cpt 08.03.07 1 neuropsychology interview and testing codes: rationale, evolution, complications and...
TRANSCRIPT
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Neuropsychology Interview and Testing Neuropsychology Interview and Testing Codes: Rationale, Evolution, Codes: Rationale, Evolution,
Complications and Current StatusComplications and Current Status
Division 40 (Clinical Neuropsychology)Division 40 (Clinical Neuropsychology)Invited AddressInvited Address
Antonio E. PuenteAntonio E. PuenteUniversity of North Carolina WilmingtonUniversity of North Carolina Wilmington
August 19, 2007August 19, 2007American Psychological AssociationAmerican Psychological Association
San Francisco, CaliforniaSan Francisco, California
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DisclaimerDisclaimer
The information contained in this extended presentation is not The information contained in this extended presentation is not intended to reflect NAN, APA, Division 40, NCPA (or any state intended to reflect NAN, APA, Division 40, NCPA (or any state psychological association), AMA, and/or CMS (Medicare) or state psychological association), AMA, and/or CMS (Medicare) or state Medicaid policy. Further, this presentation is intended to be Medicaid policy. Further, this presentation is intended to be informative and not meant to imply that it supersedes APA or informative and not meant to imply that it supersedes APA or state licensing boards’ ethical guidelines and/or local, state or state licensing boards’ ethical guidelines and/or local, state or national regulations and/or laws. Further, Local Coverage national regulations and/or laws. Further, Local Coverage Determination and specific health care contracts supersede the Determination and specific health care contracts supersede the information presented. The information contained herein is meant information presented. The information contained herein is meant to provide practitioners as well as health care institutions (e.g., to provide practitioners as well as health care institutions (e.g., insurance companies) involved in psychological services with the insurance companies) involved in psychological services with the latest information available regarding the issues addressed. This latest information available regarding the issues addressed. This is a living document that can and will be revised as additional is a living document that can and will be revised as additional information becomes available. The ultimate responsibility of the information becomes available. The ultimate responsibility of the validity and utility of the information contained herein lies with validity and utility of the information contained herein lies with the individual and/or institution using this information and not the 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 directly presentation. Suggestions or changes should be directly addressed to the author. Thank you…addressed to the author. Thank you…
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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 American Psychological Association (APA) Practice Directorate
(PD)(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 the Department of Psychology @ UNC-Wilmington, Special thanks to the Department of Psychology @ UNC-Wilmington, James Georgoulakis, Neil Pliskin, Ted Peck, Pat Pimental and AEP’s James Georgoulakis, Neil Pliskin, Ted Peck, Pat Pimental and AEP’s Clinical and Research StaffClinical and Research Staff
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Specific Support Provided by Primary Specific Support Provided by Primary OrganizationsOrganizations
APA = All expenses paid for travel associated with CPT APA = All expenses paid for travel associated with CPT activitiesactivities
NAN = (from PAIO budget) applied to UNCW activitiesNAN = (from PAIO budget) applied to UNCW activities 2002-2004 = $10,000 per year – one course for two semesters 2002-2004 = $10,000 per year – one course for two semesters
teaching reductionteaching reduction 2005 = $5,000 per year – one course for one semester teaching 2005 = $5,000 per year – one course for one semester teaching
reductionreduction 2006 = $25,000 per year – used primarily for year round one 2006 = $25,000 per year – used primarily for year round one
course per semester teaching reduction and partial support of course per semester teaching reduction and partial support of university activitiesuniversity activities
UNCW = Time away from university duties (e.g., teaching) UNCW = Time away from university duties (e.g., teaching) plus incidental support such as copying, telephone calls, plus incidental support such as copying, telephone calls, and secretarial and work-study student assistanceand secretarial and work-study student assistance
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BackgroundBackground(1988 – present)(1988 – present)
North Carolina Psychological Association (e)North Carolina Psychological Association (e) APA’s Policy & Planning Board; Div. 40 (e)APA’s Policy & Planning Board; Div. 40 (e) American Medical Association’s Current American Medical Association’s Current
Procedural Terminology Committee (IV/V) (a)Procedural Terminology Committee (IV/V) (a) Health Care Finance Administration’s Working Health Care Finance Administration’s Working
Group for Mental Health Policy (a)Group for Mental Health Policy (a) Center for Medicare/Medicaid Services’ Center for Medicare/Medicaid Services’
Medicare Coverage Advisory Committee (fa)Medicare Coverage Advisory Committee (fa) Consultant with the North Carolina Medicaid Consultant with the North Carolina Medicaid
Office;North Carolina Blue Cross/Blue Shield Office;North Carolina Blue Cross/Blue Shield (a)(a)
NAN’s Professional Affairs & Information NAN’s Professional Affairs & Information Committee (a)Committee (a)
((legend; a = appointment, fa = federal appointment, e = election)legend; a = appointment, fa = federal appointment, e = election)
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Primary Goal & General Primary Goal & General Outcome Outcome
of CPT Workof CPT Work Goal (20 year plan)Goal (20 year plan)
Parity with PhysiciansParity with Physicians Expansion of Scope of ServicesExpansion of Scope of Services
Outcome (presently)Outcome (presently) Intended/Anticipated/HopedIntended/Anticipated/Hoped
Similar reimbursement as physician servicesSimilar reimbursement as physician services General increase in the scope of practice General increase in the scope of practice Greater inclusion into health care systemGreater inclusion into health care system
Less AnticipatedLess Anticipated Transparency Transparency AccountabilityAccountability UniformityUniformity Potential impact on certain practice patternsPotential impact on certain practice patterns
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Medicare: Why?Medicare: Why?
TheThe Standard for Universal Health Care: Standard for Universal Health 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 occurred)Auditing (determination of whether it occurred)
Note: While Medicare sets the standard, Note: While Medicare sets the standard, there is no point-to-point correspondence there is no point-to-point correspondence with private carrierswith private carriers
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Medicare: Psychology’s Medicare: Psychology’s InvolvementInvolvement
First Published Article = John First Published Article = John McMillan, American Psychologist, McMillan, American Psychologist, 19651965
First Public Hearing = Arthur H. First Public Hearing = Arthur H. Brayfield, House Committee on Ways Brayfield, House Committee on Ways and Means, 1967and Means, 1967
First Publication by Elected Official = First Publication by Elected Official = Daniel K. Inouye, American Daniel K. Inouye, American Psychologist, 1983Psychologist, 1983
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Medicare: The Standard?Medicare: The Standard?(New York Times, August 12, 2007)(New York Times, August 12, 2007)
World Health Organization Ranking of World Health Organization Ranking of 191 Nations191 Nations
# 1 = France and Italy# 1 = France and Italy # 37 = United States# 37 = United States 45 Million (out of 300) Do Not Have 45 Million (out of 300) Do Not Have
Health InsuranceHealth Insurance Greatest Disparity Between Rich and Greatest Disparity Between Rich and
PoorPoor Poor Life ExpextancyPoor Life Expextancy
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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)
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Medicare: Long-term ImpactMedicare: Long-term Impact
Currently, $300 billion annuallyCurrently, $300 billion annually 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 age Medicare to younger citizens will be in age increments (e.g., 60-64, then 50-59, etc)increments (e.g., 60-64, then 50-59, 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
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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
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Current Procedural 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
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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
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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 Documented in Peer-Reviewed Scientific/Professional LiteratureScientific/Professional Literature
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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 X a Conversion Factor Set by Congress X a Conversion Factor Set by Congress
