2006 nan introductory cpt1 coding, billing and documenting clinical neuropsychological services: an...

2006 nan introductory cpt2006 nan introductory cpt 11

Coding, Billing and Documenting Coding, Billing and Documenting Clinical Neuropsychological Services:Clinical Neuropsychological Services:

An Introductory PresentationAn Introductory Presentation

Antonio E. PuenteAntonio E. PuenteUniversity of North Carolina WilmingtonUniversity of North Carolina Wilmington

National Academy of NeuropsychologyNational Academy of NeuropsychologyOctober 27, 2006October 27, 2006


DisclaimerDisclaimer

The information contained in this extended presentation is The information contained in this extended presentation is not intended to reflect NAN, APA, Division 40, NCPA, AMA not intended to reflect NAN, APA, Division 40, NCPA, AMA and/or CMS policy. Further, this presentation is intended and/or CMS policy. Further, this presentation is intended to be informative and not meant to imply that it to be informative and not meant to imply that it supersedes APA or state licensing boards’ ethical supersedes APA or state licensing boards’ ethical guidelines and/or local, state or national regulations and/or guidelines and/or local, state or national regulations and/or laws. Further, Local Coverage Determination and specific laws. Further, Local Coverage Determination and specific health care contracts supersedes the information health care contracts supersedes the information presented. The information contained herein is meant to presented. The information contained herein is meant to provide practitioners as well as health care institutions provide practitioners as well as health care institutions (e.g., insurance companies) involved in psychological (e.g., insurance companies) involved in psychological services with the latest information available regarding services with the latest information available regarding the issues addressed. This is a living document that can the issues addressed. This is a living document that can and will be revised as additional information becomes and will be revised as additional information becomes available. The ultimate responsibility of the validity and available. The ultimate responsibility of the validity and utility of the information contained herein lies with the utility of the information contained herein lies with the individual and/or institution using this information and not individual and/or institution using this information and not with any supporting organization and/or the author of this with any supporting organization and/or the author of this presentation. Suggestions or changes should be addressed presentation. Suggestions or changes should be addressed to the author. Thank you…to the author. Thank you…


AcknowledgmentsAcknowledgments

North Carolina Psychological AssociationNorth Carolina Psychological Association American Medical Association (AMA) CPT StaffAmerican Medical Association (AMA) CPT Staff American Psychological Association (APA) Practice Directorate (PD)American Psychological Association (APA) Practice Directorate (PD) National Academy of Neuropsychology (NAN)National Academy of Neuropsychology (NAN) Division of Clinical Neuropsychology of APA (40)Division of Clinical Neuropsychology of APA (40) Center for Medicare & Medicaid Services (CMS) Medical Policy Center for Medicare & Medicaid Services (CMS) Medical Policy

Staff- MedicareStaff- Medicare

Special thanks to theDepartment of Psychology, UNC-Wilmington, Special thanks to theDepartment of Psychology, UNC-Wilmington, James Georgoulakis, Neil Pliskin, Ted Peck and AEP’s Clinical and James Georgoulakis, Neil Pliskin, Ted Peck and AEP’s Clinical and Research StaffResearch Staff


Specific Support Provided by Primary Specific Support Provided by Primary OrganizationsOrganizations

APA = All expenses paid for travel associated with APA = All expenses paid for travel associated with AMA CPT activitiesAMA CPT activities

NAN = (from PAIC budget) applied to UNCW NAN = (from PAIC budget) applied to UNCW activitiesactivities 2006 = $25,000 per year – two course per semester 2006 = $25,000 per year – two course per semester

teaching reduction per academic yearteaching reduction per academic year UNCW = Time away from university duties (e.g., UNCW = Time away from university duties (e.g.,

teaching) plus incidental support such as copying, teaching) plus incidental support such as copying, telephone calls, secretarial and work-study telephone calls, secretarial and work-study student assistancestudent assistance


Part I: Coding, Billing & Part I: Coding, Billing & DocumentationDocumentation

Part I:Part I: A. MedicareA. Medicare B. Current Procedural TerminologyB. Current Procedural Terminology C. DiagnosingC. Diagnosing D. Medical NecessityD. Medical Necessity E. Documentation E. Documentation F. TimeF. Time G. TechniciansG. Technicians H. SupervisionH. Supervision


A. Medicare: Why?A. Medicare: Why?

TheThe Standard for Universal Health Standard for Universal Health Care:Care: Coding (what can be done)Coding (what can be done) Value (how much it will be paid)Value (how much it will be paid) Documentation (what needs to be said)Documentation (what needs to be said) Auditing (determination of whether it Auditing (determination of whether it

occurred)occurred)


Medicare: Immediate Medicare: Immediate ImpactImpact

As a Consequence, the Benchmark As a Consequence, the Benchmark for:for: All Commercial Carriers (e.g., HMOs)All Commercial Carriers (e.g., HMOs) As well as;As well as;

Workers CompensationWorkers Compensation Forensic ApplicationsForensic Applications Related Applications (e.g., industrial, sports)Related Applications (e.g., industrial, sports)


