REIMBURSEMENT FOR NEUROPSYCHOLOGICAL SERVICES

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REIMBURSEMENT FOR NEUROPSYCHOLOGICALSERVICES

• Antonio E. Puente
• UNC-Wilmington
• NAN 11.03.99, San Antonio

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OUTLINE

• ACKNOWLEDGMENT
• HISTORY BACKGROUND
• MODEL FOR BILLING SERVICES
• DIAGNOSES
• TESTS
• CODING
• DOCUMENTATION

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OUTLINE II

• MEDICARE MODEL POLICY
• REIMBURSEMENT ISSUES
• AUDITS
• ADDITIONAL CONCERNS
• CURRENT PROBLEMS
• SUMMARY
• FUTURE DIRECTIONS

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ACKNOWLEDGMENTS

• AMERICAN PSYCHOLOGICAL ASSOCATIONS PRACTICE
  DIRECTORATE
• DIVISION 40 OF THE AMERICAN PSYCHOLOGICAL
  ASSOCIATION
• NATIONAL ACADEMY OF NEUROPSYCHOLOGY

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BACKGROUND/HISTORY

• NORTH CAROLINA PSYCHOLOGICAL ASSOCIATION
  (1988-89)
• AMERICAN MEDICAL ASSOCIATION- CPT IV (1994)
• AMERICAN MEDICAL ASSOCIATION- CPT v (1997)
• MEDICARE COVERAGE ADVISORY COMMITTEE (1999)

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MODEL BILLING

• DIAGNOSIS
• PROFESSIONAL SERVICE
• LOCATION OF SERVICE
• PROVIDER

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DIAGNOSIS

• SYSTEM (see NAN directory)
• DSM (290-319)
• ICD (ALL OTHER DXs)
• RULE-OUT
• BY DESIGN BUT STATED
• MULTIPLE DXs
• ADVISABLE FOR MEDICALLY NECESSARY
• FIRST ONE IS MOST IMPORTANT

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TESTS

• WHAT TESTS ARE BEING USED
• HOW LONG DOES IT TAKE FOR EACH OF THESE TESTS
• ADDRESS MORE SPECIFICALLY PRE, DURING, AND POST
  PROFESSIONAL TIME

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Outline of Presentation

• I. Introduction
• II. Sample
• III. Results
• IV. Summary

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Study Sample I

• Organization National Academy of Neuropsychology
• Description
• Approximately 4,000 members
• Independent organization dedicated to clinical
  neuropsychology

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Study Sample II

• Rationale
• Not an interest group (e.g., Division 40 of APA)
• Not multidisciplinary (e.g., International
  Neuropsychological Society)

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Study Sample III

• Sample Description
• 2700 Total members of NAN in 1994
• 1200 Total sampled
• 324 Initial response (27)
• 242 Second response (20)
• 566 Total responses (47)
• 119 Reported lt5hrs/week of evaluations
• 447 Total used from original sample

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Introduction

• Rationale
• HCFA/Third Party Reimbursers
• Establish a baseline of test used with time
  values
• Prior Research
• Practice Surveys (e.g., Hartlage, et al Putnam,
  et al)
• Test Surveys (e.g., Ball, et al Lees-Haley, et
  al)

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Results

• Hours Spent Testing
• Percentage of Batteries
• Minutes to Administer
• Percentage of Testing with Computers
• Tests

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Results ITime Spent Testing

• Hours N
• 0-4 116 21
• 5-9 62 11
• 10-14 92 16
• 15-20 105 19
• gt20 188 33
• No Response 4 1

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Results IINumber of Batteries

• Practice Areas N
• Adaptive 194 43
• Aphasia 205 46
• Behavioral Med 127 28
• Developmental 115 27
• Intellectual 354 79
• Neurobehavioral 228 51
• Neuropsychological 427 95
• Personality 353 79

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Results IIIMinutes to Administer Test

• Practice Areas Admin. Score Int.
• Adaptive 74 32 48
• Aphasia 61 24 39
• Behavioral Med 110 35 58
• Developmental 113 36 59
• Intellectual 122 34 61
• Neurobehavioral 80 26 47
• Neuropsych. 304 79 135
• Personality 103 46 75

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Results IV Testing with Computers

• Activity
• Administration 2
• Scoring 10
• Interpretation 3

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Results VTest Frequency

• Total of tests 102
• Tests used exclusively by neuropsychologists 8
• Longest tests used
• HRNB (400 mins.)
• Wechsler Scales (130 mins.)

