Maintaining%20and%20Expanding%20Reimbursement%20Opportunities%20in%20Mental%20Health:%20Medicare%20as%20a%20Benchmark

1
Maintaining and Expanding Reimbursement
Opportunities in Mental Health Medicare as a
Benchmark
2
Women Childrens Health NetworkDivision of
Public HealthChapel Hill, North CarolinaMay 12,
2004

• Antonio E. Puente, Ph.D.
• Department of Psychology
• University of North Carolina at Wilmington
• Wilmington, NC 28403

3
Contact Information

• Websites
• Univ www.uncw.edu/people/puente
• Practice www.clinicalneuropsychology.us
• E-mail
• University Puente_at_uncw.edu
• Practice Puente_at_clinicalneuropsychology.us
• Telephone
• University 910.962.3812
• Practice 910.509.9371

4
Acknowledgments

• Department of Psychology, UNC-Wilmington
• NCPA Board of Directors, Practice Division,
  Staff
• NAN Board of Directors, Executive Directors
  Office, Policy and Planning Committee,
  Professional Affairs and Information Office
• Division 40 Board of Directors Practice
  Committee
• Practice Directorate of the American
  Psychological Association
• American Medical Associations CPT Staff
• CMS Medical Policy Staff
• Selected Individuals (e.g., Jim Georgoulakis)

5
Background(1988 present)

• North Carolina Psychological Association (e)
• APAs Policy Planning Board Div. 40 (e)
• American Medical Associations Current Procedural
  Terminology Committee (IV/V) (a)
• Health Care Finance Administrations Working
  Group for Mental Health Policy (a)
• Center for Medicare/Medicaid Services Medicare
  Coverage Advisory Committee (fa)
• Consultant with the North Carolina Medicaid
  OfficeNorth Carolina Blue Cross/Blue Shield (a)
• NANs Professional Affairs Information Office
  (a)
• (legend a appointment, fa federal
  appointment, e elected)

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Purpose of Presentation

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

7
Outline of Presentation

• Medicare
• Current Procedural Terminology Basic
• Current Procedural Terminology Related
• Relative Value Units
• Current Problems Possible Solutions
• Future Directions Problems
• Resources

8
Outline Highlights

• New Codes
• Expanding Paradigms
• Fraud, Abuse Coding Documentation
• The Problem with Testing

9
Medicare Overview

• Why Focus on Medicare
• The Medicare Program
• Local Medical Review (policy panels)

10
Medicare Why

• The Standard
• Coding
• Value
• Documentation
• Approximately 50 for Institutions
• Approximately 33 for Outpatient Offices
• Becoming the Standard for Workers Comp.
• Increasing Percentage for Forensic Work

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Medicare Overview

• New Name HCFA now CMS
• Centers for Medicare and Medicaid Services
• New Charge Simplify
• New Organization Beneficiary, Medicare, Medicaid
• Benefits
• Part A (Hospital)
• Part B (Supplementary)
• Part C (Medicare Choice)

12
Medicare Local Review

• Local Medical Review Policy
• LMRP vs National Policy
• Location of LMRPs
• Carrier Medical Director
• A Physician-based Model
• Policy Panels
• Lack of Understanding of Their Roles
• Lack of Representation on Such Panels

13
Medicare Payment(since 1993)

• Surgical
• Higher Reimbursement than Cognitive
• Cognitive
• Physician Cognitive Work
• Supporting Equipment Staff

14
Current Procedural Terminology Overview

• Background
• Codes Coding
• Existing Codes
• Model System X Type of Problem
• Medical Necessity
• Documenting
• Time

15
CPT Background

• American Medical Association
• Developed by Surgeons ( Physicians) in 1966 for
  Billing Purposes
• 7,500 Discrete Codes
• CMS
• AMA Under License with CMS
• CMS Now Provides Active Input into CPT

16
CPT Background/Direction

• Current System CPT 5
• Categories
• I Standard Coding for Professional Services
• II Performance Measurement
• III Emerging Technology

17
CPT Applicable Codes

• Total Possible Codes Approximately 7,500
• Possible Codes for Psychology Approximately 40
  to 60
• Sections Five Separate Sections
• Psychiatry
• Biofeedback
• Central Nervous Assessment
• Physical Medicine Rehabilitation
• Health Behavior Assessment Management
• Possibly, Evaluation Management

