Скачать презентацию APA Convention 2001 z Understanding Federal Reimbursement Medicare Скачать презентацию APA Convention 2001 z Understanding Federal Reimbursement Medicare

ece5fbfbdb8c5c5355b112016a4658b8.ppt

  • Количество слайдов: 65

APA Convention 2001 z. Understanding Federal Reimbursement, Medicare, and CPT Coding z Presented by: APA Convention 2001 z. Understanding Federal Reimbursement, Medicare, and CPT Coding z Presented by: Steve Mc. Ellin James M. Georgoulakis, Ph. D Antonio E. Puente, Ph. D z Chair: Diane M. Pedulla, JD z Guest Speaker: Gerald Rogan, MD

Psychologists and Medicare Building Stronger Relationships Steve Mc. Ellin APA Government Relations Practice Directorate Psychologists and Medicare Building Stronger Relationships Steve Mc. Ellin APA Government Relations Practice Directorate

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Resource Based Relative Value System (RBRVS) Development and Implications for Psychologists James M. Georgoulakis, Resource Based Relative Value System (RBRVS) Development and Implications for Psychologists James M. Georgoulakis, Ph. D

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

Purpose of RBRVS z. To provide equitable payment for medical services Purpose of RBRVS z. To provide equitable payment for medical services

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

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

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

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

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

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

Example Example

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

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

Coding & Documentation for Psychological Services Key Issues for Professional Psychologists Antonio E. Puente, Coding & Documentation for Psychological Services Key Issues for Professional Psychologists Antonio E. Puente, Ph. D

Model for Professional Psychological Services z. Procedure Coding z. Diagnosing z. Documenting z. Billing Model for Professional Psychological Services z. Procedure Coding z. Diagnosing z. Documenting z. Billing

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

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

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

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

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

Physical Medicine and Rehabilitation z 97532 = Cognitive Skills Development z 07533 = Sensory Physical Medicine and Rehabilitation z 97532 = Cognitive Skills Development z 07533 = Sensory integrative techniques

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

Typically Reimbursed Codes z. Interviewing y 90801 z. Assessment y 96100 z. Intervention y Typically Reimbursed Codes z. Interviewing y 90801 z. Assessment y 96100 z. Intervention y 90804, 90806, 90818

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

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

Splitting of Testing Codes z. Rationale y. No Cognitive Component y. Incident to z. Splitting of Testing Codes z. Rationale y. No Cognitive Component y. Incident to z. Status y. Work Group y. Development

Diagnosing z. If Psychiatric= DSM z. If Neurological= ICD Diagnosing z. If Psychiatric= DSM z. If Neurological= ICD

Documenting z. Purpose z. Payer Requirements z. General Principles z. History z. Examination z. Documenting z. Purpose z. Payer Requirements z. General Principles z. History z. Examination z. Decision Making

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

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

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

Chief Complaint z. Concise Statement Describing the Symptom, Problem, Condition, Diagnosis Chief Complaint z. Concise Statement Describing the Symptom, Problem, Condition, Diagnosis

Billing z. Interview y. If Dx is psychiatric, then 90801 y. If Dx is Billing z. Interview y. If Dx is psychiatric, then 90801 y. If Dx is neurological, then 96115 z. Testing y. If Dx is psychiatric, then 96100 y. If Dx is neurological, then 96117 z. Intervention y. If Dx is psychiatric, then 90804+ y. If Dx is neurological, then 97770

Billing (continued) z. Diagnoses y. If Dx is psychiatric, then use DSM y. If Billing (continued) z. Diagnoses y. If Dx is psychiatric, then use DSM y. If Dx is neurological, then use ICD x. Note: Avoid rule out diagnoses

Billing (continued) z. Issues Associated With Fraudulent Claims y. Upcoding y. Excessive or Unnecessary Billing (continued) z. Issues Associated With Fraudulent Claims y. Upcoding y. Excessive or Unnecessary Visits to Nursing Facilities y. Outpatient Billing Within 72 Hours of Hospital Discharge y. CPT Code Usage Shifts y. High Percentage of Same Code y. Use of Same Time for Testing Across all Patients

Billing (continued) z. Typical Denials z. Service Not Covered z. No Prior Authorization Obtained Billing (continued) z. Typical Denials z. Service Not Covered z. No Prior Authorization Obtained z. Exceeded Allocated Time Limits z. Invalid or Incorrect Dx Codes z. CPT and Dx do not Match

Time z. Defining y. Professional (not patient) Time Including: xpre, during, and post-clinical service Time z. Defining y. Professional (not patient) Time Including: xpre, during, and post-clinical service activities z. Interview & Assessment Codes y. Use Hourly Increments z. Intervention Codes y. Use 15, 30, or 60 Minute Increments

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

Time (continued) z. Communicating further with others z. Follow-up with patient, family and/or others Time (continued) z. Communicating further with others z. Follow-up with patient, family and/or others z. Arranging for ancillary and/or other services

Time (continued) z. Quantifying Time y. Round Up or Down to Nearest Increment z. Time (continued) z. Quantifying Time y. Round Up or Down to Nearest Increment z. Time Does Not Include y. Patient Completing Tests, Forms, Etc. y. Waiting Time by Patient y. Typing of Reports y. Non-Professional (e. g. , clerical) Time y. Literature Searches, Learning New Techniques, etc.

Time (continued) z. Preparing to see patient z. Reviewing of records z. Interviewing patient, Time (continued) z. Preparing to see patient z. Reviewing of records z. Interviewing patient, family, and/or others z. When doing assessments: y. Selection of tests y. Scoring of tests y. Reviewing results y. Interpretation of results y. Preparation and report writing

Fraud and Abuse z. History y. GAO y. Potential Financial Loss y. Coding, Documentation, Fraud and Abuse z. History y. GAO y. Potential Financial Loss y. Coding, Documentation, & Services z. Current Status y 2001 Office of Inspector General Report y. Continued Focus on Coding but More on Documentation

Summary, Directions & Resources z. Summary z. Directions y. New Codes y. CPT 5 Summary, Directions & Resources z. Summary z. Directions y. New Codes y. CPT 5 y. CMS (formerly HCFA) Interface y. Dissemination & Education y. Future

Resources z. American Psychological Association (APA) z. National Academy of Neuropsychology (NAN) z. Division Resources z. American Psychological Association (APA) z. National Academy of Neuropsychology (NAN) z. Division of Clinical Neuropsychology of APA z. CMS z. National Institutes of Health (NIH)

Resources (continued) z. APA; Practice Directorate; www. apa. org z. NAN; Directory: www. nan. Resources (continued) z. APA; Practice Directorate; www. apa. org z. NAN; Directory: www. nan. drexel. edu z. Division 40; Practice Committee, Web Page z. CMS (formerly HCFA); www. hcfa. gov z. NIH; http: //odp. od. nih. gov/consensus/cons/109_statement. htm

Resources (continued) z NAN Bulletin y 1994, Spring - Original Suggestions for Billing y Resources (continued) z NAN Bulletin y 1994, Spring - Original Suggestions for Billing y 1998, Summer - Practice Patterns y 1997 - Top 25 Tests, Costs, & Longevity z Journal of Psychopathology & Behavioral Assessment (Puente, 1997) z Professional Psychology (Camara, Nathan, & Puente, 2000) z Reimbursement for Clinical Neuropsychological Services (www. clinicalneuropsychology. com)