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Maintaining and Expanding Reimbursement Opportunities in Mental Health: Medicare as a Benchmark

Maintaining and Expanding Reimbursement Opportunities in Mental Health: Medicare as a Benchmark. Women & Children’s Health Network Division of Public Health Chapel Hill, North Carolina May 12, 2004. Antonio E. Puente, Ph.D. Department of Psychology University of North Carolina at Wilmington

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Maintaining and Expanding Reimbursement Opportunities in Mental Health: Medicare as a Benchmark

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  1. Maintaining and Expanding Reimbursement Opportunities in Mental Health: Medicare as a Benchmark DPH 2004

  2. Women & Children’s Health NetworkDivision of Public HealthChapel Hill, North CarolinaMay 12, 2004 Antonio E. Puente, Ph.D. Department of Psychology University of North Carolina at Wilmington Wilmington, NC 28403 DPH 2004

  3. Contact Information • Websites • Univ = www.uncw.edu/people/puente • Practice = www.clinicalneuropsychology.us • E-mail • University = Puente@uncw.edu • Practice = Puente@clinicalneuropsychology.us • Telephone • University = 910.962.3812 • Practice = 910.509.9371 DPH 2004

  4. Acknowledgments • Department of Psychology, UNC-Wilmington • NCPA Board of Directors, Practice Division, & Staff • NAN Board of Directors, Executive Directors’ Office, Policy and Planning Committee, & Professional Affairs and Information Office • Division 40 Board of Directors & Practice Committee • Practice Directorate of the American Psychological Association • American Medical Association’s CPT Staff • CMS Medical Policy Staff • Selected Individuals (e.g., Jim Georgoulakis) DPH 2004

  5. Background(1988 – present) • North Carolina Psychological Association (e) • APA’s Policy & Planning Board; Div. 40 (e) • American Medical Association’s Current Procedural Terminology Committee (IV/V) (a) • Health Care Finance Administration’s Working Group for Mental Health Policy (a) • Center for Medicare/Medicaid Services’ Medicare Coverage Advisory Committee (fa) • Consultant with the North Carolina Medicaid Office;North Carolina Blue Cross/Blue Shield (a) • NAN’s Professional Affairs & Information Office (a) (legend; a = appointment, fa = federal appointment, e = elected) DPH 2004

  6. Purpose of Presentation • Increase Reimbursement • Increase Range, Type & Quality of Services • Decrease Fraud & Abuse • Provide Guidelines for Professional Services • Maintain Professional Stature Within Psychology • Increase Professional Stature in Health Care, in general DPH 2004

  7. Outline of Presentation • Medicare • Current Procedural Terminology: Basic • Current Procedural Terminology: Related • Relative Value Units • Current Problems & Possible Solutions • Future Directions & Problems • Resources DPH 2004

  8. Outline: Highlights • New Codes • Expanding Paradigms • Fraud, Abuse; Coding & Documentation • The Problem with Testing DPH 2004

  9. Medicare: Overview • Why Focus on Medicare • The Medicare Program • Local Medical Review (policy & panels) DPH 2004

  10. Medicare: Why • The Standard • Coding • Value • Documentation • Approximately 50% for Institutions • Approximately 33% for Outpatient Offices • Becoming the Standard for Workers Comp. • Increasing Percentage for Forensic Work DPH 2004

  11. Medicare: Overview • New Name: HCFA now CMS • Centers for Medicare and Medicaid Services • New Charge: Simplify • New Organization: Beneficiary, Medicare, Medicaid • Benefits • Part A (Hospital) • Part B (Supplementary) • Part C (Medicare+ Choice) DPH 2004

  12. Medicare: Local Review • Local Medical Review Policy • LMRP vs National Policy • Location of LMRPs • Carrier Medical Director • A Physician-based Model • Policy Panels • Lack of Understanding of Their Roles • Lack of Representation on Such Panels DPH 2004