YearlyYearly
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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
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CPT: CategoriesCPT: Categories
Current System = CPT 5Current System = CPT 5 CategoriesCategories
I= Standard Coding for Professional I= Standard Coding for Professional ServicesServices
Codes of interestCodes of interest II = Performance MeasurementII = Performance Measurement
Starting to emerge; will be the future of CPTStarting to emerge; will be the future of CPT III = Emerging TechnologyIII = Emerging Technology
New technology and procedures New technology and procedures
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CPT: CompositionCPT: Composition
AMA House of DelegatesAMA House of Delegates 109 Medical Specialties109 Medical Specialties
HCPACHCPAC 11 Allied Health Societies (e.g., APA)11 Allied Health Societies (e.g., APA)
CPT Editorial PanelCPT Editorial Panel 17 Voting Members17 Voting Members
11 Appointed by AMA Board11 Appointed by AMA Board 1 each from BC/BS, AHA, HIAA, CMS1 each from BC/BS, AHA, HIAA, CMS 2 Appointed/Voted on by HCPAC 2 Appointed/Voted on by HCPAC
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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.) Also, Evaluation and Management Also, Evaluation and Management
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CPT: Abbreviated GlossaryCPT: Abbreviated Glossary CPTCPT
Current Procedure Terminology = professional service codeCurrent Procedure Terminology = professional service code Qualified Health ProfessionalQualified Health Professional
The person who has the contract with the insurance carrierThe person who has the contract with the insurance carrier Defined by training (e.g., see Division 40, NAN % APA statements), Defined by training (e.g., see Division 40, NAN % APA statements),
state (e.g., licensing boards) and federal statutes/laws/regulations state (e.g., licensing boards) and federal statutes/laws/regulations (e.g., Medicare)(e.g., Medicare)
May not include Master’s level AssociatesMay not include Master’s level Associates TechnicianTechnician
Anybody elseAnybody else Facility vs. Non-facilityFacility vs. Non-facility
Non-facility = all settings other than a hospital or skilled nursing facilityNon-facility = all settings other than a hospital or skilled nursing facility UnitsUnits
Time based factor which is applied as a multiplier to the RVUs agreed Time based factor which is applied as a multiplier to the RVUs agreed to by AMA CPT and CMSto by AMA CPT and CMS
Face-to-faceFace-to-face In front of the patientIn front of the patient
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CPT: Development of a CodeCPT: Development of a Code
InitialInitial Health Care Advisory Committee (non-MDs)Health Care Advisory Committee (non-MDs)
PrimaryPrimary CPT Work Group (selected organizations)CPT Work Group (selected organizations) CPT Panel (all specialties)CPT Panel (all specialties)
Time FrameTime Frame 2 to 12 years2 to 12 years
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CPT:CPT:CNS Assessment Codes CNS Assessment Codes
TimetableTimetable Activity x DateActivity x Date
Codes Without Cognitive Work Obtained, 1994Codes Without Cognitive Work Obtained, 1994 Ongoing Discussions with CMS About Lack of Work Value, 1995-2000Ongoing Discussions with CMS About Lack of Work Value, 1995-2000 Request by CMS/AMA to Obtain Work Value, approximately 2000Request by CMS/AMA to Obtain Work Value, approximately 2000 Initial Request for Practice Expense by APA, Summer, 2002Initial Request for Practice Expense by APA, Summer, 2002 APA Appeared Before AMA RUC, September, 2003APA Appeared Before AMA RUC, September, 2003 Initial Decision by AMA CPT Panel, November 7, 2004Initial Decision by AMA CPT Panel, November 7, 2004 Call for Other Societies to Participate, November 19, 2004Call for Other Societies to Participate, November 19, 2004 Final Decision by AMA CPT Panel, December 1, 2004Final Decision by AMA CPT Panel, December 1, 2004 Submission of CPT Codes to AMA RUC Committee immediately thereafterSubmission of CPT Codes to AMA RUC Committee immediately thereafter Review by AMA RUC Research Subcommittee in January, 2005Review by AMA RUC Research Subcommittee in January, 2005 Review by AMA RUC Panel in February 3-6, 2005Review by AMA RUC Panel in February 3-6, 2005 Survey of Codes, second & third week of February, 2005Survey of Codes, second & third week of February, 2005 Analysis of Surveys, March, 2005Analysis of Surveys, March, 2005 Presentation to RUC Committee in April, 2005Presentation to RUC Committee in April, 2005 Inclusion in the 2006 Physician Fee Schedule on January 1, 2006Inclusion in the 2006 Physician Fee Schedule on January 1, 2006 Meeting with CMS, April 24, 2006Meeting with CMS, April 24, 2006 CMS Transmittal and NCCI Edits published September, 2006CMS Transmittal and NCCI Edits published September, 2006 AMA CPT Assistant articles published November, 2006AMA CPT Assistant articles published November, 2006 AMA CPT Assistant Q & A published December, 2007AMA CPT Assistant Q & A published December, 2007 Presentation to AMA CPT Panel February 9, 2007Presentation to AMA CPT Panel February 9, 2007 Presentation to CMS a series of Q and As July, 2007Presentation to CMS a series of Q and As July, 2007
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Psychiatry: InterviewingPsychiatry: Interviewing
Psychiatry InterviewingPsychiatry Interviewing 9080190801 One time per illness incident or boutOne time per illness incident or bout Un-timed (approximately 1.5 hours)Un-timed (approximately 1.5 hours) Comprehensive analysis of records, Comprehensive analysis of records,
observations as well as structured and/or observations as well as structured and/or unstructured clinical interviewunstructured clinical interview
Includes mental status, history, presenting Includes mental status, history, presenting complaints, impression, dispositioncomplaints, impression, disposition
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Psychiatry: Interview Psychiatry: Interview InformationInformation
Mental Health HistoryMental Health History Chief ComplaintChief Complaint History of Present IllnessHistory of Present Illness
General HistoryGeneral History FamilyFamily PersonalPersonal SexualSexual MedicalMedical
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Interview Interview Information/MaterialsInformation/Materials
General AppearanceGeneral Appearance Attitude Towards ExaminerAttitude Towards Examiner Speech and Stream of TalkSpeech and Stream of Talk Emotional Reaction and moodEmotional Reaction and mood PerceptionPerception Thought ContentThought Content CognitionCognition
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CNS Assessment Codes :CNS Assessment Codes :Rationale for Changes of Rationale for Changes of
Testing CodesTesting Codes Avoidance of Continuation of Reimbursement Avoidance of Continuation of Reimbursement
Heavily Based on Practice ExpenseHeavily Based on Practice Expense 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 and Differentiation of Professional, Technical and
(non-assisted) Computer Testing(non-assisted) Computer Testing Most Importantly, a Mandate from CMSMost Importantly, a Mandate from CMS Testing Codes Available for Use by Physicians and Testing Codes Available for Use by Physicians and
Psychologists Only (includes neuropsychologists)Psychologists Only (includes neuropsychologists)
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CPT: CNS AssessmentCPT: CNS AssessmentAMA CPT Assistant, 03.06; AMA CPT Assistant, 11.06, 12.06AMA CPT Assistant, 03.06; AMA CPT Assistant, 11.06, 12.06
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
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Psychological Testing:Psychological Testing:By Professional (01.01.06)By Professional (01.01.06)
9610196101 –Psychological Testing –Psychological Testing Psychological testing (includes Psychological testing (includes
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 time face-to-face time with the patient and time interpreting test results and preparing the interpreting test results and preparing the report.report.
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Psychological Testing:Psychological Testing:By Professional (Revised By Professional (Revised
02.09.07)02.09.07)(revisions in italic and underlined)(revisions in italic and underlined) 9610196101 –Psychological Testing –Psychological Testing
Psychological testing (includes psychodiagnostic Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, personality and psychopathology, e.g., MMPI, Rorschach, WAIS) per hour of psychologist’s or Rorschach, WAIS) per hour of psychologist’s or physician’sphysician’s time, both face-to-face time time, both face-to-face time administering administering teststests to the patient and time interpreting to the patient and time interpreting thesethese test test results and preparing the reportresults and preparing the report
(This code is also used in those circumstances when (This code is also used in those circumstances when additional time is necessary to integrate other sources additional time is necessary to integrate other sources of clinical data, including previously completed and of clinical data, including previously completed and reported technician- and computer-administered tests.)reported technician- and computer-administered tests.)
(Do not report 96101 for the interpretation and report of (Do not report 96101 for the interpretation and report of 96102 or 96103.)96102 or 96103.)
