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Economic & Public Policy Issues in Clinical Neuropsychology

Economic & Public Policy Issues in Clinical Neuropsychology. American Psychological Association August 1, 2004. Antonio E. Puente, Ph.D. & James Georgoulakis, Ph.D. Contact Information. Websites Univ = www.uncw.edu/people/puente Practice = www.clinicalneuropsychology.us E-mail

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Economic & Public Policy Issues in Clinical Neuropsychology

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  1. Economic & Public Policy Issues in Clinical Neuropsychology APA HI 2004

  2. American Psychological AssociationAugust 1, 2004 Antonio E. Puente, Ph.D. & James Georgoulakis, Ph.D. APA HI 2004

  3. Contact Information • Websites • Univ = www.uncw.edu/people/puente • Practice = www.clinicalneuropsychology.us • E-mail • University = puente@uncw.edu • Practice = neuropsychology@bellsouth.net • Telephone • University = 910.962.3812 • Practice = 910.509.9371 APA HI 2004

  4. Acknowledgments • UNC-Wilmington • NCPA • Division 40 of APA • NAN • Practice Directorate of the American Psychological Association • American Medical Association’s CPT Staff • CMS Medical Policy Staff APA HI 2004

  5. Background(1988 – present) • American Medical Association’s Current Procedural Terminology Committee (IV/V) • American Medical Association’s Relative Values Unit • Health Care Finance Administration’s Working Group for Mental Health Policy • Center for Medicare/Medicaid Services’ Medicare Coverage Advisory Committee & Consultant • Consultants with Various Institutions and Insurance Carriers) APA HI 2004

  6. Purpose of Presentation • Increase Reimbursement & Explain the Relationship Between Economics & Science • 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 • Explain the Complexities Involving Development of Public Policy APA HI 2004

  7. Outline of Presentation • Basics of Reimbursement • Medicare • Procedure Codes: CPT System • Valuing Codes: Relative Value Units • Current Problems & Possible Solutions • Future Directions & Problems APA HI 2004

  8. Basics of Reimbursement: ISources • Cash • Contractual (Institution-Based) Fee • Indemnity & Managed Care Cost Plus Prospective Payment System (PPS) Diagnostic Related Groups (DRGs) Customary, Prevailing & Reasonable (CPR) Resource Based Relative Value System (RBRVS) APA HI 2004

  9. Basics of Reimbursement: IIVariables • Level of Provider • Physician versus Non-Physician (CMS defined) • Site of Service • Inpatient versus Outpatient (CMS defined) • Diagnoses • ICD (Health) versus Mental Health (DSM) • Procedure • Provider Activity (not patient activity) APA HI 2004

  10. Medicare: Overview • Why Focus on Medicare • The Medicare Program • Local Medical Review (policy & panels) APA HI 2004

  11. Medicare: Why • The Standard • Coding • Value • Documentation • Largest Insurance Program in the World • Fraud • Most Third Party (e.g., Medicaid), Institutions & Practices are Appling Medicare Paradigms • Increasing Percentage for Forensic Work APA HI 2004

  12. 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) • Pharmaceutical APA HI 2004

  13. 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 • Medicaid Programs are Social Work Based APA HI 2004

  14. Medicare Payment(since 1993) • Surgical • Higher Reimbursement than Cognitive • Cognitive • Physician Cognitive Work • Supporting Equipment & Staff APA HI 2004

  15. Medicare Payment • When to Bill • Inpatient - discharge, monthly • Outpatient – therapy = after visit; testing = ? • Participating Vs. Nonparticipating • 95 vs. 100% • Specialty, Provider & Revenue Codes • Specialty = 62 • Provider type = 35 • Revenue = facility based APA HI 2004

  16. Current Procedural Terminology: Overview • Background • Codes & Coding • Existing Codes • Model System X Type of Problem • Medical Necessity • Documenting • Time APA HI 2004

  17. 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 APA HI 2004

  18. CPT: Background/Direction • Current System = CPT 5 • Categories • I= Standard Coding for Professional Services (important one of the three) • II = Performance Measurement • III = Emerging Technology APA HI 2004

  19. 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 APA HI 2004

  20. CPT: Development of a Code • Initial • Health Care Advisory Committee (non-MDs) • Primary • CPT Work Group • CPT Panel • Time Frame • 3-6 years APA HI 2004

  21. 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 APA HI 2004

  22. CPT: Psychiatry (cont.) • Time Values • 30, 60, (or 90) • Interview • 90801 • Intervention • 90804 - 90857 APA HI 2004

  23. Typical Psychotherapy Codes • Individual • 20-30 = 90804 (16) • 45-50 = 90806 (18) • Other • Family (with pt) = 90847 • Group psychotherapy = 90853 APA HI 2004

  24. Biofeedback • Biofeedback • 90901 • (Psychophysiological Therapy) • 20-30’ =90875 APA HI 2004

  25. CPT: CNS Assessment(all per hour & with report) • Interview • Neurobehavioral Status Exam = 96115 • Testing • Psychological = 96100; 96110/11 • Neuropsychological = 96117 • Developmental = 96111 (not per hour) • Other = 96105, 96110/111 APA HI 2004

