Audit? No problem! Documentation and Coding of Psychological & Neuropsychological Testing

Karen E. Wills, Ph.D., L.P., A.B.P.P.NeuropsychologistChildren’s Hospitals & Clinics of MinnesotaKaren.wills@childrensmn.org 612-813-6344

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• Testing as a medically necessary procedure• Rule-making: Coverage Determination• Private payors (criterion set transparency?)• How to write an authorization for testing• How to code and bill for testing• Diagnostic Interview & documentation• Health & Behavior Assessment codes• Treatment planning (Feedback) meetings• Screening & PQRS documentation• EHR documentation of testing

Outline: Testing topics & issues

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Overview of issues:Coverage of psych testing (1)

• “Medical necessity" justification of procedures.

• Stricter limits on which procedures are covered by insurance (reimbursed to the patient or paid directly to the provider).−Caps on total number of hours authorized for

testing.−Denial of some authorization for some types of

tests.−Denial or limits on testing for some conditions

and diagnoses.

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• Pre-authorization of diagnoses & testing procedures.

• Documentation review/auditing−These processes have existed for many years−Constraints & auditing gradually becoming more

rigorous−EHR makes it easier for auditors to quickly

review for timely, thorough, documentation

Overview of issues:Coverage of psych testing (2)

“Medical necessity" is the legal and policy basis for justification of procedures billed to medical insurance.

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When medical insurance is billed, testing must be “medically necessary.”

Psychological or neuropsychological evaluation guides the referring physician and family about changes in medical and behavioral management that can improve health (physical or mental health) outcomes by:

 • facilitating the patient's functioning within the community, • habilitating or rehabilitating the patient, where possible, to

deal with new and changing life demands, • identifying and altering social/environmental impediments

to enable better progress, and • recommending strategies to compensate for irremediable

disabilities. 

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• 1.) Distinguish mental/behavioral disorders from normal variation, malingering, or other mental or physical illness, esp. if questionable or inconsistent signs & symptoms occur on PCP screening tests.

• 2.) Combine psych data with clinical, laboratory, or other medical data to diagnose systemic, neurologic, or psychiatric conditions.

When is testing medically necessary?

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When is testing medically necessary?• 3.) Quantify cognitive or behavioral deficits,

especially when the information will be useful in determining a prognosis or informing treatment planning by determining the rate of disease progression (e.g., static intellectual disability vs. progressive dementia vs. transient delirium).

• 4.) Determine patient understanding and safety for proceeding with a medical or surgical procedure that may significantly alter a patient’s mental health or functional status.

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When is testing medically necessary?

• 5.) Detect and measure adverse effects of therapeutic substances (e.g., stimulants, ECT, or antipsychotic medications), especially when this information is utilized to inform treatment planning.

• 6.) Monitor progress, recovery, and response to changing treatments, in patients with mental/ behavioral disorders, in order to determine the most effective plan of care.

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When is testing medically necessary?

• 7.) Determine functional abilities/ impairments in individuals with known or suspected mental/ behavioral disorders to inform treatment planning, case management, or rehabilitation needs−capacity for employment, −independent living, −managing finances, −driving or other community mobility, −needs for & capacity to refuse/consent to treatment,−moving from a family home into an institutional

setting.

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When is testing medically necessary?

• 8.) Design, administer, and/or monitor individual outcomes of research-based mental/behavioral treatment procedures, such as ABA for children with autism or DBT for some patients with suicidality.

• 9.) Identify psychological complications of systemic disease (e.g., depression associated with cancer; diabetes associated with neuroleptic-induced obesity in schizophrenia), to aid treatment planning and medication management.

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When is testing indicated?

• 10.) In children or adolescents, assess presence & severity of suspected developmental plateaus, deviations, or delays, as well as occurrence of abnormal symptoms, and lost or deteriorating function. (Diagnosis of mental/ behavioral impairment in children and adolescents may be based on an inability to develop expected knowledge, skills or abilities as required to adapt to new or changing cognitive, social, emotional, or physical demands.)

Restrictions on which procedures are billable

When is testing considered “not medically necessary”

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Limitations of Coverage: "not medically necessary" (1)

• The patient is not neurologically and cognitively able to participate in a meaningful way in the testing process.

• When used as screening tests given to the individual or to general populations [Section 1862(a)(7) of the Social Security Act does not extend coverage to screening procedures].

• Administered for educational or vocational purposes that do not inform medical management (e.g., testing to determine need for special education; to screen applicants for public safety positions; to evaluate college students’ needs for accommodations in class)

• Self-administered or self-scored inventories or self-administered screening tests of cognitive function (whether paper-and-pencil or computerized).

