apa convention 2001 zunderstanding federal reimbursement, medicare, and cpt coding zpresented by:...
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APA Convention 2001
Understanding Federal Reimbursement, Medicare, and CPT Coding
Presented by: Steve McEllin
James M. Georgoulakis, PhD Antonio E. Puente, PhD
Chair: Diane M. Pedulla, JD Guest Speaker: Gerald Rogan, MD
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Psychologists and Medicare
Building Stronger Relationships
Steve McEllin APA Government Relations
Practice Directorate
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Congress Calls for Medicare Reform
Congress has called on CMS to simplify the Medicare program through regulatory reform
Hearings on CMS reforms held by House Committee on Small Business and Senate Finance Committee
Medicare Education and Regulatory Fairness Act introduced in Congress
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Medicare Education and Regulatory Fairness Act
Educates providers about correct billing and documenting
Allows providers the option of repayment plans for overpayments
Prohibits CMS from taking back overpayments while an appeal is pending
APA is lobbying lawmakers to get psychologists included under the Act
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CMS Plans for Regulatory Reform of Medicare
Reorganization of CMS into three core business centers
Holding community public listening forums
Creation of external health-sector workgroups
Formation of a CMS workgroup to address regulatory reform
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Three Core Business Centers
Center for Beneficiary ChoicesCenter for Medicare ManagementCenter for Medicaid and State
Operations
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Center for Beneficiary Choices
Focus on educating beneficiaries about health care options (i.e. Medigap, Medicare+Choice, etc…)
Oversee the grievance and appeal process for beneficiaries
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Center for Medicare Management
Manage traditional fee-for-service program
Develop and oversee fee-for-service payment policies
Manage Medicare fee-for-service contractors
Center activities represent CMS’s largest function
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Center for Medicaid and State Operations
Primary responsibility will be programs administered by states
Partner with states in administration of Medicaid and SCHIP programs
Oversee insurance regulatory activities
Responsiveness to states will increase
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Public Listening Forums
CMS wants to hear from local healthcare providers and beneficiaries
Sharing of ideas and concerns
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Formation of Health-Sector Workgroups
CMS is creating seven health-sector workgroups, including physician and non-physician providers, nursing home and long-term care panels
Groups will make recommendations to improve communication with CMS, and decrease regulatory complexity of Medicare program
Senior CMS staff as contact person
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Formation of CMS Workgroup
CMS to establish internal workgroup to address regulatory reform
Composed of senior CMS staffReview regulations and make
recommendations to revise and/or clarify Medicare rules
Keep costs down w/o jeopardizing quality
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Building Relationships With Local Medicare Carriers
Helping psychology by committing resources at the local level
Educate the local carrier’s key personnel about psychological services, and develop
Awareness of the value of psychological services.
Respect for psychologists and services can be increased.
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Why are Relationships Important
Greater number of healthcare providers are competing for a smaller pool of available Medicare dollars
Carriers develop local payment policies that shape coverage decisions
More payment and coverage decisions are being made at the local level
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Decisions Made at Local Level
Local carrier important to management and operation of Medicare program
CMS doesn’t have resources to manage Medicare by itself so more payment and coverage decisions are made at local level
With few national coverage policies, local carriers develop payment policies that may result in regional inconsistencies
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LMRP
Local Medical Review PoliciesAssist providers in filing correct
claims Outline how local carriers review
claims
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Who Do We Build Relationships With?
