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

1. Coding, Documenting, Billing & Auditing Psychological Services: a 10 year of progress report Antonio E. Puente Department of Psychology University of North Carolina at Wilmington 28403-3297 Tel 910.962.3812, Fax 910.962.7010, e-mail Puente@uncwil.edu; web “clinicalneuropsychology.com” North Carolina Psychological Association Raleigh, NC, March 3, 2000

2. 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.

3. 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.

4. Acknowledgements • North Carolina Psychological Association • American Psychological Association • Practice Directorate • Division of Clinical Neuropsychology • National Academy of Neuropsychology • University of North Carolina at Wilmington

5. Outline of Presentation • History/Background of Involvement • Diagnoses • Procedural Coding • Time, Site of Service, Provider • Reimbursement • Documentation • Auditing • Related Issues • Medicare • Tests • Future Trends

6. Purpose of My Involvement with Coding & Medicare • Short Term • Reimbursement • Long 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

7. 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

8. History/Background (continued) • American Medical Association • CPT- 4 • CPT- 5 • APA’s Practice Directorate • Blue Cross/Blue Shield of North Carolina • Health Care Financing Administration • Model Mental Health Policy Workgroup • Medicare Coverage Advisory Committee

9. Medicare: Overview • Benefits • Part A (Hospital) • Part B (Supplementary) • Part C (Medicare + Choice) • HCFA Vs. Local Carrier

10. Medicare: Local Medical Review Policy • Development of Local Policy • Restrictive

11. Reimbursement Model • Diagnoses • Procedural Code • Time • Site of Service • Provider • Formula • Dx X Code X Time X Site X Provider

12. Procedural Coding • Defining Coding • History of Coding • Coding

13. 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

14. Defining Coding • Description of Professional Service Rendered • Purpose of Coding • Reimbursement • Archival/Research • Performance Assessment • Current Coding Systems • SNOMED • WHO / ICD • AMA / CPT

15. History of CPT Coding • First Developed in 1966 • Currently Using the 4th Edition • The 5th Edition Will be Used in 2002 • A Total of 7,500 Codes • AMA Developed and Owns the CPT • Under Contract with the HCFA

16. 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

17. Developing Codes • Member/Society Generated Idea • APA Practice Directorate • Health Care Professionals Advisory Committee • Integration with Specialty Groups within American Medical Association/Workgroup • Formal Panel Presentation • Relative Value of Code • Time Frame (3-6 years)

18. 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

19. Overview of Coding: An evolution of coding • Psychiatry • Neurology • Physical Medicine & Rehabilitation • “Evaluation & Management”

20. 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 Regular • Length of Time (30, 60, 90) • Biofeedback • Regular vs Psychophysiological (90901 vs 90875)

21. 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

22. Overview of Coding (cont.) • Physical Medicine • 97770 = Cognitive Skills Development • Look for New/split Codes in the Near Future

23. 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

24. Coding Modifiers • Acceptability • Medicare = 95% • Others = Approximately 80% • Modifiers • 22 = Unusual or More Extensive Service • 51 = Multiple Procedures • 52 = Reduced Service • 53 = Discontinued Service

25. 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

26. 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

27. Next Set of Codes • Splitting of the Neuropsychological (and possibly, later) the Testing Codes • Rationale • 5 Year Re-evaluation • Lack of Cognitive Component • Approach • Integration with HCFA • Involvement of NAN, 40 • Group Survey Testing

28. Coding Overview • Coding Categories • Psychiatry • Neurology; CNS/Assessment • Physical Medicine • “Evaluation & Management” • Procedures • Assessment • Intervention

29. 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

30. Reimbursement • History • Prospective Payment System • Defining RBRVS • Reimbursement Difficulties

31. Overview of the History of Reimbursement • Cost plus Reimbursement • Prospective Payment (PPS) & Diagnostic Related Groups (DRGs) • Customary. Prevailing, & Reasonable(CPR) • Resource Based Relative Value System (RBRVS) • Prospective Payment System

32. RBRVS: Purpose & History • Purpose: To Provide Equitable Payment for Medical Services • History • Phase I: Initial 12 physician specialties • Phase II: Psychiatry • Phase III: Psychology

33. RBRVS: Overview • Major Components • Physician Work Resource Value Unit • Practice Expense Resource Value Unit • Malpractice Component Resource Value Unit • Geographical Practice Cost Index

34. RBRVS: Conversion Factor • Dollar Value That Is Utilized to Convert the Resource Value Units and Geographic Practice Cost Indexes Into a Payment

35. RBRVS: Adoption • Medicare • Blue Cross/Blue Shield = 87% • Managed Care = 69% • Medicaid = 55% • Other = 44%

36. Prospective Payment System • Standard Scenario • Included in inpatient bundled service • Alternative Scenario • Bill under own provider number • Inpatient versus Patient

37. Reimbursement Difficulties • Physician Work Value • Phd/PsyD/EdD vs MD • Location Defined

38. Common Reasons for Lack of Reimbursement • Clerical Errors • Service Is Not Covered • No Prior Authorization Obtained • Exceeded Allocated Time Limits • Invalid or Incorrect Dx Code • CPT and Dx Do Not Match

39. 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

40. Testing Time Defined • Preparing to Test Patient • Reviewing of Records • Selection of Tests • Scoring of Tests • Reviewing of Results • Interpretation of Results • Preparation and Report Writing

41. Testing Time Defined (continued) • Communicating Further With Others • Follow-up With Patient, Family, and/or Others • Arranging for Ancillary and/or Other Services

42. Intervention Time Defined • All Time is Bundled in the Allocated Time • 90806 = 45 minutes of total time • 97770 = 15 minutes of total time

43. Time X Code • Interview & Assessment • Hourly Increments • Intervention • 15 • 30 • 45 • 90?

44. 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.

45. 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

46. Provider • Doctorate • Medicare: PhD/PsyD/EdD = MD • Non-Medicare: 0-50% less than MD • Non-Doctorate • Social Security • The special case of North Carolina

47. Medical Necessity • Definition • 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 procedures • Likely Types • Acute and emergency

48. Documentation • Purpose • General Guidelines • Specific Documentation • Trends • Suggestions

49. Purpose of Documentation • Evaluate and Plan for Treatment • Communication and Continuity of Care • Claims Review and Payment • Research and Education

50. General Principles of Documentation • Complete and Legible • Reason/Rationale for the Encounter • Assessment, Impression, or Diagnosi/es • Plan for Care • Date and Identity of Observer