Each company should establish their own pricing

Transcription

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3 Each company should establish their own pricing

4 If a company refuses to do business, it should be an independent decision

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7 Current Procedural Terminology (CPT) A set of medical codes used to report procedures and services Developed by the American Medical Association (AMA), adopted by the Center for Medicare and Medicaid Services (CMS) Accuracy and efficiency Report services for payment Track utilization Gather statistics on prevalence of procedures

8 Current Procedural Terminology (CPT) A set of medical codes used to report procedures and services 3 categories Category 1: Procedures and contemporary medical practices. Most common procedures medical practices Approved by the Food and Drug Administration (FDA) Performed by healthcare professionals nationwide Proven and documented Category 2: Clinical Laboratory Services. Tracking codes Optional / information only No charge / payment associated with them

9 Current Procedural Terminology (CPT) A set of medical codes used to report procedures and services Category 3: Emerging technologies, services and procedures Temporary codes that cover emerging technologies, services and procedures. Data are collected on Cat 3 codes to judge whether or not permanent codes may be established After 5 years it may become a permanent code (Cat 1)

10 Q: Who develops CPT Codes? A: AMA CPT Editorial Panel (AMA Board of Trustees ) Panel: Panel of 17 members; 5 of them make up an executive committee. Physicians Process: An individual or an organization can request a new code or alteration to an existing code CPT Editorial Panel meet 3 x/year to review proposals for changes; they have the decision-making power to accept or reject A workgroup is often formed for further review; they would present their findings to the CPT Editorial Panel

11 H-codes (HCPCS) vs. CPT

12 Getting to Know the Codes

13 Graphics by Benjamin Shain, MD, PhD, American Academy of Child and Adolescent Psychiatry in collaboration with the Association for Behavior Analysis International (icons added for this presentation)

14 Codes and Provider Types QHCP Technician CPT Assistant, 2014

15 Codes and Provider Types CPT Assistant, 2014

16 Codes and Provider Types CPT Assistant, 2014

17 Graphics by Benjamin Shain, MD, PhD, American Academy of Child and Adolescent Psychiatry in collaboration with the Association for Behavior Analysis International (icons added for this presentation)

18 0360T / 0361T 1 unit of 0360T 1 unit of 0360T 1 unit of 0361T CPT Assistant, 2014

19 Untimed Codes 0359T - Behavior identification assessment 0370T - Family adaptive behavior treatment guidance 0371T - Multiple-family group adaptive behavior treatment guidance 0372T - Adaptive behavior treatment social skills group CPT Assistant, 2014

20 Graphics by Benjamin Shain, MD, PhD, American Academy of Child and Adolescent Psychiatry in collaboration with the Association for Behavior Analysis International (icons added for this presentation)

21 CPT Assistant, 2014

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23 Add-on Codes b 0362T - Exposure behavioral follow-up assessment +0363T 0364T - Adaptive behavior treatment with protocol modification +0365T 0366T - Group adaptive behavior treatment by protocol +0367T

24 Multiple Sessions in one day Only bill the initial code once per day, even with multiple sessions Day Example: 0364T / +0365T- Adaptive behavior treatment with protocol modification Time of Session Billed Monday 4:00 6:00 1 Unit 0364T 3 Units +0365T Tuesday 12:00 2:00 1 Unit 0364T 3 Units +0365T Tuesday 4:00 6:00 4 Units +0365T CPT Assistant, 2014

25 Exposure Codes 0362T / +0363T Exposure behavioral follow-up assessment 0373T / +0374T Exposure adaptive behavior treatment with protocol modification CPT Assistant, 2014

26 Modifiers Additional information Number of procedures, reason for procedure, where procedure was performed, how many staff, etc. Two characters - numbers or letters Added to the code with a hyphen

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28 Rounding Applies to ALL insurance companies ONLY applies to timed codes Adaptive Behavior Assessment and Treatment: CPT Time Rule - ABAI, 2014

29 Rounding 30 - minute units (most timed CPT codes) 0 min 15 0 units min 0364T / +0365T- Adaptive behavior treatment with protocol modification Not reportable CPT Time Convention A unit of time is attained when the midpoint is passed 16 min 45 min 46 min 75 min 1 unit 2 units 1 unit 0364T 1 unit 0364T 1 unit +0365T Adaptive Behavior Assessment and Treatment: CPT Time Rule - ABAI, 2014

30 Rounding Applies to ALL insurance companies ONLY applies to timed codes 30 min 1 unit 30 min 1 unit 21 min 1 unit 1 unit 0366T 1 unit +0367T 1 unit +0367T TOTAL to bill: 3 units 1 unit 0366T 2 units +0367T Adaptive Behavior Assessment and Treatment: CPT Time Rule - ABAI, 2014

31 Rounding Applies to ALL insurance companies ONLY applies to timed codes 30 min 1 unit 30 min 1 unit 30 min 1 unit 14 min 0 unit TOTAL to bill: 3 units 1 unit 0360T 1 unit +0361T 1 unit +0361T Not reportable 1 unit 0360T 2 units +0361T Adaptive Behavior Assessment and Treatment: CPT Time Rule - ABAI, 2014

