|
The 97532 Procedure Code; A Number; A Procedure; The Failure of an Enterprise |
||
|
Practitioner’s Information |
Peter Magaro |
|
|
This article is to serve as an alert, an obituary of the field of cognitive rehabilitation, and an instance of what many leaders in the Division of Independent Practice have been warning us about for a number of years. This is my story about an effort to stop the enactment of a Medicare regulation that would deprive me of my livelihood. My experience with Medicare and APA could be best expressed by the child philosopher, Winnie the Poo, “I saw the enemy and it is us”. During my Sisyphusian struggle, I happened to come upon the Spring and Winter Issues of “The Independent Practitioner”. I believe I was living the admonitions of the authors so I decided to tell my story to give credence to their concerns. In January, psychologists came close to losing the option to offer a valuable treatment. We were saved, but as psychologists, had nothing to do with the salvation. We lucked out because our interest coincided with the interest of a much stronger player. They actually won the battle. We won, but we should not even have been in the battle. We were going along doing our business and someone shouted “Hey, there are more of the enemy.” We said, “No, we are not who you are looking for. We’re from a different country. We just happen to be working here. We do not even dress the same.” “No!” came the reply. “You are in the same place as they are. Off with their heads”. True, we will not lose our head over this, but we will lose our ability to practice our brand of psychology. We will lose this right because we will not be paid for providing the service we do so well. The service will continue but not by Psychologists in Independent Practice. The service will continue in a hospital or a university center. Psychologists as independent practitioners will no longer be eligible to receive reimbursement from Medicare for a service we have performed for a number of years and, strangely enough, Medicare does not want to exclude us. We were just in the wrong place at the wrong time. I believe, this is a situation that could have been and could be easily rectified if APA would become involved. Unfortunately, the matter does not seem to be important enough or socially relevant enough for APA to expend the resources to rectify the situation. Psychologists in private practice that specialize in cognitive rehabilitation are too small a group to evoke any serious interest from APA. Why does organized psychology show a lack of interest in the elimination of payments for Clinical Neuropsychologists or more exactly the cognitive psychologists who practice cognitive rehabilitation in private practice? Why when Medicare is ready to remove the ability for clinical psychologists to receive payment for their services, hardly a peep is heard even after the matter is brought to attention? Background The treatment procedure being discussed is well known and does not need much description or explanation since it is an accepted component of Cognitive Rehabilitation. There is lively debate on the extent of the applicability of the method and the target groups who can best benefit, but there is little question that the goal is the identification and retraining or improving brain functioning. The field has been active for a few decades (Lezak, 1995; Heilman and Valenstein, 1993; Prigtano, 1986) and considering the proposition that the current field of psychology is the study of cognitive functioning, it can be seen that this procedure is the primary avenue to treat medical patients with neurological problems. However, the role of cognitive rehabilitation is not unique to neurological functioning as similar methods, especially with computer aided instruction, have been applied to schizophrenia and other psychopathologies over 30 years ago (Magaro,1980). In short, psychologist have customarily engaged in cognitive rehabilitation to the point where it is a central component of Clinical Neuropsychology (Moser, 1999). The research in clinical psychology has focused upon memory enhancement techniques especially in chronic conditions such as Alzheimer’s Disease. Recent reviews have supported the promise of the technique (Grandmaison, and Simard, 2003; DeVreese et. al, 2001) and are asking the questions of what type of intervention is most effective with specialized patient populations (Backman, 1992) and what type of memory rehabilitation is most effective (Kessels and deHaan, 2003). The Procedure Psychologists are permitted to use only two rehabilitation procedure codes (PC) when they treat cognitive disorders such as memory deficits, 97532 and 97533, Cognitive Skills Development and Sensory Integration respectively. Both codes were effective January 2001. Their prior code was 97770. The typical provider of the 97533 code is an Occupational Therapist (OT) and psychologists are the primary users