APA HI 2004

Economic & Public Policy Issues in Clinical Neuropsychology

APA HI 2004

American Psychological Association

August 1, 2004

Antonio E. Puente, Ph.D.

&

James Georgoulakis, Ph.D.

APA HI 2004

Contact Information

• Websites– Univ = www.uncw.edu/people/puente– Practice = www.clinicalneuropsychology.us

• E-mail– University = puente@uncw.edu– Practice = neuropsychology@bellsouth.net

• Telephone– University = 910.962.3812– Practice = 910.509.9371

APA HI 2004

AcknowledgmentsUNC-WilmingtonNCPA Division 40 of APANANPractice Directorate of the American

Psychological AssociationAmerican Medical Association’s CPT StaffCMS Medical Policy Staff

APA HI 2004

Background(1988 – present)

American Medical Association’s Current Procedural Terminology Committee (IV/V)

American Medical Association’s Relative Values Unit Health Care Finance Administration’s Working Group

for Mental Health Policy Center for Medicare/Medicaid Services’ Medicare

Coverage Advisory Committee & Consultant Consultants with Various Institutions and Insurance

Carriers)

APA HI 2004

Purpose of Presentation

• Increase Reimbursement & Explain the Relationship Between Economics & Science

• Increase Range, Type & Quality of Services• Decrease Fraud & Abuse• Provide Guidelines for Professional Services• Maintain Professional Stature Within Psychology• Increase Professional Stature in Health Care, in

general • Explain the Complexities Involving Development

of Public Policy

APA HI 2004

Outline of Presentation

• Basics of Reimbursement

• Medicare

• Procedure Codes: CPT System

• Valuing Codes: Relative Value Units

• Current Problems & Possible Solutions

• Future Directions & Problems

APA HI 2004

Basics of Reimbursement: ISources

• Cash• Contractual (Institution-Based) Fee• Indemnity & Managed Care

Cost Plus

Prospective Payment System (PPS)

Diagnostic Related Groups (DRGs)

Customary, Prevailing & Reasonable (CPR)

Resource Based Relative Value System (RBRVS)

APA HI 2004

Basics of Reimbursement: IIVariables

• Level of Provider– Physician versus Non-Physician (CMS defined)

• Site of Service– Inpatient versus Outpatient (CMS defined)

• Diagnoses– ICD (Health) versus Mental Health (DSM)

• Procedure– Provider Activity (not patient activity)

APA HI 2004

Medicare: Overview

• Why Focus on Medicare

• The Medicare Program

• Local Medical Review (policy & panels)

APA HI 2004

Medicare: Why

• The Standard – Coding– Value– Documentation

• Largest Insurance Program in the World– Fraud

• Most Third Party (e.g., Medicaid), Institutions & Practices are Appling Medicare Paradigms

• Increasing Percentage for Forensic Work

APA HI 2004

Medicare: Overview

• New Name: HCFA now CMS– Centers for Medicare and Medicaid Services

• New Charge: Simplify

• New Organization: Beneficiary, Medicare, Medicaid

• Benefits– Part A (Hospital)– Part B (Supplementary)– Part C (Medicare+ Choice)– Pharmaceutical

APA HI 2004

Medicare: Local Review

• Local Medical Review Policy– LMRP vs National Policy– Location of LMRPs

• Carrier Medical Director– A Physician-based Model

• Policy Panels– Lack of Understanding of Their Roles– Lack of Representation on Such Panels

• Medicaid Programs are Social Work Based

APA HI 2004

Medicare Payment(since 1993)

• Surgical – Higher Reimbursement than Cognitive

• Cognitive– Physician Cognitive Work– Supporting Equipment & Staff

APA HI 2004

Medicare Payment

• When to Bill– Inpatient - discharge, monthly– Outpatient – therapy = after visit; testing = ?

