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Coding, Documenting, and Billing & Auditing Neuropsychological Services: revision of 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 [email protected]; web “clinicalneuropsychology.com” Massachusetts Neuropsychological Society Boston, MA, December 5, 2000 Outline of Presentation History/Background of Involvement Procedural Coding Reimbursement Documentation Auditing Related Issues Future Trends 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 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 Coding History of Coding Coding 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 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 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 Psychiatry Neurology Physical 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 Regular Length of Time (30, 60, 90) Biofeedback Regular vs Psychophysiological (90901 vs 90875) Overview of Coding (cont.) Central Nervous System Assessments/Test 96100 96105 96110/1 96115 96177 = = = = = Psychological Testing Aphasia Testing Developmental Testing Neurobehavioral Status Exam 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 909X2 909X3 909X4 909X5 909X6 NOTE: assessment (15 minutes) re-assessment intervention- individual intervention- group intervention- family intervention- family w/o pt. 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 ICD = 90801, 96100, 90806 = 96115, 96117, 97770 Reimbursement History Defining Formula Defining Defining Defining Defining RBRVS Time Site Necessity and Applying “Incident to” 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 RBRVS Major Components Physician Work Resource Value Unit Practice Expense Resource Value Unit Malpractice Component Resource Value Unit Conversion Factor Adoption of the RBRVS Medicare Blue Cross/Blue Shield- 87% Managed Care- 55% Reimbursement Formula Procedural Code Time Diagnosis Site of Service Provider Formula Code X Time X Dx X Site X Provider Reimbursement Difficulties Physician Work Value Phd/PsyD/EdD vs MD Location Defined 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 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 Patient Reviewing of Records Selection of Tests Scoring of Tests Reviewing of Results Interpretation of Results Preparation and Report Writing Documentation Purpose General Guidelines Specific Documentation Trends Suggestions Purpose of Documentation Evaluate and Plan for Treatment Communication and Continuity of Care Claims Review and Payment Research and Education 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 Documentation History Chief Complaint History of Present Illness (HPI) Review of Systems Past, 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 Illness Chronological 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 Psychiatric Neurological Other Documentation of History Past History Family History Social 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 Tests Interpretation of Tests Results Disposition Time Documentation Suggestions Avoid Handwritten Notes Do Not Use Red Ink Document on Every Encounter, Every Procedure, and Every Patient Re-Cap Status, Whenever Possible, At Least Change From Session to Session Document Soon After Procedure Trends Issues of Confidentiality Over-Diagnosing Over-Documenting Limited Interventions & Diagnostic Procedure Auditing Fraud & Abuse vs Erroneous Self-Auditing Suggestions Risk Situations Development of an Internal Auditing System Fraud vs Error Fraud = Intentional, Pattern Erroneous = Clerical, etc. Self-Auditing Suggestions Written Policies Compliance Officer Training & Education Lines of Communication Should Exist Internal Monitoring & Auditing Enforce Standards Alter as Necessary Risk Areas for Fraud Coding & Billing Reasonable & Necessary Services Documentation Improper Inducements Fraudulent Claims Flags Upcoding Excessive or Unnecessary Visits to ACF Outpatient Service 72 Hrs. Post-Discharge CPT Code Usage Shift High Percentage of the Same Codes Use 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 Issues Incident 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 Codes Health Care Finance Administration Committee for the Advance of Professional Practice Practice Directorate of the APA General Trends Future of Clinical Neuropsychology Resources Surveys Rationale for Surveys All Decisions are Empirical Reasonably Large Ns Adequate Data Support Required If Asked, Participate Two Ongoing; NAN/Division 40 Practice Survey Re-evaluation of “Cognitive Rehabilitation” Health Care Financing Administration Problems Definition of Physician (Social Security Practice Act of 1989) Doctoral vs Non-Doctoral Providers Directions 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 Trends Fraud, Abuse, & Effects of Regulations Clinical Neuropsychology Standardizing & Expanding Into Non-Traditional Areas “Boutique” vs “Industrial” Neuropsych. Psychometrics as Clinical Neuropsychology Assessment & Rehabilitation Neuropsychology’s “Technical” Pipeline Establishment of “Grassroots Network” Future of Clinical Neuropsychology: A Holiday Wish List More (normative?) Data & A Few Theories Measurement of the Cultural & Subjective Less 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 Resources Web 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)
