & CodingCodes & Coding Existing CodesExisting Codes Model System X Type of ProblemModel System X Type of Problem

cptcpt 1515

CPT: BackgroundCPT: Background

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

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

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

cptcpt 1616

CPT: CompositionCPT: Composition

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

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

CPT Editorial PanelCPT Editorial Panel 17 Voting Members17 Voting Members

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

cptcpt 1717

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

A Coding System Developed by AMA in A Coding System Developed by AMA in Conjunction with CMS to Describe Conjunction with CMS to Describe Professional Services Professional Services

Each Code has a Specific Number and Each Code has a Specific Number and Description as well as a Reimbursable ValueDescription as well as a Reimbursable Value

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

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

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

cptcpt 1818

CPT: Applicable CodesCPT: Applicable Codes

Total Possible Codes = Approximately 7,500Total Possible Codes = Approximately 7,500 Possible Codes for Psychology = Possible Codes for Psychology =

Approximately 40 to 60Approximately 40 to 60 Sections = Five Primary Separate SectionsSections = Five Primary Separate Sections

Psychiatry (e.g., mental health)Psychiatry (e.g., mental health) BiofeedbackBiofeedback Central Nervous System Assessment (testing)Central Nervous System Assessment (testing) Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Health & Behavior Assessment & Management Health & Behavior Assessment & Management

(h.p.)(h.p.) Evaluation and Management Evaluation and Management

cptcpt 1919

CPT: Development of a CodeCPT: Development of a Code

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

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

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

cptcpt 2020

CPT: PsychiatryCPT: Psychiatry

Sections (or Categories)Sections (or Categories) Interview (Interview (9080190801) vs. Intervention (e.g., ) vs. Intervention (e.g., 9080690806)) These codes are one unitThese codes are one unit Office vs. InpatientOffice vs. Inpatient Regular vs. Evaluation & ManagementRegular vs. Evaluation & Management OtherOther

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

vs. Interactivevs. Interactive

cptcpt 2121

Psychiatric CodesPsychiatric Codes

InterviewingInterviewing 9080190801 One time per illness incident or boutOne time per illness incident or bout UntimedUntimed Comprehensive analysis of records, Comprehensive analysis of records,

observations as well as structured observations as well as structured and/or unstructured clinical interviewand/or unstructured clinical interview

cptcpt 2222

Psychiatric CodesPsychiatric Codes

TherapyTherapy 20 minutes = 9080420 minutes = 90804 45-50 minutes = 9080645-50 minutes = 90806 80-90 minutes = 9080880-90 minutes = 90808

cptcpt 2323

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

TimetableTimetable Activity x DateActivity x Date

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

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

cptcpt 2424

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

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

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

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

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

cptcpt 2525

Psychological Testing:Psychological Testing:By ProfessionalBy Professional

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

emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology, e.g., personality and psychopathology, e.g., MMPI, Rorschach, WAIS (per hour of MMPI, Rorschach, WAIS (per hour of psychologist’s orpsychologist’s or physician’sphysician’s time, both time, both face-to-face time with the patient and face-to-face time with the patient and time interpreting test results and time interpreting test results and preparing the report)preparing the report)(note: “psychologist’s or physician’s” will (note: “psychologist’s or physician’s” will probably be changed to “qualified health probably be changed to “qualified health professional”)professional”)

cptcpt 2626

Psychological Testing:Psychological Testing:By TechnicianBy Technician

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

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

cptcpt 2727

Psychological Testing:Psychological Testing:By ComputerBy Computer

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

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

cptcpt 2828

Neurobehavioral Status Neurobehavioral Status ExamExam

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

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

(note: “psychologist’s or physician’s” will (note: “psychologist’s or physician’s” will probably be changed to “qualified health probably be changed to “qualified health professional”)professional”)

cptcpt 2929

Neuropsychological Testing-Neuropsychological Testing-By ProfessionalBy Professional