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Limitations of Coverage:"not medically necessary" (2)

• Testing repeated when not required for medical decision-making (i.e., such as making a diagnosis or deciding whether to start or continue a particular rehabilitative or pharmacologic therapy) (e.g. tests required as part of a research protocol but not clinically indicated or standard of care).

• Testing administered when the patient has a substance abuse background and any of the following apply:− the patient has ongoing substance abuse such that test results

would be inaccurate, or − the patient is currently intoxicated.

• The patient has been diagnosed previously with a specific medical/behavioral disorder and there is no expectation that the testing would impact the patient's medical management.

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Limitations of Coverage:"not medically necessary" (3)

• When the reason to do testing, and the connection between the test results and later management of the patient, is not clearly explained:− “to better understand the patient”− “to clarify the person’s strengths and weaknesses”− “to measure the person’s intelligence”− “to explore his aggressive impulses”− “to assess whether memory problems are organic”− “because the parent/doctor/person wanted testing”− “because social services ordered testing for foster placement”

Who decides (and how) what services are covered, for which patients?

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We are Medicare Region V Michigan, MI Minnesota, MN Ohio, OH Illinois, IL Indiana, IN Wisconsin, WI

NCD: National Coverage Determination

“Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category).

National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. “

- cms.gov (3/20/15)

LCD: Local Coverage Determination

In some cases, CMS' own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC).

In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD). - cms.gov (3/20/15)

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• Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental Status, Speech Testing) (96101, 96102, 96103, 96105, 96110*, 96111, 96116, 96118, 96119, 96120)

• Local Coverage Determination (LCD): Psychiatry and Psychology Services (L26895)

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• E.g., Michelle Braun et al. (2011) regional ad hoc group of neuropsychologists advocated for better coverage of psychological and neuropsychological testing in Region V

• When new agent took over CMS payments for Region V and tried to roll back coverage, the AACN and MPA and other regional psych associations stepped in AGAIN and maintained the good coverage policy that had been established

• Another example: Arkansas State Psych Association advocated for good Medicaid coverage of ADHD testing (we could try it!)

Psychologists play a role in advocating needed coverage

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Neuropsychology Model Local Coverage Determination (July, 2011, for WPS, the Midwest regional Medicare payer)

• Michelle Braun, PhD, ABPP-CN (Chairperson); drmichellebraun@gmail.com

• Teresa Deer, PhD • Paul Kaufmann, JD, PhD, ABPP-CN• Karen Postal, PhD, ABPP-CN• David Tupper, PhD, ABPP-CN• Michael Westerveld, PhD, ABPP-CN• Karen Wills, PhD, ABPP-CN

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• Are influenced by CMS guidelines but not obliged to conform to Medicare/Medicaid

• BUT set their coverage policies based on recs from private health info businesses (e.g., McKesson, which advises BCBS) or in-house study (e.g., UBH, HealthPartners)

• Coverage policies usu. posted online• Basis of policies (which research studies?

Which experts? How were focus groups composed?) is NOT required to be transparent and may be deemed “proprietary” by companies like McKesson

Private payers

Pre-authorization of diagnoses & testing procedures

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Components of the Evaluation

• Record Review−Is any evaluation necessary? −Can the questions be answered by interviews or questionnaires

without further testing? −Medical as well as school, work, or psychological history−Should be facilitated by integrated electronic medical record−Billable as part of 96101/96102 or 96118/96119

• Diagnostic Interview, Mental Status or Neurobehavioral Status Examination−Clinical assessment of the patient−Collateral interviews as needed−CODED for interactive complexity−CODED for medical (Axis III) as well as Axis I & II disorders

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• What is the medically necessary justification to test this person?

• What questions can be answered with testing that cannot be answered simply by interviewing the person & relatives?

• What tests must be done, in order to generate relevant information, that will answer specific questions, that will help to cure disease or prevent complications or promote wellness for this person and his or her caregivers?

How to write a request for authorization of testing:Key questions to start with

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- Hold your lane (code ethically)- Know where you're going (codes justify specific testing procedures)- Signal intentions (explain codes) - Notice everything (code it ALL)- Watch out (code defensively)

Diagnosis is like driving:

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1. Code ethically: Think like a utilization reviewer.

• Pretend YOUR job is to  • (a) reject any claim that is not "medically necessary" 

• (b) reject any claim that is incomplete, illegible, imprecise, or not adequately justified 

• (c) retain your client's goodwill, and • (d) spot fraud, incompetence, or other problems that could harm your client.

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2. Do not include differential diagnoses, or diagnostic codes, that are unethical or implausible.

• Do not invent or lie about diagnoses; do not commit fraud or practice unethically.

