Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of 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”

Massachusetts Neuropsychological SocietyBoston, MA, December 5, 2000

Outline of PresentationHistory/Background of InvolvementProcedural CodingReimbursementDocumentationAuditingRelated IssuesFuture 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 Parity with Other Doctoral Level Health Providers

in Health Care Shape Psychology Towards a Biological Model

History/BackgroundNorth Carolina Psychological Association

Blue-Cross Blue ShieldAmerican Psychological Association

Chair or Member of Approx.a Dozen Committees/Boards, (e.g., Neuropsychology)

Division 40 Board- 1987 to present Two Terms on APA’s Council of

Representatives (1994 to present) Policy and Planning Board

History/Background (continued)American Medical Association

CPT- 4 CPT- 5

Health Care Financing Administration Model Mental Health Policy Workgroup Medicare Coverage Advisory Committee

Procedural CodingDefining CodingHistory of CodingCoding

Defining CodingDescription of Professional Service

RenderedPurpose of Coding

Archival/Research Reimbursement

Coding Systems SNOMED WHO / ICD AMA / CPT

History of CPT CodingFirst 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

Overview of CodingTotal 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 codingPsychiatryNeurologyPhysical 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: these codes need to be valued...

Coding OverviewCoding 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

ReimbursementHistoryDefining RBRVSFormulaDefining TimeDefining SiteDefining NecessityDefining and Applying “Incident to”

History of ReimbursementCost plus ReimbursementProspective Payment (PPS) &

Diagnostic Related Groups (DRGs)Customary. Prevailing, &

Reasonable(CPR)Resource Based Relative Value System

(RBRVS)Prospective Payment System

RBRVSMajor Components

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

Conversion FactorAdoption of the RBRVS

Medicare Blue Cross/Blue Shield- 87% Managed Care- 55%

Reimbursement FormulaProcedural CodeTimeDiagnosisSite of ServiceProviderFormula

Code X Time X Dx X Site X Provider

Reimbursement DifficultiesPhysician Work ValuePhd/PsyD/EdD vs MDLocation Defined

Common Reasons for Lack of ReimbursementClerical ErrorsService Is Not CoveredNo Prior Authorization ObtainedExceeded Allocated Time LimitsInvalid or Incorrect Dx CodeCPT and Dx Do Not Match

Defining TimeDefining Time

Professional (not patient) ActivityInterview vs Assessment Codes

Hourly Increments Includes Pre and Post-clinical Service

Intervention Codes 15, 30, 60, & 90 Face-to-face Contact No Pre or Post-clinical Service Time Included

Testing Time DefinedPreparing to Test PatientReviewing of RecordsSelection of TestsScoring of TestsReviewing of ResultsInterpretation of ResultsPreparation and Report Writing

DocumentationPurposeGeneral GuidelinesSpecific DocumentationTrendsSuggestions

Purpose of DocumentationEvaluate and Plan for TreatmentCommunication and Continuity of

CareClaims Review and PaymentResearch and Education

General Principles of DocumentationComplete and LegibleReason/Rationale for the EncounterAssessment, Impression, or

Diagnosi/esPlan for CareDate and Identity of Observer

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

Documentation of Chief ComplaintConcise 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 SystemsPsychiatricNeurologicalOther

Documentation of HistoryPast 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/ImpressionVariables

Attention, Memory, Visuo-Spatial, Lanague, Planning

Specific Documentation Suggestions: TestingName, Date, Observer,

Dx/ImpressionNames of TestsInterpretation of Tests ResultsDispositionTime

Documentation SuggestionsAvoid 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

TrendsIssues of ConfidentialityOver-DiagnosingOver-Documenting

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

System

Fraud vs ErrorFraud = Intentional, Pattern

Erroneous = Clerical, etc.

Self-Auditing SuggestionsWritten PoliciesCompliance OfficerTraining & Education Lines of Communication Should ExistInternal Monitoring & AuditingEnforce Standards Alter as Necessary

Risk Areas for FraudCoding & BillingReasonable & Necessary ServicesDocumentationImproper Inducements

Fraudulent Claims FlagsUpcodingExcessive 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)

Defining Necessity“reasonable and necessary for the

diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member”

All services must “stand alone”Acute and emergency services more

like to be considered necessary

Evaluating EffectivenessAdequacy 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

Additional IssuesIncident to

in vs outpatient technical vs professional component performing vs billing

Graduate Medical Education allied health vs medical interns vs postdoctoral fellows

CPT I, II, & III I = standard codes II = performance measures III = emerging technology

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

Professional Practice Practice Directorate of the APAGeneral TrendsFuture of Clinical NeuropsychologyResources

SurveysRationale for Surveys

All Decisions are Empirical Reasonably Large Ns Adequate Data

Support Required If Asked, Participate Two Ongoing;

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

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

Observers Joe Fishburn (NAN), Ida Sue Baron (Div

40)Attitude

Division 40; NAN Gift Positive, Receptive Additional Staff Member for Medicare

Program

General TrendsFraud, Abuse, & Effects of RegulationsClinical Neuropsychology Standardizing &

Expanding Into Non-Traditional Areas“Boutique” vs “Industrial” Neuropsych.Psychometrics as Clinical

NeuropsychologyAssessment & Rehabilitation

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

Future of Clinical Neuropsychology: A Holiday Wish ListMore (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)