18
CPT Development of a Code

• Initial
• Health Care Advisory Committee (non-MDs)
• Primary
• CPT Work Group
• CPT Panel
• Time Frame
• 3-5 years

19
CPT Psychiatry

• Sections
• Interview vs. Intervention
• Office vs. Inpatient
• Regular vs. Evaluation Management
• Other
• Types of Interventions
• Insight, Behavior Modifying, and/or Supportive
  vs. Interactive

20
CPT Psychiatry (cont.)

• Time Value
• 30, 60, or 90
• Interview
• 90801
• Intervention
• 90804 - 90857

21
CPT Biofeedback

• Psychophysiological Training
• 90901
• Biofeedback
• 90875

22
CPT CNS Assessment

• Interview
• 96115
• Testing
• Psychological 96100 96110/11
• Neuropsychological 96117
• Other 96105, 96110/111

23
CPT Physical Medicine Rehabilitation

• 97770 now 97532
• Note 15 minute increments

24
CPT Health Behavior Assessment Management

• Purpose Medical Diagnosis
• Time 15 Minute Increments
• Assessment
• Intervention

25
CPT Modifiers

• Acceptability
• Medicare about 100
• Others approximating 90
• Modifiers
• 22 unusual or more extensive service
• 51 multiple procedures
• 52 reduced service
• 53 discontinued service

26
CPT Model System

• Psychiatric
• Neurological
• Non-Neurological Medical
• Possibly, Evaluation Management

27
CPT Psychiatric Model(Children Adult)

• Interview
• 90801
• Testing
• 96100, or
• 96110/11
• Intervention
• e.g., 90806
• The challenge of New Mexico

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CPT Neurological Model(Children Adult)

• Interview
• 96115
• Testing
• 96117
• Intervention
• 97532

29
CPT Non-Neurological Medical Model(Children
Adult)

• Interview Assessment
• 96150 (initial)
• 96151 (re-evaluation)
• Intervention
• 96152 (individual)
• 96153 (group)
• 96154 (family with patient)
• 96155 (family without patient)

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CPT New Paradigms

• Initial Psychiatric
• Next Neurological
• Now Medical
• Medical as Evaluation Management

31
CPT Evaluation Management

• Role of Evaluation Management Codes
• Procedures
• Case Management
• Limitations Imposed by AMAs House of Delegates
  for CMS but not for Private Payers
• Health Behavior Codes as an Alternative to E
  M Codes
• The Use of E M Codes is Accepted by Some Third
  Party Reimburses (e.g., MedCost)
• Example 99201 New Patient

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CPT Diagnosing

• Psychiatric
• DSM
• The problem with DSM and neuropsych testing of
  developmentally-related neurological problems
• Neurological Non-Neurological Medical
• ICD (or see NAN Paio web page membership
  directory)
• Neurological Code Updates Available by 01.01.03

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CPT Medical Necessity

• Scientific Clinical Necessity
• Local Medical Review or Carrier Definitions of
  Necessity
• Necessity CPT x DX
• Necessity Dictates Type and Level of Service
• Necessity Can Only be Proven with Documentation

34
CPT Coding Matrices

• EMSCO Fraud
• Underlying Problem Medical Decision Making
• Do not use
• Coding Matrices
• Grids
• Related Shortcuts

35
CPT Documenting

• Purpose
• Payer Requirements
• General Principles
• History
• Examination
• Decision Making

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Documentation Purpose

• Medical Necessity
• Evaluate and Plan for Treatment
• Communication and Continuity of Care
• Claims Review and Payment
• Research and Education

37
Documentation Payer Requirements

• Site of Service
• Medical Necessity for Service Provided
• Appropriate Reporting of Activity

38
Documentation General Principles

• Rationale for Service
• Complete and Legible
• Reason/Rationale for Service
• Assessment, Progress, Impression, or Diagnosis
• Plan for Care
• Date and Identity of Observe
• Timely
• Confidential

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Documentation Basic Information Across All Codes

• Date
• Time, if applicable
• Identify of Observer (technician ?)
• Reason for Service
• Status
• Procedure
• Results/Finding
• Impression/Diagnoses
• Disposition
• Stand Alone

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Documentation Chief Complaint