Medicare: Long-term ImpactMedicare: Long-term Impact

By 2015, Medicare will represent By 2015, Medicare will represent approximately 50% of all health care approximately 50% of all health care payments in the United Statespayments in the United States

Eventually, a national (US) health Eventually, a national (US) health insurance will be establishedinsurance will be established

One possible model will be to introduce One possible model will be to introduce Medicare to younger citizens will be in Medicare to younger citizens will be in age increments (e.g., 60-64, then 50-59, age increments (e.g., 60-64, then 50-59, etc)etc)

Hence, Medicare will come to set the Hence, Medicare will come to set the standard for all of health carestandard for all of health care


Medicare: OverviewMedicare: Overview

Centers for Medicare and Medicaid Centers for Medicare and Medicaid ServicesServices

BenefitsBenefits Part A (Hospital)Part A (Hospital) Part B (Supplementary)Part B (Supplementary) Part C (Medicare+ Choice)Part C (Medicare+ Choice) Part D (Pharmaceutical)Part D (Pharmaceutical)


Medicare: Local ReviewMedicare: Local Review

Medical Review Policy Medical Review Policy National Policy Sets Overall ModelNational Policy Sets Overall Model Local Coverage Determination (LCD) Sets Local Coverage Determination (LCD) Sets

Local/Regional Policy-Local/Regional Policy- More restrictive than national policyMore restrictive than national policy Over-rides national policyOver-rides national policy Changes frequently without warning or publicityChanges frequently without warning or publicity Information best found on respective web pagesInformation best found on respective web pages


B. Current Procedural B. Current Procedural Terminology (CPT): Terminology (CPT):

OverviewOverview

BackgroundBackground Codes & CodingCodes & Coding Existing CodesExisting Codes Model System X Type of ProblemModel System X Type of Problem


CPT CopyrightCPT Copyright

CPT is Copyrighted by the American CPT is Copyrighted by the American Medical AssociationMedical Association

CPT Manuals May be Ordered from CPT Manuals May be Ordered from the AMA at 1.800.621.8335the AMA at 1.800.621.8335


CPT: BackgroundCPT: Background

AmericanAmerican Medical Association Medical Association Developed by Surgeons (& Physicians) Developed by Surgeons (& Physicians)

in 1966 for Billing Purposesin 1966 for Billing Purposes 7,500+ Discrete Codes7,500+ Discrete Codes CPT Meets a Minimum of 3 Times/YearCPT Meets a Minimum of 3 Times/Year

Center for Medicare & Medicaid Center for Medicare & Medicaid ServicesServices AMA Under License by CMSAMA Under License by CMS CMS Now Provides Active Input into CPTCMS Now Provides Active Input into CPT


CPT: TheoryCPT: Theory

Order of Value - PersonnelOrder of Value - Personnel Surgeons, Physicians, Doctorate Level Surgeons, Physicians, Doctorate Level

Allied Health, Non-Doctorate Level Allied Allied Health, Non-Doctorate Level Allied HealthHealth

Order of Value - CostsOrder of Value - Costs Cognitive Work, Expense, MalpracticeCognitive Work, Expense, Malpractice X a Geographic Location FactorX a Geographic Location Factor


What Is a CPT Code?What Is a CPT Code?

A Coding System Developed by AMA in A Coding System Developed by AMA in Conjunction with CMS to Describe Conjunction with CMS to Describe Professional Services Professional Services

Each Code has a Specific Number and Each Code has a Specific Number and Description as well as a Reimbursable ValueDescription as well as a Reimbursable Value

Professional Health Service Provided Across Professional Health Service Provided Across the Country at Multiple Locationsthe Country at Multiple Locations

Many “Physicians” or “Qualified Health Many “Physicians” or “Qualified Health Professional” Perform ServicesProfessional” Perform Services

Clinical Efficacy is Established and Clinical Efficacy is Established and Documented in Peer-Reviewed LiteratureDocumented in Peer-Reviewed Literature


CPT: Applicable CodesCPT: Applicable Codes

Total Possible Codes = Approximately 7,500Total Possible Codes = Approximately 7,500 Possible Codes for Psychology = Possible Codes for Psychology =

Approximately 40 to 60Approximately 40 to 60 Sections = Five Primary Separate SectionsSections = Five Primary Separate Sections

Psychiatry (e.g., mental health)Psychiatry (e.g., mental health) BiofeedbackBiofeedback Central Nervous System Assessment (testing)Central Nervous System Assessment (testing) Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Health & Behavior Assessment & Management Health & Behavior Assessment & Management

(h.p.)(h.p.) Evaluation and Management Evaluation and Management


CPT: PsychiatryCPT: Psychiatry

Sections (or Categories)Sections (or Categories) Interview (Interview (9080190801) vs. Intervention (e.g., ) vs. Intervention (e.g., 9080690806)) These codes are one unit (time = un-timed to These codes are one unit (time = un-timed to

varied)varied) Office vs. InpatientOffice vs. Inpatient Regular vs. Evaluation & ManagementRegular vs. Evaluation & Management OtherOther

