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Recent Changes in Coding and Related Issues

Recent Changes in Coding and Related Issues. American Psychological Association State Leadership Conference Washington, D.C. 03.06.05. Outline. Current Procedural Terminology Documentation Defining Time Relative Value Units Ongoing CPT Developments. CPT: Background.

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Recent Changes in Coding and Related Issues

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  1. Recent Changes in Coding and Related Issues • American Psychological Association • State Leadership Conference • Washington, D.C. • 03.06.05 APA SLC 2005

  2. Outline • Current Procedural Terminology • Documentation • Defining Time • Relative Value Units • Ongoing CPT Developments APA SLC 2005

  3. 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 APA SLC 2005

  4. CPT: Background/Direction • Current System = CPT 5 • Categories • I= Standard Coding for Professional Services • II = Performance Measurement • III = Emerging Technology APA SLC 2005

  5. CPT: Composition • AMA House of Delegates • 109 Medical Specialties • HCPAC • 11 Societies (e.g., APA) • CPT Editorial Panel • 17 Voting Members • 11 Appointed by AMA Board • 1 each from BC/BS, AHA, HIAA, CMS • 2 HCPAC APA SLC 2005

  6. What Is a CPT Code? • Professional Health Service Provided Across the Country at Multiple locations • Many Physicians Perform Services • Clinical Efficacy is Established and Documented in Peer-Reviewed Literature APA SLC 2005

  7. 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 APA SLC 2005

  8. CPT: Development of a Code • Initial • Health Care Advisory Committee (non-MDs) • Primary • CPT Work Group • CPT Panel • Time Frame • 3-5 to over a decade APA SLC 2005

  9. CPT: Psychiatry • Sections • Interview (90801) vs. Intervention (e.g., 908.06) • Office vs. Inpatient • Regular vs. Evaluation & Management • Other • Types of Interventions • Insight, Behavior Modifying, and/or Supportive vs. Interactive APA SLC 2005

  10. CPT: CNS Assessment • Interview • 96115 • Testing • Psychological = 96100; 96110/11 • Neuropsychological = 96117 • Aphasia = 96105 • Developmental = 96110/111 APA SLC 2005

  11. CPT: Physical Medicine & Rehabilitation • 97770 now 97532 • Note: 15 minute increments APA SLC 2005

  12. CPT: Health & Behavior Assessment & Management • Purpose: Medical Diagnosis • Time: 15 Minute Increments • Assessment • Intervention APA SLC 2005

  13. Rationale: General • Acute or chronic (health) illness may not meet the criteria for a psychiatric diagnosis • Avoids inappropriate labeling of a patient as having a mental health disorder • Increases the accuracy of correct coding of professional services • Increase range of services APA SLC 2005

  14. Overview of Codes • New Subsection • Six New Codes • Assessment • Intervention • Established Medical Illness or Diagnosis • Focus on Biopsychosocial Factors APA SLC 2005

  15. Health & Behavior Assessment Codes • 96150 • Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires) • each 15 minutes • face-to-face with the patient • initial assessment • 96151 • re-assessment APA SLC 2005

  16. Health & Behavior Intervention Codes • 96152 • Health and behavior intervention • each 15 minutes • face-to-face • individual • 96153 • group (2 or more patients) • 96154 • family (with the patient present) • 96155 • family (without the patient present; not being reimbursed) APA SLC 2005

  17. CPT: Model System • Psychiatric • Neurological • Non-Neurological Medical • Alternatives APA SLC 2005

  18. CPT Model • Rationale for CPT Code: • Choose Code that Best Describes the Service Provided • Match the Interview with the Testing with the Intervention Code • Match All that With a Diagnosis • Goal = Uniformity and Fluency APA SLC 2005

  19. CPT: Psychiatric Model(Children & Adult) • Interview • 90801- adult • 90802- child • Testing • 96100- adult • 96110/11- child • Intervention • e.g., 90806- adult • e.g., 90820-child APA SLC 2005