• Concise Statement Describing the Symptom,
  Problem, Condition, Diagnosis
• Foundation for Medical Necessity
• Must be Complete Exhaustive

41
Documentation Present Illness

• Symptoms
• Location, Quality, Severity, Duration, timing,
  Context, Modifying Factors Associated Signs
• Follow-up
• Changes in Condition
• Compliance

42
Documentation History

• Past
• Family
• Social
• Medical/Psychological

43
DocumentationMental Status

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

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

44
DocumentationNeurobehavioral Status Exam

• Attention
• Memory
• Visuo-spatial
• Language
• Planning

45
Documentation Testing

• Names of Tests (including edition/version)
• Interpretation of Tests (narrative possibly
  quantitative)
• Disposition
• Time/Dates
• In Hours (rounded to nearest hour)
• Document on Day Service is Provided
• Might be Best to Separate from Interview

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Documentation Intervention

• Reason for Service
• Status
• Intervention
• Results
• Impression
• Disposition
• Time

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DocumentationSuggestions

• Avoid Handwritten Notes
• Do Not Use Red Ink
• Avoid Color Paper
• Document On and After Every Encounter, Every
  Procedure, Every Patient
• Review Changes Whenever Applicable
• Avoid Standard Phrases

48
Documentation Ethical Issues

• How Much and To Whom Should Information be
  Divulged
• Medical Necessity vs. Confidentiality
• HIPAA vs. Documentation

49
Time

• Defining
• Professional (not patient) Time Including
• pre, intra post-clinical service activities
• Interview Assessment Codes
• Generally use hourly increments
• For new codes, use 15 minute increments
• Intervention Codes
• Use 15, 30, or 60 minute increments

50
Time Definition

• AMA Definition of Time
• Physicians also spend time during work, before,
  or after the face-to-face time with the patient,
  performing such tasks as reviewing records
  tests, arranging for services communicating
  further with other professionals the patient
  through written reports telephone contact.

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Time (continued)

• Communicating further with others
• Follow-up with patient, family, and/or others
• Arranging for ancillary and/or other services

52
Time Defined Further

• Evaluation Versus Therapy Time
• Therapy is Essentially Face to Face
• Testing is Essentially Professional Time
• Inpatient Versus Outpatient
• - If Outpatient face to face only for E M
• - If Inpatient time on floor for E M

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Time Testing

• Quantifying Time
• Round up or down to nearest increment
• Testing 15 or 60 (probably soon 30)
• Time Does Not Include
• Patient completing tests, forms, etc.
• Waiting time by patient
• Typing of reports
• Non-Professional (e.g., clerical) time
• Literature searches, learning new techniques, etc.

54
Time (continued)

• Preparing to See Patient
• Reviewing of Records
• Interviewing Patient, Family, and Others
• When Doing Assessments
• Selection of tests
• Scoring of tests
• Reviewing results
• Interpretation of results
• Preparation and report writing

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Reimbursement History

• Cost Plus
• Prospective Payment System (PPS)
• Diagnostic Related Groups (DRGs)
• Customary, Prevailing Reasonable (CPR)
• Resource Based Relative Value System (RBRVS)

56
Relative Value Units Overview

• Components
• Units
• Values
• Current Problems

57
RVU Components

• Physician Work Resource Value
• Practice Expense Resource Value
• Malpractice
• Geographic
• Conversion Factor (approx. 34)

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RVU Values

• Psychotherapy
• Prior Value 1.86
• New Value 2.0 (01.01.02)
• Psych/NP Testing
• Work value 0
• Hsiao study recommendation 2.2
• New Value undetermined
• Health Behavior
• .25 (per 15 minutes increments)

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RVU Acceptance

• Medicare
• Blue Cross/Blue Shield 87
• Managed Care 69
• Medicaid 55
• Other 44
• New Trends
• RVUs as a Model for All Insurance Companies
• RVUs as a Basis for Compensation Formulas

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CPT x RVU
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Current Problems

• Definition of Physician
• Incident to
• Supervision
• Face-to-Face
• Time
• RVUs
• Work Values
• Qualification of Technicians
• Practice Expense Testing Survey
• Payment
• Prospective Payment System
• Skilled Nursing Facilities
• Provider Based Facilities
• Focus for Fraud Abuse

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Current Problems Highlights

• Work Value for Testing Codes
• Provision Coding of Technical Services (e.g.,
  who is qualified to provide them)
• Mental vs. Physical Health