Carrier Medical DirectorOther key personnel of the local
Medicare carrier
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Importance of the Carrier Medical Director
Carrier Medical Directors develop payment policies, and implement coverage decisions
Carrier Medical Directors play an active role in their state’s carrier advisory process
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Participation in Carrier Advisory Process
Healthcare providers can advise local carriers about payment policies, as well as educate carriers about healthcare services
Through these efforts, providers have an opportunity to influence payment policies and change coverage decisions
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“HEAR” Is The Goal
Sharing information about psychological services
Communicating value of psychological services
Advocating for patientsBuilds relationships with local
Medicare carriers and respect for psychological services
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Resource Based Relative Value System (RBRVS)
Development and Implications for Psychologists
James M. Georgoulakis, PhD
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History of Reimbursement
Cost Plus ReimbursementProspective Payment (PPS) and Diagnostic
Related Groups (DRGs)Customary, Prevailing, and Reasonable (CPR)Physician Prospective Payment and Physician
Diagnostic Related Groups (DRGs)Resource Based Relative Value System
(RBRVS)Ambulatory Payment Categories
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Purpose of RBRVS
To provide equitable payment for medical services
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Development of the RBRVS
Phase I: Initial twelve physician specialties
Phase II: PsychiatryPhase III: Psychology
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RBRVS and Psychology
APA and CMSAPA Technical Advisory Group (TAG)Development of Survey VignettesSurvey Results
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Major Components of the RBRVS
Resource Value UnitsGeographical Practice Cost IndexesConversion Factor
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Resource Value Units
Physician Work Resource Value UnitPractice Expense Resource Value Unit
Non Facility Facility
Professional Liability Insurance (Malpractice) Component Resource Value Unit
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Geographic Practice Cost Indexes (GPCIs)
Physician Work GPCIPractice Expense GPCIProfessional Liability (Malpractice)
Insurance GPCI
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Conversion Factor
Dollar value that is utilized to convert the resource value units
and geographic practice cost indexes into a payment
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Example
CPT Code 90806 – Individual, insight-oriented Psychotherapy in anoffice setting, 45-50 minutes face-to-face with the patient
Local Work* Practice* Malpractice*Conversion
FactorPayment
AL 0.978 0.872 0.876 $34.732 $84.09
AK 1.063 1.173 1.533 $34.732 $97.53
* Includes adjustment for the Geographic Practice Cost Indexesnumbers based on 1999 figures
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Adoption of the RBRVS
MedicareBlue Cross / Blue Shield 87%Managed Care 69%Medicaid 55%Other 44%
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AMA /CMS Resource Value Update Committee
PurposeAPA’s RoleMembers ResponsibilitiesBenefits
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Coding & Documentation for Psychological Services
Key Issues for Professional Psychologists
Antonio E. Puente, PhD
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Model for Professional Psychological Services
Procedure CodingDiagnosingDocumentingBilling
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Procedure Coding
Defining Coding Description of Professional Service Rendered
Purpose of Coding Research / Archival Reimbursement
Coding Systems SNOMED WHO / ICD AMA / CPT
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Background & Mechanics of the CPT
First Developed in 1966Currently Using CPT 4th Edition7,500 Discrete CodesAMA Developed & Owns the CPTUnder Contract with HCFAAPA has 1 Seat on the Advisory Panel
to the CPT
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CPT Codes Applicable to Psychological Services
Total = Approximately 40Sections = Four Separate Sections
Psychiatry Biofeedback Central Nervous System Assessment Physical Medicine & Rehabilitation
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Psychiatry Codes
Sections Office or Other Outpatient Inpatient Hospital, Partial Hospital or
Residential Care Facility Other Psychotherapy Other Psychiatric Services or Procedures
Insight Oriented, Behavior Modifying, and/or Supportive vs. Interactive Therapy
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Central Nervous System Assessments/Tests
96100 = Psychological Testing96105 = Aphasia Testing96110/11 = Developmental Testing96115 = Neurobehavioral Status96117 = Neuropsychological Testing
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Physical Medicine and Rehabilitation
97532 = Cognitive Skills Development
07533 = Sensory integrative techniques
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Current Coding Problems
Total Possible Codes Which Are Usable in the CPT System = 60
Total Number of Possible Codes Which Are Almost Always Reimbursable = 6
Total Number of Possible Codes Which Are Sometimes Reimbursed = 35