• Participating Vs. Nonparticipating– 95 vs. 100%

• Specialty, Provider & Revenue Codes– Specialty = 62– Provider type = 35– Revenue = facility based

APA HI 2004

Current Procedural Terminology: Overview

• Background

• Codes & Coding

• Existing Codes

• Model System X Type of Problem

• Medical Necessity

• Documenting

• Time

APA HI 2004

CPT: Background

• American Medical Association– Developed by Surgeons (& Physicians) in

1966 for Billing Purposes– 7,500+ Discrete Codes

• CMS– AMA Under License with CMS– CMS Now Provides Active Input into CPT

APA HI 2004

CPT: Background/Direction

• Current System = CPT 5

• Categories– I= Standard Coding for Professional Services

(important one of the three)– II = Performance Measurement– III = Emerging Technology

APA HI 2004

CPT: Applicable Codes

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

40 to 60• Sections = Five Separate Sections

– Psychiatry– Biofeedback– Central Nervous Assessment– Physical Medicine & Rehabilitation– Health & Behavior Assessment & Management– Possibly, Evaluation & Management

APA HI 2004

CPT: Development of a Code

• Initial– Health Care Advisory Committee (non-MDs)

• Primary– CPT Work Group– CPT Panel

• Time Frame– 3-6 years

APA HI 2004

CPT: Psychiatry

• Sections– Interview vs. Intervention– Office vs. Inpatient– Regular vs. Evaluation & Management– Other

• Types of Interventions– Insight, Behavior Modifying, and/or Supportive

vs. Interactive

APA HI 2004

CPT: Psychiatry (cont.)

• Time Values– 30, 60, (or 90)

• Interview– 90801

• Intervention– 90804 - 90857

APA HI 2004

Typical Psychotherapy Codes

• Individual– 20-30 = 90804 (16)– 45-50 = 90806 (18)

• Other– Family (with pt) = 90847– Group psychotherapy = 90853

APA HI 2004

Biofeedback

• Biofeedback– 90901

• (Psychophysiological Therapy)– 20-30’ =90875

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CPT: CNS Assessment(all per hour & with report)

• Interview– Neurobehavioral Status Exam = 96115

• Testing– Psychological = 96100; 96110/11– Neuropsychological = 96117– Developmental = 96111 (not per hour)– Other = 96105, 96110/111

APA HI 2004

CPT: 96117 in Detail

• Number of Encounters;– 2000 = 293,000– 2003 = 341,777 (96100 = 193,593)

• Number of Medical Specialties Using 96117 = over 40

• Psychiatry & Neurology = Approximately 3% each

• Clinics or Other Groups = 3%• Primary Provider = clinical psychologist

APA HI 2004

CPT: Physical Medicine & Rehabilitation

• 97770 now 97532– Note: 15 minute increments

APA HI 2004

CPT: Health & Behavior Assessment & Management

• Purpose: Medical Diagnosis

• Time: 15 Minute Increments

• Assessment

• Intervention

APA HI 2004

CPT: Health & Behavior CodesHistory

• APA Interdivisional Health Committee

• First Draft (5) of Codes – 09.11.98

• First HCPAC Presentation – 11.06.98

• First CPT (4) Presentation – 08.14.99

• Workgroup Meeting – 12.17.99

• CMS Acceptance = 11.01.02

• Revisions to Language = ongoing

APA HI 2004

Rationale: General

• Acute or chronic (health) illness which does not meet the criteria for a psychiatric diagnosis

• Avoids inappropriate labeling of a patient as having a mental health disorder

• Increases the accuracy of correct coding of professional services

• May expand the type of assessments and interventions afforded to individuals with health problems

APA HI 2004

Rationale: Continued

• The Problem with the Preamble– Prevention Codes are not reimbursed– Original wording suggested the possibility of

preventing a disease– Wording change reduced that possibility– Now some carriers have interpreted the wording

change to mean; if there is now or if there ever was a mental health diagnosis, these codes would not apply

– We are attempting to change the preamble wording

APA HI 2004

Rationale: Specific Examples

• Patient Adherence to Medical Treatment

• Symptom Management & Expression

• Health-promoting Behaviors

• Health-related Risk-taking Behaviors

• Overall Adjustment to Medical Illness

APA HI 2004

Overview of Codes

• New Subsection

• Six New Codes– Assessment– Intervention

• Established Medical Illness or Diagnosis

• Focus on Biopsychosocial Factors

APA HI 2004

Assessment Explanation

• Identification of psychological, behavioral, emotional, cognitive, and social factors

• In the prevention, treatment, and/or management of physical health problems

• Focus on biopsychosocial factors (not mental health)

APA HI 2004

Assessment (continued)

• May include (examples);– health-focused clinical interview– behavioral observations– psychophysiological monitoring– health-oriented questionnaires– and, assessment/interpretation of the

aforementioned

APA HI 2004

Intervention Explanation

• Modification of psychological, behavioral, emotional, cognitive, and/or social factors