32 Rounding 0373T / +0374T Exposure adaptive behavior treatment with protocol modification A 60 - minute unit, followed by a 30 -minute addon 0 min 30 mins 0 units Not reportable 31 mins 75 mins 1 unit 0373T (60 min unit) CPT Time Convention A unit of time is attained when the midpoint is passed 76 mins 105 mins 2 units 0373T (60 min unit) +0374T (30 min unit) 106 min-135 min 3 units 0373T (60 min unit) +0374T (30 min unit) x2 Adaptive Behavior Assessment and Treatment: CPT Time Rule - ABAI, 2014

33 Practice Your staff does a follow-up assessment of a new client. 3 staff (2 techs and 1 QHCP) did an analog FA in a treatment center. It was a 30 minute session, but the staff spent 30 minutes beforehand reviewing the plan and 30 minutes afterward discussing the data. Which code(s) should be billed? 0362T Exposure follow-up assessment What type of practitioner should bill for the service? Technician How much time is billable? 30 minutes How many units should be billed? 1 unit of 0362T CPT Assistant, 2014

34 Practice Your staff member, who does not have an official credential, provides 1:1 direct service for 2 hours and 10 minutes. 0 min 15 mins 0 units 16 mins 45 mins 1 unit 46 mins 75 mins 2 units Which code(s) should be billed? 0364T / 0365T What type of practitioner should have performed the service? Technician How many units should be billed? Four Adaptive Behavior Assessment and Treatment: CPT Time Rule - ABAI, 2014 CPT Assistant, 2014

35 Who is receiving the face-to-face service? 1 Client Family/Caregivers 1 Client > 1 Client Family/Caregivers for > 1 Client Who is providing the service? Who is providing the service? Who is providing the service? Who is providing the service? QH CP Tech QH CP QH CP Tech CH CP Treatment or Assessment? Treatment or Assessment? Treatment Assessment Treatment Assessment Treatment Treatment Treatment Treatment Staff R atio? Staff R atio? 1:1 2:1 1:1 2:1 0368T 0339T 0359T 0364T 0365T 0373T 0374T 0360T 0361T 0362T 0363T 0370T 0372T 0366T 0367T 0371T

36 Answer Key Client Rounding Hint Client Family/Caregivers 1 Client > 1 Client Family/Caregivers > 1 Client Provider QHCP Technician Assessment or Treatment Assessment Treatment Ratios 1:1 2:1 Timing Timed Unitemed Free Think Code (s) Proposed --> Unit (s) Proposed -->

37 Practice Scenario 1 You are a BCBA and you completed an intake for a client, which included record review, patient observation, a caregiver interview, and the writing of a report. Completing the above task took a required four total hours.

38 Practice Scenario 2 You are a BCBA and you completed an intake for a client, which included only record review and no face-to-face time. You are confident based on the information provided you can provided services to the child. This required 60 minutes of your time.

39 Practice Scenario 3 You are a staff member who does not have a credential and you provide 1:1 direct service for 3 hours and 44 minutes.

40 Practice Scenario 4 A therapist provides 1:1 direct service for 3 hours and 44 minutes. A BCBA also supervises the entire duration of the session face-to-face.

41 Practice Scenario 5 You (the BCBA) arrive at a client s house for supervision. Your appointment was schedule for 5:00. Unfortunately, the client is not there. When you call the client s parent, they state they will be at 5:45, leaving 15 minutes for supervision.

42 Practice Scenario 6 You (the BCBA) recognize that your client would benefit from a program which teaches a problem-solving repertoire. Unfortunately, your light bulb idea will have to be written later, as the session has ended. You are so excited about the idea you go straight to the nearest coffee shop and write the program, by yourself, for 2 hours.

43 Practice Scenario 7 East Coast ABA is transitioning several of its early learner students into social skills program. You have openings for a group of four students. Two of the students (Charlie and Rosie) require 1:1 support. The sessions will occur occur for two hours each. Two of the students (Jake and Ryan) do not require 1:1 support.

44 Practice Scenario 8 A credentialed BCBA offers a 2 hour parent education class to parents of three patients at the clinic, where they engage in live role-play of neutrality during challenging episodes.

45 Practice Scenario 9 A case BCBA meets with a family to review carry over of the behavior support plan, which includes grandma, grandpa, mom, dad, brother, sister, and third cousin Fred. No one is certain why Fred is there, but he is. The carry over plan lasts 5 hours, because Fred keeps asking questions.

46 Practice Scenario 10 You completed a functional analysis for self-injury suspected to be maintained by automatic reinforcement. You were interested in running procedures similar to Iwata et al., 1982, 1994 because you believed the patterns uncovered will help you predict which treatments will be effective. Two technicians completed the analysis and one BCBA supervised. The analysis required a total of 4 hours to complete.

47 Practice Scenario 11 Your hypothesis is confirmed. The pattern in the FA indicated that self-injury would not likely respond well to interventions based on positive reinforcement. When you probed blocking of self-injury, it evoked dangerous aggression. You decide the student will require three technicians. Each session will be two hours.

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50 Primary No ABA benefit You re in-network Secondary 100% ABA benefit You re in-network

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54 Primary $20/day co-pay You re in-network Secondary 100% ABA benefit You re in-network

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56 Primary You re in-network Secondary You re in-network Higher rates

57 The Dramatic Difference: What a Hospital Charges Vs. What Medicare Pays

58 Primary $20/day co-pay You re in-network CPT codes Secondary 100% ABA benefit You re in-network HCPCS codes

59 Rates listed are Tricare s current public rates

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72 Ø Valuing the rates of different services / add-ons Ø Discrepancies in margins Ø Tech assessments Ø Services that are not covered Ø Untimed services

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