Total Number of Possible Codes Which Are Rarely Reimbursed = 19
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Typically Reimbursed Codes
Interviewing 90801
Assessment 96100
Intervention 90804, 90806, 90816, 90818
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Coding Modifiers
Acceptability Medicare = 95% Other = Approximately 80%
Modifiers 22= Unusual or More Extensive Service 51= Multiple Procedure 52= Reduced Service 53= Discontinued Service
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New Codes
Health and Behavior Assessment/Intervention Assessment (15 minutes) Re-assessment Intervention- individual Intervention- group Intervention- with patient Intervention- without patient
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Splitting of Testing Codes
Rationale No Cognitive Component Incident to
Status Work Group Development
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Diagnosing
If Psychiatric= DSM If Neurological= ICD
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Documenting
PurposePayer RequirementsGeneral PrinciplesHistoryExaminationDecision Making
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Purpose of Documentation
Evaluate and Plan for TreatmentCommunication and Continuity of
Care with Other ProfessionalsClaims Review & PaymentResearch & Education
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Payer Requirements
Site of ServiceMedical Necessity for Service
ProvidedAppropriate Reporting of Activity
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General Principles of Documentation
Complete & LegibleReason for EncounterAssessment, Impression, or DiagnosisPlan for CareDate & Identity of ObserverAlso;
Rationale for requested service Risk factors Progress or changes should be noted
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Chief Complaint
Concise Statement Describing the Symptom, Problem, Condition,
Diagnosis
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Billing
Interview If Dx is psychiatric, then 90801 If Dx is neurological, then 96115
Testing If Dx is psychiatric, then 96100 If Dx is neurological, then 96117
Intervention If Dx is psychiatric, then 90804+ If Dx is neurological, then 97770
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Billing (continued)
Diagnoses If Dx is psychiatric, then use DSM If Dx is neurological, then use ICD
Note: Avoid rule out diagnoses
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Billing (continued)
Issues Associated With Fraudulent Claims Upcoding Excessive or Unnecessary Visits to Nursing
Facilities Outpatient Billing Within 72 Hours of Hospital
Discharge CPT Code Usage Shifts High Percentage of Same Code Use of Same Time for Testing Across all
Patients
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Billing (continued)
Typical Denials Service Not CoveredNo Prior Authorization ObtainedExceeded Allocated Time LimitsInvalid or Incorrect Dx CodesCPT and Dx do not Match
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Time
Defining Professional (not patient) Time Including:
pre, during, and post-clinical service activities
Interview & Assessment Codes Use Hourly Increments
Intervention Codes Use 15, 30, or 60 Minute Increments
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Time (continued)
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 and tests, arranging for services and communicating further with
other professionals and the patient through written reports and telephone
contact
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Time (continued)
Communicating further with othersFollow-up with patient, family and/or
othersArranging for ancillary and/or other
services
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Time (continued)
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.
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Time (continued)
Preparing to see patientReviewing of recordsInterviewing patient, family, and/or othersWhen doing assessments:
Selection of tests Scoring of tests Reviewing results Interpretation of results Preparation and report writing
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Fraud and Abuse
History GAO Potential Financial Loss Coding, Documentation, & Services
Current Status 2001 Office of Inspector General Report Continued Focus on Coding but More on
Documentation
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Summary, Directions & Resources
SummaryDirections
New Codes CPT 5 CMS (formerly HCFA) Interface Dissemination & Education Future
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Resources
American Psychological Association (APA)
National Academy of Neuropsychology (NAN)
Division of Clinical Neuropsychology of APA
CMSNational Institutes of Health (NIH)
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Resources (continued)
APA; Practice Directorate; www.apa.orgNAN; Directory: www.nan.drexel.eduDivision 40; Practice Committee, Web
PageCMS (formerly HCFA); www.hcfa.govNIH;
http://odp.od.nih.gov/consensus/cons/109/109_statement.htm
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Resources (continued)
NAN Bulletin 1994, Spring - Original Suggestions for Billing 1998, Summer - Practice Patterns 1997 - Top 25 Tests, Costs, & Longevity
Journal of Psychopathology & Behavioral Assessment (Puente, 1997)
Professional Psychology (Camara, Nathan, & Puente, 2000)
Reimbursement for Clinical Neuropsychological Services (www.clinicalneuropsychology.com)