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

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

(note: “psychologist’s or physician’s” will (note: “psychologist’s or physician’s” will probably be changed to “qualified health probably be changed to “qualified health professional”)professional”)

cptcpt 3030

Neuropsychological Testing:Neuropsychological Testing:By TechnicianBy Technician

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

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

cptcpt 3131

Neuropsychological Testing-Neuropsychological Testing-By ComputerBy Computer

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

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

cptcpt 3232

CNS Assessment ExamplesCNS Assessment Examples

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

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

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

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

cptcpt 3333

CPT: Physical Medicine & CPT: Physical Medicine & RehabilitationRehabilitation

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

cptcpt 3434

CPT: Cognitive CPT: Cognitive RehabilitationRehabilitation

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

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

cptcpt 3535

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

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

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

cptcpt 3636

Overview of H & B CodesOverview of H & B Codes

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

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

Established Medical Illness or Established Medical Illness or DiagnosisDiagnosis

Focus on Biopsychosocial FactorsFocus on Biopsychosocial Factors

cptcpt 3737

H & B: RationaleH & B: Rationale

Acute or Chronic Health IllnessAcute or Chronic Health Illness Not Applicable to Psychiatric IllnessNot Applicable to Psychiatric Illness However, Both Could be Treated However, Both Could be Treated

Simultaneously But Not Within the Simultaneously But Not Within the Same SessionSame Session

cptcpt 3838

H & B: Examples of ServiceH & B: Examples of Service

Symptom Management & ExpressionSymptom Management & Expression Patient Adherence to Medical Patient Adherence to Medical

TreatmentTreatment Health Promoting BehaviorsHealth Promoting Behaviors Overall Adjustment to Medical IllnessOverall Adjustment to Medical Illness

cptcpt 3939

Health & Behavior Health & Behavior Assessment CodesAssessment Codes

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

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

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

9615196151 re-assessmentre-assessment

cptcpt 4040

H & B: Assessment H & B: Assessment ExplanationExplanation

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

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

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

cptcpt 4141

H & B: Assessment H & B: Assessment ExamplesExamples

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

cptcpt 4242

Health & Behavior Health & Behavior Intervention CodesIntervention Codes

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

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

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

9615596155 (limited acceptability)(limited acceptability) family (without the patient present; not being family (without the patient present; not being

reimbursedreimbursed))

cptcpt 4343

H & B: Intervention H & B: Intervention ExplanationExplanation

Modification of Psychological, Behavioral, Modification of Psychological, Behavioral, Emotional, Cognitive and/or Social Emotional, Cognitive and/or Social FactorsFactors

Affecting Physiological Functioning, Affecting Physiological Functioning, Disease Status, Health and/or Well-BeingDisease Status, Health and/or Well-Being

Focus = Improvement of Health with Focus = Improvement of Health with Cognitive, Behavioral, Social and/or Cognitive, Behavioral, Social and/or Psychophysiological ProceduresPsychophysiological Procedures

cptcpt 4444

H & B: Intervention H & B: Intervention ExamplesExamples

CognitiveCognitive BehavioralBehavioral Social Social PsychophysiologicalPsychophysiological

cptcpt 4545

H & B: DiagnosesH & B: Diagnoses

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

Not Applicable to Psychiatric Not Applicable to Psychiatric DiagnosesDiagnoses

cptcpt 4646

CPT: Model SystemCPT: Model System

PsychiatricPsychiatric NeurologicalNeurological Non-Neurological MedicalNon-Neurological Medical

cptcpt 4747

CPT ModelCPT Model

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

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

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

Goal = Uniformity and FluencyGoal = Uniformity and Fluency

cptcpt 4848

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

InterviewInterview 9080190801- adult- adult 9080290802- child- child

TestingTesting 96101-0396101-03 Also, Also, 9611196111 for childrenfor children

InterventionIntervention e.g., e.g., 9080690806- adult- adult e.g., e.g., 9082090820-child-child

cptcpt 4949

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

InterviewInterview 9611696116

TestingTesting 96118/19/2096118/19/20

InterventionIntervention 9753297532

cptcpt 5050

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

(Children & Adult)(Children & Adult)

Interview & AssessmentInterview & Assessment 96150 96150 (initial)(initial) 9615196151 (re-evaluation) (re-evaluation)

InterventionIntervention 9615296152 (individual) (individual) 9615396153 (group) (group) 9615496154 (family with patient) (family with patient)

cptcpt 5151

C. CPT: DiagnosingC. CPT: Diagnosing

PsychiatricPsychiatric DSMDSM

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

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

cptcpt 5252

D. CPT: Medical NecessityD. CPT: Medical Necessity

Scientific & Clinical NecessityScientific & Clinical Necessity Local Medical Review or Carrier Definitions of Local Medical Review or Carrier Definitions of

NecessityNecessity Necessity = CPT x DX formularyNecessity = CPT x DX formulary Necessity Dictates Type and Level of ServiceNecessity Dictates Type and Level of Service Necessity Can Only be Proven with Necessity Can Only be Proven with