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Results VTop 26 Tests

• MMPI
• WAIS-R
• WMS-R
• TRAIL MAKING
• FAS WORD FLUENCY
• FINGER TAPPING
• HRNB
• BOSTON NAMING
• CATEGORY TEST
• WRAT-R/III
• BECK DEPRESSION
• REY COMPLEX FIGURE TEST
• WISCONSIN CARD SORTING

• CALIFORNIA VERBAL LEARN.
• GROOVED PEGBOARD
• WISC-R/III
• APHASIA SCREENING TEST
• RORSCHACH INKBLOT
• HOOPER VISUAL ORGAN.
• HAND DYNAMOTER
• DEMENTIA RATING SCALE
• STROOP
• PASAT
• MILLON
• BENDER GESTALT
• THEMATIC APPERCEPTION

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Summary

• First extended study on
• Tests used in clinical practice
• Overallratings
• Assessment of time values
• Implications
• Clinical Practice
• Public Policy

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CODING

• SYSTEMS
• ICD/WHO
• SNOMED
• CPT

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CODING II

• DEFINITION OF CPT- CURRENT PROCEDURAL TERMINOLOGY
• LISTING OF DESCRIPTIVE TERMS FOR REPORTING
  PROFESSIONAL SERVICES
• USE OF CPT
• MOST WIDELY ACCEPTED NOMENCLATURE USED TO REPORT
  HEALTH SERVICES

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CODING III

• DEVELOPMENT OF CPT
• DEVELOPED AMA
• FIRST EDITION 1966
• CURRENT EDITION 4TH
• NEXT EDITION 5TH, 2002

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CODING IV

• INTERVIEW
• PSYCHIATRIC 90801
• NEUROLOGICAL 96115
• TESTING
• PSYCHIATRIC 96100
• NEUROLOGICAL 96117

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CODING V

• INTERVENTION
• PSYCHIATRIC908xx
• Individual Vs Group
• Brief vs Regular vs Extended
• Inpatient vs Outpatient
• Regular vs Interactive
• NEUROLOGICAl
• Cognitive Rehab 97770 (and others)
• Biofeedback 90875 or 90901

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CODING VI

• MATCH THE DX WITH THE RX
• PSYCHIATRIC DSM WITH 90801
• NEUROLOGICAL ICD WITH 96115

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DOCUMENTATION

• GENERAL VS SPECIFIC
• IMPORTANCE OF DOCUMENTING

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DOCUMENTATION II

• PSYCH INTERVIEW
• HISTORY
• CHIEF COMPLAINT
• MENTAL STATUS
• DISPOTION
• COMMUNICATION WITH OTHERS
• ORDERING OR INTERPRETING TESTS
• DIAGNOSIS

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DOCUMENTATION III

• PSYCH THERAPEUTIC PROCEDURES
• PURPOSE RESOLVING PROBLEMS OR ALLEVIATING OF
  EMOTIONAL DISTURBANCES, OR CHANGING MALADAPTIVE
  PATTERNS OF BEHAVIOR, OR ENCOURAGING PERSONAL
  GROWTH AND DEVELOPMENT

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(No Transcript)
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DOCUMENTATION IV

• APPROACHES
• REGULAR- DEVELOPMENT OF INSIGHT OR AFFECTIVE
  UNDERSTANDING, THE USE OF BEHAVIOR MODIFICATION
  TECHNIQUES, THE USE OF SUPPORTIVE INTERACTIONS,
  THE USE OF COGNITIVE DISCUSSION OF REALITY
• INTERACTIVE THE USE OF PHSYICAL AIDS OR
  NON-VERBAL COMMUNICATION

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DOCUMENTATION V (Psy)

• SPEECH
• LANGUAGE
• THOUGHT PROCESS
• INSIGHT
• JUDGMENT
• RELIABILITY
• REASONING
• PERCEPTIONS

• SUICIDALITY
• VIOLENCE
• MOOD AFFECT
• ORIENTATION
• MEMORY
• ATTENTION
• INTELLIGENCE
• MIN-MENTAL STATUS

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DOCUMENTATION VI

• COMPLETE AND LEGIBLE
• ASSESSMENT, IMPRESSION, OR DX
• PLAN FOR CARE
• DATE IDENTITY OF OBSERVER
• TESTING RATIONALE SHOULD BE CLEAR
• RISK FACTORS SHOULD BE IDENTIFIED
• CONFIDENTIALITY