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Psychological Testing:Psychological Testing:By Technician (01.01.06)By Technician (01.01.06)
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 reportand report, administered by , administered by techniciantechnician, per hour of technician time, , per hour of technician time, face-to-faceface-to-face
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Psychological Testing:Psychological Testing:By Computer (01.01.06)By Computer (01.01.06)
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
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Neurobehavioral Status Exam Neurobehavioral Status Exam (01.01.06)(01.01.06)
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
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Neurobehavioral Status Neurobehavioral Status ExamExam
Effective 01.01.08 96116 Will Be Effective 01.01.08 96116 Will Be Available as a TeleMedicine CodeAvailable as a TeleMedicine Code
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Neuropsychological Testing-Neuropsychological Testing-By Professional (01.01.06)By Professional (01.01.06)
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
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Neuropsychological Testing:Neuropsychological Testing:By Professional (Revised By Professional (Revised
02.09.07)02.09.07)(revisions in italic and underlined)(revisions in italic and underlined) 96118 96118 – Neuropsychological Testing– Neuropsychological Testing
(e.g., Halstead-Reitan Neuropsychological, WMS, (e.g., Halstead-Reitan Neuropsychological, WMS, Wisconsin Card Sorting) Wisconsin Card Sorting) per hour of psychologist’s or per hour of psychologist’s or physician’sphysician’s time, both face-to-face time time, both face-to-face time administering testsadministering tests to the patient and time to the patient and time interpreting interpreting thesethese test results and preparing the test results and preparing the reportreport
(This code is also used in those circumstances when (This code is also used in those circumstances when additional time is necessary to integrate other additional time is necessary to integrate other sources of clinical data, including previously sources of clinical data, including previously completed and reported technician- and computer-completed and reported technician- and computer-administered tests.)administered tests.)
(Do not report 96118 for the interpretation and (Do not report 96118 for the interpretation and report of 96119 or 96120.)report of 96119 or 96120.)
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Neuropsychological Testing:Neuropsychological Testing:By Technician (01.01.06)By Technician (01.01.06)
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 interpretation and reportreport, administered by a , administered by a techniciantechnician per hour of technician time, face-to-faceper hour of technician time, face-to-face
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Neuropsychological Testing-Neuropsychological Testing-By Computer (01.01.06)By Computer (01.01.06)
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
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Psychological & Psychological & NeuropsychologicalNeuropsychological
Testing Codes:Testing Codes:Simultaneous Use of Professional and Simultaneous Use of Professional and
Technical/Computer CodesTechnical/Computer Codes Local Carrier Policy Trumps National PolicyLocal Carrier Policy Trumps National Policy Possibilities IncludePossibilities Include
No use of two codesNo use of two codes No problem in using codesNo problem in using codes Alternatives (e.g., modifier 59)Alternatives (e.g., modifier 59)
The Use of Modifier 59The Use of Modifier 59 When professional codes and technical/computer When professional codes and technical/computer
codes are used simultaneouslycodes are used simultaneously The modifier is used with the non-professional The modifier is used with the non-professional
codecode
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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 Being Provided (since the final Different Services are Being Provided (since the final product should be a product should be a comprehensive/integrative comprehensive/integrative report)report)
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Other Testing Codes: Other Testing Codes: Developmental TestingDevelopmental Testing
Developmental Testing CodesDevelopmental Testing Codes ApplicabilityApplicability
ChildrenChildren BackgroundBackground
Part of Central Nervous System family of codesPart of Central Nervous System family of codes Hence, no work value (& lower reimbursement rate)Hence, no work value (& lower reimbursement rate) Recently “re-surveyed” by pediatriciansRecently “re-surveyed” by pediatricians
Specific ChangesSpecific Changes 96110 96110
Continues to have no work valueContinues to have no work value Use for completion of forms (Connors; by parents)Use for completion of forms (Connors; by parents)
96111 96111 Has physician work value Has physician work value Assessment of child’s social, emotional, etc status (WJ)Assessment of child’s social, emotional, etc status (WJ)
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New Code:New Code:fMRIfMRI
96020- Functional Brain Mapping96020- Functional Brain Mapping Neurofunctional test selection and Neurofunctional test selection and
administration during non-invasive imaging administration during non-invasive imaging functional brain mapping with test functional brain mapping with test administered entirely by a physician or administered entirely by a physician or psychologist with review of test results and psychologist with review of test results and reportreport
(vs. diagnostic radiology imaging)(vs. diagnostic radiology imaging)
CPT 08.03.07CPT 08.03.07 4343
Other Testing Codes:Other Testing Codes:Functional Brain MappingFunctional Brain Mapping
96020 and 70555 were established 96020 and 70555 were established to report neurofunctional brain to report neurofunctional brain mapping of blood changes in the mapping of blood changes in the brain by MRI in response to tests brain by MRI in response to tests administered by physicians and administered by physicians and psychologists correlating to specific psychologists correlating to specific brain functions (e.g., motor skills, brain functions (e.g., motor skills, vision, language and memory). vision, language and memory).
CPT 08.03.07CPT 08.03.07 4444
Functional Brain MappingFunctional Brain Mapping
Functional brain mapping should be Functional brain mapping should be used with patients with;used with patients with; Brain neoplasmasBrain neoplasmas Arteriovenous malformationsArteriovenous malformations Intractable epilepsyIntractable epilepsy Other brain lesions that may require Other brain lesions that may require
invasive or focal treatmentinvasive or focal treatment
CPT 08.03.07CPT 08.03.07 4545
Functional Brain MappingFunctional Brain Mapping
96020 is used to report neurofunctional test 96020 is used to report neurofunctional test selection and administration during noninvasive selection and administration during noninvasive imaging Functional Brain Mapping, with test imaging Functional Brain Mapping, with test administration entirely by a physician or administration entirely by a physician or psychologist, with review of test results and psychologist, with review of test results and report. report.
Measurement of;Measurement of; LanguageLanguage MemoryMemory CognitionCognition Movement SensationMovement Sensation Other neurological functionsOther neurological functions
CPT 08.03.07CPT 08.03.07 4646
New Cognitive Testing Code for New Cognitive Testing Code for Use by OT, ST and OthersUse by OT, ST and Others
A New Cognitive Testing Code will A New Cognitive Testing Code will go into effect on 01.01.08 for use by go into effect on 01.01.08 for use by non-doctoral ancillary health non-doctoral ancillary health professionals (e.g., OT, ST…) professionals (e.g., OT, ST…)
The Code is Not Intended to be Used The Code is Not Intended to be Used by Psychologists, Neuropsychologists by Psychologists, Neuropsychologists and/or Physiciansand/or Physicians
The Code is Valued Differently The Code is Valued Differently
CPT 08.03.07CPT 08.03.07 4747
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
CPT 08.03.07CPT 08.03.07 4848
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
CPT 08.03.07CPT 08.03.07 4949
Health & Behavior: Health & Behavior: Assessment Assessment
9615096150 Health and behavior assessment (e.g., health-Health and behavior assessment (e.g., health-
focused clinical interview, behavioral focused clinical interview, behavioral observations, psychophysiological monitoring, observations, psychophysiological monitoring, health-oriented questionnaires)health-oriented questionnaires)
each unit = 15 minuteseach unit = 15 minutes face-to-face with the patientface-to-face with the patient initial assessmentinitial assessment
9615196151 re-assessmentre-assessment each unit = 15 minuteseach unit = 15 minutes Face-to-face with the patientFace-to-face with the patient
CPT 08.03.07CPT 08.03.07 5050
H & B: Assessment H & B: Assessment ExplanationExplanation
Identification of Psychological, Identification of Psychological, Behavioral, Emotional, Cognitive Behavioral, Emotional, Cognitive and/or Social Factorsand/or Social Factors
In the Prevention, Treatment and/or In the Prevention, Treatment and/or Management of Physical Health Management of Physical Health ProblemsProblems
Focus on Biopsychosocial and not Focus on Biopsychosocial and not Mental Health FactorsMental Health Factors
CPT 08.03.07CPT 08.03.07 5151
H & B: Assessment H & B: Assessment ExamplesExamples
Health-Focused Clinical InterviewHealth-Focused Clinical Interview Behavioral ObservationsBehavioral Observations Psychophysiological MonitoringPsychophysiological Monitoring Health-Oriented QuestionnairesHealth-Oriented Questionnaires
CPT 08.03.07CPT 08.03.07 5252
CPT: Alternative CodesCPT: Alternative Codes(probably not reimbursable)(probably not reimbursable)