DocumentationDocumentation Screening or Regularly Scheduled Evaluations Screening or Regularly Scheduled Evaluations

Do Not Meet Criteria for NecessityDo Not Meet Criteria for Necessity Will Results Affect Outcome of Patient?Will Results Affect Outcome of Patient? Will New Information Be Obtained as a Will New Information Be Obtained as a

Function of the Activity?Function of the Activity?

cptcpt 5353

Medically Reasonable and Medically Reasonable and NecessaryNecessary

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

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

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

cptcpt 5454

E. CPT: DocumentingE. CPT: Documenting

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

cptcpt 5555

Documentation: PurposeDocumentation: Purpose

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

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

cptcpt 5656

Documentation: General Documentation: General PrinciplesPrinciples

Rationale for ServiceRationale for Service Assessment, Progress, Impression, or Assessment, Progress, Impression, or

DiagnosisDiagnosis Plan for CarePlan for Care Date and Identity of ObserverDate and Identity of Observer AlsoAlso

LegibleLegible TimelyTimely ConfidentialConfidential

cptcpt 5757

Documentation: Basic Documentation: Basic Information Across CodesInformation Across Codes

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

cptcpt 5858

Documentation:Documentation: Chief Complaint Chief Complaint

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

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

cptcpt 5959

Documentation: Documentation: Present IllnessPresent Illness

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

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

Follow-upFollow-up Changes in ConditionChanges in Condition ComplianceCompliance

cptcpt 6060

Documentation: HistoryDocumentation: History

PastPast Family Family SocialSocial Medical/PsychologicalMedical/Psychological

cptcpt 6161

Documentation: AssessmentDocumentation: Assessment

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

cptcpt 6262

Documentation: Documentation: InterventionIntervention

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

cptcpt 6363

CPT X ReportCPT X Report

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

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

cptcpt 6464

Documentation:Documentation:SuggestionsSuggestions

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

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

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

cptcpt 6565

Documentation Suggestions Documentation Suggestions (continued)(continued)

Two Tiered System of Documentation Two Tiered System of Documentation (using HIPPA as Model)(using HIPPA as Model) Raw data = handwritten and not for Raw data = handwritten and not for

distribution psychotherapy notesdistribution psychotherapy notes Report = “typed” notes for more public Report = “typed” notes for more public

consumptionconsumption

cptcpt 6666

E. TimeE. Time

Time is Broadly Defined as What the Time is Broadly Defined as What the Professional DoesProfessional Does

For Intervention – Time is face-to-For Intervention – Time is face-to-faceface

For Assessment - Time could be For Assessment - Time could be either face-to-face or professional either face-to-face or professional timetime

cptcpt 6767

Time: DefinitionTime: Definition

AMA Definition of TimeAMA Definition of Time

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

cptcpt 6868

Time: TestingTime: Testing

Quantifying TimeQuantifying Time Round up or down to nearest incrementRound up or down to nearest increment Actual time vs. Elapsed time?Actual time vs. Elapsed time?

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

cptcpt 6969

TimeTime((CPT AssistantCPT Assistant, 08.05, , 08.05, 1515, #8, pg. 12), #8, pg. 12)(www.cms.hhs.gov/providers/therapy)(www.cms.hhs.gov/providers/therapy)

For Timed Codes (in physical For Timed Codes (in physical medicine): The Beginning and Ending medicine): The Beginning and Ending Time Should be DocumentedTime Should be Documented

Time Should be Documented Along Time Should be Documented Along with the Treatment Descriptionwith the Treatment Description

cptcpt 7070

Time: Physical Medicine CodesTime: Physical Medicine Codes(effective 07.01.05)(effective 07.01.05)

Physical Medicine Codes are in 15’ Physical Medicine Codes are in 15’ IncrementsIncrements

Multiple Units Can Be Billed on a Date Multiple Units Can Be Billed on a Date of Service for Same or Different of Service for Same or Different ProceduresProcedures

““A substantial amount portion of 15 A substantial amount portion of 15 minutes must be spent in performing minutes must be spent in performing the pre, intra, and post-service work…”the pre, intra, and post-service work…”

cptcpt 7171

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

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

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

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

cptcpt 7272

Part II: Specific IssuesPart II: Specific Issueswith CPT (Intermediate)with CPT (Intermediate)