• Affecting physiological functioning, disease status, health, and/or well being

• Focus = improvement of health with cognitive, behavioral, social, and/or psychophysiological procedures

APA HI 2004

Intervention (continued)

• May include the following procedures (examples);– Cognitive– Behavioral– Social– Psychophysiological

APA HI 2004

Diagnosis Match

• Associated with acute or chronic illness

• Prevention of a physical illness or disability

• Not meeting criteria for a psychiatric diagnosis or representing a preventative medicine service

APA HI 2004

Related Psychiatric Codes

• If psychiatric services are required (90801-90899) along with these, report predominant service

• Do not report psychiatric and these codes on the same day

APA HI 2004

Related Evaluation & Management Codes

• Do not report Evaluation & Management codes the same day

APA HI 2004

Code X Personnel (examples)

• Physicians (pediatricians, family physicians, internists, & psychiatrists)

• Psychologists• Advanced Practice Nurses• Clinical Social Workers Excluded• Other health care professionals within their

scope of practice who have specialty or subspecialty training in health and behavior assessments and interventions

APA HI 2004

Health & Behavior Assessment Codes

• 96150– Health and behavior assessment (e.g.,

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

– each 15 minutes– face-to-face with the patient– initial assessment

• 96151– re-assessment

APA HI 2004

Health & Behavior Intervention Codes

• 96152– Health and behavior intervention

– each 15 minutes

– face-to-face

– individual

• 96153– group (2 or more patients)

• 96154– family (with the patient present)

• 96155– family (without the patient present)

APA HI 2004

Relative Values for Health & Behavior A/I Codes

• 96150 = .50

• 96151 = .48

• 96152 = . 46

• 96153 = .10

• 96154 = .45

• 96155 = .44

APA HI 2004

Expected Payment for Health & Behavior Codes

• Individual (per hour)– Range $98-106

• Group (per person/ per hour)– Approximately $22

APA HI 2004

CPT: Modifiers

• Acceptability– Medicare = about 100%– Others = approximating 90%

• Modifiers– 22 = unusual or more extensive service– 51 = multiple procedures– 52 = reduced service– 53 = discontinued service

APA HI 2004

CPT: Possibilities

• Telephone contact– Established– Very well defined– Telephone web– Telephone with documentation

APA HI 2004

CPT Possibilities

• Work Related or Medical Disability Evaluation Services– 99450 Basic life and/or disability evaluation– 99555 Evaluation by treating physician– 99456 Evaluation by non-treating physician

would include;historyevaluationdiagnosisfuture treatment planscompletion of documentation/certificates

APA HI 2004

CPT: Mutually Exclusive Codes

• 90804; 99294,-98, -99

• 90806; 99293, -94, -98, -99

• Possibly;– Psychotherapy and Testing on Same Day

APA HI 2004

CPT: Model System

• Psychiatric

• Neurological

• Non-Neurological Medical

• Possibly, Evaluation & Management

(in essence, case management)

APA HI 2004

CPT: Psychiatric Model(Children & Adult)

• Interview– 90801

• Testing– 96100, or– 96110/11

• Intervention– e.g., 90806

APA HI 2004

CPT: Neurological Model(Children & Adult)

• Interview– 96115

• Testing– 96117

• Intervention

– 97532

APA HI 2004

CPT: Medical Model(Children & Adult)

• Interview & Assessment– 96150 (initial)– 96151 (re-evaluation)

• Intervention– 96152 (individual)– 96153 (group)– 96154 (family with patient)

APA HI 2004

CPT: New Paradigms

• Initial, Psychiatric

• Then, Neurological

• Now, Medical

• Next? Evaluation & Management?