of 97532. The definition of the procedure is as follows: “Development of cognitive skills to improve attention, memory, problem solving, including compensatory training and or sensory integrative activities, direct (one-on-one) with the patient is reimbursed in 15-minute increments……It is currently only reimbursable when performed in the office or inpatient settings. Provision of this service is limited to physicians and clinical psychologists. Medical records should document that the patient has a neurological condition.” (Medicare Guidelines for Mental Health Services. March, 2004 Edition. Centers for Medicare and Medicaid Services. p.36 ) It is important to emphasize that these are not mental health codes and are limited to neurological diseases such as cardiovascular dementia, dementias due to a medical condition, and Alzheimer’s disease. Incidentally, the conditions correspond nicely with the diagnosis relevant to the new Health and Behavior Codes in terms of diagnostic groups and intent to supplement medical treatment with cognitive techniques excluding psychotherapy. The psychologist’s use of these rehabilitation codes has been in effect at least since 2000 and were instituted to allow psychologist to apply their knowledge of cognitive and neural functioning to individuals with neurological conditions. It was recognized that OTs and PTs did not have the knowledge base of psychologists to develop adequate cognitive treatment programs, especially when treatment methods were computerized and dealt with very specific information processing procedures and functions. (Magaro, 1986) However, even though it was expected that only psychologists would utilize the codes, physicians were also given the right to use the procedure which led to the prescription for cognitive therapy given to PTs and OTs. Psychologists do not require physician prescription. One need not ask why physicians may use this procedure considering they have no training in cognitive rehabilitation. And it certainly seems reasonable for OTs to have some skills in cognitive rehabilitation; however, there are very few PTs who have such neither training nor interest in this type of treatment. The Problem Medicare plans to effectively discontinue Physical Therapy as an independent practice. This will be accomplished by excluding all rehabilitation codes from reimbursement for all independent practitioners using rehabilitation procedures. (There are exceptions to this as can be seen in the Medicare Bulletin (April 2003), however, none of the exceptions are related to clinical psychologists but have to do with cast and splints, and audiology services; a very small segment of rehabilitation services performed by PT’s. Interestingly, there is not even a qualifying code for psychologists to distinguish them from PTs and OTs or MDs when using the procedure. When a procedure is reported to Medicare, it is treated as an OT or PT procedure no matter who performs the service. The discontinuance of this service came in the guise of a financial limitation on the service. Section 4541 of the Balanced Budget Act of 1997 imposed a financial limitation for outpatient PT and OT services. This limitation was $1590 a year for OT services and $1590 for PT and SPL services. With deductibles this amounted to $1272 a year reimbursed by Medicare. (See Financial Limitation of claims for Outpatient Rehabilitation Services, Empire Medicare services, MNB-2003-5 August/September, 2003). This limitation basically eliminated cognitive rehabilitation because the limitation applied to all rehab services. The limitation was to take effect January 1, 1999, however, Section 211 of the balanced Budget Refinement Act of 1999 placed a 2 year moratorium on the limitation until December 31, 2002 extended to July 2003. The limitation applies to the service itself and not who provides the service. Finally, and here is the good news, the Bush Medicare Prescription Drug, Improvement, and Modernization Act of 2003 placed another 2 year moratorium on the financial limitation regulation, therefore, we have until January 2006 before the service is denied to psychologists. The Political Context Before discussing action, we again should provide a lesson from the past and consider who was responsible for the delays in implementation of this regulation. First, it wasn’t psychologists. I have heard of no lobbying effort of APA to Congress on this matter. The only person who showed any interest was Diana Pedulla, Director of Regulatory Affairs in APA’s Practice Directorate However, when I contacted her, she was not aware of this problem, and told me she did not know of anyone else who was concerned about it. Prior to the last moratorium she gathered data to present to Medicare and gave me a contact there, but when I spoke to the Medicare office, they were not even aware psychologists were affected by this matter. I had a financial interest in continuing to treat patients