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 Presentation

History/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/Background

North Carolina Psychological Association Blue-Cross Blue Shield

American 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 Coding

Defining CodingHistory of CodingCoding

Defining Coding

Description of Professional Service Rendered

Purpose of Coding Archival/Research Reimbursement

Coding Systems SNOMED WHO / ICD AMA / CPT

History of CPT Coding

First 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 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

Overview of Coding: An evolution of coding

PsychiatryNeurologyPhysical 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 Overview

Coding 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

Reimbursement

HistoryDefining RBRVSFormulaDefining TimeDefining SiteDefining NecessityDefining and Applying “Incident to”

History of Reimbursement

Cost plus ReimbursementProspective Payment (PPS) &

Diagnostic Related Groups (DRGs)Customary. Prevailing, &

Reasonable(CPR)Resource Based Relative Value

System (RBRVS)Prospective Payment System

RBRVS

Major 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 Formula

Procedural CodeTimeDiagnosisSite of ServiceProviderFormula

Code X Time X Dx X Site X Provider

Reimbursement Difficulties

Physician Work ValuePhd/PsyD/EdD vs MDLocation Defined

Common Reasons for Lack of Reimbursement

Clerical ErrorsService Is Not CoveredNo Prior Authorization ObtainedExceeded Allocated Time LimitsInvalid or Incorrect Dx CodeCPT and Dx Do Not Match

Defining Time

Defining Time Professional (not patient) Activity

Interview 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 Defined

Preparing to Test PatientReviewing of RecordsSelection of TestsScoring of TestsReviewing of ResultsInterpretation of ResultsPreparation and Report Writing

Documentation

PurposeGeneral GuidelinesSpecific DocumentationTrendsSuggestions

Purpose of Documentation

Evaluate and Plan for TreatmentCommunication and Continuity of

CareClaims Review and PaymentResearch and Education

General Principles of Documentation

Complete and LegibleReason/Rationale for the EncounterAssessment, Impression, or

Diagnosi/esPlan for CareDate and Identity of Observer

Documentation History

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

Documentation of Chief Complaint

Concise 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 Systems

PsychiatricNeurologicalOther

Documentation of History

Past 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 Exam

Name, Date, Observer, Dx/Impression

Variables Attention, Memory, Visuo-Spatial,

Lanague, Planning

Specific Documentation Suggestions: Testing

Name, Date, Observer, Dx/Impression

Names of TestsInterpretation of Tests ResultsDispositionTime

Documentation Suggestions

Avoid 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

Trends

Issues of ConfidentialityOver-DiagnosingOver-Documenting

Auditing

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

System

Fraud vs Error

Fraud = Intentional, Pattern

Erroneous = Clerical, etc.

Self-Auditing Suggestions

Written PoliciesCompliance OfficerTraining & Education Lines of Communication Should ExistInternal Monitoring & AuditingEnforce Standards Alter as Necessary

Risk Areas for Fraud

Coding & BillingReasonable & Necessary ServicesDocumentationImproper Inducements

Fraudulent Claims Flags

UpcodingExcessive 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 Effectiveness

Adequacy 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 Trends

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

Professional Practice Practice Directorate of the APAGeneral TrendsFuture of Clinical NeuropsychologyResources

Surveys

Rationale 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)