ReimbursementReimbursement Supervision & Incident to Supervision & Incident to TechniciansTechnicians TimeTime Coverage & PaymentCoverage & Payment Fraud & AbuseFraud & Abuse UPIN #UPIN #

cptcpt 7373

A. Reimbursement HistoryA. Reimbursement History

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

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

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

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

cptcpt 7474

Relative Value Units: OverviewRelative Value Units: Overview

ComponentsComponents UnitsUnits ValuesValues Current ProblemsCurrent Problems

cptcpt 7575

RVU: ComponentsRVU: Components

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

02.2005)02.2005)

cptcpt 7676

RVU Components PercentagesRVU Components Percentages

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

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

cptcpt 7777

Defining Physician WorkDefining Physician Work

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

cptcpt 7878

Defining Practice ExpenseDefining Practice Expense

Constitutes 43% of Medicare Constitutes 43% of Medicare PaymentsPayments

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

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

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

cptcpt 7979

RVU: ValuesRVU: Values

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

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

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

cptcpt 8080

RVU: AcceptanceRVU: Acceptance

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

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

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

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

cptcpt 8181

2006 RVU Changes2006 RVU Changes((CPT AssistantCPT Assistant, January, 2006, , January, 2006, 1616, 1), 1)

283 RVU Changes Submitted283 RVU Changes Submitted Medicare Accepted 97%Medicare Accepted 97% Professional Liability to Change to Professional Liability to Change to

1.001.00 Geographic Index is Revised Every 3 Geographic Index is Revised Every 3

yrs.yrs.

cptcpt 8282

CPT x RVU CPT x RVU Pre 2006Pre 2006

CPTCode

WorkValue

PracticeExpense

MalpracticeExpense

TotalRVU

MutuallyExclusive

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

90806 1.86 0.75 0.04 2.65 90801 (?)

96100 0 1.67 0.15 1.82 96110, 96 115

96115 0 1.67 0.15 1.82 - // -

96117 0 1.67 0.15 1.82 96110, 96111

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

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

cptcpt 8383

National Work National Work RVU/Estimated $ 2006 RVU/Estimated $ 2006

ValuesValuesop=outpatient, ip=inpatient, est=estimate rvu = op=outpatient, ip=inpatient, est=estimate rvu =

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

9610196101 2.562.56 2.542.54 92.6192.61 91.8991.89

9610296102 1.171.17 0.680.68 42.3342.33 24.6024.60

9610396103 0.740.74 0.700.70 26.7726.77 25.3225.32

9611696116 2.872.87 2.682.68 103.83103.83 96.9596.95

9611896118 3.433.43 2.672.67 124.09124.09 96.5996.59

9611996119 1.751.75 0.920.92 63.3163.31 33.2833.28

9612096120 1.271.27 0.700.70 45.9445.94 25.3225.32

cptcpt 8484

B. SupervisionB. Supervision( ( Federal Register, Federal Register, 6969, #150, August 5, 2004, page 47553), #150, August 5, 2004, page 47553)

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

(and not “independent” psychologists as (and not “independent” psychologists as defined by Medicare)defined by Medicare)

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

Recommended Supervision Level = GeneralRecommended Supervision Level = General

cptcpt 8585

SupervisionSupervision

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

psychologistpsychologist

cptcpt 8686

SupervisionSupervisionProgram Memorandum CarriersProgram Memorandum Carriers

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

Levels of SupervisionLevels of Supervision GeneralGeneral

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

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

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

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

performance of the procedureperformance of the procedure

cptcpt 8787

Incident toIncident to Rationale for Incident toRationale for Incident to

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

Definition of Physician ExtenderDefinition of Physician Extender HowHow LimitationsLimitations

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

Probably Limited Future to Incident to Due Probably Limited Future to Incident to Due to Inclusion of New Testing Codesto Inclusion of New Testing Codes

cptcpt 8888

Defining Incident toDefining Incident to

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

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

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

cptcpt 8989

More Incident toMore Incident to

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

ProbablyProbably Psychotherapy – CMS does not have a Psychotherapy – CMS does not have a

national policy prohibiting national policy prohibiting psychotherapy as a incident to but it has psychotherapy as a incident to but it has supported local carriers when they took supported local carriers when they took the position that psychotherapy should the position that psychotherapy should not be incident tonot be incident to

cptcpt 9090

Incident to & Incident to & Site of ServiceSite of Service

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

cptcpt 9191

Incident to versus Incident to versus Independent ServiceIndependent Service

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

Becomes DisproportionateBecomes Disproportionate Distance DifficultiesDistance Difficulties Supervision DifficultiesSupervision Difficulties

cptcpt 9292

Difficulties with Incident toDifficulties with Incident to

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

No Clear Guidelines Regarding No Clear Guidelines Regarding Reasonable Mix of Physician to Reasonable Mix of Physician to Extender ActivitiesExtender Activities