Types of InterventionsTypes of Interventions Insight, Behavior Modifying, and/or Supportive Insight, Behavior Modifying, and/or Supportive

vs. Interactivevs. Interactive


Psychiatric CodesPsychiatric Codes

InterviewingInterviewing 9080190801 One time per illness incident or boutOne time per illness incident or bout Un-timedUn-timed Comprehensive analysis of records, Comprehensive analysis of records,

observations as well as structured observations as well as structured and/or unstructured clinical interviewand/or unstructured clinical interview


Psychiatric CodesPsychiatric Codes

TherapyTherapy 20 minutes = 20 minutes = 9080490804 45-50 minutes = 45-50 minutes = 9080690806** 80-90 minutes = 80-90 minutes = 9080890808

* = most typical* = most typical


CPT: CNS AssessmentCPT: CNS AssessmentUntil 12.31.05Until 12.31.05

InterviewInterview 9611596115

TestingTesting Psychological = Psychological = 96100; 96110/1196100; 96110/11 Neuropsychological = Neuropsychological = 9611796117 Aphasia = Aphasia = 9610596105 Developmental = Developmental = 96110/11196110/111


Rationale for CPT Changes:Rationale for CPT Changes:CNS Assessment CodesCNS Assessment Codes

Avoidance of Continuation of Avoidance of Continuation of Reimbursement Heavily Based on Practice Reimbursement Heavily Based on Practice ExpenseExpense

Greater Clarification of Activities Including Greater Clarification of Activities Including Interviewing and Testing by Professional, Interviewing and Testing by Professional, Technician and/or ComputerTechnician and/or Computer

Recognition of Cognitive WorkRecognition of Cognitive Work Great Clarity of What Actual is HappeningGreat Clarity of What Actual is Happening Differentiation of Professional, Technical Differentiation of Professional, Technical

and (non-assisted) Computer Testingand (non-assisted) Computer Testing Most Importantly, a Mandate from CMSMost Importantly, a Mandate from CMS


CPT: CNS AssessmentCPT: CNS AssessmentEffective 01.01.06 Effective 01.01.06 (no grace (no grace

period)period) Psychological Testing (e.g., 5 units)Psychological Testing (e.g., 5 units)

Three New CodesThree New Codes New Numbers & DescriptorsNew Numbers & Descriptors

Neurobehavioral Status Exam (e.g., 2 Neurobehavioral Status Exam (e.g., 2 units)units) New Number & Revised DescriptorNew Number & Revised Descriptor

Neuropsychological Testing (e.g., 10 units)Neuropsychological Testing (e.g., 10 units) Three New CodesThree New Codes New Numbers & DescriptorsNew Numbers & Descriptors


Psychological Testing:Psychological Testing:By ProfessionalBy Professional

9610196101 –Psychological Testing –Psychological Testing Psychodiagnostic assessment of Psychodiagnostic assessment of

emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology, e.g., personality and psychopathology, e.g., MMPI, Rorschach, WAIS (per hour of MMPI, Rorschach, WAIS (per hour of psychologist’s orpsychologist’s or physician’sphysician’s time, both time, both face-to-face time with the patient and face-to-face time with the patient and time interpreting test results and time interpreting test results and preparing the report)preparing the report)


Psychological Testing:Psychological Testing:By TechnicianBy Technician

9610296102- Psychological Testing- Psychological Testing Psychodiagnostic assessment of Psychodiagnostic assessment of

emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology (e.g., personality and psychopathology (e.g., MMPI, Rorschach, WAIS) with MMPI, Rorschach, WAIS) with qualified qualified health care professionalhealth care professional interpretation interpretation and report, administered by and report, administered by techniciantechnician, , per hour of technician time, face-to-faceper hour of technician time, face-to-face


Psychological Testing:Psychological Testing:By ComputerBy Computer

9610396103 - Psychological Testing- Psychological Testing Psychodiagnostic assessment of Psychodiagnostic assessment of

emotionality, intellectual abilities, emotionality, intellectual abilities, personality and psychopathology, (e.g., personality and psychopathology, (e.g., MMPI) administered by a MMPI) administered by a computercomputer, , with with qualified health professionalqualified health professional interpretation and the reportinterpretation and the report


Neurobehavioral Status Neurobehavioral Status ExamExam

9611696116 - Neurobehavioral status exam - Neurobehavioral status exam Clinical assessment of thinking, reasoning Clinical assessment of thinking, reasoning

and judgment ( e.g., acquired knowledge, and judgment ( e.g., acquired knowledge, attention, language, memory, planning attention, language, memory, planning and problem solving, and visual-spatial and problem solving, and visual-spatial abilities) per hour of abilities) per hour of psychologist’s or psychologist’s or physician’sphysician’s time, both face-to-face time time, both face-to-face time with the patient and time interpreting with the patient and time interpreting test results and preparing the reporttest results and preparing the report


Neuropsychological Testing-Neuropsychological Testing-By ProfessionalBy Professional

9611896118 - Neuropsychological testing - Neuropsychological testing (e.g., Halstead-Reitan (e.g., Halstead-Reitan