  20. CPT: Neurological Model(Children & Adult) • Interview • 96115 • Testing • 96117 • Intervention • 97532 APA SLC 2005

  21. 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) APA SLC 2005

  22. Recent CPT Changes • Biofeedback (90911) • Minor editorial changes in biofeedback training APA SLC 2005

  23. Recent CPT Changes • Developmental Testing Codes • Applicability • Children • Background • Part of Central Nervous System family of codes • Hence, no work value (& lower reimbursement rate) • Recently “re-surveyed” by pediatricians • Specific Changes • 96110 • Continues to have no work value • Use for completion of forms (Connors; by parents) • 96111 • Has physician work value • Assessment of child’s social, emotional, etc status (WJ) APA SLC 2005

  24. Recent CPT Changes :Health & Behavior Assessment Codes • Brief History • Inter-divisional Health Care Committee (22, 38, 40, 54; Glueckauf) • Convened in 1995 by APA Practice Directorate (Phelps) • Drafts • First Draft - September 11, 1998; Final Working Draft – July 1, 2000 • Presentations • First Presentation to AMA November 6, 1998 ; Final Presentation – August 8, 2000 • 7 total presentations- Ft. Lauderdale, Chicago, Denver, San Francisco, Washington, DC, Chicago, Chicago • Surveys • First Survey January 31, 2001; Final Survey April 26, 2001 • Revisions to Language • First Preamble revision – March, 2002; Last Preamble revision – November, 2004 • Applicability • When behavioral, cognitive, emotional, and/or psychological techniques are used to assess and/or treat health (medical not psychiatric) problems APA SLC 2005

  25. Recent CPT Changes:Health & Behavior Assessment Codes • Acceptability • All Medicare carriers (minus Florida’s) • Some Medicaid programs (e.g., Colorado, Vermont) • Some private insurers (BC/BS in NC, DC; Nationwide) • Changes • Preamble • Clarification • Not a preventive medicine code • Patient can have a history or presence of mental illness • Future Expectation • No further changes • Increased carrier acceptance, especially if providers educate carriers • Final Verification Anticipated • December 1, 2004 • Applicability starting January 1, 2005 APA SLC 2005

  26. Develiping CPT Changes:CNS Assessment Codes • Neurobehavioral Status Exam • Re-write (different language; same concept) • Addition of “Physician” Work Value • Psychological Testing • Expansion of existing code • Addition of “Physician” Work Value • Neuropsychological Testing • Expansion of existing code • Addition of “Physician” Work Value APA SLC 2005

  27. Probable CPT Changes:CNS Assessment Codes • Net Effect • Avoidance of Continuation of Reimbursement Strictly Based on Practice Expense • Potential catastrophe in terms of reimbursement • Potential reimbursement rates in the vicinity of $40/hr • Greater Clarity of Professional and Non-Professional Activities • Differentiation of professional, technical and computer activity • Accounting/auditing, research, and salary purposes • Recognition of “Physician” Work • Ending a 10 year struggle • Possibly, Increased Reimbursement APA SLC 2005

  28. Pro28bable CPT Changes:CNS Assessment Codes • Timetable (activity x date) • Initial Decision by AMA CPT Panel, November 7, 2004 • Call for Other Societies to Participate, November 19, 2004 • Final Decision by AMA CPT Panel, December 1, 2004 • Submission of CPT Codes to AMA RUC Committee immediately thereafter • Review by AMA RUC Research Subcommittee in January, 2005 • Review by AMA RUC Panel in February 3-6, 2005 • Survey of Codes, second & third week of February, 2005 • Analysis of surveys, March, 2005 • Presentation to RUC Committee in April, 2005 • Hopeful inclusion in the 2006 Physician Fee Schedule for January 1, 2006 APA SLC 2005

  29. CPT X Report • Each CPT Code Should Generate a Separate Report • Alternative Clearly Label/Title Sections of the Report to Match Codes Used APA SLC 2005

  30. 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 & Protocols APA SLC 2005

  31. Time • Defining • Professional (not patient) Time Including: • pre, intra & post-clinical service activities • Interview & Assessment Codes • Use 15 minute increments • Intervention Codes • Use 15 minute increments APA SLC 2005