APA HI 2004

CPT: Evaluation & Management

• Role of Evaluation & Management Codes– Procedures– Case Management

• Limitations Imposed by AMA’s House of Delegates for CMS but not for Private Payers

• Health & Behavior Codes as an Alternative to E & M Codes

• The Use of E & M Codes is Accepted by Some Third Party Reimburses (e.g., MedCost)– Example; 99201 New Patient

APA HI 2004

CPT: Diagnosing

• Psychiatric– DSM

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

• Neurological & Non-Neurological Medical– ICD (or see NAN Paio web page; membership

directory)

APA HI 2004

CPT: Medical Necessity

• Scientific Versus Clinical Necessity• Local Medical Review or Carrier Definitions

of Necessity• Necessity =

– CPT x DX– Symptom & Progress Based

• Necessity Dictates Type and Level of Service• Necessity Can Only be Proven with

Appropriate Documentation

APA HI 2004

CPT: Documenting

• Purpose

• Payer Requirements

• General Principles

• History

• Examination

• Decision Making

APA HI 2004

Development of Codes:Testing Codes

• Initial– Health Care Advisory Committee (non-MDs)

• Primary– CPT Work Group– CPT Panel

• Time Frame– 3-6 years

APA HI 2004

Development of Codes:H & B Codes

• APA Interdivisional Health Committee

• First Draft (5) of Codes – 09.11.98

• First HCPAC Presentation – 11.06.98

• First CPT (4) Presentation – 08.14.99

• Workgroup Meeting – 12.17.99

• CMS Acceptance = 11.01.02

• Revisions to Language = ongoing

APA HI 2004

CPT: Development of Codes

• Original Testing Codes– Part of Psychiatry– Removal from Psychiatry to Neurology– Removal from Neurology to CNS Assessment

• Current Development– The problem of work value– The problem of practice expense– The problem of two non-accepted surveys– Development of a new series of codes

APA HI 2004

Development of Codes:Testing Code, Ongoing

• Number of Staff Members Involved– Volunteer = 2 (AEP & JG)– APA Staff = 2 (Diane Pedulla & Kim Moore)

• Number of Consultants Involved– 40 = Practice Committee (Neil Pliskin)– NAN = Testing Code Task Force) (Julie Lynch)– SPA = Testing Code Committee (Bruce Smith)

• Number of Trips– Since non-acceptance of surveys last fall, approx. 6

• Number of Telephone Calls, E-mails (?)• Total Costs (?)

APA HI 2004

Documentation: Purpose

• Medical Necessity

• Evaluate and Plan for Treatment

• Communication and Continuity of Care

• Claims Review and Payment

• Research and Education

APA HI 2004

Documentation: Payer Requirements

• Site of Service

• Medical Necessity for Service Provided

• Appropriate Reporting of Activity

APA HI 2004

Documentation: General Principles

• Rationale for Service

• Complete and Legible

• Reason/Rationale for Service

• Assessment, Progress, Impression, or Diagnosis

• Plan for Care

• Date and Identity of Observe

• Timely

• Confidential

APA HI 2004

Documentation: Basic Information Across All Codes

• Date• Time, if applicable• Identity of Observer (technician ?)• Reason for Service• Status• Procedure• Results/Findings• Impressions/Diagnoses (plural)• Disposition

APA HI 2004

Documentation: Basic

• One CPT code = One Documentation Entry (i.e., do not mix)

• Each Entry Should be Stand Alone

• Similar Code Should Flow from One to the Other– 90801 to 96100 to 90806– 96115 to 96117 to 96581

APA HI 2004

Documentation: Chief Complaint

• Concise Statement Describing the Symptom, Problem, Condition, & Diagnosis

• Foundation for Medical Necessity

• Must be Complete & Exhaustive

APA HI 2004

Documentation: Present Illness

• Symptoms– Location, Quality, Severity, Duration, timing,

Context, Modifying Factors Associated Signs

• Follow-up– Changes in Condition– Compliance

APA HI 2004

Documentation: History

• Past

• Family

• Social

• Medical/Psychological

APA HI 2004

Documentation:Mental Status

• Language• Thought Processes• Insight• Judgment• Reliability• Reasoning• Perceptions

• Suicidality• Violence• Mood & Affect• Orientation• Memory• Attention• Intelligence

APA HI 2004

Documentation:Neurobehavioral Status Exam

• Attention

• Memory

• Visuo-spatial

• Language

• Planning

APA HI 2004

Documentation: Testing

• Names of Tests (including edition/version)• Interpretation of Tests (narrative; possibly

quantitative)• Disposition• Time/Dates

– In Hours (rounded to nearest hour; in discussion with AMA staff at present)

– Document on Day Service is Provided Versus Documentation on Last Date of Service (CMS?)