Neuropsychological, WMS, Wisconsin Neuropsychological, WMS, Wisconsin Card Sorting) per hour of the Card Sorting) per hour of the psychologist’s or physician’spsychologist’s or physician’s time, time, both face-to-face time with the patient both face-to-face time with the patient and time interpreting test results and and time interpreting test results and preparing the reportpreparing the report


Neuropsychological Testing:Neuropsychological Testing:By TechnicianBy Technician

9611996119 - Neuropsychological testing - Neuropsychological testing (e.g., Halstead-Reitan (e.g., Halstead-Reitan

Neuropsychological, WMS, Wisconsin Neuropsychological, WMS, Wisconsin Card Sorting) with Card Sorting) with qualified health care qualified health care professionalprofessional interpretation and report, interpretation and report, administered by a administered by a techniciantechnician per hour per hour of technician time, face-to-faceof technician time, face-to-face


Neuropsychological Testing-Neuropsychological Testing-By ComputerBy Computer

9612096120 - Neuropsychological testing - Neuropsychological testing (e.g., WCST) administered by a (e.g., WCST) administered by a

computercomputer with with qualified health care qualified health care professionalprofessional interpretation and the interpretation and the reportreport


CNS Assessment ExamplesCNS Assessment Examples Neurobehavioral Status with Neuropsychological Neurobehavioral Status with Neuropsychological

TestingTesting Interview by the ProfessionalInterview by the Professional Testing byTesting by

Professional, and/orProfessional, and/or Technician, and/orTechnician, and/or Computer.Computer.

Interpretation & Report Writing by Qualified Health Interpretation & Report Writing by Qualified Health ProfessionalProfessional

A Technician or Computer Code are Typically Billed A Technician or Computer Code are Typically Billed Together with a Professional Code Assuming that Together with a Professional Code Assuming that Different Services are Provided (since the final product Different Services are Provided (since the final product should be a should be a comprehensive/integrative comprehensive/integrative report)report)


CPT: Cognitive CPT: Cognitive RehabilitationRehabilitation

Application RationaleApplication Rationale Allied Health & Physical Medicine CodeAllied Health & Physical Medicine Code

AcceptabilityAcceptability GN – Speech TherapistsGN – Speech Therapists GO – Occupational TherapistsGO – Occupational Therapists GP – Physical TherapistsGP – Physical Therapists AH – Mental Health (not applicable)AH – Mental Health (not applicable)


CPT: Health & Behavior CPT: Health & Behavior Assessment & ManagementAssessment & Management

((CPT AssistantCPT Assistant, 03.04), 03.04)((CPT AssistantCPT Assistant, 08.05, , 08.05, 1515, #6, 10), #6, 10)

Purpose: Medical DiagnosisPurpose: Medical Diagnosis Time: 15 Minute IncrementsTime: 15 Minute Increments AssessmentAssessment InterventionIntervention


H & B: RationaleH & B: Rationale

Acute or Chronic Health IllnessAcute or Chronic Health Illness Not Applicable to Psychiatric IllnessNot Applicable to Psychiatric Illness However, Both Could be Treated However, Both Could be Treated

Simultaneously But Not Within the Simultaneously But Not Within the Same SessionSame Session


Health & Behavior Health & Behavior Assessment CodesAssessment Codes

9615096150 Health and behavior assessment (e.g., Health and behavior assessment (e.g.,

health-focused clinical interview, health-focused clinical interview, behavioral observations, behavioral observations, psychophysiological monitoring, health-psychophysiological monitoring, health-oriented questionnaires)oriented questionnaires)

each 15 minuteseach 15 minutes face-to-face with the patientface-to-face with the patient initial assessmentinitial assessment

9615196151 re-assessmentre-assessment


Health & Behavior Health & Behavior Intervention CodesIntervention Codes

9615296152 Health and behavior interventionHealth and behavior intervention each 15 minuteseach 15 minutes face-to-faceface-to-face individualindividual

9615396153 group (2 or more patients)group (2 or more patients)

9615496154 family (with the patient present)family (with the patient present)

9615596155 (limited acceptability)(limited acceptability) family (without the patient present; not being family (without the patient present; not being

reimbursedreimbursed))


CPT: Model SystemCPT: Model System

PsychiatricPsychiatric NeurologicalNeurological Non-Neurological MedicalNon-Neurological Medical


CPT ModelCPT Model

Rationale for a Specific CPT Code:Rationale for a Specific CPT Code: Choose Code that Best Describes the Choose Code that Best Describes the

Service Service Match the Interview with the Testing Match the Interview with the Testing

with the Intervention Code with the with the Intervention Code with the DiagnosisDiagnosis

Goal = Uniformity and FluencyGoal = Uniformity and Fluency


CPT: Psychiatric ModelCPT: Psychiatric Model(Children & Adult)(Children & Adult)

InterviewInterview 9080190801- adult- adult 9080290802- child- child

TestingTesting 96101-0396101-03 Also, Also, 9611196111 for childrenfor children

InterventionIntervention e.g., e.g., 9080690806- adult- adult e.g., e.g., 9082090820-child-child


CPT: Neurological ModelCPT: Neurological Model(Children & Adult)(Children & Adult)