  32. 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. APA SLC 2005

  33. Time: Testing • Quantifying Time • Round up or down to nearest increment • Time Does Not Include • Patient completing tests, forms, etc. • Waiting time by patient • Typing of reports • Non-Professional (e.g., clerical) time • Literature searches, learning new techniques, etc. APA SLC 2005

  34. Relative Value Units: Overview • Components • Units • Values • Current Problems APA SLC 2005

  35. RVU: Components • Physician Work Resource Value • Practice Expense Resource Value • Malpractice • Geographic • Conversion Factor (approx. $34) APA SLC 2005

  36. RVU Components Percentages • Physician Work = 52% • Practice Expense = 44% • Liability = 4% APA SLC 2005

  37. Defining Physician Work • Clinical Work • Mental Effort and Judgment • Technical Skill/Physical Effort • Psychological Stress APA SLC 2005

  38. Estimate of Psychologists’ Value • Audiologist .52 • Dietician .43 • RN .42 • Speech Pathologist .55 • Psychologist .82 APA SLC 2005

  39. Defining Practice Expense • Medical Supplies • Expendable medical equipment (e.g., forms) • Medical Equipment • Durable medical equipment (e.g., tests) • Professional Support Staff • e.g., time APA SLC 2005

  40. RVU: Values • Psychotherapy: • Prior Value =1.86 • New Value = 2.65 • Psych/NP Testing: • Work value= 0 • Hsiao study recommendation = 2.2 • New Value = undetermined • Health & Behavior • .25 (per 15 minutes increments) APA SLC 2005

  41. RVU: Acceptance • Medicare (100% since 01.01.92) • Medicaid 100% • Private Payors 74% • Blue Cross/Blue Shield 87% • Managed Care 69% • Other 44% • New Trends: • RVUs as a Model for All Insurance Companies • RVUs as a Basis for Compensation Formulas APA SLC 2005

  42. CPT x RVU APA SLC 2005

  43. Medicare Rates Type Deductible Co-Payment Part A $912 0-$456 (days) Part B $110 Health – 20% Psych- 50% Note: Premiums are $78.20/month APA SLC 2005

  44. Problem:Supervision • Supervision • 1.General = overall direction • 2.Direct = present in office suite • 3.Personal = in actual room • 4.Psychological = when supervised by a psychologist APA SLC 2005

  45. SupervisionProgram Memorandum CarriersDepartment of Health and Human Services- HCFATransmittal b-01-28; April 19, 2001 • Levels of Supervision • General • Furnished under overall direction and control, presence is not required • Direct • Must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure • Personal • Must be in attendance in the room during the performance of the procedure APA SLC 2005

  46. Problem: Incident to • Rationale for Incident to • Congress intended to provide coverage for services not typically covered elsewhere • Definition of Physician Extender • How • Limitations • Definition of In vs. Outpatient • Geographic Vs Financial • Why No Incident to (DRG) • Solution Available for Some Training Programs • Probably no Future to Incident to APA SLC 2005

  47. Problem: More Incident to • When is “Incident to” Acceptable: • Testing • Cognitive Rehabilitation; Biofeedback • Psychotherapy • Definition • Commonly furnished service • Integral, though incidental to psychologist • Performed under the supervision • Either furnished without charge or as part of the psychologist’s charge APA SLC 2005

  48. Supervision Applies to whether and how a “physician” oversees the work of ancillary personnel A clinical concept Can occur at any level of supervision (from general to personal) “Incident to” Applies when billing for services supervised by a “physician” An economic concept Can only occur when supervision is “direct” (i.e., in the same office suite) Note: no “incident to” in inpatient settings for Medicare Difference Between Supervision and “Incident to” APA SLC 2005

  49. Problem: Face-to-Face • Implications • Technical versus Professional Services • Surgery is the Foundation for CPT (and most work is face-to-face) • Hard to Document & Trace Non-Face-to-Face Work APA SLC 2005

  50. Problem: Work Value • Physician Activities (e.g., Psychotherapy) Result in Work Values • Psychological Based Activities (i.e., Testing) Have no Work Values • RVUs are Heavily Based on Practice Expenses (which are being reduced) • Net Result = Maybe Up to a Half Lower APA SLC 2005

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