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

cptcpt 9393

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

SupervisionSupervision Applies to whether Applies to whether

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

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

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

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

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

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

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

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

cptcpt 9494

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

Incident toIncident to InterventionIntervention

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

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

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

if a technician is usedif a technician is used

cptcpt 9595

C. Defining a TechnicianC. Defining a Technician

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

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

Level of TrainingLevel of Training Level of SupervisionLevel of Supervision

cptcpt 9696

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

40382)40382) RequirementRequirement

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

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

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

Common PracticeCommon Practice Independent ContractorIndependent Contractor

cptcpt 9797

Defining a TechnicianDefining a Technician

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

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

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

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

cptcpt 9898

Acceptance of TechniciansAcceptance of Technicians

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

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

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

considerationconsideration

cptcpt 9999

Uses of TechniciansUses of Technicians

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

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

cptcpt 100100

Use of TechnicianUse of Technician

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

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

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

cptcpt 101101

Use of TechniciansUse of Technicians

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

workwork That engagement would include;That engagement would include;

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

cptcpt 102102

The Problem with TrainingThe Problem with Training

Medicare Will Pay When:Medicare Will Pay When: The physician provides the service aloneThe physician provides the service alone The physician provides the service in The physician provides the service in

conjunction with the medical studentconjunction with the medical student The physician is present in the same room The physician is present in the same room

when the student provides the servicewhen the student provides the service Possibility of Students as Incident toPossibility of Students as Incident to A Student/Extern/Intern/Postdoc, For All A Student/Extern/Intern/Postdoc, For All

Practical Purposes = a TechnicianPractical Purposes = a Technician

cptcpt 103103

Medicare Billing Medicare Billing SuggestionsSuggestions

When to BillWhen to Bill Overall = after documentation is in placeOverall = after documentation is in place Diagnostic ServicesDiagnostic Services

After the InterviewAfter the Interview After all testing is completed aAfter all testing is completed andnd a report has been a report has been

completedcompleted Billing should occur only once after testingBilling should occur only once after testing

Therapeutic ServicesTherapeutic Services Could occur after each sessionCould occur after each session Should occur at least by the end of the monthShould occur at least by the end of the month

cptcpt 104104

Billing ModelBilling Model

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

ProvidedProvided Date of ServiceDate of Service

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

cptcpt 105105

E. Office of Inspector General E. Office of Inspector General (2005 Orange Book)(2005 Orange Book)

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

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

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

cptcpt 106106

Expenditures & FraudExpenditures & Fraud

ProjectionsProjections CurrentCurrent

14%14% By 2011;By 2011;

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

cptcpt 107107

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

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

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

PractitionerPractitioner Inappropriate DocumentationInappropriate Documentation

cptcpt 108108

Defining FraudDefining Fraud

FraudFraud IntentionalIntentional PatternPattern

ErrorError ClericalClerical DatesDates

cptcpt 109109

Problem: Fraud & AbuseProblem: Fraud & Abuse

26 Different Kinds of Fraud Types26 Different Kinds of Fraud Types Psychological Services Have Been Psychological Services Have Been

Identified as ProblematicIdentified as Problematic

cptcpt 110110

Fraud & Office of Inspector Fraud & Office of Inspector GeneralGeneral

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

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

Psychological TestingPsychological Testing # of Hours# of Hours DocumentationDocumentation

cptcpt 111111

Fraud (continued)Fraud (continued)

Nursing HomesNursing Homes Identification Identification Overuse of ServicesOveruse of Services

ChildrenChildren

cptcpt 112112

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

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

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

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

cptcpt 113113

OIG Report (continued)OIG Report (continued)

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

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

65%65%

cptcpt 114114

Fraud (cont.)Fraud (cont.)