– Best to Separate from Interview

APA HI 2004

Documentation: Intervention

• Reason for Service

• Status

• Intervention

• Results

• Impression

• Disposition

• Time (total minutes versus time start/stop)

APA HI 2004

Documentation for Workers Compensation/Disability

• Completion of comprehensive history• Performance of appropriate examination• Assessment of functional capacities• Referral for appropriate further testing• Recommendation for treatment• Preparation of report• Analysis of causation• Determination of impairment• Review of records• Review of prior treatment for medical necessity• Discussion with appropriate parties• Other case management activities

APA HI 2004

Documentation:Suggestions

• Avoid Handwritten Notes

• Do Not Use Red Ink

• Avoid Color Paper

• Document On and After Every Encounter, Every Procedure, Every Patient

• Review Changes Whenever Applicable

• Avoid Standard Phrases (e.g., computer generated reports could be problematic)

APA HI 2004

Documentation: Ethical Issues

• How Much and To Whom Should Information be Divulged

• Medical Necessity vs. Confidentiality

• HIPAA vs. Documentation

APA HI 2004

Time

• Defining– Professional (not patient) Time Including:

• pre, intra & post-clinical service activities

• Interview & Assessment Codes– Generally use hourly increments– For new codes, use 15 minute increments

• Intervention Codes– Use 15, 30, or 60 minute increments

APA HI 2004

Time: Definition

• 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 & tests, arranging for services & communicating further with other professionals & the patient through written reports & telephone contact.

APA HI 2004

Time (continued)

• Communicating further with others

• Follow-up with patient, family, and/or others

• Arranging for ancillary and/or other services

APA HI 2004

Time: Defined Further

• Evaluation Versus Therapy Time– Therapy is Essentially Face to Face– Testing is Essentially Professional Time

• Inpatient Versus Outpatient

- If Outpatient: face to face only for E & M

- If Inpatient: time on floor for E & M

APA HI 2004

Time: Testing

• Quantifying Time– Round up or down to nearest increment– Testing = 15 or 60 (probably soon 30)

• 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.

APA HI 2004

Time (continued)

• Preparing to See Patient• Reviewing of Records• Interviewing Patient, Family, and Others• When Doing Assessments:

– Selection of tests– Scoring of tests– Reviewing results– Interpretation of results– Preparation and report writing

APA HI 2004

Time: Example of 96117

• Pre-Service– Review of medical records– Planning of testing

• Intra-Service– Administration

• Post-Service– Scoring, interpretation, integration with other

records, written report, follow-up...

APA HI 2004

Reimbursement History

• Cost Plus

• Prospective Payment System (PPS)

• Diagnostic Related Groups (DRGs)

• Customary, Prevailing & Reasonable (CPR)

• Resource Based Relative Value System (RBRVS)

APA HI 2004

Relative Value Units: Overview

• Components

• Units

• Values

• Current Problems

APA HI 2004

RVU: Components

• Physician Work Resource Value

• Practice Expense Resource Value

• Malpractice

• Geographic

• Conversion Factor (approx. $37)

APA HI 2004

RVU: Values

• Psychotherapy:– Prior Value =1.86– New Value = 2.0+ (01.01.02)

• Psych/NP Testing: – Work value= 0– Hsiao study recommendation = 2.2– New Value = undetermined

• Health & Behavior– .25 (per 15 minutes increments)

APA HI 2004

RVU Values

• Practice Expense = 43.60%

• Work Value =52.47%

• Liability = 3.80%

APA HI 2004

RVU: Acceptance

• Medicare 100%• Blue Cross/Blue Shield 87%• Managed Care 69%• Medicaid 55%• Other 44%• New Trends:

– RVUs as a Model for All Insurance Companies– RVUs as a Basis for Compensation Formulas

APA HI 2004

Current Problems • Definition of Physician• Incident to• Supervision• Face-to-Face• Time• RVUs & Work Values• Qualification of Technicians• Payment• Prospective Payment System• Skilled Nursing & Rehabilitation Facilities• Medicaid• Focus for Fraud & Abuse

APA HI 2004

Problem: Defining Physician

• Definition of a Physician– Social Security Practice Act of 1980– Definition of a Physician– Need for Congressional Act– Likelihood of Congressional Act– The Value of Technical Services of a

Psychologist is $.83/hour (second highest after physicist)

– Consequence of the preceding; grouping with non-doctoral level allied health providers

APA HI 2004

Problem: Incident to

• Rationale for Incident to– Congress intended to provide coverage for services not

typically covered elsewhere

• Definition of Physician Extender– How– Limitations

• Definition of In vs. Outpatient– Geographic Vs Financial

• Why No Incident to (DRG)• Solution Available for Some Training Programs

Through General Medical Education• Probably no Future to Incident to

APA HI 2004

Problem: More Incident to

• When is “Incident to” Acceptable:– Testing – Cognitive Rehabilitation; Biofeedback– Psychotherapy ?