with cognitive rehabilitation but was I the only one? I doubt it. I believe few knew and even if few were involved, this should have been an institutional matter for APA as the matter affected their membership. What was most telling is when I went to Medicare directly, they were surprised that this was an issue for psychologists. They thought this just affected PTs and their independent practice. On the phone, they seemed very sympathetic to not excluding psychologists for the limitation because the intent of the limitation was not directed at psychologists but at PTs. They asked for information that I thought was sent to them by APA and did not pursue it further. The Office of the Practice Directorate continued to be sympathetic but it was obvious this issue was on a very back burner compared to other legislative issues at the fore. When I asked for basic data such as how many psychologists billed for the service, or what proportion of billing for this procedure were psychologists, or what percentage of total rehab billing was attributable to this procedure, I got the proverbial we will get back to you. The answers never came from the data base available to APA. The point is that a small specialty does not bear much weight even when we have a wining situation. To repeat, our problem was an accident. I do not believe Medicare’s intent was to limit psychology services. Such billing by psychologists is probably miniscule and does not even reach the magnitude to be recorded. Medicare’s problem was the large amount of payments sent to the PT independent practitioner. I do not know why Medicare is so intend on trying to wipe out the independent practitioner of PT. I do not know if it was a large expenditure relative to other medical services. It could not simply be a matter of spending too much money on rehab. Since the limitation only applies to outpatient treatment, the purpose of the limitation act would be to force all PT back into the hospital where the service would be more expensive, but in some way Medicare saw it as more controlled. The service would still exist but not in a private practice setting. Obviously this act would be a windfall for hospitals. The Lesson The lesson for psychologists is not that Medicare will take on Independent Practitioners and try and exclude them from a main source of funding, although a harbinger is here to be considered. No, the striking lesson to be learned from this story is that Medicare failed. They were not able to find Congressional support for their regulation. Every time they set a date for the regulation to be effective, Congress added an amendment to some bill, in the last case, the 2003 Medicare Prescription Drug Act, to postpone the enactment of the regulation. Moreover, this legislation gave PTs a 1.5% increase in payments where they were facing a 4.5% decrease and directs Medicare to assess the impact of providing Medicare patients with direct access to PTs! In other words, Congress not only maintained the outpatient practice of PTs, they improved it. Has psychology had any such clout on any such issue such as parity or prescribing medication or hospital privileges? If the administration decided to control the costs of Medicare by eliminating the procedures that are employed by psychologists to administer individual therapy in private offices, would psychologists have the legislative muscle to override the regulation? Barnett (2004) possibly gives us the most obvious answer why PTs succeed and psychologists fail to control Medicare decisions that affect their membership. Quoting the AAP Advance (2002) report on political giving, he notes that psychologists came in dead last. Psychologists gave $1.05 per year per professional. What is most telling for this story is that in the high giving groups were PTs ($4.70) and, of course, physicians ($7.75). I believe we are seeing one of the rare observations of cause and effect. Graham (2004) notes that less than 3% of psychologists participate in political giving and they are mainly the old geezers who are retiring. Barnett (2004) went on to ask why psychologists are so passive and concludes they fall on the E side of the I-E scale. More obviously, PTs gave because they were facing the elimination of their livelihood and they responded accordingly. I am as guilty as the majority of clinical psychologists. I do not contribute enough. However, I believe my inexcusable reason is that I see little relevance to the giving and the benefit I personally derive. I will not benefit from psychologists prescribing medication and all the other issues brought to me with a return envelope. Of course, that is short sighted as I will benefit indirectly with stronger richer professionals from the same discipline. I do contribute to my state organization and in a prior professional life, I hired lobbyists to promote my practice, but the issue is not about how much one contributes. The blame, however, does not