Estimated Pattern of Fraud AnalysisEstimated Pattern of Fraud Analysis For-profit Medical CentersFor-profit Medical Centers For-profit Medical ClinicsFor-profit Medical Clinics Non-profit Medical CentersNon-profit Medical Centers Non-profit Medical ClinicsNon-profit Medical Clinics Nursing HomesNursing Homes Group PracticesGroup Practices Individual Practices Individual Practices Research Grants and, if applicable, Clinical TrialsResearch Grants and, if applicable, Clinical Trials

cptcpt 115115

Fraud: (can go back 10 Fraud: (can go back 10 years)years)

Initial Review (14 points of submitted Initial Review (14 points of submitted claims)claims) LegibilityLegibility CoverageCoverage Matching datesMatching dates SignatureSignature

Subsequent Review (occurs if over 5-6 Subsequent Review (occurs if over 5-6 items are failed in initial review)items are failed in initial review) Does the service affect a potential change in Does the service affect a potential change in

medical condition?medical condition?

cptcpt 116116

Fraud: CERT ProgramFraud: CERT Program(www.oig.hhs.gov)(www.oig.hhs.gov)

Comprehensive Error Rate Testing Comprehensive Error Rate Testing ProgramProgram NationalNational Contractor-specificContractor-specific Service-specificService-specific Reviews both denied and accepted claimsReviews both denied and accepted claims An initial written request is followed by 4 An initial written request is followed by 4

letters and 3 phone calls followed by an letters and 3 phone calls followed by an overpayment demand letter and interpreted as overpayment demand letter and interpreted as services non-renderedservices non-rendered

cptcpt 117117

Fraud: New InformationFraud: New Information

The Good Enough or Common Sense The Good Enough or Common Sense ApproachApproach

If Medicare Audit Occurs then an Increased If Medicare Audit Occurs then an Increased Likelihood of Medicaid AuditLikelihood of Medicaid Audit

Practice Situations That Increase Potential Practice Situations That Increase Potential Audits;Audits; Skilled Nursing FacilitiesSkilled Nursing Facilities Statistical OutliersStatistical Outliers TestingTesting

States with Increased Audit Activity;States with Increased Audit Activity; TX, CA, FL, PRTX, CA, FL, PR

cptcpt 118118

Fraud: 2006 Red BookFraud: 2006 Red Book

Section 1862(a)(1)(A) of the Social Section 1862(a)(1)(A) of the Social Security Practice Act requires all Security Practice Act requires all services to be reasonable and services to be reasonable and necessary for the diagnosis or necessary for the diagnosis or treatment of an illness or injury.treatment of an illness or injury.

Claim errors have exceed 34%Claim errors have exceed 34%

cptcpt 119119

Fraud: Red Book (continued)Fraud: Red Book (continued)

Problem AreasProblem Areas Acute Hospital outpatient Services ($224)Acute Hospital outpatient Services ($224) Partial Hospitalization ($180)Partial Hospitalization ($180) Psychiatric Hospital outpatient ($57)Psychiatric Hospital outpatient ($57) Nursing Home ($30)Nursing Home ($30) General Mental Health ($185)General Mental Health ($185)

Beneficiaries who are unable to benefit from Beneficiaries who are unable to benefit from psychotherapy servicespsychotherapy services

Note: in millions (total for 2005 - $676,000,000)Note: in millions (total for 2005 - $676,000,000)

cptcpt 120120

F. Unique Physician F. Unique Physician Identification Number (UPIN)Identification Number (UPIN)

HistoricalHistorical UPIN #UPIN # Box 17 a CMS (insurance) 1500 formBox 17 a CMS (insurance) 1500 form

PresentPresent National Provide Identification NumberNational Provide Identification Number

cptcpt 121121

National Provider IdentificationNational Provider IdentificationNumber Number (CMS memo, 45 CFR Part 16c)(CMS memo, 45 CFR Part 16c)

Basic InformationBasic Information 10 Position numeric & individual number10 Position numeric & individual number No specific information about providerNo specific information about provider Managed by CMS’s Provider SystemManaged by CMS’s Provider System

Dates of ImplementationDates of Implementation May 23, 2005 – ApplyMay 23, 2005 – Apply May 23, 2007 – Most entities will useMay 23, 2007 – Most entities will use May 23, 2008 – All entities will useMay 23, 2008 – All entities will use