9905099050 – Office, outside regular office hrs. – Office, outside regular office hrs. 9905299052 - Service provided btw. 10pm-8am - Service provided btw. 10pm-8am 9905499054 – Service provided on Sun/holidays – Service provided on Sun/holidays 0074T0074T – Online service – Online service 90825 90825 – Review of records– Review of records 99148-9915099148-99150- Addition of a second provider- Addition of a second provider 0074T0074T – Online evaluation and management – Online evaluation and management Evaluation and management codesEvaluation and management codes
CPT 08.03.07CPT 08.03.07 5353
CPT: Model SystemCPT: Model System
PsychiatricPsychiatric NeurologicalNeurological Non-Neurological MedicalNon-Neurological Medical
CPT 08.03.07CPT 08.03.07 5454
CPT: Model RationaleCPT: Model Rationale
Rationale for a Specific CPT Code:Rationale for a Specific CPT Code: Choose Code that Best Describes the Service Choose Code that Best Describes the Service Match the Interview with the Testing with the Match the Interview with the Testing with the
Intervention Code with the DiagnosisIntervention Code with the Diagnosis It is Possible, Maybe Desirable, to Mix Codes It is Possible, Maybe Desirable, to Mix Codes
(e.g., 90801 with 96118 if the purpose & (e.g., 90801 with 96118 if the purpose & procedure of the activities in question changes procedure of the activities in question changes due to the information obtained in the process due to the information obtained in the process of the evaluation)of the evaluation)
Goal = Parsimony, Uniformity and FluencyGoal = Parsimony, Uniformity and Fluency
CPT 08.03.07CPT 08.03.07 5555
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 08.03.07CPT 08.03.07 5656
CPT: Neurological ModelCPT: Neurological Model(Children & Adult)(Children & Adult)
InterviewInterview 9611696116
TestingTesting 96118/19/2096118/19/20
InterventionIntervention 9753297532
CPT 08.03.07CPT 08.03.07 5757
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)
CPT 08.03.07CPT 08.03.07 5858
CPT: ModifiersCPT: Modifiers(from Appendix A in CPT book; see oig (from Appendix A in CPT book; see oig
reports)reports) ExamplesExamples
22 = unusual service22 = unusual service 25 = additional payment for an E & M code as a specific 25 = additional payment for an E & M code as a specific
procedure code (problematic)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
CANNOT USE ANOTHER MODIFIER WITH # 59CANNOT USE ANOTHER MODIFIER WITH # 59
GN, GO, AH, etc. = local carrier specificGN, GO, AH, etc. = local carrier specific ProblemsProblems
Incomplete support for modifier from 15 to 35% of Incomplete support for modifier from 15 to 35% of documentation results in paybacks documentation results in paybacks
CPT 08.03.07CPT 08.03.07 5959
DiagnosingDiagnosing
Limited Formulary Often Offered by Third Limited Formulary Often Offered by Third PartiesParties
Multiple Diagnoses May be of ValueMultiple Diagnoses May be of Value PsychiatricPsychiatric
DSMDSM The problem with DSM and neuropsych testing of The problem with DSM and neuropsych testing of
developmentally-related neurological problemsdevelopmentally-related neurological problems
Neurological & Non-Neurological MedicalNeurological & Non-Neurological Medical 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
CPT 08.03.07CPT 08.03.07 6060
Medical NecessityMedical Necessity
Scientific & Clinical NecessityScientific & Clinical Necessity Local Medical Determinations of Necessity Local Medical Determinations of Necessity
May Not Reflect Standard Clinical PracticeMay Not Reflect Standard Clinical Practice Necessity = CPT x DX formularyNecessity = CPT x DX formulary Necessity Dictates Type and Level of Necessity Dictates Type and Level of
ServiceService Will New Information or Outcome Be Will New Information or Outcome Be
Obtained as a Function of the Activity?Obtained as a Function of the Activity? Typically Not Meeting Criteria for Necessity;Typically Not Meeting Criteria for Necessity;
ScreeningScreening Regularly scheduled/interval based evaluationsRegularly scheduled/interval based evaluations Repeated evaluations without documented and Repeated evaluations without documented and
valid specific purposevalid specific purpose
CPT 08.03.07CPT 08.03.07 6161
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
CPT 08.03.07CPT 08.03.07 6262
National Coverage Policy National Coverage Policy ExclusionsExclusions
Services That Are Not Reasonable Services That Are Not Reasonable and Necessary for the Diagnosing and Necessary for the Diagnosing and Treatment of an Illness or Injuryand Treatment of an Illness or Injury
Screening Services, in the Absence of Screening Services, in the Absence of Symptoms or History of Disease are Symptoms or History of Disease are DeniedDenied
CPT 08.03.07CPT 08.03.07 6363
DocumentationDocumentation
General PrinciplesGeneral Principles AssessmentAssessment InterventionIntervention
CPT 08.03.07CPT 08.03.07 6464
Documentation: General Documentation: General PurposePurpose
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
CPT 08.03.07CPT 08.03.07 6565
Documentation: General Documentation: General PrinciplesPrinciples
Rationale for ServiceRationale for Service ProcedureProcedure Results/ProgressResults/Progress Impression and/or DiagnosisImpression and/or Diagnosis Plan for Care/DispositionPlan for Care/Disposition If Applicable, TimeIf Applicable, Time Date and Identity of ObserverDate and Identity of Observer
CPT 08.03.07CPT 08.03.07 6666
Documentation: Basic Documentation: Basic Information Across CodesInformation Across Codes
Identifying InformationIdentifying Information DateDate Time, if applicable (total time Vs. Time, if applicable (total time Vs. actual timeactual time)) Identity of Observer (technician ?)Identity of Observer (technician ?) Reason for ServiceReason for Service StatusStatus ProcedureProcedure Results/FindingsResults/Findings Impression/DiagnosisImpression/Diagnosis Plan for Care/DispositionPlan for Care/Disposition
CPT 08.03.07CPT 08.03.07 6767
Documentation:Documentation: Chief Complaint Chief Complaint
Concise Statement Describing the Concise Statement Describing the Symptom, Problem, Condition, & Symptom, Problem, Condition, & DiagnosisDiagnosis
Foundation for Medical NecessityFoundation for Medical Necessity Must be Free-Standing, Complete & Must be Free-Standing, Complete &
Exhaustive (i.e., other information is Exhaustive (i.e., other information is not needed to understand the not needed to understand the situation)situation)
CPT 08.03.07CPT 08.03.07 6868
Documentation: Documentation: Present IllnessPresent Illness
SymptomsSymptoms Location, Quality, Severity, Duration, Location, Quality, Severity, Duration,
timing, Context, Modifying Factors timing, Context, Modifying Factors Associated SignsAssociated Signs
Follow-upFollow-up Changes in ConditionChanges in Condition ComplianceCompliance
CPT 08.03.07CPT 08.03.07 6969
Documentation: AssessmentDocumentation: Assessment
Identifying InformationIdentifying Information Reason for ServiceReason for Service Dates Dates Time (amount of service time; total Vs. Time (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 Impression(s) or Diagnosis(es)Impression(s) or Diagnosis(es) DispositionDisposition
CPT 08.03.07CPT 08.03.07 7070
Documentation: Documentation: InterventionIntervention
Identifying InformationIdentifying Information Reason for ServiceReason for Service DateDate Time (face-to-face time; total Vs. actual)Time (face-to-face time; total Vs. actual) Status of PatientStatus of Patient Intervention PerformedIntervention Performed Results ObtainedResults Obtained Impression(s) or Diagnosis (es)Impression(s) or Diagnosis (es) DispositionDisposition
CPT 08.03.07CPT 08.03.07 7171
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)separate section)
If Separate Sections Within One If Separate Sections Within One Report, Clearly Label/Title Sections of Report, Clearly Label/Title Sections of the Report to Match Code Used (e.g., the Report to Match Code Used (e.g., Neuropsychological Testing by Neuropsychological Testing by Technician)Technician)
CPT 08.03.07CPT 08.03.07 7272
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 such Internal routing sheets documenting such
information as start/stop time, technician information as start/stop time, technician name, dates, etc. (a master sheet could name, dates, etc. (a master sheet could track technician as well as professional track technician as well as professional time)time)
Final reportFinal report
CPT 08.03.07CPT 08.03.07 7373
TimeTime
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 (i.e., H & B) or either face-to-face (i.e., H & B) or professional time (e.g., Psych & professional time (e.g., Psych & Neuropsych)Neuropsych)
CPT 08.03.07CPT 08.03.07 7474
Time: Conceptual Time: Conceptual
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
CPT 08.03.07CPT 08.03.07 7575
Time (continued)Time (continued)
Communicating Further With OthersCommunicating Further With Others Follow-up With Patient, Family, Follow-up With Patient, Family,
and/or Othersand/or Others Arranging for Ancillary and/or Other Arranging for Ancillary and/or Other
ServicesServices
CPT 08.03.07CPT 08.03.07 7676
““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), Assuming a missed service), Assuming a Contractual Relationship and Contractual Relationship and Understanding Has Been Previously Understanding Has Been Previously EstablishedEstablished
CPT 08.03.07CPT 08.03.07 7777
Time: DefinitionTime: Definition((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: Beginning and Ending Medicine: 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
CPT 08.03.07CPT 08.03.07 7878
Time: Defining 15 MinutesTime: Defining 15 Minutes(from CPT Assistant, 08.05, 11-12)(from CPT Assistant, 08.05, 11-12)
((www.cms.hhs.gov/manuals/104_claims/clm104c05.www.cms.hhs.gov/manuals/104_claims/clm104c05.pdf)pdf)
Defining 15 Minute IncrementsDefining 15 Minute Increments UnitsUnits Amount of MinutesAmount of Minutes
11 >08; <23>08; <23 22 >22; <38>22; <38 33 >38; <53>38; <53 44 >53; <68>53; <68 55 >68; <83>68; <83 66 >83; <98>83; <98 77 >98; <113>98; <113 88 >113;<128>113;<128 Over 2 hoursOver 2 hours similar pattern as abovesimilar pattern as above
CPT 08.03.07CPT 08.03.07 7979
Time: Quantifying for Time: Quantifying for TestingTesting
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.
