Coding, Documenting, Billing & Auditing Psychological Services: a 10 year of progress report

Antonio E. PuenteDepartment of PsychologyUniversity of North Carolina at Wilmington 28403-3297Tel 910.962.3812, Fax 910.962.7010, e-mail Puente@uncwil.edu; web “clinicalneuropsychology.com”

North Carolina Psychological AssociationRaleigh, NC, March 3, 2000

Disclaimer

This workshop presents a list of recommendation for obtaining reimbursement for and documenting professional psychological services. These recommendations are based on the the author’s work with the AMA-CPT Panel (4th and 5th editions) as well as HCFA’s Medical Directors’ Workgroup and the Medicare Coverage Advisory Committee.

Disclaimer (continued)

These suggestions are being constantly revised and serve as general guidelines. Legal and third-party state and federal regulations may vary relative to these recommendations.

Acknowledgements

North Carolina Psychological AssociationAmerican Psychological Association

Practice Directorate Division of Clinical Neuropsychology

National Academy of NeuropsychologyUniversity of North Carolina at

Wilmington

Outline of PresentationHistory/Background of InvolvementDiagnosesProcedural CodingTime, Site of Service, ProviderReimbursementDocumentationAuditingRelated IssuesMedicareTestsFuture Trends

Purpose of My Involvement with Coding & MedicareShort Term

ReimbursementLong Term

Why the Focus on Medicare Bring Some Standardization to the Field Expand the Scope and Value of Clinical

Neuropsychology and Psychology Parity with Other Doctoral Level Health Providers

in Health Care Shape Psychology Towards a Biological Model

History/Background

North Carolina Psychological Association NCPA & NCPF President Blue-Cross Blue Shield

American Psychological Association Chair or Member of Approximately a Dozen

Committees/Boards, (e.g., CE, BCA) Division 40 Board- 1987 to present Two Terms on APA’s Council of Representatives-

Div. 40 (1994 to present) Policy and Planning Board

History/Background (continued)

American Medical Association CPT- 4 CPT- 5

APA’s Practice DirectorateBlue Cross/Blue Shield of North CarolinaHealth Care Financing Administration

Model Mental Health Policy Workgroup Medicare Coverage Advisory Committee

Medicare: Overview

Benefits Part A (Hospital) Part B (Supplementary) Part C (Medicare + Choice)

HCFA Vs. Local Carrier

Medicare: Local Medical Review Policy

Development of Local PolicyRestrictive

Reimbursement Model

DiagnosesProcedural CodeTimeSite of ServiceProviderFormula

Dx X Code X Time X Site X Provider

Procedural Coding

Defining CodingHistory of CodingCoding

Diagnoses

System (World Health Organization) DSM= 290-319 ICD = all other diagnoses

Referral Diagnosis Referral versus Final Diagnoses Rule-Out Diagnoses

Multiple Diagnoses Advisable for Medically Necessary First Diagnosis is Most Important

Defining CodingDescription of Professional Service

RenderedPurpose of Coding

Reimbursement Archival/Research Performance Assessment

Current Coding Systems SNOMED WHO / ICD AMA / CPT

History of CPT Coding

First Developed in 1966Currently Using the 4th EditionThe 5th Edition Will be Used in 2002A Total of 7,500 CodesAMA Developed and Owns the CPTUnder Contract with the HCFA

CPT & HCFA

Federal Register, August 17,2000 Health Insurance Reform: Standards for

Electronic Transactions The CPT is the standard code set for

reporting physician and other health care services

Developing Codes

Member/Society Generated IdeaAPA Practice Directorate Health Care Professionals Advisory

CommitteeIntegration with Specialty Groups within

American Medical Association/WorkgroupFormal Panel PresentationRelative Value of CodeTime Frame (3-6 years)

Overview of Coding

Total Possible Codes = 60+# Of Typically Reimbursed Codes = 5

interview, testing, & psychotherapy# Of Codes Sometimes Reimbursed = 35

family/group therapy biofeedback

# Of Codes Rarely Reimbursed = 20+ evaluation and management report evaluation and writing

Overview of Coding: An evolution of coding

PsychiatryNeurologyPhysical Medicine & Rehabilitation“Evaluation & Management”

Overview of Coding (cont.)