InterviewInterview 9611696116

TestingTesting 96118/19/2096118/19/20

InterventionIntervention 9753297532


CPT: Non-Neurological CPT: Non-Neurological Medical ModelMedical Model

(Children & Adult)(Children & Adult)

Interview & AssessmentInterview & Assessment 9615096150 (initial)(initial) 9615196151 (re-evaluation) (re-evaluation)

InterventionIntervention 9615296152 (individual) (individual) 9615396153 (group)(group) 9615496154 (family with patient)(family with patient)


ModifiersModifiers(from Appendix A in CPT book; see oig reports)(from Appendix A in CPT book; see oig reports)

ExamplesExamples 22 = reduced service22 = reduced service 25 = additional payment for an E & M code as 25 = additional payment for an E & M code as

a specific procedure code (problematic)a specific procedure code (problematic) 51 = multiple procedures51 = multiple procedures 52 = reduced services52 = reduced services 59 = when two procedures occur on same day59 = when two procedures occur on same day GN, GO, AH, etc. = local carrier specificGN, GO, AH, etc. = local carrier specific

ProblemsProblems Incomplete support for modifier from 15 to Incomplete support for modifier from 15 to

35% of documentation results in paybacks 35% of documentation results in paybacks


National Work National Work RVU/Estimated $ 2006 RVU/Estimated $ 2006

ValuesValuesop=outpatient, ip=inpatient, est.=estimate rvu = op=outpatient, ip=inpatient, est.=estimate rvu =

workworkCode #Code # OP RVUOP RVU IP RVUIP RVU OP $ estOP $ est IN IN $est$est

9610196101 2.562.56 2.542.54 97.0297.02 96.2696.26

9610296102 1.171.17 0.680.68 44.3444.34 25.7725.77

9610396103 0.740.74 0.700.70 28.0428.04 26.5326.53

9611696116 2.872.87 2.682.68 108.77108.77 101.5101.577

9611896118 3.433.43 2.672.67 129.99129.99 101.1101.199

9611996119 1.751.75 0.920.92 66.3266.32 34.8734.87

9612096120 1.271.27 0.700.70 48.1348.13 26.5326.53


C. CPT: DiagnosingC. CPT: Diagnosing

PsychiatricPsychiatric DSMDSM

The problem with DSM and neuropsych The problem with DSM and neuropsych testing of developmentally-related testing of developmentally-related neurological problemsneurological problems

Neurological & Non-Neurological Neurological & Non-Neurological MedicalMedical ICD – 9 CM (physical diagnosis coding)ICD – 9 CM (physical diagnosis coding) www.cdc.gov/nchs/about/otheract/icd9www.cdc.gov/nchs/about/otheract/icd9


D. CPT: Medical NecessityD. CPT: Medical Necessity

Scientific & Clinical NecessityScientific & Clinical Necessity Local Medical Review or Carrier Definitions of Local Medical Review or Carrier Definitions of

NecessityNecessity Necessity = CPT x DX formularyNecessity = CPT x DX formulary Necessity Dictates Type and Level of ServiceNecessity Dictates Type and Level of Service Necessity Can Only be Proven with Necessity Can Only be Proven with

DocumentationDocumentation Screening or Regularly Scheduled Evaluations Screening or Regularly Scheduled Evaluations

Do Not Meet Criteria for NecessityDo Not Meet Criteria for Necessity Will Results Affect Outcome of Patient?Will Results Affect Outcome of Patient? Will New Information Be Obtained as a Will New Information Be Obtained as a

Function of the Activity?Function of the Activity?


Medically Reasonable and Medically Reasonable and NecessaryNecessary

Section 1862 (a)(1) 1963Section 1862 (a)(1) 196342, C.F.R., 411.15 (k)42, C.F.R., 411.15 (k)

““Services which are reasonable and necessary Services which are reasonable and necessary for the diagnosis and treatment of illness or for the diagnosis and treatment of illness or injury or to improve the functioning of a injury or to improve the functioning of a malformed body member”malformed body member”

Re-evaluation should only occur when there is a Re-evaluation should only occur when there is a potential change in;potential change in; DiagnosisDiagnosis SymptomsSymptoms


E. CPT: DocumentingE. CPT: Documenting

PurposePurpose General PrinciplesGeneral Principles AssessmentAssessment InterventionIntervention


Documentation: PurposeDocumentation: Purpose

Medical NecessityMedical Necessity Evaluate and Plan for TreatmentEvaluate and Plan for Treatment Communication and Continuity of Communication and Continuity of

CareCare Claims Review and PaymentClaims Review and Payment Research and EducationResearch and Education


Documentation: General Documentation: General PrinciplesPrinciples

Rationale for ServiceRationale for Service Assessment, Progress, Impression, or Assessment, Progress, Impression, or

DiagnosisDiagnosis Plan for CarePlan for Care Date and Identity of ObserverDate and Identity of Observer AlsoAlso

LegibleLegible TimelyTimely ConfidentialConfidential


Documentation: Basic Documentation: Basic Information Across CodesInformation Across Codes