ApplicabilityApplicability Federal plans – immediatelyFederal plans – immediately State plans – this yearState plans – this year Other health plans- as soon as feasibleOther health plans- as soon as feasible

cptcpt 122122

Part III: Part III: Summary, Trajectories, Summary, Trajectories,

Resources & Resources & Questions/AnswersQuestions/Answers

Summary of Present Problems Summary of Present Problems TrajectoriesTrajectories ResourcesResources Questions & AnswersQuestions & Answers

cptcpt 123123

A. Present ProblemsA. Present Problems

Commercial CarriersCommercial Carriers Medical vs. Mental Health vs. No CoverageMedical vs. Mental Health vs. No Coverage Upper limits on # of hours/evaluationUpper limits on # of hours/evaluation Limited test formulariesLimited test formularies Specific time per testSpecific time per test ““Phantom benefits”- carrier states a Phantom benefits”- carrier states a

service is covered but no authorization is service is covered but no authorization is possiblepossible

cptcpt 124124

Summary of Present Problems Summary of Present Problems with New Codes- Carrier-Basedwith New Codes- Carrier-Based

Code Acceptance-Code Acceptance- Use of new codes at allUse of new codes at all If 96101/96118 accepted, technical and computer codes not If 96101/96118 accepted, technical and computer codes not

being acceptedbeing accepted Overall interpretation of codes (EOBs are still out)Overall interpretation of codes (EOBs are still out)

Code Payment-Code Payment- Lower than expected RVU % by private carriersLower than expected RVU % by private carriers Medicare carriers not paying- too high of a value placed by Medicare carriers not paying- too high of a value placed by

AMA and CMSAMA and CMS Human error in interpreting code submission Human error in interpreting code submission

(manuals/software)(manuals/software) ““Congressional action pending”Congressional action pending”

TechniciansTechnicians Current and operational definitionCurrent and operational definition Acceptance by carriers & licensing boards (e.g., NY)Acceptance by carriers & licensing boards (e.g., NY)

cptcpt 125125

Summary of Present Problems Summary of Present Problems with New Codes- Provider-with New Codes- Provider-

BasedBased General Understanding & UsageGeneral Understanding & Usage Specific Code Usage-Specific Code Usage-

Mixing of psychiatric with neuropsychological Mixing of psychiatric with neuropsychological procedures as well as mixing of diagnostic codesprocedures as well as mixing of diagnostic codes

Time (estimates, rounding)Time (estimates, rounding) Professional having to see the patient at allProfessional having to see the patient at all Professional having to interpret and write the Professional having to interpret and write the

evaluationevaluation Misunderstanding of potential difference between Misunderstanding of potential difference between

computerized testing and computer code computerized testing and computer code (interactive computerized testing with tech or (interactive computerized testing with tech or professional is coded as such) and computerized professional is coded as such) and computerized testing (non-interactive is coded as a computer testing (non-interactive is coded as a computer code)code)

cptcpt 126126

Summary of Present Problems Summary of Present Problems with Codes- Provider-Based with Codes- Provider-Based

(continued)(continued) TechniciansTechnicians

Training programs (externs, interns and postdoctoral Training programs (externs, interns and postdoctoral fellows)fellows)

Essentially no difference between a bachelor’s level Essentially no difference between a bachelor’s level technician and a postdoctoral fellowtechnician and a postdoctoral fellow

Difference between training and providing professional Difference between training and providing professional servicesservices

““Limited” interpretation of scoring (away from the Limited” interpretation of scoring (away from the patient)patient)

Difference among psychometricians and psychometrists Difference among psychometricians and psychometrists as well as techniciansas well as technicians

Psychometricians = doctoral level scientist involved in Psychometricians = doctoral level scientist involved in testing issuetesting issue

Technicians = any provider that does not have a contract Technicians = any provider that does not have a contract with the insurance carrier with the insurance carrier

Psychometrists= typically a certified technician (e.g., NAP)Psychometrists= typically a certified technician (e.g., NAP)

cptcpt 127127

Summary of Present Problems Summary of Present Problems with Testing Codes- Potential with Testing Codes- Potential

ConcernsConcerns QualificationsQualifications

Who can perform neuropsychological services?Who can perform neuropsychological services? CMS/AMA delegates that restriction to states licensing CMS/AMA delegates that restriction to states licensing

boards and carriersboards and carriers TechniciansTechnicians

Could no acceptance of technical code = incident to?Could no acceptance of technical code = incident to? Understanding that scoring time is built in the code valueUnderstanding that scoring time is built in the code value One could score while the patient is being tested, easier One could score while the patient is being tested, easier

for adults than for children but information about the for adults than for children but information about the observation has to occurobservation has to occur