Psychiatry Interview (90801) Psychotherapy (90804 - 90857)

Types of Psychotherapy (regular vs interactive)# of “Patients” (individual vs group vs family)Locations of Intervention (in vs outpatient)Evaluation & Management vs RegularLength of Time (30, 60, 90)

BiofeedbackRegular vs Psychophysiological (90901 vs 90875)

Overview of Coding (cont.)

Central Nervous System Assessments/Test 96100 = Psychological Testing 96105 = Aphasia Testing 96110/1 = Developmental Testing 96115 = Neurobehavioral Status

Exam 96177 = Neuropsychological Testing

Overview of Coding (cont.)

Physical Medicine 97770 = Cognitive Skills Development Look for New/split Codes in the Near

Future

Overview of Coding (cont.)

Health & Behavior 909X1 assessment (15 minutes) 909X2 re-assessment 909X3 intervention- individual 909X4 intervention- group 909X5 intervention- family 909X6 intervention- family w/o pt. NOTE: codes have been valued and will be

available for use in 01.2002

Coding Modifiers

Acceptability Medicare = 95% Others = Approximately 80%

Modifiers 22 = Unusual or More Extensive Service 51 = Multiple Procedures 52 = Reduced Service 53 = Discontinued Service

New Category II Codes:Performance Measurement

Purpose Reduction of detailed chart review Provide performance measurement

Use Alphanumeric identifier with a letter in the

last field Evidenced-based measurement that

address conditions of high prevalence, risk or cost with established health outcomes

New Category III Codes:Emerging Technology Purpose

Collect data and assess efficacy of new procedures

Use Alphanumeric identifier

Example 0018T Repetitive Transcranial Magnetic Stimulation Delivery of high power, focal magnetic pulses for

direct stimulation of cortical neurons

Next Set of Codes

Splitting of the Neuropsychological (and possibly, later) the Testing Codes Rationale

5 Year Re-evaluationLack of Cognitive Component

ApproachIntegration with HCFAInvolvement of NAN, 40Group Survey Testing

Coding Overview

Coding Categories Psychiatry Neurology; CNS/Assessment Physical Medicine “Evaluation & Management”

Procedures Assessment Intervention

Overview of Coding (cont.)

Diagnosing If Problem is Psychiatric = DSM If Problem is Neurological = ICD

Matching Dx with CPT DSM = 90801, 96100, 90806 ICD = 96115, 96117, 97770

Reimbursement

HistoryProspective Payment SystemDefining RBRVSReimbursement Difficulties

Overview of the History of Reimbursement

Cost plus ReimbursementProspective Payment (PPS) &

Diagnostic Related Groups (DRGs)Customary. Prevailing, &

Reasonable(CPR)Resource Based Relative Value

System (RBRVS)Prospective Payment System

RBRVS: Purpose & History

Purpose: To Provide Equitable Payment for Medical Services

History Phase I: Initial 12 physician specialties Phase II: Psychiatry Phase III: Psychology

RBRVS: Overview

Major Components Physician Work Resource Value Unit Practice Expense Resource Value Unit Malpractice Component Resource Value

Unit Geographical Practice Cost Index

RBRVS: Conversion Factor

Dollar Value That Is Utilized to Convert the Resource Value Units and Geographic Practice Cost Indexes Into a Payment

RBRVS: Adoption

MedicareBlue Cross/Blue Shield = 87%Managed Care = 69%Medicaid = 55%Other = 44%

Prospective Payment System

Standard Scenario Included in inpatient bundled service

Alternative Scenario Bill under own provider number

Inpatient versus Patient

Reimbursement Difficulties

Physician Work ValuePhd/PsyD/EdD vs MDLocation Defined

Common Reasons for Lack of Reimbursement

Clerical ErrorsService Is Not CoveredNo Prior Authorization ObtainedExceeded Allocated Time LimitsInvalid or Incorrect Dx CodeCPT and Dx Do Not Match

Time

Defining Time Professional (not patient) Activity

AMA Definition Physicians also spend time during work,

before, or after the face-to-face time with the patient, performing such tasks as reviewing records and tests, arranging for services and communicating further with other professional and the patient through written reports and telephone contact

Testing Time Defined

Preparing to Test PatientReviewing of RecordsSelection of TestsScoring of TestsReviewing of ResultsInterpretation of ResultsPreparation and Report Writing

Testing Time Defined (continued)

Communicating Further With OthersFollow-up With Patient, Family,

and/or OthersArranging for Ancillary and/or Other

Services

Intervention Time Defined

All Time is Bundled in the Allocated Time 90806 = 45 minutes of total time 97770 = 15 minutes of total time

Time X Code

Interview & Assessment Hourly Increments

Intervention 15 30 45 90?