DateDate Time, if applicableTime, if applicable Identity of Observer (technician ?)Identity of Observer (technician ?) Reason for ServiceReason for Service StatusStatus ProcedureProcedure Results/FindingResults/Finding Impression/DiagnosesImpression/Diagnoses DispositionDisposition Stand AloneStand Alone


Documentation: AssessmentDocumentation: Assessment

Reason for ServiceReason for Service Dates (amount of service time; total Vs. Dates (amount of service time; total Vs.

actual)actual) Identity of Tester (technician?)Identity of Tester (technician?) Tests and Protocols (included editions)Tests and Protocols (included editions) Narrative of ResultsNarrative of Results ImpressionImpression DispositionDisposition


Documentation: Documentation: InterventionIntervention

Reason for ServiceReason for Service Status of PatientStatus of Patient Intervention PerformedIntervention Performed Results ObtainedResults Obtained Impression(s) or Diagnosis (es)Impression(s) or Diagnosis (es) DispositionDisposition TimeTime


Documentation:Documentation:CPT X ReportCPT X Report

Each CPT Code Should Generate a Each CPT Code Should Generate a Separate Report (or at least a Separate Report (or at least a separate section; titles should reflect separate section; titles should reflect the code that is being billed such as the code that is being billed such as “psychological testing)“psychological testing)

Alternatively, Clearly Label/Title Alternatively, Clearly Label/Title Sections of the Report to Match Sections of the Report to Match Codes UsedCodes Used


Documentation: Documentation: SuggestionsSuggestions

Consider Having a Multi-level System Consider Having a Multi-level System of Documentation;of Documentation; Raw data (e.g., test protocols)Raw data (e.g., test protocols) Internal routing sheets documenting Internal routing sheets documenting

such information as start/stop time, such information as start/stop time, dates, etc. (a master sheet could track dates, etc. (a master sheet could track technician as well as professional time)technician as well as professional time)

Final reportFinal report


F. CPT: TimeF. CPT: Time

Time is Broadly Defined as What the Time is Broadly Defined as What the Professional DoesProfessional Does

For Intervention – Time is face-to-For Intervention – Time is face-to-faceface

For Assessment - Time could be For Assessment - Time could be either face-to-face or professional either face-to-face or professional timetime


TimeTime

DefiningDefining Professional (not patient) Time Including:Professional (not patient) Time Including:

pre, intra & post-clinical service activitiespre, intra & post-clinical service activities Interview & Assessment CodesInterview & Assessment Codes

Use 15 or 60 minute increments, as applicableUse 15 or 60 minute increments, as applicable Intervention CodesIntervention Codes

Use 15, 30, 60 or 90 minute increments, as Use 15, 30, 60 or 90 minute increments, as applicableapplicable


Time (continued)Time (continued)

Communicating further with othersCommunicating further with others Follow-up with patient, family, and/or Follow-up with patient, family, and/or

othersothers Arranging for ancillary and/or other Arranging for ancillary and/or other

servicesservices


““Missed” TimeMissed” TimeSection 20.3.1.Section 20.3.1.

Billing for Services That Were Not Billing for Services That Were Not Provided” is FraudProvided” is Fraud

The Patient Possibly Could be Billed The Patient Possibly Could be Billed for Missed Appointment (not for for Missed Appointment (not for missed service)missed service)


TimeTime((CPT AssistantCPT Assistant, 08.05, , 08.05, 1515, #8, pg. 12), #8, pg. 12)(www.cms.hhs.gov/providers/therapy)(www.cms.hhs.gov/providers/therapy)

For Timed Codes (in physical For Timed Codes (in physical medicine): The Beginning and Ending medicine): The Beginning and Ending Time Should be DocumentedTime Should be Documented

Time Should be Documented Along Time Should be Documented Along with the Treatment Descriptionwith the Treatment Description


Time: TestingTime: Testing

Quantifying TimeQuantifying Time Round up or down to nearest incrementRound up or down to nearest increment Actual time vs. Elapsed time?Actual time vs. Elapsed time?

Time Does Not IncludeTime Does Not Include Patient completing tests, scales, forms, etc.Patient completing tests, scales, forms, etc. Waiting time by patientWaiting time by patient Typing of reportsTyping of reports Non-Professional (e.g., clerical) timeNon-Professional (e.g., clerical) time Literature searches, learning new techniques, etc.Literature searches, learning new techniques, etc.


G. CPT: Defining a G. CPT: Defining a TechnicianTechnician

What is the Minimum Level of What is the Minimum Level of Training Required for a Technician?Training Required for a Technician? National Association of PsychometristsNational Association of Psychometrists 40 & NAN Position Paper40 & NAN Position Paper

Level of Education- Probably a minimum of Level of Education- Probably a minimum of BachelorsBachelors

Level of TrainingLevel of Training Level of SupervisionLevel of Supervision


Defining a TechnicianDefining a Technician(Federal Register, Vol. 66, #149, page (Federal Register, Vol. 66, #149, page

40382)40382) RequirementRequirement

Employee (e.g., 1099); “employees, leased Employee (e.g., 1099); “employees, leased employees, or independent contractor”employees, or independent contractor”

Most common is independent contractorMost common is independent contractor ““We do not believe that the nature of the We do not believe that the nature of the

employment relationship is critical for purposes employment relationship is critical for purposes of payment to the services of physician…as of payment to the services of physician…as long as…(the personnel) is under the required long as…(the personnel) is under the required level of supervision.”level of supervision.”

