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

Psychologists and Medicare

Building Stronger Relationships

Steve McEllin APA Government Relations

Practice Directorate

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

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

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

Three Core Business Centers

Center for Beneficiary ChoicesCenter for Medicare ManagementCenter for Medicaid and State

Operations

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

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

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

Public Listening Forums

CMS wants to hear from local healthcare providers and beneficiaries

Sharing of ideas and concerns

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

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

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.

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

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

LMRP

Local Medical Review PoliciesAssist providers in filing correct

claims Outline how local carriers review

claims

Who Do We Build Relationships With?

Carrier Medical DirectorOther key personnel of the local

Medicare carrier

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

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

“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

Resource Based Relative Value System (RBRVS)

Development and Implications for Psychologists

James M. Georgoulakis, PhD

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

Purpose of RBRVS

To provide equitable payment for medical services

Development of the RBRVS

Phase I: Initial twelve physician specialties

Phase II: PsychiatryPhase III: Psychology

RBRVS and Psychology

APA and CMSAPA Technical Advisory Group (TAG)Development of Survey VignettesSurvey Results

Major Components of the RBRVS

Resource Value UnitsGeographical Practice Cost IndexesConversion Factor

Resource Value Units

Physician Work Resource Value UnitPractice Expense Resource Value Unit

Non Facility Facility

Professional Liability Insurance (Malpractice) Component Resource Value Unit

Geographic Practice Cost Indexes (GPCIs)

Physician Work GPCIPractice Expense GPCIProfessional Liability (Malpractice)

Insurance GPCI

Conversion Factor

Dollar value that is utilized to convert the resource value units

and geographic practice cost indexes into a payment

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

Adoption of the RBRVS

MedicareBlue Cross / Blue Shield 87%Managed Care 69%Medicaid 55%Other 44%

AMA /CMS Resource Value Update Committee

PurposeAPA’s RoleMembers ResponsibilitiesBenefits

Coding & Documentation for Psychological Services

Key Issues for Professional Psychologists

Antonio E. Puente, PhD

Model for Professional Psychological Services

Procedure CodingDiagnosingDocumentingBilling

Procedure Coding

Defining Coding Description of Professional Service Rendered

Purpose of Coding Research / Archival Reimbursement

Coding Systems SNOMED WHO / ICD AMA / CPT

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

CPT Codes Applicable to Psychological Services

Total = Approximately 40Sections = Four Separate Sections

Psychiatry Biofeedback Central Nervous System Assessment Physical Medicine & Rehabilitation

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

Central Nervous System Assessments/Tests

96100 = Psychological Testing96105 = Aphasia Testing96110/11 = Developmental Testing96115 = Neurobehavioral Status96117 = Neuropsychological Testing

Physical Medicine and Rehabilitation

97532 = Cognitive Skills Development

07533 = Sensory integrative techniques

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

Typically Reimbursed Codes

Interviewing 90801

Assessment 96100

Intervention 90804, 90806, 90816, 90818

Coding Modifiers

Acceptability Medicare = 95% Other = Approximately 80%

Modifiers 22= Unusual or More Extensive Service 51= Multiple Procedure 52= Reduced Service 53= Discontinued Service

New Codes

Health and Behavior Assessment/Intervention Assessment (15 minutes) Re-assessment Intervention- individual Intervention- group Intervention- with patient Intervention- without patient

Splitting of Testing Codes

Rationale No Cognitive Component Incident to

Status Work Group Development

Diagnosing

If Psychiatric= DSM If Neurological= ICD

Documenting

PurposePayer RequirementsGeneral PrinciplesHistoryExaminationDecision Making

Purpose of Documentation

Evaluate and Plan for TreatmentCommunication and Continuity of

Care with Other ProfessionalsClaims Review & PaymentResearch & Education

Payer Requirements

Site of ServiceMedical Necessity for Service

ProvidedAppropriate Reporting of Activity

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

Chief Complaint

Concise Statement Describing the Symptom, Problem, Condition,

Diagnosis

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

Billing (continued)

Diagnoses If Dx is psychiatric, then use DSM If Dx is neurological, then use ICD

Note: Avoid rule out diagnoses

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

Billing (continued)

Typical Denials Service Not CoveredNo Prior Authorization ObtainedExceeded Allocated Time LimitsInvalid or Incorrect Dx CodesCPT and Dx do not Match

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

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

Time (continued)

Communicating further with othersFollow-up with patient, family and/or

othersArranging for ancillary and/or other

services

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.

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

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

Summary, Directions & Resources

SummaryDirections

New Codes CPT 5 CMS (formerly HCFA) Interface Dissemination & Education Future

Resources

American Psychological Association (APA)

National Academy of Neuropsychology (NAN)

Division of Clinical Neuropsychology of APA

CMSNational Institutes of Health (NIH)

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

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)