CPT 08.03.07CPT 08.03.07 8080
TechniciansTechnicians
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
www.napnet.orgwww.napnet.org 40 & NAN Position Paper40 & NAN Position Paper
Level of Education- Minimum of BachelorsLevel of Education- Minimum of Bachelors Level of TrainingLevel of Training Level of SupervisionLevel of Supervision
CPT 08.03.07CPT 08.03.07 8181
Technician: DefinitionTechnician: DefinitionFederal Register, Vol. 66, #149, page 40382Federal Register, Vol. 66, #149, page 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
CPT 08.03.07CPT 08.03.07 8282
Technician: 1500 FormsTechnician: 1500 Forms
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
That individual is the person with whom the That individual is the person with whom the contractual relationship is established contractual relationship is established
Anybody else, from high school to post-doctoral Anybody else, from high school to post-doctoral fellow to independently licensed psychologist fellow to independently licensed psychologist (but not contractually related professional), is, (but not contractually related professional), is, for all practical purposes, a technicianfor all practical purposes, a technician
CPT 08.03.07CPT 08.03.07 8383
Technician: Federal Technician: Federal Government’s Definition Government’s Definition
DM & S Supplement, MP-5, Part IDM & S Supplement, MP-5, Part I Authority: 38 U.S.C. 4105Authority: 38 U.S.C. 4105 Appendix 17A Change 43Appendix 17A Change 43 Psychology Technician GS-181-5/7/9Psychology Technician GS-181-5/7/9
DefinitionDefinition Bachelor’s degree from accredited Bachelor’s degree from accredited
college/university with a major in college/university with a major in appropriate social or biological sciences (+ appropriate social or biological sciences (+ 12 psy hours)12 psy hours)
CPT 08.03.07CPT 08.03.07 8484
Technician: NAN’s Definition Technician: NAN’s Definition
Approved by NAN Board of DirectorsApproved by NAN Board of Directors 08.200608.2006
Archives of Clinical Neuropsychology- Archives of Clinical Neuropsychology- 2006 (e.g., Puente, et al)2006 (e.g., Puente, et al)
CPT 08.03.07CPT 08.03.07 8585
Technician: NAN’s Definition Technician: NAN’s Definition ExplainedExplained
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
CPT 08.03.07CPT 08.03.07 8686
Technicians: ApplicationTechnicians: Application
Practice Expense & Practice ImplicationsPractice Expense & Practice Implications Each tech code has .51 work valueEach tech code has .51 work value This means that the professional is engaged in This means that the professional is engaged in
the work, namely, supervisionthe work, namely, supervision That supervision would include;That supervision 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 Assisting with concerns raised by the patientAssisting with concerns raised by the patient
CPT 08.03.07CPT 08.03.07 8787
Technicians: Interfacing with Technicians: Interfacing with ProfessionalsProfessionals
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 and NOTE: Pattern similar to medical and other health providersother health providers
CPT 08.03.07CPT 08.03.07 8888
Technicians: FacilityTechnicians: Facility
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
CPT 08.03.07CPT 08.03.07 8989
Technicians: Next StepsTechnicians: Next Steps
Development of a National, Widely Development of a National, Widely Accepted System for Identifying Accepted System for Identifying TechniciansTechnicians NANNAN Division 40Division 40 National Association of PsychometristsNational Association of Psychometrists
CPT 08.03.07CPT 08.03.07 9090
SupervisionSupervision( ( 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
CPT 08.03.07CPT 08.03.07 9191
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
CPT 08.03.07CPT 08.03.07 9292
Supervision: LevelsSupervision: Levels 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
CPT 08.03.07CPT 08.03.07 9393
Supervision: Supervision Vs. Supervision: Supervision Vs. Incident toIncident to
Supervision - Clinical ConceptSupervision - Clinical Concept Behavior of a “qualified health Behavior of a “qualified health
professional” and a “technician”professional” and a “technician” Incident to - Economic ConceptIncident to - Economic Concept
The concept of a contractual The concept of a contractual relationship (e.g., 1099) between a relationship (e.g., 1099) between a “qualified health professional” and a “qualified health professional” and a “technician”“technician”
CPT 08.03.07CPT 08.03.07 9494
Correct Coding InitiativeCorrect Coding Initiative
PurposePurpose Used to evaluate submissions when Used to evaluate submissions when
provider bills more than one service for provider bills more than one service for the same beneficiary and same date of the same beneficiary and same date of serviceservice
Example; psychotherapy and testingExample; psychotherapy and testing ActivationActivation
Automatic editsAutomatic edits
CPT 08.03.07CPT 08.03.07 9595
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
CPT 08.03.07CPT 08.03.07 9696
Developing a Fee ScheduleDeveloping a Fee Schedule
Medicare Medicare Conversion Factor in 2008 = $34.1350Conversion Factor in 2008 = $34.1350
Standard Method of Developing Fee Standard Method of Developing Fee ScheduleSchedule Obtain Medicare RVU values for selected Obtain Medicare RVU values for selected
CPT codesCPT codes Multiple by 150%Multiple by 150% Revise fee schedule as RVUs changeRevise fee schedule as RVUs change
CPT 08.03.07CPT 08.03.07 9797
CMS Determination of CMS Determination of CoverageCoverage
Coverage TypesCoverage Types Coverage with Conditions (specific DX, facility or Coverage with Conditions (specific DX, facility or
provider)provider) Coverage without ConditionsCoverage without Conditions
Data ReviewedData Reviewed BenefitBenefit Risks Vs. BenefitsRisks Vs. Benefits Available Clinical StudiesAvailable Clinical Studies
DatabasesDatabases Longitudinal or cohort studiesLongitudinal or cohort studies Prospective studiesProspective studies Randomized clinical trialsRandomized clinical trials
CPT 08.03.07CPT 08.03.07 9898
Medicare: Payment Medicare: Payment QuestionsQuestions
Cannot Impose a Limitation on a Medicare Cannot Impose a Limitation on a Medicare Patient That is Not Imposed on Other Pts.Patient That is Not Imposed on Other Pts.
