Transcript Coding, Documenting, and Billing &Auditing

Coding, Documenting, and
Billing & Auditing
Neuropsychological Services:
revision of a 10 year of progress report
Antonio E. Puente
Department of Psychology
University of North Carolina at Wilmington 28403-3297
Tel 910.962.3812, Fax 910.962.7010, e-mail
[email protected]; web “clinicalneuropsychology.com”
Massachusetts
Neuropsychological Society
Boston, MA, December 5, 2000
Outline of Presentation
History/Background of Involvement
Procedural Coding
Reimbursement
Documentation
Auditing
Related Issues
Future Trends
Purpose of My Involvement
with Coding & Medicare
Short Term
Reimbursement
Long Term
Why the Focus on Medicare
Bring Some Standardization to the Field
Expand the Scope and Value of Clinical
Neuropsychology
Parity with Other Doctoral Level Health
Providers in Health Care
Shape Psychology Towards a Biological
Model
History/Background
North Carolina Psychological Association
Blue-Cross Blue Shield
American Psychological Association
Chair or Member of Approx.a Dozen
Committees/Boards, (e.g., Neuropsychology)
Division 40 Board- 1987 to present
Two Terms on APA’s Council of
Representatives (1994 to present)
Policy and Planning Board
History/Background
(continued)
American Medical Association
CPT- 4
CPT- 5
Health Care Financing Administration
Model Mental Health Policy Workgroup
Medicare Coverage Advisory Committee
Procedural Coding
Defining Coding
History of Coding
Coding
Defining Coding
Description of Professional Service
Rendered
Purpose of Coding
Archival/Research
Reimbursement
Coding Systems
SNOMED
WHO / ICD
AMA / CPT
History of CPT Coding
First Developed in 1966
Currently Using the 4th Edition
The 5th Edition Will be Used in 2002
A Total of 7,500 Codes
AMA Developed and Owns the CPT
Under Contract with the HCFA
Overview of Coding
Total Possible Codes = 60+
# Of Typically Reimbursed Codes = 5
interview, testing, & psychotherapy
# Of Codes Sometimes Reimbursed = 35
family/group therapy
biofeedback
# Of Codes Rarely Reimbursed = 20+
evaluation and management
report evaluation and writing
Overview of Coding: An
evolution of coding
Psychiatry
Neurology
Physical Medicine & Rehabilitation
“Evaluation & Management”
Overview of Coding (cont.)
Psychiatry
Interview (90801)
Psychotherapy (90804 - 90857)
Types of Psychotherapy (regular vs interactive)
# of “Patients” (individual vs group vs family)
Locations of Intervention (in vs outpatient)
Evaluation & Management vs Regular
Length of Time (30, 60, 90)
Biofeedback
Regular vs Psychophysiological (90901 vs 90875)
Overview of Coding (cont.)
Central Nervous System Assessments/Test
96100
96105
96110/1
96115
96177
=
=
=
=
=
Psychological Testing
Aphasia Testing
Developmental Testing
Neurobehavioral Status Exam
Neuropsychological Testing
Overview of Coding (cont.)
Physical Medicine
 97770 = Cognitive Skills Development
 Look for New/split Codes in the Near Future
Overview of Coding (cont.)
Health & Behavior
909X1
909X2
909X3
909X4
909X5
909X6
NOTE:
assessment (15 minutes)
re-assessment
intervention- individual
intervention- group
intervention- family
intervention- family w/o pt.
these codes need to be valued...
Coding Overview
Coding Categories
Psychiatry
Neurology; CNS/Assessment
Physical Medicine
“Evaluation & Management”
Procedures
Assessment
Intervention
Overview of Coding (cont.)
Diagnosing
If Problem is Psychiatric
= DSM
If Problem is Neurological = ICD
Matching Dx with CPT
DSM
ICD
= 90801, 96100, 90806
= 96115, 96117, 97770
Reimbursement
History
Defining
Formula
Defining
Defining
Defining
Defining
RBRVS
Time
Site
Necessity
and Applying “Incident to”
History of Reimbursement
Cost plus Reimbursement
Prospective Payment (PPS) & Diagnostic
Related Groups (DRGs)
Customary. Prevailing, & Reasonable(CPR)
Resource Based Relative Value System
(RBRVS)
Prospective Payment System
RBRVS
Major Components
Physician Work Resource Value Unit
Practice Expense Resource Value Unit
Malpractice Component Resource Value Unit
Conversion Factor
Adoption of the RBRVS
Medicare
Blue Cross/Blue Shield- 87%
Managed Care- 55%
Reimbursement Formula
Procedural Code
Time
Diagnosis
Site of Service
Provider
Formula
Code X Time X Dx X Site X Provider
Reimbursement Difficulties
Physician Work Value
Phd/PsyD/EdD vs MD
Location Defined
Common Reasons for Lack
of Reimbursement
Clerical Errors
Service Is Not Covered
No Prior Authorization Obtained
Exceeded Allocated Time Limits
Invalid or Incorrect Dx Code
CPT and Dx Do Not Match
Defining Time
Defining Time
Professional (not patient) Activity
Interview vs Assessment Codes
Hourly Increments
Includes Pre and Post-clinical Service
Intervention Codes
15, 30, 60, & 90
Face-to-face Contact
No Pre or Post-clinical Service Time Included
Testing Time Defined
Preparing to Test Patient
Reviewing of Records
Selection of Tests
Scoring of Tests
Reviewing of Results
Interpretation of Results
Preparation and Report Writing
Documentation
Purpose
General Guidelines
Specific Documentation
Trends
Suggestions
Purpose of Documentation
Evaluate and Plan for Treatment
Communication and Continuity of Care
Claims Review and Payment
Research and Education
General Principles of
Documentation
Complete and Legible
Reason/Rationale for the Encounter
Assessment, Impression, or Diagnosi/es
Plan for Care
Date and Identity of Observer
Documentation History
Chief Complaint
History of Present Illness (HPI)
Review of Systems
Past, Family, and/or Social History
Documentation of Chief
Complaint
Concise Statement Describing the
Symptom, Problem, Condition, Diagnosis,
Physician Recommended Return, or other
Factor that is the Reason for the
Encounter.
