APA Convention 2001

1. APA Convention 2001 • Understanding Federal Reimbursement, Medicare, and CPT Coding • Presented by: • Steve McEllin • James M. Georgoulakis, PhD • Antonio E. Puente, PhD • Chair: Diane M. Pedulla, JD • Guest Speaker: Gerald Rogan, MD

2. Psychologists and Medicare • Building Stronger Relationships • Steve McEllin • APA Government Relations • Practice Directorate

3. Congress Calls for Medicare Reform • Congress has called on CMS to simplify the Medicare program through regulatory reform • Hearings on CMS reforms held by House Committee on Small Business and Senate Finance Committee • Medicare Education and Regulatory Fairness Act introduced in Congress

4. Medicare Education and Regulatory Fairness Act • Educates providers about correct billing and documenting • Allows providers the option of repayment plans for overpayments • Prohibits CMS from taking back overpayments while an appeal is pending • APA is lobbying lawmakers to get psychologists included under the Act

5. CMS Plans for Regulatory Reform of Medicare • Reorganization of CMS into three core business centers • Holding community public listening forums • Creation of external health-sector workgroups • Formation of a CMS workgroup to address regulatory reform

6. Three Core Business Centers • Center for Beneficiary Choices • Center for Medicare Management • Center for Medicaid and State Operations

7. Center for Beneficiary Choices • Focus on educating beneficiaries about health care options (i.e. Medigap, Medicare+Choice, etc…) • Oversee the grievance and appeal process for beneficiaries

8. Center for Medicare Management • Manage traditional fee-for-service program • Develop and oversee fee-for-service payment policies • Manage Medicare fee-for-service contractors • Center activities represent CMS’s largest function

9. Center for Medicaid and State Operations • Primary responsibility will be programs administered by states • Partner with states in administration of Medicaid and SCHIP programs • Oversee insurance regulatory activities • Responsiveness to states will increase

10. Public Listening Forums • CMS wants to hear from local healthcare providers and beneficiaries • Sharing of ideas and concerns

11. Formation of Health-Sector Workgroups • CMS is creating seven health-sector workgroups, including physician and non-physician providers, nursing home and long-term care panels • Groups will make recommendations to improve communication with CMS, and decrease regulatory complexity of Medicare program • Senior CMS staff as contact person

12. Formation of CMS Workgroup • CMS to establish internal workgroup to address regulatory reform • Composed of senior CMS staff • Review regulations and make recommendations to revise and/or clarify Medicare rules • Keep costs down w/o jeopardizing quality

13. Building Relationships With Local Medicare Carriers • Helping psychology by committing resources at the local level • Educate the local carrier’s key personnel about psychological services, and develop • Awareness of the value of psychological services. • Respect for psychologists and services can be increased.

14. Why are Relationships Important • Greater number of healthcare providers are competing for a smaller pool of available Medicare dollars • Carriers develop local payment policies that shape coverage decisions • More payment and coverage decisions are being made at the local level

15. Decisions Made at Local Level • Local carrier important to management and operation of Medicare program • CMS doesn’t have resources to manage Medicare by itself so more payment and coverage decisions are made at local level • With few national coverage policies, local carriers develop payment policies that may result in regional inconsistencies

16. LMRP • Local Medical Review Policies • Assist providers in filing correct claims • Outline how local carriers review claims

17. Who Do We Build Relationships With? • Carrier Medical Director • Other key personnel of the local Medicare carrier

18. Importance of the Carrier Medical Director • Carrier Medical Directors develop payment policies, and implement coverage decisions • Carrier Medical Directors play an active role in their state’s carrier advisory process

19. Participation in Carrier Advisory Process • Healthcare providers can advise local carriers about payment policies, as well as educate carriers about healthcare services • Through these efforts, providers have an opportunity to influence payment policies and change coverage decisions

20. “HEAR” Is The Goal • Sharing information about psychological services • Communicating value of psychological services • Advocating for patients • Builds relationships with local Medicare carriers and respect for psychological services

21. Resource Based Relative Value System (RBRVS) • Development and Implications for Psychologists • James M. Georgoulakis, PhD

22. History of Reimbursement • Cost Plus Reimbursement • Prospective Payment (PPS) and Diagnostic Related Groups (DRGs) • Customary, Prevailing, and Reasonable (CPR) • Physician Prospective Payment and Physician Diagnostic Related Groups (DRGs) • Resource Based Relative Value System (RBRVS) • Ambulatory Payment Categories