• All billing diagnoses that are recorded to document the medical necessity for testing must be reasonable, defensible, hypotheses, based on evidence from the referral source, relevant records, and/or a diagnostic interview.

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Test Selection

• Targeted to answer referral questions and the goals of the evaluation (establishing a diagnosis, measuring treatment effects, etc.)

• Vary with patient characteristics (level of education, premorbid level of functioning, sensory abilities, physical limitations, fatigue level, age, ethnicity)

• Reliability, validity, & utility of tests matters• Cost-benefit ratio: the "so what" criterion• CODE for use of psychometrist (technician) or

computerized administration (96102, 96103, 96119)• CODE for integration & report-writing (96101, 96118)• CODE for feedback & factor in time (90887, 96101)

Caps on number of hours authorized.

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• Cost-effective• Efficient• Problem-focused• If you cannot imagine answering the

question, “So WHAT?” then reconsider whether that test is necessary and appropriate.

• Symptom Validity Testing may become more common in future for ALL psychologists not just neuropsychologists

Test battery needs to be problem-focused & efficient

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• Medicaid = typically −2 diagnostic interviews per calendar year (1 hr each)−Up to 10 hours psychological testing per year

Test administration Test scoring Test interpretation (assign a meaning to EACH score,

e.g., “raw score X = Scaled Score 10 = Average”) Review of records Test integration (formulate conclusions) Report writing

−1 hr Feedback (90887 vs. 96118)

How many hours can be billed for testing?

Denial of some tests, conditions, or Dx codes.

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• Any and all “315 codes” –- LD, language• (Some payers) ADHD diagnoses• (Some payers) ID diagnoses (was “MR”)• More than one psych eval per year• Neuropsychological testing unless you have

a national board-certification • (Some payers) projective tests

You usually cannot test for…

Technician/trainee & computer testing codes.

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• Psychometrist bills face-to-face testing time only, hour for hour

• Licensed psychologist bills for integration• Document properly – use the buzz words• Codes for psychometrist, computer, and

licensed psychologist may be billed same day

• Student trainees may NOT bill if their work in administering tests is an educational requirement (e.g. practicum for which they pay tuition, cannot bill for them in addition)

Billing for testing done with psychometrists

Documentation review & auditing for time & content.

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Documentation...fully supports the medical necessity for services,

including−the initial evaluation that determines the need for testing−the types of testing indicated −the time involved and whether this is initial testing or follow-

up−previous testing by the same or different provider, and

efforts to obtain previous test results performed−the test(s) administered, scoring and interpretation −treatment recommendations−FOR NEUROPSYCH, relevant medical history, physical

examination, and results of pertinent diagnostic tests or procedures AND suspected mental illness, central nervous system dysfunction, or neuropsychological abnormality

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3. Think in terms of how a physician might use your results.

• - Prescribe or modify medication, nutrition, or other medical procedures;

• - Prescribe or modify psychotherapy, behavior therapy, speech, OT, PT, cognitive rehab;

• - Invite the PCP to refer the patient for additional tests such as neuroimaging, genetics, neurology, endocrine, etc.

• - Document functional abilities in relation to questions of (eventual) competence to make legal, financial, or healthcare decisions

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4. Consider every reasonable, plausible, differential diagnosis and code which can be justified by evidence provided in the diagnostic interview summary.

M.E.S.S. =Medical (health, pain) issues first;Emotional (behavior) issues, second;Social (family) issues, third;School (learning) issues LAST.

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5. In an auth or bill, prioritize physical health conditions.

• If there are any physical health risks, current problems, or relevant history, describe those problems first in the authorization and, if there is an applicable DSM code, code those first.

•  Use medical language: "dyspraxia" not "incoordination," "anergia" not "laziness", "encephalopathy" not "slow learner," "question of impaired memory" not "forgets homework."

• EXAMPLE: Consider the 307.xx codes related to pain, sleep, eating, elimination, or movement disorders.

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6. Emphasize the negative. • Code the worst problems first; don't under-diagnose.

(EXAMPLE: If major depression is a reasonable diagnosis, code depression, not dysthymia or adjustment disorder).

•  Next, if there is any suspected or documented major mental health risk or history, describe and code it (e.g., mood disorders, psychosis).

•  Then code milder mental health risks, history, or disorders, or behavioral problems that (e.g., Disruptive Behavior Disorder, Adjustment Disorders).

•  Then code problems that indicate the patient is having trouble even if those problems are not the main reason for psych testing (e.g., tics, enuresis, sleepwalking).

 

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7. Code as precisely & thoroughly as possible.

• Avoid using the xxx.9 "not otherwise specified" codes which can be red flags.

