Antonio E. Puente Department of Psychology University of North Carolina at Wilmington 28403-3297

1. 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 Puente@uncwil.edu; web “clinicalneuropsychology.com” Massachusetts Neuropsychological Society Boston, MA, December 5, 2000

2. Outline of Presentation • History/Background of Involvement • Procedural Coding • Reimbursement • Documentation • Auditing • Related Issues • Future Trends

3. 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

4. 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

5. History/Background (continued) • American Medical Association • CPT- 4 • CPT- 5 • Health Care Financing Administration • Model Mental Health Policy Workgroup • Medicare Coverage Advisory Committee

6. Procedural Coding • Defining Coding • History of Coding • Coding

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

8. 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

9. 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

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

11. 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)

12. 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

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

14. 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...

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

16. 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

17. Reimbursement • History • Defining RBRVS • Formula • Defining Time • Defining Site • Defining Necessity • Defining and Applying “Incident to”

18. 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

19. 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%

20. Reimbursement Formula • Procedural Code • Time • Diagnosis • Site of Service • Provider • Formula • Code X Time X Dx X Site X Provider

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

22. 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

23. 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

24. 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

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

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

27. 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

28. Documentation History • Chief Complaint • History of Present Illness (HPI) • Review of Systems • Past, Family, and/or Social History

29. 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.

30. 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.

31. Review of Systems • Psychiatric • Neurological • Other

32. Documentation of History • Past History • Family History • Social History

33. 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

34. Specific Documentation Suggestions: Neurobehavioral Status Exam • Name, Date, Observer, Dx/Impression • Variables • Attention, Memory, Visuo-Spatial, Lanague, Planning

35. Specific Documentation Suggestions: Testing • Name, Date, Observer, Dx/Impression • Names of Tests • Interpretation of Tests Results • Disposition • Time

36. 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

37. Trends • Issues of Confidentiality • Over-Diagnosing • Over-Documenting

38. Auditing • Fraud & Abuse vs Erroneous • Self-Auditing Suggestions • Risk Situations • Development of an Internal Auditing System

39. Fraud vs Error • Fraud = Intentional, Pattern • Erroneous = Clerical, etc.

40. Self-Auditing Suggestions • Written Policies • Compliance Officer • Training & Education • Lines of Communication Should Exist • Internal Monitoring & Auditing • Enforce Standards • Alter as Necessary

41. Risk Areas for Fraud • Coding & Billing • Reasonable & Necessary Services • Documentation • Improper Inducements

42. 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)

43. 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

44. Evaluating Effectiveness • Adequacy of Evidence • Bias • External Validity • Size of Effect • From Not Effective to Breakthrough

45. 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

46. 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

47. 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

48. 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”

49. 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

50. 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