Quantifying Time

Rounding Round up or down to nearest increment

Time Does Not Include; Patient completing tests, forms, etc. Waiting time by patient Type of reports Non-professional time Literature searches, learning new

techniques, etc.

Site of Service

Inpatient Physical location Billing and business relations Origin of the patient Skilled and assisted nursing fascilities

Outpatient By definition, anything that is not

inpatient

Provider

Doctorate Medicare: PhD/PsyD/EdD = MD Non-Medicare: 0-50% less than MD

Non-Doctorate Social Security The special case of North Carolina

Medical NecessityDefinition

Reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member

Stand Alone Each activity must stand alone Point-to-point correspondence between

symptoms and proceduresLikely Types

Acute and emergency

Documentation

PurposeGeneral GuidelinesSpecific DocumentationTrendsSuggestions

Purpose of Documentation

Evaluate and Plan for TreatmentCommunication and Continuity of

CareClaims Review and PaymentResearch and Education

General Principles of Documentation

Complete and LegibleReason/Rationale for the EncounterAssessment, Impression, or

Diagnosi/esPlan for CareDate and Identity of Observer

Documentation History

Chief ComplaintHistory of Present Illness (HPI)Review of SystemsPast, Family, and/or Social History

Documentation of Chief Complaint

Concise Statement Describing the Symptom, Problem, Condition, Diagnosis, Physician Recommended Return, or other Factor that is the Reason for the Encounter.

Documentation of Present IllnessChronological Description of the

Development of the Patient’s Present Illness from the First Sign and/or Symptom or from the Previous Encounter to the Present. For Symptoms: Location, Quality, Severity,

Duration, Timing, Context, Modifying Factors Including Medications, Associated Signs, Symptoms, etc.

For Follow up: Changes in Condition Since Last Visit, Compliance with Treatment, etc.

Review of Systems

PsychiatricNeurologicalOther

Documentation of History

Past HistoryFamily HistorySocial History

Specific Documentation Suggestions: Psychiatric Interview

Name, Date, Observer, Dx/Impression

Mental Status Exam Language, Thought Processes, Insight,

Judgment, Reliability, Reasoning, Perceptions, Suicidality, Violence, Mood & Affect, Orientation, Memory, Attention, Intelligence

Specific Documentation Suggestions: Neurobehavioral Status ExamName, Date, Observer, Dx/ImpressionDefinition

Clinical assessment of thinking, reasoning and judgment

Variables Attention, Memory, Visuo-Spatial,

Language, Planning Acquired knowledge, attention, memory,

visual spatial abilities, language functioning, planning

Specific Documentation Suggestions: Testing

Name, Date, Observer, Dx/Impression

Names of TestsInterpretation of Tests ResultsDispositionTime

Defining PsychotherapyPurpose

Resolving problems or alleviating of emotional disturbances, or changing maladaptive patterns of behavior, or encouraging personal growth and development

Approaches Development of insight or affective

understanding, the use of behavior modifying techniques, the use of supportive interactions, the use of cognitive discussion of reality

the use of physical aids or non-verbal techs.

Specific Documentation Suggestion: Psychotherapy

Basic Elements Date Reason for Service Intervention Results Impression Disposition Identity Time

Specific Documentation Suggestion: Cog. Rehab.

Basic Elements Date Reason for Service Training activity Results Identity of Observer Time

Documentation Suggestions

Avoid Handwritten NotesDo Not Use Red InkDocument on Every Encounter, Every

Procedure, and Every PatientRe-Cap Status, Whenever Possible, At

Least Change From Session to SessionDocument Soon After Procedure

Trends

Issues of ConfidentialityOver-DiagnosingOver-DocumentingLimited Interventions & Diagnostic

Procedure

Auditing

Fraud & Abuse vs ErroneousSelf-Auditing SuggestionsRisk SituationsDevelopment of an Internal Auditing

System

Fraud vs Error

Fraud = Intentional, Pattern

Erroneous = Clerical, etc.