  13. Medicare Payment(since 1993) • Surgical • Higher Reimbursement than Cognitive • Cognitive • Physician Cognitive Work • Supporting Equipment & Staff DPH 2004

  14. Current Procedural Terminology: Overview • Background • Codes & Coding • Existing Codes • Model System X Type of Problem • Medical Necessity • Documenting • Time DPH 2004

  15. CPT: Background • American Medical Association • Developed by Surgeons (& Physicians) in 1966 for Billing Purposes • 7,500+ Discrete Codes • CMS • AMA Under License with CMS • CMS Now Provides Active Input into CPT DPH 2004

  16. CPT: Background/Direction • Current System = CPT 5 • Categories • I= Standard Coding for Professional Services • II = Performance Measurement • III = Emerging Technology DPH 2004

  17. CPT: Applicable Codes • Total Possible Codes = Approximately 7,500 • Possible Codes for Psychology = Approximately 40 to 60 • Sections = Five Separate Sections • Psychiatry • Biofeedback • Central Nervous Assessment • Physical Medicine & Rehabilitation • Health & Behavior Assessment & Management • Possibly, Evaluation & Management DPH 2004

  18. CPT: Development of a Code • Initial • Health Care Advisory Committee (non-MDs) • Primary • CPT Work Group • CPT Panel • Time Frame • 3-5 years DPH 2004

  19. CPT: Psychiatry • Sections • Interview vs. Intervention • Office vs. Inpatient • Regular vs. Evaluation & Management • Other • Types of Interventions • Insight, Behavior Modifying, and/or Supportive vs. Interactive DPH 2004

  20. CPT: Psychiatry (cont.) • Time Value • 30, 60, or 90 • Interview • 90801 • Intervention • 90804 - 90857 DPH 2004

  21. CPT: Biofeedback • Psychophysiological Training • 90901 • Biofeedback • 90875 DPH 2004

  22. CPT: CNS Assessment • Interview • 96115 • Testing • Psychological = 96100; 96110/11 • Neuropsychological = 96117 • Other = 96105, 96110/111 DPH 2004

  23. CPT: Physical Medicine & Rehabilitation • 97770 now 97532 • Note: 15 minute increments DPH 2004

  24. CPT: Health & Behavior Assessment & Management • Purpose: Medical Diagnosis • Time: 15 Minute Increments • Assessment • Intervention DPH 2004

  25. CPT: Modifiers • Acceptability • Medicare = about 100% • Others = approximating 90% • Modifiers • 22 = unusual or more extensive service • 51 = multiple procedures • 52 = reduced service • 53 = discontinued service DPH 2004

  26. CPT: Model System • Psychiatric • Neurological • Non-Neurological Medical • Possibly, Evaluation & Management DPH 2004

  27. CPT: Psychiatric Model(Children & Adult) • Interview • 90801 • Testing • 96100, or • 96110/11 • Intervention • e.g., 90806 • The challenge of New Mexico DPH 2004

  28. CPT: Neurological Model(Children & Adult) • Interview • 96115 • Testing • 96117 • Intervention • 97532 DPH 2004

  29. CPT: Non-Neurological Medical Model(Children & Adult) • Interview & Assessment • 96150 (initial) • 96151 (re-evaluation) • Intervention • 96152 (individual) • 96153 (group) • 96154 (family with patient) • 96155 (family without patient) DPH 2004

  30. CPT: New Paradigms • Initial Psychiatric • Next Neurological • Now Medical • Medical as Evaluation & Management DPH 2004

  31. CPT: Evaluation & Management • Role of Evaluation & Management Codes • Procedures • Case Management • Limitations Imposed by AMA’s House of Delegates for CMS but not for Private Payers • Health & Behavior Codes as an Alternative to E & M Codes • The Use of E & M Codes is Accepted by Some Third Party Reimburses (e.g., MedCost) • Example; 99201 New Patient DPH 2004