Tests Tests Time estimates (HMOs) for test administration & Time estimates (HMOs) for test administration &

interpretationinterpretation Documentation of start/stop timesDocumentation of start/stop times Listing of actual tests for documentationListing of actual tests for documentation Formulary (both in terms of tests as well as time allocated)Formulary (both in terms of tests as well as time allocated)

cptcpt 128128

Summary of Present Problems Summary of Present Problems with Testing Codes- Potential with Testing Codes- Potential

ConcernsConcerns DocumentationDocumentation

Inclusion of #s along with narratives in Inclusion of #s along with narratives in documentationdocumentation

Matching of documentation with carrier Matching of documentation with carrier requirementsrequirements

Inclusion of Actual TimeInclusion of Actual Time Inclusion of name of technicianInclusion of name of technician

Masters Level PractitionersMasters Level Practitioners Will they be viewed as “qualified health Will they be viewed as “qualified health

practitioners?practitioners?

cptcpt 129129

B. Future PerspectivesB. Future Perspectives: : 2003 Predictions2003 Predictions

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

cptcpt 130130

2004 Predictions2004 Predictions

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

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

obtainedobtained EconomicEconomic

Overall, PositiveOverall, Positive

cptcpt 131131

2004 (Continued)2004 (Continued)

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

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

Primary Issues of ConcernPrimary Issues of Concern Medical NecessityMedical Necessity DocumentationDocumentation

cptcpt 132132

2004 (Continued)2004 (Continued)

ProfessionalProfessional Institutionally BasedInstitutionally Based

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

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

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

cptcpt 133133

20052005

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

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

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

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

forensic)forensic) PracticePractice

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

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

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

cptcpt 134134

20052005

Issues to be AddressedIssues to be Addressed Information disseminationInformation dissemination

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

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

computerized but interactivecomputerized but interactive Appropriate documentationAppropriate documentation

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

cptcpt 135135

20062006

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

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

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

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

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

cptcpt 136136

Pay for Performance (P4P)Pay for Performance (P4P)InitiativesInitiatives

PremisePremise Evidence-based guidelinesEvidence-based guidelines Outcome more than procedure basedOutcome more than procedure based

Initial ApplicationInitial Application Dartmouth, Duke & MichiganDartmouth, Duke & Michigan

Final ApplicationFinal Application 5-10 years5-10 years

cptcpt 137137

Beyond 2006Beyond 2006(CMS)(CMS)

Health Care Spending & GDPHealth Care Spending & GDP 1960 =1960 = 5.0% 5.0% 1970 =1970 = 7.0% 7.0% 1990 =1990 = 9.0%9.0% 2002 = 2002 = 15.4%15.4% 2004 = 2004 = 16.0%16.0% 2005 = 2005 = 16.2%16.2% 2010=2010= 18.0%18.0% 2015 =2015 = 20.0% ( or 4 trillion $) 20.0% ( or 4 trillion $) Final =Final = 33.3%33.3%

cptcpt 138138

Beyond 2006:Beyond 2006:What Does the American Public What Does the American Public

Want?Want?

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

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

Shift Cost of Health Care to Consumers and Shift Cost of Health Care to Consumers and the Governmentthe Government

Government (e.g., Medicare) Will, However, Government (e.g., Medicare) Will, However, Set the Standard for Health Care Set the Standard for Health Care

cptcpt 139139

Mechanisms to Keep Mechanisms to Keep InformedInformed

APA Practice Website (www.apa.org)APA Practice Website (www.apa.org) NAN Website (NAN Website (www.nanonline.orgwww.nanonline.org)) 40 Website (www.div40.org)40 Website (www.div40.org)

Support these continuing efforts by Support these continuing efforts by joining APA, NAN, Division 40, SPA as joining APA, NAN, Division 40, SPA as well as your state associationwell as your state association

cptcpt 140140

C. ResourcesC. Resources

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

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

cptcpt 141141

Resources Resources (continued)(continued)

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

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

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

cptcpt 142142

Resources Resources (continued)(continued)

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

9.htm9.htm (ccd) (ccd)

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

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

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

(coding edits)(coding edits)

cptcpt 143143

ResourcesResources

Telephone NumbersTelephone Numbers APA Practice Directorate’s Government APA Practice Directorate’s Government

Relations Office; 202.336.5889Relations Office; 202.336.5889 AMA CPT Office; 800.621.8335AMA CPT Office; 800.621.8335 Medicare National Coverage Medicare National Coverage

Determinations;Determinations;

410.786.2281410.786.2281

cptcpt 144144

Contact InformationContact Information

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

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

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