63
Problem Defining Physician

• Definition of a Physician
• Social Security Practice Act of 1980
• Definition of a Physician
• Need for Congressional Act
• Likelihood of Congressional Act
• The Value of Technical Services of a Psychologist
  is .83/hour (second highest after physicist)
• Consequence of the preceding grouping with
  non-doctoral level allied health providers

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Problem Incident to

• Rationale for Incident to
• Congress intended to provide coverage for
  services not typically covered elsewhere
• Definition of Physician Extender
• How
• Limitations
• Definition of In vs. Outpatient
• Geographic Vs Financial
• Why No Incident to (DRG)
• Solution Available for Some Training Programs
• Probably no Future to Incident to

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Problem More Incident to

• When is Incident to Acceptable
• Testing
• Cognitive Rehabilitation Biofeedback
• Psychotherapy
• Definition
• Commonly furnished service
• Integral, though incidental to psychologist
• Performed under the supervision
• Either furnished without charge or as part of the
  psychologists charge

66
Problem Incident to Site of Service

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

67
Problem Incident to versus Independent Service

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

68
ProblemsRecent Difficulties with Incident to

• Who Bills Incident to
• Treating Physician Bills not the Supervising
  Physician
• Then, Who is the Responsible Party
• The Physician Must Treat the Patient First
• Physician Bonuses Must Tied to a Groups Overall
  Pool of Income (e.g., not referral or possibly
  individual productivity)

69
ProblemSupervision

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

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Problem Face-to-Face

• Implications
• Technical versus Professional Services
• Surgery is the Foundation for CPT (and most work
  is face-to-face)
• Hard to Document Trace Non-Face-to-Face Work

71
Problem Time

• Time Based Professional Activity
• Current 15, 30, 60, 90
• Expected 15 30

72
Problem RVUs

• Bad News
• 2000 5.5 increase
• 2001 4.5 increase
• 2002 5.4 decrease
• 2003 4.4 to 5.7 decrease (34.14)
• Really Bad News
• Bush Administration not supportive of changing
  the conversion formula
• Change Continued to Probably 2005 Depending on
  Such Factors as the Stock Market (e.g., 5000)

73
Problem Work Value

• Physician Activities (e.g., Psychotherapy) Result
  in Work Values
• Psychological Based Activities (i.e., Testing)
  Have no Work Values
• RVUs are Heavily Based on Practice Expenses
  (which are being reduced)
• Net Result Maybe Up to a Half Lower

74
ProblemAn Artificial Practice Expense

• Five Year Reviews
• Prior Methodology
• Current Methodology
• Current Value approximately 1.5 of 1.75 is
  practice
• Deadline for New Practice Expense 2002
• Currently in Check Due to the Ongoing Survey
• Expected Value closer to 50 of total value at
  best

75
Problem Work Value of Testing

• First Round
• Second Round
• Third Round
• Current Round

76
Problem Qualification of Technician

• What is the Minimum Level of Training Required
  for a Technician?
• Bachelors vs. Masters
• Intern vs. Postdoctoral

77
Problem Payment

• Origins of the Problem
• Balanced Budget Act of 1997
• Employers Cost for Health Care in 2002 5,000
  per employee
• What Should Your Code Be Payed at?
• www.webstore.ama-assn.org-
• State Legislation
• www.insure.com/health/lawtool.cfm

78
ProblemPayment Problems

• Payment Reduction Software Programs
• Claimcheck (McKesson product Cigna, PacifiCare)
• Patterns (McKesson product United)
• Refilling
• 51 require refilling of original forms
• But, up to 60 do not follow up
• Errors
• 54 plan administrator
• 17 provider
• 29 member

79
Problem Payment

• Use of HMOs Third Party
• Shift in Practice Patterns by Psychiatry (14
  increase)
• Exclusion of MSW, etc.
• Worst Hit Are Psychologists (2 decrease)
• Compensation
• Gross Charges
• Adjusted Charges
• RVUs
• Receivables

80
Problem PPS

• Application of PPS (inpatient rehab)
• Traditional Reimbursement
• Current Unbundling
• Potential Situation