Self-Auditing Suggestions

Written PoliciesCompliance OfficerTraining & Education Lines of Communication Should ExistInternal Monitoring & AuditingEnforce Standards Alter as Necessary

Risk Areas for Fraud

Coding & BillingReasonable & Necessary ServicesDocumentationImproper Inducements

Fraudulent Claims Flags

UpcodingExcessive or Unnecessary Visits to ACFOutpatient Service 72 Hrs. Post-DischargeCPT Code Usage ShiftHigh Percentage of the Same CodesUse of Similar Time for Testing Across Pts.Medical Necessity (dx; interpretation)

Evaluating Effectiveness

Adequacy of Evidence Bias External Validity

Size of Effect From Not Effective to Breakthrough

Evaluating Effectiveness (continued)

Organized Approaches to Evaluation of Scientific Evidence American College of Physicians Agency for Health Care Policy and

Research BC/BS Technology Evaluation Center American College of Cardiology American College of Urology

Related IssuesGraduate Medical Education

allied health vs medical interns vs postdoctoral fellows

Related Issues

Incident to Definition

technical services that are an extension of the professional service(s)

inpatient as inpatient

Billingappropriate to provide technical services

anywherenot appropriate to bill technical services

inpatient

Tests

PurposeFundingSampleResults Summary

Tests: Purpose

Which Tests Are Being UsedHow Long Does Each Test TakeAddress More Carefully Pre, During,

and Post-Testing Time

Tests: Sample

Clinical APA

Neuropsychological NAN Total Possible Sample = 2700 Total Sampled = 1200 Total Used = 447

Tests: Time Spent Testing

Hours %0-4 215-9 1110-14 1615-20 19>20 33

Tests: TypesType of Testing %Adaptive43Aphasia 46Behavioral Med 28Developmental 27Intellectual 79Neurobehavioral 51Neuropsychological 95Personality 79

Tests: Time X Test

Type Admin Score InterpretAdaptive 74 32 48Aphasia 61 24 39Beh Med 110 35 58Develop 113 36 59IQ 122 34 61Neurobeh 80 26 47Neuropsy 304 79 135

Future Trends

Surveys; Practice, Ongoing & New CodesHealth Care Finance AdministrationCommittee for the Advance of

Professional Practice Practice Directorate of the APAGeneral TrendsFuture of Clinical PsychologyResources

Surveys

Rationale for Surveys All Decisions are Empirical Reasonably Large Ns Adequate Data

Support Required If Asked, Participate Three Ongoing;

NAN/Division 40 Practice SurveyRe-evaluation of “Cognitive Rehabilitation”Splitting of Testing Codes

Health Care Financing AdministrationProblems

Definition of Physician (Social Security Practice Act of 1989)

Doctoral vs Non-Doctoral ProvidersDirections

Physician Work Value Practice Expense Matching of CPT with Reimbursement

Committee for the Advancement of Professional Practice

ObserversAttitude

Positive, Receptive New Full-time Staff Member for

Medicare Program (American College of Surgeons)

General TrendsFraud, Abuse, & Effects of RegulationsStandardizing & Expanding Into Non-

Traditional Areas“Boutique” Vs “Industrial” PsychologyPsychometrics as Clinical PsychologyAssessment & Rehabilitation

Psychology’s “Technical” PipelineEstablishment of “Grassroots Network”

Future of Professional Psychology

More (normative?) Data & A Few TheoriesMeasurement of the Cultural & SubjectiveLess Focus on Conserving the Medicare

Trust Fund & Stockholder Profits by Focusing on the Aged & Disabled

Appreciating that Brain is Inside a Person Which is Inside a System (Value?)

Conscilience

ResourcesWeb Sites

neuropsych; NANonline.org, Div40.org government; HCFA.gov, NIH.gov personal; clinicalneuropsychology.com

Publications APA Medicare Handbook (PP; 2000) NAN Bulletin (1994, 1997, 1998, 2000) Journal of Psychopathology & Behavioral

Assessment (1987) Professional Psychology (with Camara & Nathan,

2000)

Resources (continued)Initial Intake FormsPatient Service FormsCoding SheetBilling FormsMedicare/Cigna Information Including

Local Medical Review Revision PolicyBlue Cross/Blue Shield InformationCigna Behavioral Health Forms & ExampleWorkers Compensation Forms

Resources (continued)

CPT ProcessNew Health and Behavior

Assessment and Intervention CodesExisting CPT CodesPsychological Test Usage in

Professional Psychology (Camara, Nathan & Puente, 2000)