• Supervision versus Independent Service

• Definition– Commonly furnished service– Integral, though incidental to psychologist– Performed under the supervision– Either furnished without charge or as part of the

psychologist’s charge

APA HI 2004

Problem: Incident to & Site of Service

• Outpatient vs. Inpatient– Geographical Location– Corporate Relationship– Billing Service– Chart Information & Location

APA HI 2004

Problem: Incident to vs.Independent Service

• When Does Incident to Become Independent Service– Appearance of No Supervision– Clinical Decisions are Made by Staff– Ratio of Physician to Staff Time Becomes

Disproportionate Small or Non-Existent– Geographic Distance and Communication

Difficulties– Supervision Difficulties

APA HI 2004

Problem:Recent Difficulties with Incident to

• Who Bills Incident to– Treating Physician Bills not the Supervising

Physician– Then, Who is the Responsible Party

• The Provider Must Interview the Patient First• The Provider Must Continue Involvement in

Evaluation & Treatment• Non-Providers Probably Should not Interpret

Tests and Dictate Reports

APA HI 2004

Problem:Supervision

• Supervision– 1.General = overall direction– 2.Direct = present in office suite– 3.Personal = in actual room– 4.Psychological = when supervised by a

psychologist

APA HI 2004

Problem: Face-to-Face

• Implications

• Technical versus Professional Services

• Surgery is the Foundation for CPT (and most work is face-to-face)

• Hard to Document & Trace Non-Face-to-Face Work

APA HI 2004

Problem: Time

• Time Based Professional Activity

• Current =15, 30, 60, & 90

• Expected = 15 & 30

APA HI 2004

Problem: RVUs

• Bad News– 2000 = 5.5% increase– 2001 = 4.5% increase– 2002 = 5.4% decrease– 2003 = 4.4 to 5.7% decrease ($34.14)– 2004 = 1.5% increase ($37?)

• Really Bad News– Bush Administration not supportive of changing the

conversion formula– Change Continued to Probably 2005 Depending on

Such Factors as the Stock Market (e.g., 5000)

APA HI 2004

Problem: Work Value

• Physician Activities (e.g., Psychotherapy) Result in Work Values

• Psychological Based Activities (i.e., Testing) Have no Work Values

• RVUs are Heavily Based on Practice Expenses (which are being reduced)

• Net Result = Maybe Up to a Half Lower

APA HI 2004

Problem:An Artificial Practice Expense

• Five Year Reviews• Methodological Problems in Obtaining Accurate

Practice Expenses• Current Value = approximately 1.5 of 1.75 is

practice• Deadline for New Practice Expense = 2002

– Currently in Check Due to the Development of Codes

• Expected Value = closer to 50% of total value at best

APA HI 2004

Problem: Work Value of Testing

• First Round• Second Round• Current Round

– Tucson– San Juan– Boston– RUC in Chicago, September (educational)– CPT in Chicago, November (formal proposal)

APA HI 2004

Problem: Qualification of Technician

• What is the Minimum Level of Training Required for a Technician?– Bachelor’s vs. Masters– Intern vs. Postdoctoral

• Will a Registry be Available?– Is This Something Division 40 and NAN

Should Consider?

APA HI 2004

Problem: Payment

• Origins of the Problem– Balanced Budget Act of 1997– Employer’s Cost for Health Care in 2002 =

$5,000 per employee

• What Should Your Code Be Payed at?– www.webstore.ama-assn.org-

• State Legislation– www.insure.com/health/lawtool.cfm

APA HI 2004

Problem:Payment Problems

• Payment Reduction Software Programs– Claimcheck (McKesson product; Cigna, PacifiCare)– Patterns (McKesson product; United)

• Refilling– 51% require refilling of original forms– But, up to 60% do not follow up