81
ProblemSkilled Nursing Facility

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

82
ProblemProvider-Based Facilities

• Is Facility Located on Main Hospital Campus or
  Within 35 Miles of it
• Appropriate Reporting Relationship Exists Between
  Hospital and Clinical Staff
• Medicare Cost Report Includes Facility
• Records are Fully Integrated
• Facility is Presented to the Public as Part of
  the Hospital

83
Problem Expenditures Fraud

• Projections
• Current
• 14
• By 2011
• 17 (2.8 trillion)
• Examples
• Nadolni Billing Service (Memphis)
• 5 million in claims to CIGNA for psychological
  services
• 250,000 fine ( tax evasion) July 12th

84
Defining Fraud

• Fraud
• Intentional
• Pattern
• Error
• Clerical
• Dates

85
Problem Fraud Abuse

• 26 Different Kinds of Fraud Types
• Mental Health Profiled
• Estimates of Less Than 10 Recovered
• Psychotherapy Estimates/Day 9.67 hours
• Review Likely if Over 12 Hours Per Day
• Problems with Methodology
• MS level and RN
• Limited Sampling

86
Problem FraudOffice of Inspector General

• Primary Problems
• Medical Necessity (approximately 5 billion)
• Documentation
• Psychotherapy (oig.hhs/gov/reports/region5/5010006
  8)
• Individual
• Group
• of Hours
• Who Does the Therapy
• Psychological Testing
• of Hours
• Documentation

87
Problem Fraud The Orange Book

• Contractor Operations
• Strengthen Regional Offices Oversight
• Improve Evaluation of Fraud Unit
• Prevent Duplicate Payments for Same Service
• Hospital Operations
• Identify Patterns of Aberrant Overpayment
• Improve External Review of Psychiatric Hospitals
• Managed Care
• Retool Medicaid Programs for Managed Care
• Nursing Homes
• Improve Assessments of Mental Illness
• Identify Patients with Mental Illness

88
ProblemThe Orange Book (continued)

• Physicians/Allied Health Professionals
• Improve Oversight of Rural Health Clinics
• Eliminate Inappropriate Payments for Mental
  Health Services
• Yet, Improve Medicaid Mental Health Programs

89
Problem Fraud (cont.)

• Nursing Homes
• Identification
• Overuse of Services
• Children
• Experience
• California Texas
• Corporation Audit
• Company Audit
• Personal Audit

90
Problem Fraud (cont.)

• Estimated Pattern of Fraud Analysis
• For-profit Medical Centers
• For-profit Medical Clinics
• Non-profit Medical Centers
• Non-profit Medical Clinics
• Nursing Homes
• Group Practices
• Individual Practices

91
Problem Mental vs. Physical

• Historical vs. Traditional vs. Recent Diagnostic
  Trends
• Recent Insurance Interpretations of Dxs
• Limitations of the DSM
• The Endless Loop of Mental vs. Physical
• NOTE Important to realize that LMRP is almost
  always more restrictive than national guidelines

92
Problem HIPAA

• Health Insurance Portability and Accountability
  Act
• Ethics versus Practicality

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Possible SolutionsGeneral Approaches

• Better Understanding Application of CPT
• More Involvement in Billing (especially in large,
  medical, multidisciplinary, and academic
  settings)
• Comprehensive Understanding of LMRP
• More Representation/Involvement with AMA, CMS,
• Local Medical Review Panels
• Meetings with CMS
• Survey for Testing Codes
• APA Increased Staff Relationship with CAPP

94
Possible Solutions Resources

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

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Resources (continued)

• LMRP Reconsideration Process
• www.cms.gov/manuals/pm_trans/R28PIM.pdf
• Coding Web Sites
• www.aapcnatl.org (academy of coders)
• www.ntis.gov/product/correct-coding (coding
  edits)
• Compliance Web Sites
• www.apa.org (psychologists hipaa)
• www.cms.hhs.gov/hipaa. (hipaa)
• www.hcca-info.org (health care compliance assoc.)

96
Future Perspectives

• Income
• Steadier (if economy does not further erode)
• Probable incremental declines, up to 10-20
• If Medicaid dependent (25 or more), then
  declines could be even higher
• Possible final stabilization by 2005
• Recognition
• Masters Level Psychotherapy?

97
Future Perspectives(continued)

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

98
Future Perspectives

• Evolving Paradigm Continued and Significant
  Change
• ARE YOU READY?