reside in the individual members of the organization, but in the organization itself that is charged with promoting the interests of its members. In my case, APA did not mobilize its efforts. In fact, I received the impression that they had no one on staff whose sole job was to work with Medicare. Considering that Medicare is the gold standard that all other insurance companies follow to set policies on what is reimbursed and for how much, I would expect we would have a full office devoted to working with this very important agency. Again, in my experience, Medicare was very professional and anxious to learn more about the issue. They were not threatened or dismissive as has been found with managed care companies. Of course, I hope I am wrong and just did not ask the right question to find who on the APA staff was responsible for Medicare issues, but I did not find such a person. Can you imagine Boeing without a department devoted to the Defense Department? The solution may be we can not rely on others to lobby for us. I will second Martin Williams’ (2004) effort to set up a virtual community of psychologists who will respond to the interests and needs of members as they arise. I wish I had this vehicle available in my struggle with APA. I could have had many psychologists e-mail Diana Pedulla, and she would not have said that I was the only one who was interested in this matter. The Action I believe this is called learning the hard way, but the decisive battle has not yet been fought. As I say, a moratorium is in place through 2005. In 2004, reports were to be submitted to Congress stating the case for and against a limitation on payments. I do not know if APA has participated in these reports. I only know we have until the end of 2005 to convince Medicare to exclude us from this battle. We have until then to accomplish two goals. One; to mobilize APA or The Division of Psychologists in Independent Practice to establish a working group to meet and coordinate policies with Medicare/Medicaid. Two; to organize psychologists affected by this regulation into a lobbying force to combat the regulation in Medicare and the legislature. I will begin by using the listserve of Division 42, div42@lists.apa.org. to alert psychologists to the problem and to find solutions. We need to know who to speak to in Medicare and what type of presentations to develop. We must find the relevant data on usage and costs. Most important, I believe we must have APA become involved in a direct manner or we must find an alternative to represent those who are affected.. I will keep members informed through my email and listserve. We need suggestions on how to proceed from those who have engaged in similar efforts. I would appreciate having emails to establish a network on this issue. I hope many will join in devising an approach to protect a small group of the brethren. References: Association for the Advancement of Psychology. (Spring, 2002). Comparison of health care professions political giving performance. The AAP Advance, 6. Backman, L. (1992) Memory training and memory improvement in Alzheimer’s disease: rules and exceptions. Acta Neurological Scandavia Supplement, 139, 84-89 Barnett, J.E. (2004) On being a psychologist and how to save our profession. The Independent Practitioner, Winter, 45-46. DeVreese, L P. et. al. (20010 Memory rehabilitation in Alzheimer’s disease: a review of progress. International Journal of Geriatric Psychiatry, 16, 794-809 Fox, R.E. (2004) Joining the political process: We are not giving until it hurts, but it still hurts. The Independent Practitioner, Winter, 4-5. Graham, S.R. (2004) The little APA. The Independent Practitioner, Spring, 61- 62 Grandmaison, E. and Simard, M. (2003) A critical review of memory stimulation programs in Alzheimer’s disease. 15:2, 130-144. Heilman, K. and Valenstein, E (Eds.) (1993) Clinical Neuropsychology (3rd edit.). New York: Oxford University Press. Kessels, R.P. and deHaan, E.H.F. (2003) Implicit learning in memory rehabilitation: A meta-analysis on errorless learning and vanishing cues methods. Journal of Clinical and Experimental Neuropsychology, 25, 805-814 Lezak, M. (1980) Neuropsychological assessment (3rd ed.) Oxford: Oxford University Press. Magaro, P.A. (1980) Cognitive Processes in Schizophrenia and Paranoia. Lawrence Erlbaum Associates. Inc. New Jersey Magaro, P.A. Johnson, M., and Boring, R., (1986) Information processing approaches to the treatment of schizophrenia. In Information Processing Approaches to psychopathology and clinical psychology. R. Ingrim (Ed.) New York: Academic Press. Moser, R.S. (1999) Niche Practice Specifications: Clinical Neuropsychology. Psychologist in Independent Practice: Practice Clearing House of Knowledge. Prigatano, G. (1986) Neuropsychological rehabilitation after brain injury. Baltimore: John Hopkins University Press. Williams, M.H. (2004) From the editor. The Independent Practitioner. Winter, 5-6. |
||
