CPT 08.03.07 1 Neuropsychology Interview and Testing Codes: Rationale, Evolution, Complications and Current Status Division 40 (Clinical Neuropsychology)

CPT 08.03.07CPT 08.03.07 11

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

CPT 08.03.07CPT 08.03.07 22

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…

CPT 08.03.07CPT 08.03.07 33

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

CPT 08.03.07CPT 08.03.07 44

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

CPT 08.03.07CPT 08.03.07 55

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)

CPT 08.03.07CPT 08.03.07 66

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

CPT 08.03.07CPT 08.03.07 77

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

CPT 08.03.07CPT 08.03.07 88

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

CPT 08.03.07CPT 08.03.07 99

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

CPT 08.03.07CPT 08.03.07 1010

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)

CPT 08.03.07CPT 08.03.07 1111

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

CPT 08.03.07CPT 08.03.07 1212

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

CPT 08.03.07CPT 08.03.07 1313

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

CPT 08.03.07CPT 08.03.07 1414

CPT: CopyrightCPT: Copyright

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

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

CPT 08.03.07CPT 08.03.07 1515

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

CPT 08.03.07CPT 08.03.07 1616

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

CPT 08.03.07CPT 08.03.07 1717

CPT: BackgroundCPT: Background

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

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

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

CPT 08.03.07CPT 08.03.07 1818

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

CPT 08.03.07CPT 08.03.07 1919

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

CPT 08.03.07CPT 08.03.07 2020

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

CPT 08.03.07CPT 08.03.07 2121

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

CPT 08.03.07CPT 08.03.07 2222

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

CPT 08.03.07CPT 08.03.07 2323

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

CPT 08.03.07CPT 08.03.07 2424

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

CPT 08.03.07CPT 08.03.07 2525

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

CPT 08.03.07CPT 08.03.07 2626

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

CPT 08.03.07CPT 08.03.07 2727

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)

CPT 08.03.07CPT 08.03.07 2828

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

CPT 08.03.07CPT 08.03.07 2929

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.

CPT 08.03.07CPT 08.03.07 3030

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.)

CPT 08.03.07CPT 08.03.07 3131

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

CPT 08.03.07CPT 08.03.07 3232

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

CPT 08.03.07CPT 08.03.07 3333

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

CPT 08.03.07CPT 08.03.07 3434

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

CPT 08.03.07CPT 08.03.07 3535

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

CPT 08.03.07CPT 08.03.07 3636

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.)

CPT 08.03.07CPT 08.03.07 3737

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

CPT 08.03.07CPT 08.03.07 3838

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

CPT 08.03.07CPT 08.03.07 3939

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

CPT 08.03.07CPT 08.03.07 4040

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)

CPT 08.03.07CPT 08.03.07 4141

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)

CPT 08.03.07CPT 08.03.07 4242

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


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


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


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


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