• Errors– 54% = plan administrator– 17% = provider– 29% = member

APA HI 2004

Problem: Payment

• Use of HMOs & Third Party– Shift in Practice Patterns by Psychiatry (14%

increase)– Exclusion of MSW, etc.– Worst Hit Are Psychologists (2% decrease)

• Compensation– Gross Charges– Adjusted Charges– RVUs– Receivables

APA HI 2004

Problem: Payment of Health & Behavior Codes

• Medicare Almost all Resolved• Non-Medicare Resolving

APA HI 2004

Problem: PPS

• Application of PPS (inpatient rehab)

• Traditional Reimbursement

• Current Unbundling

• Potential Situation

APA HI 2004

Problem:Skilled Nursing Facility

• Consolidated Billing

• BBA 1997– $1,500 total for outpatient services

• Excluded Codes in Consolidated Billing– 96115 (Neurobehavioral Status Exam)– 90901 & 90911 (Biofeedback)

APA HI 2004

Problem: 65/75 Split for Rehabilitation Facilities

• 75% Rule – Stroke– Spinal Cord Injury– Congenital Deformity– Amputation– Multiple Trauma– Hip Fracture– Brain Injury– Arthritis

» Changing to 75% pf 20 of 21 Rehabilitation Impairment Categories

» Possibly changing to 65%

APA HI 2004

Problem:Provider-Based Facilities

• Is Facility Located on Main Hospital Campus or Within 35 Miles of it

• Appropriate Reporting Relationship Exists Between Hospital and Clinical Staff

• Medicare Cost Report Includes Facility

• Records are Fully Integrated

• Facility is Presented to the Public as Part of the Hospital

APA HI 2004

Problems: Medicaid

• Using Medicaid in North Carolina as an example;– Extremely low reimbursement rates bordering

on barely covering actual costs of service– Questioning the use of technicians– Not allow reimbursement for non-face-to-face

contact– NCPA & Division of Medical Assistance Task

Force has been formed and meeting in 08.04

APA HI 2004

Problem: Expenditures & Fraud

• Projections– Current

• 14%

– By 2011;• 17% ($2.8 trillion)

APA HI 2004

Problems: Expenditures & Fraud

• Examples– New York (08.2003)

• Sharing a provider number • Physical therapy services provided under provider number

– New York (05.2003)• Falsifying services that were not rendered

– West Virginia (02.2003)• Presigned on Saturdays, services performed during week

– Nadolni Billing Service (Memphis)• $5 million in claims to CIGNA for psychological services• $250,000 fine (& tax evasion)

APA HI 2004

Defining Fraud

• Fraud– Intentional– Pattern

• Error– Clerical– Dates

APA HI 2004

Problem: Fraud & Abuse • 26 Different Kinds of Fraud Types

• Mental Health Profiled

• Estimates of Less Than 10% Recovered

• Psychotherapy Estimates/Day = 9.67 hours– Review Likely if Over 12 Hours Per Day

• Problems with Methodology;– MS level and RN– Limited Sampling

APA HI 2004

Problem: FraudOffice of Inspector General

• Primary Problems– Medical Necessity (approximately $5 billion)– Documentation

• Psychotherapy (oig.hhs/gov/reports/region5/50100068)– Individual– Group– # of Hours– Who Does the Therapy

• Psychological Testing– # of Hours– Documentation

APA HI 2004

Problem: Fraud & “The Orange Book”

• Contractor Operations– Strengthen Regional Offices Oversight– Improve Evaluation of Fraud Unit– Prevent Duplicate Payments for Same Service

• Hospital Operations– Identify Patterns of Aberrant Overpayment– Improve External Review of Psychiatric Hospitals

• Managed Care– Retool Medicaid Programs for Managed Care

• Nursing Homes– Improve Assessments of Mental Illness– Identify Patients with Mental Illness

APA HI 2004

Problem:The “Orange Book” (continued)

• Physicians/Allied Health Professionals– Improve Oversight of Rural Health Clinics– Eliminate Inappropriate Payments for Mental

Health Services– Yet, Improve Medicaid Mental Health

Programs

APA HI 2004

Problem: Fraud (cont.)

• Nursing Homes– Identification – Overuse of Services

• Children

• Clinical Trials

APA HI 2004

Problem: Fraud (cont.)