Non-Covered Services Can Be Charged if Non-Covered Services Can Be Charged if Patient Knows and Agrees Ahead of TimePatient Knows and Agrees Ahead of Time
Records Should be Retained, state law or;Records Should be Retained, state law or; Adult- 5 years post serviceAdult- 5 years post service Children- until 21Children- until 21
CPT 08.03.07CPT 08.03.07 9999
Medicare: Billing Medicare: Billing SuggestionsSuggestions
When to BillWhen to Bill Overall = after documentation is in placeOverall = after documentation is in place Diagnostic ServicesDiagnostic Services
After the InterviewAfter the Interview After all testing is completed aAfter all testing is completed andnd a report has been a report has been
completedcompleted Billing should occur only once after testingBilling should occur only once after testing
Therapeutic ServicesTherapeutic Services Could occur after each sessionCould occur after each session Should occur at least by the end of the monthShould occur at least by the end of the month
CPT 08.03.07CPT 08.03.07 100100
Payment: Billing ModelPayment: Billing Model
ComponentsComponents Procedure CompletedProcedure Completed Number of Units of that ProcedureNumber of Units of that Procedure Location or Site Where the Service was Location or Site Where the Service was
ProvidedProvided Date of ServiceDate of Service
CPT CPT XX # of Units # of Units X X Dx Dx XX Site of Site of Service Service XX Date Date
CPT 08.03.07CPT 08.03.07 101101
Fraud: Potential Recovery by Fraud: Potential Recovery by Federal GovernmentFederal Government
ProjectionsProjections CurrentCurrent
14%14% By 2011;By 2011;
17% ($2.8 trillion)17% ($2.8 trillion)
CPT 08.03.07CPT 08.03.07 102102
Fraud: Medicare’s Fraud: Medicare’s Interpretation of Physician Interpretation of Physician
LiabilityLiability Overpayment From Incorrect ChargeOverpayment From Incorrect Charge Mathematical or Clerical ErrorMathematical or Clerical Error Billing for Items Known Not to be Billing for Items Known Not to be
CoveredCovered Services Provided by Non-qualified Services Provided by Non-qualified
PractitionerPractitioner Inappropriate DocumentationInappropriate Documentation
CPT 08.03.07CPT 08.03.07 103103
Fraud: Office of Inspector Fraud: Office of Inspector GeneralGeneral
Primary ProblemsPrimary Problems Medical Necessity (approximately $5 billion)Medical Necessity (approximately $5 billion) DocumentationDocumentation
Psychotherapy Psychotherapy (oig.hhs/gov/reports/region5/50100068)(oig.hhs/gov/reports/region5/50100068) IndividualIndividual GroupGroup # of Hours# of Hours Who Does the TherapyWho Does the Therapy
Psychological TestingPsychological Testing # of Hours# of Hours DocumentationDocumentation
CPT 08.03.07CPT 08.03.07 104104
Fraud (continued)Fraud (continued)
Nursing HomesNursing Homes Identification Identification Overuse of ServicesOveruse of Services
ChildrenChildren
CPT 08.03.07CPT 08.03.07 105105
Fraud: OIG’s May 2001 StudyFraud: OIG’s May 2001 StudyInvolving PsychologyInvolving Psychology
OEI-03-99-00130OEI-03-99-00130
Overall Payments in 1998 = $1.2 billionOverall Payments in 1998 = $1.2 billion(62% outpatient = $718 million)(62% outpatient = $718 million)
Currently, 7-14% of all reimbursementsCurrently, 7-14% of all reimbursements Inappropriate Outpatient Mental HealthInappropriate Outpatient Mental Health ““Particularly Problematic” due to Particularly Problematic” due to
Medically unnecessaryMedically unnecessary Billed incorrectlyBilled incorrectly Rendered by unqualified providersRendered by unqualified providers Undocumented or poorly documentedUndocumented or poorly documented
CPT 08.03.07CPT 08.03.07 106106
OIG Report (continued)OIG Report (continued)
Provider Not QualifiedProvider Not Qualified = 11%= 11% Medically Unnecessary Medically Unnecessary = =
23%23% Billed IncorrectlyBilled Incorrectly = 41%= 41% Insufficient DocumentationInsufficient Documentation = =
65%65%
CPT 08.03.07CPT 08.03.07 107107
Fraud: Review History (10 Fraud: Review History (10 years)years)
Initial Review (14 points of submitted Initial Review (14 points of submitted claims)claims) LegibilityLegibility CoverageCoverage Matching datesMatching dates SignatureSignature
Subsequent Review (occurs if over 5-6 Subsequent Review (occurs if over 5-6 items are failed in initial review)items are failed in initial review) Does the service affect a potential change in Does the service affect a potential change in
medical condition?medical condition?
CPT 08.03.07CPT 08.03.07 108108
Fraud: New InformationFraud: New Information
The Good Enough or Common Sense The Good Enough or Common Sense ApproachApproach
If Medicare Audit Occurs then an Increased If Medicare Audit Occurs then an Increased Likelihood of Medicaid AuditLikelihood of Medicaid Audit
Practice Situations That Increase Potential Practice Situations That Increase Potential Audits;Audits; Skilled Nursing FacilitiesSkilled Nursing Facilities Statistical OutliersStatistical Outliers TestingTesting
States with Increased Audit Activity;States with Increased Audit Activity; TX, CA, FL, PRTX, CA, FL, PR
CPT 08.03.07CPT 08.03.07 109109
Fraud: 2006 Red BookFraud: 2006 Red Book
Section 1862(a)(1)(A) of the Social Section 1862(a)(1)(A) of the Social Security Practice Act requires all Security Practice Act requires all services to be reasonable and services to be reasonable and necessary for the diagnosis or necessary for the diagnosis or treatment of an illness or injury.treatment of an illness or injury.
Claim errors have exceed 34%Claim errors have exceed 34%
CPT 08.03.07CPT 08.03.07 110110
Fraud: Red Book (continued)Fraud: Red Book (continued)
Problem AreasProblem Areas Acute Hospital outpatient Services ($224)Acute Hospital outpatient Services ($224) Partial Hospitalization ($180)Partial Hospitalization ($180) Psychiatric Hospital outpatient ($57)Psychiatric Hospital outpatient ($57) Nursing Home ($30)Nursing Home ($30) General Mental Health ($185)General Mental Health ($185)
Beneficiaries who are unable to benefit from Beneficiaries who are unable to benefit from psychotherapy servicespsychotherapy services
Note: in millions (total for 2005 - $676,000,000)Note: in millions (total for 2005 - $676,000,000)
CPT 08.03.07CPT 08.03.07 111111
Fraud: Voluntary Fraud: Voluntary ComplianceCompliance
D. Raisin-Waters, APA, 2005D. Raisin-Waters, APA, 2005
Address Risk or Problematic Areas Address Risk or Problematic Areas (e.g., denied claims)(e.g., denied claims)
Develop a Compliance Program (with Develop a Compliance Program (with designated individual, written plan, designated individual, written plan, etc.)etc.)
CPT 08.03.07CPT 08.03.07 112112
Increasing Probability of Increasing Probability of Successful AuditsSuccessful Audits
Potential Solutions;Potential Solutions; Establish Formal Internal Auditing SystemEstablish Formal Internal Auditing System Engage in Informal Internal Peer ReviewEngage in Informal Internal Peer Review Consider Periodic External Peer ReviewConsider Periodic External Peer Review Keep Abreast of Carrier ChangesKeep Abreast of Carrier Changes Understanding of Medical NecessityUnderstanding of Medical Necessity Match Procedure CodesMatch Procedure Codes Match Diagnostic & Procedure CodesMatch Diagnostic & Procedure Codes Document ProperlyDocument Properly If Audited, Comply (thoroughly & quickly)If Audited, Comply (thoroughly & quickly) If Trial, Appreciate & Appraise SituationIf Trial, Appreciate & Appraise Situation
CPT 08.03.07CPT 08.03.07 113113
Challenges & ApproachesChallenges & Approaches
CMS National Directive CMS National Directive National Correct Coding InitiativeNational Correct Coding Initiative Potential Solutions to Current Potential Solutions to Current
ProblemsProblems The FutureThe Future
CPT 08.03.07CPT 08.03.07 114114
CMS National Directive: CMS National Directive: Summary of September, 2006 Summary of September, 2006
StatementStatement TitleTitle
Pub 100-02 Medicare Benefit PolicyPub 100-02 Medicare Benefit Policy Transmittal 55Transmittal 55
DatesDates Issued September 29, 2006Issued September 29, 2006 Effective Date: January 1, 2006Effective Date: January 1, 2006 Implementation Date: December 28, Implementation Date: December 28,
20062006
CPT 08.03.07CPT 08.03.07 115115
CMS National Directive: CMS National Directive: Summary of September, 2006 Summary of September, 2006
StatementStatement 5204.15204.1
““Carriers and fiscal intermediaries shall pay for Carriers and fiscal intermediaries shall pay for medically necessary diagnostic psychological medically necessary diagnostic psychological and neuropsychological tests…”and neuropsychological tests…”
5204.25204.2 ““Contractors need not search their files to Contractors need not search their files to
either retract payment for claims already paid either retract payment for claims already paid or to retroactively pay claims to 01.01.06. or to retroactively pay claims to 01.01.06. However, contractors shall adjust claims However, contractors shall adjust claims brought to their attention”.brought to their attention”.
