CogniFit - Medical billing codes

Disclaimer

CogniFit has compiled this information for your convenience. The information provided in this document was obtained from third-party sources and is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, and policies. All content on this document is informational only, general in nature, and does not cover all situations or all payers' rules and policies. These guidelines provide no specific guarantees for reimbursement and are subject to obsolescence as Medicare and other payers amend their policies. Each unique combination of healthcare provider, procedure, and patient condition must be independently considered in terms of applicable coding and reimbursement. Medical providers should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing, and payment levels for healthcare procedures. It is the responsibility of the medical provider and or the medical provider's staff to make the final determination about what constitutes an appropriate procedure and/or diagnostic code(s). CogniFit specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on this information.

Neuropsychological and neurological tests

Estimated national average reimbursements are systematically and significantly higher than CogniFit’s cost per cognitive assessment.

The American Medical Association (AMA) and the Center for Medical Services (CMS) are the governing agencies that generally set the procedure codes and how they are used. Regional or local insurance companies such as Medicare third-party administrators, Blue Cross/Shield or large national carriers generally follow these rules but there can be regional differences or variance.

Even though the patient may not qualify for Medicare most payers design their coverage rules according to CMS criteria. The value of neurocognitive testing is well recognized as CMS has sent out several memos mandating coverage for these codes. Generally, there is widespread reimbursement or coverage for these procedure codes used for CogniFit assessments

Many patients that are not covered for cognitive testing e.g. Medicare, Private Carriers will pay out-of-pocket to have their neurocognitive function measured. Patients that have a family history of cognitive impairment e.g., dementia, Alzheimer’s disease, Parkinson’s disease, etc. will be candidates for this clinical service.

Cognitive rehabilitation

The CPT code 97127 code is untimed and can only be billed once per day regardless of the length of the session. Note that Medicare does not accept CPT code 97127 but recognizes its own 15-minute G-code, G0515, for cognitive therapy. Check with non-Medicare payers regarding implementation of 97127. You should also make sure reimbursement rates are reflective of a session, and not 15-minute units.

While cognitive training by itself is not typically covered by insurance, it may be possible for a health care provider to incorporate cognitive training as a component of their therapeutic interventions and have the services covered by the client’s insurance company. A treatment plan is required, progress must be documented and this type of therapy has restrictions for its use with specific patient populations. In addition, the patient needs to be qualified to show that he or she can possibly benefit from this form of treatment. Currently, neurological disorders, strokes, cancer treatment (medicines used to treat cancer are toxic to the brain) and traumatic brain injuries are generally covered. Alzheimer’s is usually not covered. Insurance coverage varies according to insurance company and state. Providers who typically use these codes include: psychologists, speech language pathologists, occupational therapists, physicians in rehabilitative medicine, neurologists, psychiatrists, and other related medical specialists.

Matching CPT Codes with ICD or DSM Codes

Coverage for neurocognitive procedures can vary by payer. The CPT procedure code and ICD -DSM codes need to “match” according to each payers requirements. Contacting the payer's provider representative(s) can assist in the appropriate or correct coding. ICD and DSM Code coverage can vary from plan to plan. Clinicians should consult with their office’s coding and billing staff to determine the combination of codes that will work best for testing services.

Suggestions for Documentation

CMS (Recovery Audit Program) and other payers have active and ongoing audit programs to recover fraudulent claims. Coding experts have expressed the following tips to help a practice be prepared for an audit.

• Technical Component - Label which Tech or Admin or Computer admin, Number of Tests.
• Professional Component - Label Activities: Testing by Professional, Interpretation, Report, or Integration of findings which may include history, prior records, interview(s), and compilation of tests.
• Testing Time – Minimum documentation should be: Date(s) & Total Time Elapsed, Maximum: Date(s) Start and Stop Times; Testing Time Backup - Scheduling System (e.g., schedule book; agenda, etc.), Testing Sheet with Lists of Tests with Start/Stop Times, Keep Time Information as long as records are kept. *Medical Necessity can vary by Payer. CogniFit reports contain an automatic Time and Date stamps.

Denial of Coverage

Most payers consider computerized neurocognitive assessment procedures medically necessary because the assessment procedure aids in the assessment of neurocognitive impairment due to medical or psychiatric conditions. Neurocognitive testing such as CogniFit helps clinicians better understand the nature of their patient’s illness, in making recommendations regarding coping with and compensating for their neurocognitive difficulties, and encourages treatment adherence. If for some reason the carrier or plan denies coverage it is important to educate and inform the carrier or plan’s personnel about the importance of covering the procedure.