• Estimated Chronological Pattern of Fraud Analysis (from mid-1990s to present)– For-profit Medical Centers– For-profit Medical Clinics– Non-profit Medical Centers– Non-profit Medical Clinics– Nursing Homes– Group Practices– Individual Practices

• Outliers• Specialists

APA HI 2004

Problem: Mental vs. Physical

• Historical vs. Traditional vs. Recent Diagnostic Trends

• Recent Insurance Interpretations of Dxs • Limitations of the DSM • The Endless Loop of Mental vs. Physical

• NOTE: Important to realize that LMRP is almost always more restrictive than national guidelines

APA HI 2004

Problem: Medicaid

• Reimbursement Values

• Face to Face versus Professional Time

• Use of Technicians

APA HI 2004

Possible Solutions

• General Approaches

• Intra-practice Analyses

• Information Gathering

• Understanding of Possible Trajectories

APA HI 2004

Possible Solutions:General Approaches

• Better Understanding & Application of CPT• More Involvement in Billing (especially in large,

medical, multidisciplinary, and academic settings)• Comprehensive Understanding of LMRP• More Representation/Involvement with AMA, CMS,

& Local Medical Review Panels• Involvement and Support for APA, NAN and your

state psychological association

APA HI 2004

Possible Solutions: Defining Payers

• Defining Payers– Review contracts– Compare relative values of contracts– Determine what each payer actually pays per

CPT code– Determine hassle factor– Determine current payer’s mix– Determine a desired payer’s mix

APA HI 2004

Possible Solutions: Value of Contracts

• Face vs. Net Value of Contracts– Referrals – Authorizations– Medical Necessity– Coding– Coverage– Post-Service Audit

APA HI 2004

Possible Solutions: Fees

• Setting Your Fees– Usual Rate– Maximum Allowable– RBRVS– Fees Across Drs but Within a Practice

• Fees can vary across and within practices

– Standard Physician Fees• Between 200 and 400% of Medicare• Typical multiplier is RVRVS x 2.5

APA HI 2004

Possible Solutions: Compensation for Administration

• Compensation for Administration– Divide total annual compensation by 2080,

multiply by number of hours of tasks, and add this to compensation

– MD salary average = $181, 560 per year

– Typical MD Stipends = $2,000 to $15,000 per year

APA HI 2004

Possible Solutions: Resources

• General Web Sites– www.cms.org (medicare/medicaid)– www.hhs.org (health & human services)– www.oig.hhs.gov (inspector general)– www.ahrq.gov (agency for healthcare research)– www.medpac.gov (medical payment advisory comm.)– www.whitehouse.gov/fsbr/health (statistics)– www.healthcare.group.com (staff salaries)– www.qualitytools.ahrq.gov (quality control)– www.div40.org (clinical neuropsychology div of apa)– www.nanonline.org/paio (nan)

APA HI 2004

Resources (continued)

• LMRP Reconsideration Process– www.cms.gov/manuals/pm_trans/R28PIM.pdf

• Coding Web Sites– www.aapcnatl.org (academy of coders)– www.ntis.gov/product/correct-coding (coding edits)

• Compliance Web Sites– www.apa.org (psychologists & hipaa)– www.cms.hhs.gov/hipaa. (hipaa)– www.hcca-info.org (health care compliance assoc.)

APA HI 2004

Future Perspectives• Income

– Steady, slow decline (pending national election and if economy does not further erode)

– If traditional mental health practice, probable incremental declines, up to 10-20% over the foreseeable future

– If Medicaid dependent (25% or more), then declines could be even higher

– Possible “final” stabilization by 2005– Testing codes values by 2007

• Recognition– Mental to Physical Health to…

APA HI 2004

Future Perspectives: Medicare

• Conversion Factor– $37.3374– Increases of approximately 1.5%

• New Paradigms for Reimbursement Issues– Written response within 45 days– Toll-free telephone number– Training to providers– ALJs and appeals process in place– Prepayment audits limited– Extrapolation may not be used to determine

overpayment

APA HI 2004

Future Perspectives(continued)

• Understanding the Community You Live In– Geographic Diversity– Cultural Diversity– Socio-political Perspectives

• Paradigms– Industrial vs. Boutique/Niche– Clinical vs. Forensic– Mental Health vs. Health– Existing vs. Developing

APA HI 2004

Future Perspectives

• Evolving Paradigm = Continued and Significant Change – Expect Major Changes in Coding Within Two Years– Expect Major Changes in Reimbursement Within Two Years– Expect to be Audited