Common PracticeCommon Practice Independent ContractorIndependent Contractor


Defining a TechnicianDefining a Technician

HCFA/CMS Line 25HCFA/CMS Line 25 This is the line that identifies in a common This is the line that identifies in a common

insurance form who is the “qualified health insurance form who is the “qualified health provider” that is responsible for and completing provider” that is responsible for and completing the servicethe service

Anybody else, from high school to post-doctoral Anybody else, from high school to post-doctoral fellow, is, for all practical purposes, a technicianfellow, is, for all practical purposes, a technician

Extern, Intern, Postdoctoral Fellow, Extern, Intern, Postdoctoral Fellow, TechnicianTechnician


NAN’s Definition of NAN’s Definition of TechnicianTechnician

Approved by NAN Board of Directors Approved by NAN Board of Directors 08.200608.2006

Archives of Clinical Neuropsychology- Archives of Clinical Neuropsychology- in pressin press


NAN’s Definition of a NAN’s Definition of a TechnicianTechnician

Function- administration & scoring of testsFunction- administration & scoring of tests Responsibility- supervisor Responsibility- supervisor Education- minimum, bachelor’s levelEducation- minimum, bachelor’s level Training- include ethics, neuropsy, psychopath, Training- include ethics, neuropsy, psychopath,

testingtesting Confidentiality- APA ethics, HIPAA…Confidentiality- APA ethics, HIPAA… Emergencies- contingencies must be in placeEmergencies- contingencies must be in place Cultural Sensitivity- must be consideredCultural Sensitivity- must be considered Supervision- general (Medicare) levelSupervision- general (Medicare) level Contract- must be in placeContract- must be in place Liability Insurance- must be in placeLiability Insurance- must be in place


Use of TechniciansUse of Technicians

Practice Expense & Practice ImplicationsPractice Expense & Practice Implications Each tech code has .51 work valueEach tech code has .51 work value This means that the provider is engaged in the This means that the provider is engaged in the

workwork That engagement would include;That engagement would include;

Selection of testsSelection of tests Determination of testing protocolDetermination of testing protocol Supervision of testingSupervision of testing Interpretation of individual testsInterpretation of individual tests Reporting on individual testsReporting on individual tests


Uses of TechniciansUses of Technicians

The Qualified Health Provider must;The Qualified Health Provider must; See the patient firstSee the patient first Supervise the activitySupervise the activity Interpret and write the note/reportInterpret and write the note/report Engaged in an ongoing capacityEngaged in an ongoing capacity

NOTE: Pattern similar to medical NOTE: Pattern similar to medical providersproviders


Use of TechnicianUse of Technician

Technicians in a “Facility”Technicians in a “Facility” A “facility” in essentially an inpatient settingA “facility” in essentially an inpatient setting If a technician is an employee of a private If a technician is an employee of a private

provider but the service is provided in an provider but the service is provided in an inpatient setting, the inpatient fee would be inpatient setting, the inpatient fee would be usedused

If a technician is an employee of a a facility, If a technician is an employee of a a facility, there is some question as to whether they there is some question as to whether they could be supervised by a provider who is not could be supervised by a provider who is not an employee of the facilityan employee of the facility


H. CPT: SupervisionH. CPT: Supervision( ( Federal Register, Federal Register, 6969, #150, August 5, 2004, page 47553), #150, August 5, 2004, page 47553)

Hold Doctoral Degree in PsychologyHold Doctoral Degree in Psychology Licensed or Certified as a PsychologistLicensed or Certified as a Psychologist Applicable Only to “clinical psychologists” Applicable Only to “clinical psychologists”

(and not “independent” psychologists as (and not “independent” psychologists as defined by Medicare)defined by Medicare)

RationaleRationale Allows for higher level of expertise to superviseAllows for higher level of expertise to supervise Could relieve burden on physicians and Could relieve burden on physicians and

facilitiesfacilities May increase services in rural areasMay increase services in rural areas


SupervisionSupervision

SupervisionSupervision 1. General = overall direction1. General = overall direction 2. Direct = present in office suite2. Direct = present in office suite 3. Personal = in actual room3. Personal = in actual room 4. Psychological = when supervised by a 4. Psychological = when supervised by a

psychologistpsychologist


SupervisionSupervisionProgram Memorandum CarriersProgram Memorandum Carriers

Department of Health and Human Services- HCFADepartment of Health and Human Services- HCFATransmittal b-01-28; April 19, 2001Transmittal b-01-28; April 19, 2001

Levels of SupervisionLevels of Supervision GeneralGeneral

Furnished under overall direction and control, Furnished under overall direction and control, presence is not requiredpresence is not required

DirectDirect Must be present in the office suite and immediately Must be present in the office suite and immediately

available to furnish assistance and direction available to furnish assistance and direction throughout the performance of the procedurethroughout the performance of the procedure