  32. CPT: Diagnosing • Psychiatric • DSM • The problem with DSM and neuropsych testing of developmentally-related neurological problems • Neurological & Non-Neurological Medical • ICD (or see NAN Paio web page; membership directory) • Neurological Code Updates Available by 01.01.03 DPH 2004

  33. CPT: Medical Necessity • Scientific & Clinical Necessity • Local Medical Review or Carrier Definitions of Necessity • Necessity = CPT x DX • Necessity Dictates Type and Level of Service • Necessity Can Only be Proven with Documentation DPH 2004

  34. CPT: Coding Matrices • EMSCO & Fraud • Underlying Problem = Medical Decision Making • Do not use: • Coding Matrices • Grids • Related Shortcuts DPH 2004

  35. CPT: Documenting • Purpose • Payer Requirements • General Principles • History • Examination • Decision Making DPH 2004

  36. Documentation: Purpose • Medical Necessity • Evaluate and Plan for Treatment • Communication and Continuity of Care • Claims Review and Payment • Research and Education DPH 2004

  37. Documentation: Payer Requirements • Site of Service • Medical Necessity for Service Provided • Appropriate Reporting of Activity DPH 2004

  38. Documentation: General Principles • Rationale for Service • Complete and Legible • Reason/Rationale for Service • Assessment, Progress, Impression, or Diagnosis • Plan for Care • Date and Identity of Observe • Timely • Confidential DPH 2004

  39. Documentation: Basic Information Across All Codes • Date • Time, if applicable • Identify of Observer (technician ?) • Reason for Service • Status • Procedure • Results/Finding • Impression/Diagnoses • Disposition • Stand Alone DPH 2004

  40. Documentation: Chief Complaint • Concise Statement Describing the Symptom, Problem, Condition, & Diagnosis • Foundation for Medical Necessity • Must be Complete & Exhaustive DPH 2004

  41. Documentation: Present Illness • Symptoms • Location, Quality, Severity, Duration, timing, Context, Modifying Factors Associated Signs • Follow-up • Changes in Condition • Compliance DPH 2004

  42. Documentation: History • Past • Family • Social • Medical/Psychological DPH 2004

  43. Language Thought Processes Insight Judgment Reliability Reasoning Perceptions Suicidality Violence Mood & Affect Orientation Memory Attention Intelligence Documentation:Mental Status DPH 2004

  44. Documentation:Neurobehavioral Status Exam • Attention • Memory • Visuo-spatial • Language • Planning DPH 2004

  45. Documentation: Testing • Names of Tests (including edition/version) • Interpretation of Tests (narrative; possibly quantitative) • Disposition • Time/Dates • In Hours (rounded to nearest hour) • Document on Day Service is Provided • Might be Best to Separate from Interview DPH 2004

  46. Documentation: Intervention • Reason for Service • Status • Intervention • Results • Impression • Disposition • Time DPH 2004

  47. Documentation:Suggestions • Avoid Handwritten Notes • Do Not Use Red Ink • Avoid Color Paper • Document On and After Every Encounter, Every Procedure, Every Patient • Review Changes Whenever Applicable • Avoid Standard Phrases DPH 2004

  48. Documentation: Ethical Issues • How Much and To Whom Should Information be Divulged • Medical Necessity vs. Confidentiality • HIPAA vs. Documentation DPH 2004

  49. Time • Defining • Professional (not patient) Time Including: • pre, intra & post-clinical service activities • Interview & Assessment Codes • Generally use hourly increments • For new codes, use 15 minute increments • Intervention Codes • Use 15, 30, or 60 minute increments DPH 2004

  50. Time: Definition • AMA Definition of Time • Physicians also spend time during work, before, or after the face-to-face time with the patient, performing such tasks as reviewing records & tests, arranging for services & communicating further with other professionals & the patient through written reports & telephone contact. DPH 2004

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