CPT 08.03.07CPT 08.03.07 116116
CMS National Directive: CMS National Directive: Summary of September, 2006 Summary of September, 2006
StatementStatement
““When diagnostic psychological tests When diagnostic psychological tests are performed by a psychologists are performed by a psychologists who is not practicing independently, who is not practicing independently, but is on the staff of an institution, but is on the staff of an institution, agency or clinic, that entity bills for agency or clinic, that entity bills for the psychological tests.”the psychological tests.”
CPT 08.03.07CPT 08.03.07 117117
CMS National Directive: CMS National Directive: Summary of September, 2006 Summary of September, 2006
StatementStatement
Independent is defined as:Independent is defined as: ““Free of professional control...”Free of professional control...” ““The persons they treat are their own patients”The persons they treat are their own patients” ““They have the right to bill directly…”They have the right to bill directly…”
For those psychologists practicing in an office For those psychologists practicing in an office located in an institution;located in an institution; The office is confined to a separately-identified part of The office is confined to a separately-identified part of
the facility which is used solely as the psychologist’s the facility which is used solely as the psychologist’s officeoffice
The psychologists conducts a private practice…services The psychologists conducts a private practice…services are rendered to patients in and outside of the institutionare rendered to patients in and outside of the institution
CPT 08.03.07CPT 08.03.07 118118
CMS National Directive: CMS National Directive: Summary of September, 2006 Summary of September, 2006
StatementStatement ““CPT … test codes 96101/96118 should CPT … test codes 96101/96118 should
not be paid when billed for not be paid when billed for the same the same tests or servicestests or services performed under the… performed under the…test codes 96102/103/96119/120.”test codes 96102/103/96119/120.”
““Medicare does not pay for services Medicare does not pay for services represented by CPT codes 96102 and represented by CPT codes 96102 and 96119 when performed by a student or 96119 when performed by a student or a trainee.”a trainee.”
CPT 08.03.07CPT 08.03.07 119119
Correct Coding Initiative:Correct Coding Initiative:September, 2006 StatementSeptember, 2006 Statement
Introduced in March 30, 2006 for Comment; Introduced in March 30, 2006 for Comment; Effective 10.01.06Effective 10.01.06
When 96118, 96119 and/or 961120 occur When 96118, 96119 and/or 961120 occur together, a modifier might be of value;together, a modifier might be of value; Most appropriate code is probably 59 (possibly Most appropriate code is probably 59 (possibly
51)51) Model used is radiology (when more than one Model used is radiology (when more than one
service is provided by the same provider to the service is provided by the same provider to the same patient)same patient)
CPT 08.03.07CPT 08.03.07 120120
Solutions: Use of ModifiersSolutions: Use of Modifiers
Routine in Medicine, Especially Routine in Medicine, Especially Radiology (since their common use of Radiology (since their common use of technicians)technicians)
Describes That More Than One Describes That More Than One Procedure Was Provide to the Same Procedure Was Provide to the Same Patient on the Same DayPatient on the Same Day
Should not Increase Time to Should not Increase Time to Reimbursement or Audit Probability Reimbursement or Audit Probability Nor Decrease ReimbursementNor Decrease Reimbursement
CPT 08.03.07CPT 08.03.07 121121
Solutions: AMA CPT Assistant Solutions: AMA CPT Assistant PublicationsPublications
Q & A Appeared September, 2006Q & A Appeared September, 2006 Full Length Article Last Approved 10.02.06 & Full Length Article Last Approved 10.02.06 &
Published in November, 2006Published in November, 2006 A Comprehensive Review of the Information A Comprehensive Review of the Information
Previously PresentedPreviously Presented Approved by the AMA CPT Editorial PanelApproved by the AMA CPT Editorial Panel Allows for the Use of All Codes Simultaneously or Allows for the Use of All Codes Simultaneously or
AloneAlone A Follow-up Q & Appeared in December, A Follow-up Q & Appeared in December,
20062006
CPT 08.03.07CPT 08.03.07 122122
APA’s Official Statement on APA’s Official Statement on Testing CodesTesting Codes
““APA is Going to Work With Outside APA is Going to Work With Outside Counsel to Analyze This Situation and Counsel to Analyze This Situation and Obtain Recommendations on the Obtain Recommendations on the Best Way to Proceed with CMS”Best Way to Proceed with CMS”
““Psychologists Should Read the CMS Psychologists Should Read the CMS Documents Carefully and be Alert for Documents Carefully and be Alert for Any New Information Issued by Their Any New Information Issued by Their Local Carriers”Local Carriers”
CPT 08.03.07CPT 08.03.07 123123
Solutions: AlternativesSolutions: Alternatives
Not Accept Medicare Patients (if so, you Not Accept Medicare Patients (if so, you may want to contact your local may want to contact your local representative and/or congressmen)representative and/or congressmen)
Take a Conservative Approach Take a Conservative Approach Interface with Individual Carriers to Develop Interface with Individual Carriers to Develop
Specific Understanding and ProceduresSpecific Understanding and Procedures Use of ModifiersUse of Modifiers
The final decision on how to code rests on the individual The final decision on how to code rests on the individual and/or their institution’s assessment of carrier contract and/or their institution’s assessment of carrier contract as well as their understanding of the current policy as well as their understanding of the current policy situationsituation
CPT 08.03.07CPT 08.03.07 124124
Solutions: Ongoing ActivitiesSolutions: Ongoing Activities
CMSCMS Direct Interfacing with Director of Medical Director’s Direct Interfacing with Director of Medical Director’s
Workgroup (Dick Whitten, M.D.)Workgroup (Dick Whitten, M.D.) AMAAMA
CPT Assistant Article (November, 2006)CPT Assistant Article (November, 2006) CPT Assistant Q & A (December, 2006)CPT Assistant Q & A (December, 2006) CPT Manual- Parenthetical, preamble, and/or footnote?CPT Manual- Parenthetical, preamble, and/or footnote? Presentation at February, 2007 AMA CPT Meeting in San Presentation at February, 2007 AMA CPT Meeting in San
DiegoDiego APAAPA
Twice Monthly Conference Calls with Psychological Test Twice Monthly Conference Calls with Psychological Test Work GroupWork Group
Submission of Case Vignettes Along with All PossibleSubmission of Case Vignettes Along with All Possible Clinical PermutationsClinical Permutations
Presentation at the State Leadership Conference, APA Presentation at the State Leadership Conference, APA annual conference, NANannual conference, NAN
CPT 08.03.07CPT 08.03.07 125125
The Future: Pay for The Future: Pay for Performance (P4P) InitiativesPerformance (P4P) Initiatives
PremisePremise Evidence-based guidelinesEvidence-based guidelines Outcome more than procedure basedOutcome more than procedure based
Initial ApplicationInitial Application Dartmouth, Duke & MichiganDartmouth, Duke & Michigan AMA and APA Practice forming work groupsAMA and APA Practice forming work groups
Estimated Application in Payment Estimated Application in Payment SystemsSystems 5-10 years5-10 years
CPT 08.03.07CPT 08.03.07 126126
The Future: Medicare The Future: Medicare ChangesChanges
CMS Payment ChangesCMS Payment Changes 08.02.0708.02.07 CMS will increase payments of $690 CMS will increase payments of $690
million or 3.3% of the Medicare Budget million or 3.3% of the Medicare Budget for Medicare Skilled Nursing Facilitiesfor Medicare Skilled Nursing Facilities
http://www.cms.hhs.gov/SNFPPS/http://www.cms.hhs.gov/SNFPPS/downloads/cms-1545-f-display.pdfdownloads/cms-1545-f-display.pdf
CPT 08.03.07CPT 08.03.07 127127
The Future: General Medical The Future: General Medical EducationEducation
$2.6 billion or 5.5% in 2002 $2.6 billion or 5.5% in 2002 (Office of (Office of Actuary, 2001)Actuary, 2001)