Documentation of Present
Illness
Chronological Description of the
Development of the Patient’s Present
Illness from the First Sign and/or
Symptom or from the Previous Encounter
to the Present.
For Symptoms: Location, Quality, Severity,
Duration, Timing, Context, Modifying Factors
Including Medications, Associated Signs,
Symptoms, etc.
For Follow up: Changes in Condition Since
Last Visit, Compliance with Treatment, etc.
Review of Systems
Psychiatric
Neurological
Other
Documentation of History
Past History
Family History
Social History
Specific Documentation
Suggestions: Psychiatric
Interview
Name, Date, Observer, Dx/Impression
Mental Status Exam
Language, Thought Processes, Insight,
Judgment, Reliability, Reasoning, Perceptions,
Suicidality, Violence, Mood & Affect,
Orientation, Memory, Attention, Intelligence
Specific Documentation
Suggestions:
Neurobehavioral Status
Exam
Name, Date, Observer, Dx/Impression
Variables
Attention, Memory, Visuo-Spatial, Lanague,
Planning
Specific Documentation
Suggestions: Testing
Name, Date, Observer, Dx/Impression
Names of Tests
Interpretation of Tests Results
Disposition
Time
Documentation
Suggestions
Avoid Handwritten Notes
Do Not Use Red Ink
Document on Every Encounter, Every
Procedure, and Every Patient
Re-Cap Status, Whenever Possible, At
Least Change From Session to Session
Document Soon After Procedure
Trends
Issues of Confidentiality
Over-Diagnosing
Over-Documenting
Auditing
Fraud & Abuse vs Erroneous
Self-Auditing Suggestions
Risk Situations
Development of an Internal Auditing
System
Fraud vs Error
Fraud = Intentional, Pattern
Erroneous = Clerical, etc.
Self-Auditing Suggestions
Written Policies
Compliance Officer
Training & Education
Lines of Communication Should Exist
Internal Monitoring & Auditing
Enforce Standards
Alter as Necessary
Risk Areas for Fraud
Coding & Billing
Reasonable & Necessary Services
Documentation
Improper Inducements
Fraudulent Claims Flags
Upcoding
Excessive or Unnecessary Visits to ACF
Outpatient Service 72 Hrs. Post-Discharge
CPT Code Usage Shift
High Percentage of the Same Codes
Use of Similar Time for Testing Across Pts.
Medical Necessity (dx; interpretation)
Defining Necessity
“reasonable and necessary for the
diagnosis or treatment of an illness or
injury or to improve the functioning of a
malformed body member”
All services must “stand alone”
Acute and emergency services more like
to be considered necessary
Evaluating Effectiveness
Adequacy of Evidence
Bias
External Validity
Size of Effect
From Not Effective to Breakthrough
Evaluating Effectiveness
(continued)
Organized Approaches to Evaluation of
Scientific Evidence
American College of Physicians
Agency for Health Care Policy and Research
BC/BS Technology Evaluation Center
American College of Cardiology
American College of Urology
Additional Issues
Incident to
in vs outpatient
technical vs professional component
performing vs billing
Graduate Medical Education
allied health vs medical
interns vs postdoctoral fellows
CPT I, II, & III
I
= standard codes
II = performance measures
III = emerging technology
Future Trends
Surveys; Practice, Ongoing & New Codes
Health Care Finance Administration
Committee for the Advance of
Professional Practice
Practice Directorate of the APA
General Trends
Future of Clinical Neuropsychology
Resources
Surveys
Rationale for Surveys
All Decisions are Empirical
Reasonably Large Ns
Adequate Data
Support Required
If Asked, Participate
Two Ongoing;
NAN/Division 40 Practice Survey
Re-evaluation of “Cognitive Rehabilitation”
Health Care Financing
Administration
Problems
Definition of Physician (Social Security
Practice Act of 1989)
Doctoral vs Non-Doctoral Providers
Directions
Physician Work Value
Practice Expense
Matching of CPT with Reimbursement
Committee for the
Advancement of
Professional Practice
Observers
Joe Fishburn (NAN), Ida Sue Baron (Div 40)
Attitude
Division 40; NAN Gift
Positive, Receptive
Additional Staff Member for Medicare
Program
General Trends
Fraud, Abuse, & Effects of Regulations
Clinical Neuropsychology Standardizing &
Expanding Into Non-Traditional Areas
“Boutique” vs “Industrial” Neuropsych.
Psychometrics as Clinical Neuropsychology
Assessment & Rehabilitation
Neuropsychology’s “Technical” Pipeline
Establishment of “Grassroots Network”
Future of Clinical
Neuropsychology:
A Holiday Wish List
More (normative?) Data & A Few Theories
Measurement of the Cultural & Subjective
Less Focus on Conserving the Medicare
Trust Fund & Stockholder Profits by
Focusing on the Aged & Disabled
Appreciating that Brain is Inside a Person
Which is Inside a System (Value?)
Conscilience
Resources
Web Sites
neuropsych; NANonline.org, Div40.org
government; HCFA.gov, NIH.gov
personal;
clinicalneuropsychology.com
Publications
APA Medicare Handbook (PP; 2000)
NAN Bulletin (1994, 1997, 1998, 2000)
Journal of Psychopathology & Behavioral
Assessment (1987)
Professional Psychology (with Camara &
Nathan, 2000)