• EXAMPLE: A child has anxiety symptoms that mother suspects trigger his asthma attacks, he chews up the collar of his shirt, and he wets the bed. Instead of just "300.00 Anxiety Disorder NOS" the billing diagnosis for that same child is "316 Psychological factors affecting physical condition; 300.00 Anxiety disorder NOS; 307.52 Pica; 307.6 Enuresis."

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8. Remember that psychological testing for educational, vocational, or legal purposes is NOT covered by any medical insurer, including Medicaid.

... so, what can you do when the parent or PCP says their mainconcern is "learning disability"or "problems in school"?

The billable MEDICAL problem may be whatever health problems CAUSE those school issues, or whatever health problems RESULT from the school issues.

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CONDITIONS THAT CAUSE SCHOOL/LEARNING PROBLEMS(Memory impairment, Anxiety,

Depression, Brain injury, Systemic illness, etc.)

School, Learning, Educational, Academic, Reading, Math, Writing,

DevelopmentalFUNCTIONAL IMPAIRMENT THAT

MAY RESULTS FROM SCHOOL/LEARNING PROBLEMS

(Anxiety, Depression, Disruptive Behavior, Somatization, etc.)

EXAMPLE: Instead of coding "LD-NOS" or "ADHD-NOS," if the child is developing symptoms of anxiety, dysthymia, conduct disorder, oppositional defiant disorder, a sleep or eating disorder, or a habit disorder such as trichotillomania, testing might be medically necessary to determine whether those symptoms are manifest emotional stress resulting from under-treated Learning Disability. The LD or ADHD diagnosis should be listed last, e.g., "307.9 Trichotillomania; 309.24 Adjustment disorder with anxious mood; 315.5 Mixed developmental disorder."

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9. Be specific.

• Be precise about exactly what MENTAL OR PHYSICAL HEALTH question(s) your test results are going to answer.

• Avoid vague phrases like "understand the patient's needs" or "testing is needed to clarify the diagnosis."

• Tell the insurance reviewer HOW you will clarify WHICH diagnoses: Say "the diagnosis could be X, Y, or Z," and each test listed is necessary to "rule out X" or "rule out Y" or "rule out Z."

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10. Forewarn your patients as part of informed consent for

testing. Most will not understand that an authorization is NOT a promise to pay the bill.

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 11. Read the manual.

•Read the medical policy governing coverage of psychological testing for insurers you bill.

•These policies are online. •Or you can call or email the “providers line” of any payer.

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12. Document everything...

• Templates are your friend.• It will help you to have one documentation template for all cases, that follows what the most stringent payers require.

• Start with a blank read-only template every time; do not try to edit the authorization or other documentations by revising another patient's note (the wrong PHI will show up sooner or later).

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13. Keep reports brief and problem-focused.

Pediatric 5-10 hours

Adult 2-3 hours

Geriatric 2-3 hours

Forensic 10-20 hours

Karen Postal's IOPC study of 644 neuropsychologists: Modal time to write a report

84% of neuropsychologists believe that referral sources do not read or only occasionally read their reports.

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Feedback Session• Discussion of the relationship between test results

and information about diagnosis and prognosis. • Evidence-based treatment recommendations that are

not typically managed by medical providers:−tailored behavioral strategies to maximize

functioning,− recommendations for nonpharmacological

interventions −community resources.

• Referrals to other specialty providers (e.g. psychiatry, rehabilitative therapists) MAY CHANGE UNDER ACO's where additional costs impact the PCP

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• Karen Postal, Ph.D., IOPC/AACN/Mass. Psych Assn.• Robert McGrath, Fairleigh Dickinson University• Trisha Stark, Ph.D., MN Psych Assn.• Alliance for Health Reform• Robert Wood Johnson Foundation• Take Action Minnesota• NAMI Minnesota• National Academy for State Health Policy• The Commonwealth Fund• Rainbow Health Initiative (MN)• SAMHSA

Thank You to

Electronic medical records (scores/interpretations).

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• Posting scores (after not before the narrative interpretation!)

• Posting trainee/psychometrist work (after not before the LP oversees!)

• Posting psychological/neuropsych reports (limits to access)

Testing and the EHR

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• CMS = Center for Medicaid & Medicare Services• CPT = Current Procedural Terminology (American

Medical Association)• DSM-V = Diagnostic & Statistical Manual (5th edition)

of American Psychiatric Association• ICD-10 = International Classification of Diseases• Mnsure = Minnesota’s state health exchange• PPACA = Patient Protection & Affordable Care Act (of

2010)• QHP = Qualified Health Plan (insurance plans that

meet requirements to be part of state exchange)

Fun acronyms to know