Includes Funding for Education of Includes Funding for Education of Residents Residents But Does Not Include But Does Not Include PsychologyPsychology
CPT 08.03.07CPT 08.03.07 128128
SummarySummary
New CodesNew Codes 7 + 1 for a total of 8 new codes7 + 1 for a total of 8 new codes Allows the use of technicians and fMRIAllows the use of technicians and fMRI Allows for general supervision (used to be direct)Allows for general supervision (used to be direct)
Greater ReimbursementGreater Reimbursement 22 to 68% increase over 2005 levels22 to 68% increase over 2005 levels
Problems with the Use of Two Codes Simultaneously with Problems with the Use of Two Codes Simultaneously with MedicareMedicare
At worse, return to 2005 levels for now but with supervision At worse, return to 2005 levels for now but with supervision and technicians gainsand technicians gains
APA PD, 40, NAN PAIC are working together for this resolutionAPA PD, 40, NAN PAIC are working together for this resolution Presentation to CPT in February 8, 2007- San DiegoPresentation to CPT in February 8, 2007- San Diego CMS. in principle, has indicated that they understand the CMS. in principle, has indicated that they understand the
problemproblem Working towards a language change that should be Working towards a language change that should be
implemented on 01.01.08 that will resolve these problemsimplemented on 01.01.08 that will resolve these problems
CPT 08.03.07CPT 08.03.07 129129
New Initiatives: InsuranceNew Initiatives: Insurance
Private PayorsPrivate Payors Restricted interpretation by BC/BS of testing codesRestricted interpretation by BC/BS of testing codes Working on resolving this in specific states (e.g., Working on resolving this in specific states (e.g.,
Alabama)Alabama) CMS Interpretation of Students/TraineesCMS Interpretation of Students/Trainees
Presently cannot use students/trainees and request Presently cannot use students/trainees and request reimbursement from Medicare patients using a CPT codereimbursement from Medicare patients using a CPT code
This is due to the interpretation by CMS that we receive This is due to the interpretation by CMS that we receive General Medical Education fundsGeneral Medical Education funds
We are requesting either the use of GME funds or We are requesting either the use of GME funds or allowing student/trainees to bill using CPT codesallowing student/trainees to bill using CPT codes
This only applies to MedicareThis only applies to Medicare
CPT 08.03.07CPT 08.03.07 130130
New Initiatives: Registration of New Initiatives: Registration of PsychometriciansPsychometricians
Collaborative Project of National Collaborative Project of National Association of Psychometrists, NAN Association of Psychometrists, NAN and 40and 40 Initial proposal developedInitial proposal developed Currently being revisedCurrently being revised Will be presented to NAN and 40 Boards Will be presented to NAN and 40 Boards
in August, 2007in August, 2007
CPT 08.03.07CPT 08.03.07 131131
Your InvolvementYour Involvement
Professional MembershipProfessional Membership Join NAN, APA/40, and your state associationJoin NAN, APA/40, and your state association Start a local/state neuropsychological Start a local/state neuropsychological
association (e.g., North Carolina NP Society)association (e.g., North Carolina NP Society) Professional ParticipationProfessional Participation
Join a committee, listservJoin a committee, listserv Join an insurance committeeJoin an insurance committee Track insurance patterns in your state/areaTrack insurance patterns in your state/area
CPT 08.03.07CPT 08.03.07 132132
Part IV: ResourcesPart IV: Resources
General Web SitesGeneral Web Sites www.apa.orgwww.apa.org www.nanonline.org/paiowww.nanonline.org/paio www.cms.orgwww.cms.org (medicare/medicaid) (medicare/medicaid) www.hhs.orgwww.hhs.org (health & human services) (health & human services) www.oig.hhs.govwww.oig.hhs.gov (inspector general) (inspector general) www.apa.org/practice/cptwww.apa.org/practice/cpt (apa’s cpt information) (apa’s cpt information) www.ahrq.gov (agency for healthcare research)www.ahrq.gov (agency for healthcare research) www.medpac.govwww.medpac.gov (medical payment advisory comm.) (medical payment advisory comm.) www.whitehouse.gov/fsbr/healthwww.whitehouse.gov/fsbr/health (statistics) (statistics) www.div40.orgwww.div40.org (clinical neuropsychology div of apa) (clinical neuropsychology div of apa) www.napnet.orgwww.napnet.org (national association of (national association of
psychometrists)psychometrists) www.access.gpo.govwww.access.gpo.gov (federal statutes and (federal statutes and
regulations)regulations) www.healthcare.group.comwww.healthcare.group.com (staff salaries) (staff salaries)
CPT 08.03.07CPT 08.03.07 133133
Resources Resources (continued)(continued)
Payment/CoveragePayment/Coverage www.myhealthscore.com/consumer/phyoutcptsearch.htmwww.myhealthscore.com/consumer/phyoutcptsearch.htm www.cms.hhs.gov/statistics/feeforservice/defailt.aspwww.cms.hhs.gov/statistics/feeforservice/defailt.asp (covered services) (covered services) www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=167www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=167 (non-covered) (non-covered) www.apa.org/pi/aging/lmrp/toolkit/homepage.htmlwww.apa.org/pi/aging/lmrp/toolkit/homepage.html (apa lmrp) (apa lmrp) www.cms.hhs.gov/providers/mr/lmrp/aspwww.cms.hhs.gov/providers/mr/lmrp/asp (medicare lmrp) (medicare lmrp) www.quickfacts.census.gov/qfdwww.quickfacts.census.gov/qfd (census x type of procedure data) (census x type of procedure data)
LMRP Reconsideration ProcessLMRP Reconsideration Process www.cms.gov/manuals/pm_trans/R28PIM.pdfwww.cms.gov/manuals/pm_trans/R28PIM.pdf
Compliance Web SitesCompliance Web Sites www.oig.hhs.gov (office of inspector general)www.oig.hhs.gov (office of inspector general) www.cms.hhs.gov/manualswww.cms.hhs.gov/manuals (medicare) (medicare) www.uscode.house.gov/usc.htmwww.uscode.house.gov/usc.htm (united states codes) (united states codes) www.apa.orgwww.apa.org (psychologists & hipaa) (psychologists & hipaa) www.cms.hhs.gov/hipaawww.cms.hhs.gov/hipaa. (hipaa). (hipaa) www.hcca-info.orgwww.hcca-info.org (health care compliance assoc.) (health care compliance assoc.)
CPT 08.03.07CPT 08.03.07 134134
Resources Resources (continued)(continued)
ICDICD www.who.int/icd/vol1htm2003/fr-icd.htmwww.who.int/icd/vol1htm2003/fr-icd.htm (who) (who) www.cdc.gov/nchas/about/otheract/icd9/abticdwww.cdc.gov/nchas/about/otheract/icd9/abticd
9.htm9.htm (ccd) (ccd)
Coding Web SitesCoding Web Sites www.catalog.ama-assn.org/Catalog/cpt/cptwww.catalog.ama-assn.org/Catalog/cpt/cpt
_search.jsp_search.jsp (ama cpt) (ama cpt)
www.aapcnatl.orgwww.aapcnatl.org (academy of coders) (academy of coders) www.ntis.gov/product/correct-codingwww.ntis.gov/product/correct-coding
(coding edits)(coding edits)
CPT 08.03.07CPT 08.03.07 135135
AMA Contact InformationAMA Contact Information
WebsiteWebsite www.amabookstore.comwww.amabookstore.com Link to; Link to;
catalog.ama-assn.org/Catalog/cpt/catalog.ama-assn.org/Catalog/cpt/issue_search.jspissue_search.jsp
TelephoneTelephone Matt MenningMatt Menning 312.464.5116312.464.5116
CPT 08.03.07CPT 08.03.07 136136
APA Contact InformationAPA Contact Information
American Psychological AssociationAmerican Psychological Association Russ Newman, J.D., Ph.D.Russ Newman, J.D., Ph.D. Practice DirectoratePractice Directorate American Psychological AssociationAmerican Psychological Association 750 First Street, N.W.750 First Street, N.W. Washington, D.C. 2002Washington, D.C. 2002
Association for the Advancement of PsychologyAssociation for the Advancement of Psychology www.aapnet.orgwww.aapnet.org P.O.Box 38129P.O.Box 38129 Colorado Springs, Colorado 38129Colorado Springs, Colorado 38129
CPT 08.03.07CPT 08.03.07 137137
Puente Contact InformationPuente Contact Information
WebsitesWebsites Univ = Univ = www.uncw.edu/people/puentewww.uncw.edu/people/puente Practice = Practice = www.clinicalneuropsychology.uswww.clinicalneuropsychology.us NAN = www.nanonline.org/paioNAN = www.nanonline.org/paio
E-mailE-mail University = pUniversity = [email protected]@uncw.edu Practice = [email protected] = [email protected]
TelephoneTelephone University = 910.962.3812University = 910.962.3812 Practice = 910.509.9371Practice = 910.509.9371