23. Purpose of RBRVS • To provide equitable payment for medical services

24. Development of the RBRVS • Phase I: Initial twelve physician specialties • Phase II: Psychiatry • Phase III: Psychology

25. RBRVS and Psychology • APA and CMS • APA Technical Advisory Group (TAG) • Development of Survey Vignettes • Survey Results

26. Major Components of the RBRVS • Resource Value Units • Geographical Practice Cost Indexes • Conversion Factor

27. Resource Value Units • Physician Work Resource Value Unit • Practice Expense Resource Value Unit • Non Facility • Facility • Professional Liability Insurance (Malpractice) Component Resource Value Unit

28. Geographic Practice Cost Indexes (GPCIs) • Physician Work GPCI • Practice Expense GPCI • Professional Liability (Malpractice) Insurance GPCI

29. Conversion Factor • Dollar value that is utilized to convert the resource value units and geographic practice cost indexes into a payment

30. Example

31. Adoption of the RBRVS • Medicare • Blue Cross / Blue Shield 87% • Managed Care 69% • Medicaid 55% • Other 44%

32. AMA /CMS Resource Value Update Committee • Purpose • APA’s Role • Members Responsibilities • Benefits

33. Coding & Documentation for Psychological Services • Key Issues for Professional Psychologists • Antonio E. Puente, PhD

34. Model for Professional Psychological Services • Procedure Coding • Diagnosing • Documenting • Billing

35. Procedure Coding • Defining Coding • Description of Professional Service Rendered • Purpose of Coding • Research / Archival • Reimbursement • Coding Systems • SNOMED • WHO / ICD • AMA / CPT

36. Background & Mechanics of the CPT • First Developed in 1966 • Currently Using CPT 4th Edition • 7,500 Discrete Codes • AMA Developed & Owns the CPT • Under Contract with HCFA • APA has 1 Seat on the Advisory Panel to the CPT

37. CPT Codes Applicable to Psychological Services • Total = Approximately 40 • Sections = Four Separate Sections • Psychiatry • Biofeedback • Central Nervous System Assessment • Physical Medicine & Rehabilitation

38. Psychiatry Codes • Sections • Office or Other Outpatient • Inpatient Hospital, Partial Hospital or Residential Care Facility • Other Psychotherapy • Other Psychiatric Services or Procedures • Insight Oriented, Behavior Modifying, and/or Supportive vs. Interactive Therapy

39. Central Nervous System Assessments/Tests • 96100 = Psychological Testing • 96105 = Aphasia Testing • 96110/11 = Developmental Testing • 96115 = Neurobehavioral Status • 96117 = Neuropsychological Testing

40. Physical Medicine and Rehabilitation • 97532 = Cognitive Skills Development • 07533 = Sensory integrative techniques

41. Current Coding Problems • Total Possible Codes Which Are Usable in the CPT System =60 • Total Number of Possible Codes Which Are Almost Always Reimbursable=6 • Total Number of Possible Codes Which Are Sometimes Reimbursed =35 • Total Number of Possible Codes Which Are Rarely Reimbursed =19

42. Typically Reimbursed Codes • Interviewing • 90801 • Assessment • 96100 • Intervention • 90804, 90806, 90816, 90818

43. Coding Modifiers • Acceptability • Medicare = 95% • Other = Approximately 80% • Modifiers • 22= Unusual or More Extensive Service • 51= Multiple Procedure • 52= Reduced Service • 53= Discontinued Service

44. New Codes • Health and Behavior Assessment/Intervention • Assessment (15 minutes) • Re-assessment • Intervention- individual • Intervention- group • Intervention- with patient • Intervention- without patient

45. Splitting of Testing Codes • Rationale • No Cognitive Component • Incident to • Status • Work Group • Development

46. Diagnosing • If Psychiatric= DSM • If Neurological= ICD

47. Documenting • Purpose • Payer Requirements • General Principles • History • Examination • Decision Making

48. Purpose of Documentation • Evaluate and Plan for Treatment • Communication and Continuity of Care with Other Professionals • Claims Review & Payment • Research & Education

49. Payer Requirements • Site of Service • Medical Necessity for Service Provided • Appropriate Reporting of Activity

50. General Principles of Documentation • Complete & Legible • Reason for Encounter • Assessment, Impression, or Diagnosis • Plan for Care • Date & Identity of Observer • Also; • Rationale for requested service • Risk factors • Progress or changes should be noted