PersonalPersonal Must be in attendance in the room during the Must be in attendance in the room during the

performance of the procedureperformance of the procedure


Level of SupervisionLevel of Supervision 42 CFR 410.32 42 CFR 410.32

According to Medicare published According to Medicare published guidelines as of July, 2006;guidelines as of July, 2006; General- activity is directed and General- activity is directed and

supervised by the doctoral level supervised by the doctoral level provider but the provider does not need provider but the provider does not need to be in office suiteto be in office suite


Part II: Part II: Summary, Resources & Summary, Resources &

Questions/AnswersQuestions/Answers

Summary of Present Problems Summary of Present Problems Contact InformationContact Information Questions & AnswersQuestions & Answers


Summary of Problems:Summary of Problems:Carrier-BasedCarrier-Based

Commercial CarriersCommercial Carriers Medical vs. Mental Health vs. No CoverageMedical vs. Mental Health vs. No Coverage The Simultaneous Use of Two or More The Simultaneous Use of Two or More

Testing CodesTesting Codes For Managed Care, an Extremely For Managed Care, an Extremely

Conservative Interpretation of Information Conservative Interpretation of Information Available (e.g., APA Toolkit) May Result in Available (e.g., APA Toolkit) May Result in an Unintended and Highly Restrictive an Unintended and Highly Restrictive Interpretation of the Use of CodesInterpretation of the Use of Codes


Summary of Problems:Summary of Problems: Provider-Based Provider-Based

General Understanding & UsageGeneral Understanding & Usage Specific Code Usage-Specific Code Usage-

Mixing of psychiatric with neuropsychological Mixing of psychiatric with neuropsychological procedures as well as mixing of diagnostic codesprocedures as well as mixing of diagnostic codes

Time (estimates, rounding)Time (estimates, rounding) Professional having to see the patient at allProfessional having to see the patient at all Professional having to interpret and write the Professional having to interpret and write the

evaluationevaluation Misunderstanding of potential difference between Misunderstanding of potential difference between

computerized testing and computer code computerized testing and computer code (interactive computerized testing with tech or (interactive computerized testing with tech or professional is coded as such) and computerized professional is coded as such) and computerized testing (non-interactive is coded as a computer testing (non-interactive is coded as a computer code)code)


Summary of Present:Summary of Present: Provider-Based (continued) Provider-Based (continued)

TechniciansTechnicians Training programs (externs, interns and Training programs (externs, interns and

postdoctoral fellows)postdoctoral fellows) Essentially no difference between a Essentially no difference between a

bachelor’s level technician and a bachelor’s level technician and a postdoctoral fellowpostdoctoral fellow

Difference between training and Difference between training and providing professional servicesproviding professional services

““Limited” interpretation of scoring (away Limited” interpretation of scoring (away from the patient)from the patient)


The FutureThe Future

Personal ApproachPersonal Approach Stay InformedStay Informed Stay FlexibleStay Flexible

Short TermShort Term Volatility and significant changeVolatility and significant change

Long TermLong Term StabilityStability Possible 14% cut resulting in zero to minimal Possible 14% cut resulting in zero to minimal

overall increasesoverall increases


ResourcesResources

OrganizationsOrganizations NAN (PAIC; 804.285.2555)NAN (PAIC; 804.285.2555) APA (40, Practice Directorate; 800.374.2723)APA (40, Practice Directorate; 800.374.2723) AAPAAP AMAAMA

WebsitesWebsites www.nanonline.org www.apa.orgwww.apa.org

NAN Digital VideoNAN Digital Video Contains 3 hour video with multiple resourcesContains 3 hour video with multiple resources Over 74 total hits per weekOver 74 total hits per week

http://www.nanonline.org/


Contact InformationContact Information

WebsitesWebsites Univ = Univ = www.uncw.edu/people/puente Practice = Practice = www.clinicalneuropsychology.us NAN = www.nanonline.org/paioNAN = www.nanonline.org/paio

E-mailE-mail University = pUniversity = [email protected] Practice = [email protected] = [email protected]

TelephoneTelephone University = 910.962.3812University = 910.962.3812 Practice = 910.509.9371Practice = 910.509.9371

http://www.uncw.edu/people/puente

http://www.clinicalneuropsychology.us/

mailto:[email protected]


Q & AQ & A

Friday, October 27, 2006; 7:45 – 8:45 amFriday, October 27, 2006; 7:45 – 8:45 am Ted Peck, Ph.D., PAICTed Peck, Ph.D., PAIC Via Telephone-Via Telephone-

Randy Phelps, Ph.D., Associate Director, APA PDRandy Phelps, Ph.D., Associate Director, APA PD Diane Pedulla, J.D., Legal and Regulatory AffairsDiane Pedulla, J.D., Legal and Regulatory Affairs Kimberly Moore, Medicare Staff OfficerKimberly Moore, Medicare Staff Officer

Saturday, October 28, 2006; 8:45 – 9:45 Saturday, October 28, 2006; 8:45 – 9:45 amam Ted Peck, Ph.D., PAICTed Peck, Ph.D., PAIC

2006 nan introductory cpt1 coding, billing and documenting clinical neuropsychological services: an...

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