  26. CPT: 96117 in Detail • Number of Encounters; • 2000 = 293,000 • 2003 = 341,777 (96100 = 193,593) • Number of Medical Specialties Using 96117 = over 40 • Psychiatry & Neurology = Approximately 3% each • Clinics or Other Groups = 3% • Primary Provider = clinical psychologist APA HI 2004

  27. CPT: Physical Medicine & Rehabilitation • 97770 now 97532 • Note: 15 minute increments APA HI 2004

  28. CPT: Health & Behavior Assessment & Management • Purpose: Medical Diagnosis • Time: 15 Minute Increments • Assessment • Intervention APA HI 2004

  29. CPT: Health & Behavior CodesHistory • APA Interdivisional Health Committee • First Draft (5) of Codes – 09.11.98 • First HCPAC Presentation – 11.06.98 • First CPT (4) Presentation – 08.14.99 • Workgroup Meeting – 12.17.99 • CMS Acceptance = 11.01.02 • Revisions to Language = ongoing APA HI 2004

  30. Rationale: General • Acute or chronic (health) illness which does not meet the criteria for a psychiatric diagnosis • Avoids inappropriate labeling of a patient as having a mental health disorder • Increases the accuracy of correct coding of professional services • May expand the type of assessments and interventions afforded to individuals with health problems APA HI 2004

  31. Rationale: Continued • The Problem with the Preamble • Prevention Codes are not reimbursed • Original wording suggested the possibility of preventing a disease • Wording change reduced that possibility • Now some carriers have interpreted the wording change to mean; if there is now or if there ever was a mental health diagnosis, these codes would not apply • We are attempting to change the preamble wording APA HI 2004

  32. Rationale: Specific Examples • Patient Adherence to Medical Treatment • Symptom Management & Expression • Health-promoting Behaviors • Health-related Risk-taking Behaviors • Overall Adjustment to Medical Illness APA HI 2004

  33. Overview of Codes • New Subsection • Six New Codes • Assessment • Intervention • Established Medical Illness or Diagnosis • Focus on Biopsychosocial Factors APA HI 2004

  34. Assessment Explanation • Identification of psychological, behavioral, emotional, cognitive, and social factors • In the prevention, treatment, and/or management of physical health problems • Focus on biopsychosocial factors (not mental health) APA HI 2004

  35. Assessment (continued) • May include (examples); • health-focused clinical interview • behavioral observations • psychophysiological monitoring • health-oriented questionnaires • and, assessment/interpretation of the aforementioned APA HI 2004

  36. Intervention Explanation • Modification of psychological, behavioral, emotional, cognitive, and/or social factors • Affecting physiological functioning, disease status, health, and/or well being • Focus = improvement of health with cognitive, behavioral, social, and/or psychophysiological procedures APA HI 2004

  37. Intervention (continued) • May include the following procedures (examples); • Cognitive • Behavioral • Social • Psychophysiological APA HI 2004

  38. Diagnosis Match • Associated with acute or chronic illness • Prevention of a physical illness or disability • Not meeting criteria for a psychiatric diagnosis or representing a preventative medicine service APA HI 2004

  39. Related Psychiatric Codes • If psychiatric services are required (90801-90899) along with these, report predominant service • Do not report psychiatric and these codes on the same day APA HI 2004

  40. Related Evaluation & Management Codes • Do not report Evaluation & Management codes the same day APA HI 2004

  41. Code X Personnel (examples) • Physicians (pediatricians, family physicians, internists, & psychiatrists) • Psychologists • Advanced Practice Nurses • Clinical Social Workers Excluded • Other health care professionals within their scope of practice who have specialty or subspecialty training in health and behavior assessments and interventions APA HI 2004

  42. Health & Behavior Assessment Codes • 96150 • Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires) • each 15 minutes • face-to-face with the patient • initial assessment • 96151 • re-assessment APA HI 2004

  43. Health & Behavior Intervention Codes • 96152 • Health and behavior intervention • each 15 minutes • face-to-face • individual • 96153 • group (2 or more patients) • 96154 • family (with the patient present) • 96155 • family (without the patient present) APA HI 2004

  44. Relative Values for Health & Behavior A/I Codes • 96150 = .50 • 96151 = .48 • 96152 = . 46 • 96153 = .10 • 96154 = .45 • 96155 = .44 APA HI 2004

  45. Expected Payment for Health & Behavior Codes • Individual (per hour) • Range $98-106 • Group (per person/ per hour) • Approximately $22 APA HI 2004

  46. 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 APA HI 2004

  47. CPT: Possibilities • Telephone contact • Established • Very well defined • Telephone web • Telephone with documentation APA HI 2004

  48. CPT Possibilities • Work Related or Medical Disability Evaluation Services • 99450 Basic life and/or disability evaluation • 99555 Evaluation by treating physician • 99456 Evaluation by non-treating physician would include; history evaluation diagnosis future treatment plans completion of documentation/certificates APA HI 2004

  49. CPT: Mutually Exclusive Codes • 90804; 99294,-98, -99 • 90806; 99293, -94, -98, -99 • Possibly; • Psychotherapy and Testing on Same Day APA HI 2004

  50. CPT: Model System • Psychiatric • Neurological • Non-Neurological Medical • Possibly, Evaluation & Management (in essence, case management) APA HI 2004

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