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DOCUMENTATION VII

• TESTING
• DATE
• REASON FOR SERVICE
• NAME OF TESTS USED
• INTERPRETATION OF TESTS RESULTS
• IMPRESSION/DIAGNOSIS
• DISPOSITION
• IDENTITY OF OBSERVER
• TIME

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DOCUMENTATION VIII- neurobehavioral status

• DATE
• REASON FOR SERVICE
• ATTENTION
• MEMORY
• VISUAL-SPATIAL
• LANGUAGE

• PLANNING
• IMPRESSION/DX
• DISPOSITION
• IDENTITY OF OBSER.
• TIME

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DOCUMENTATION IX

• PSYCH THERAPY
• DATE
• REASON
• INTERVENTION
• RESULTS
• IMPRESSION
• DISPOSITION
• IDENTITY
• TIME

• COG REHAB
• DATE
• REASON
• TRAINING ACTIVITY
• IDENTITY
• TIME

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MODEL POLICY

• BACKGROUND
• APPLICATION
• CODE
• CATEGORY
• INDICATION
• DESCRIPTION
• DOCUMENTATION
• COMMENTS

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MODEL POLICY II

• NEUROPSYCHOLOGICAL TESTING
• DESCRIPTION INTEGRITY OF THE BRAIN
• TIME 5-7 HOURS, IF OVER 11 HOURS THEN A REPORT
  SHOULD BE SUBMITTED
• DIAGNOSES ICD

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REIMBURSEMENT

• MEDICARE RATES
• 90801 127.81
• 90806 88.57
• 96100 68.77
• 96115 68.77
• 96117 68.77
• 97770 100.04

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AUDITS

• BACKGROUND
• Balanced Budget Act
• CODING DOCUMENTATION
• MEDICALLY NECESSARY
• Is the service rendered needed for the question
  considered?

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TIME

• DEFINING TIME
• professional time- pre, during, post
• not patient activity alone (e.g., MMPI)

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ADDITIONAL CONCERNS

• GENERAL MEDICAL EDUCATION
• DEFINING
• TRAINING OF HEALTH-CARE PROFESSIONALS
• PROVISION OF SERVICES FOR INDIGENT
• SCOPE
• INTERNS
• POST-DOCTORAL FELLOWS

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ADDITIONAL CONCERNS II

• INCIDENT TO
• DEFINING
• EXTENSION OF PROFESSIONAL SERVICES
• SCOPE
• APPLIES ONLY TO MEDICARE
• SERVICE CAN BE DONE BUT WILL NOT BE REIMBURSED
• NO INCIDENT TO IN INPATIENT SETTINGS
• INCIDENT TO IN OUTPATIENT SETTINGS IS ACCEPTABLE

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CURRENT PROBLEMS

• AUDITING (CODING/DOCUMENTATION)
• DECREASED REIMBURSEMENT
• GREATER LIMITS ON WHAT IS MEDICALLY NECESSARY
• MENTAL HEALTH VS MEDICAL CARVE-OUTS
• NON-PSYCHOLOGISTS (BOTH MDs AND NON-MDS)

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SUMMARY

• MODELSYSTEM
• EACH CARRIER HAS UNIQUE SYSTEM
• EDUCATION IS CRITICAL
• LITIGATION MAY BE NECESSARY

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FUTURE DIRECTIONS

• CODING
• GREATER ACCOUNTABILITY
• LESS REIMBURSEMENT FOR STANDARD CLINICAL SERVICES
• SPILL-OVER INTO RELATED AREAS INCLUDING
  FORENSICS, NON-NEUROLOGICAL MEDICINE, SPORTS,
  INDUSTRY

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FUTURE DIRECTIONS II

• CONTRACTS CONSULTATION VS FEE FOR SERVICE
• USE OF TECHNICIANS SHOULD BE OR WILL BE FURTHER
  CLARIFIED
• DECREASE OF PRACTICE EXPENSES
• INCREASED USE OF INFORMATION SYSTEMS ELECTRONIC
  OFFICES
• DECREASED INSTITUTIONAL ACTIVITY