Is NY State taking steps toward a paraprofessional delivery model for their Early Intervention Program???

New York State has an electronic information management system for the Early Intervention Program that involves a mechanism for billing and reporting services to the municipalities and state.  This system is called the New York Early Intervention System and is generally referred to as NYEIS. 

I received email today regarding use of procedure codes in the NYEIS system and I want other practitioners to be aware of some issues.

The email describes the difference between Level I and Level II HCPCS codes.  In quick summary, Level I codes are also referred to as CPT codes and are standard and typically accepted codes that represent the professional activities of licensed health care professionals.  Some of them are rather specific and include things like "OCCUPATIONAL THERAPY EVALUATION" or "PHYSICAL THERAPY EVALUATION" or "THERAPEUTIC EXERCISE."  Some insurance companies don't approve of some of these codes, particularly if they think that there is not enough research or evidence to support the interventions (like SENSORY INTEGRATION THERAPY). Still, most of those CPT codes are reimbursed by private insurance.

Level II HCPCS codes often refer to services that are not provided by physicians or health care professionals like DME suppliers (durable medical equipment, prosthetics, orthotics, and supplies - all often referred to as DMEPOS) , educational services, and other services or items that are typically not 'covered' by standard insurance. 

The email from the DOH states:

The Bureau of Early Intervention has reviewed these (Level II) codes with the Office of Health Insurance Programs (OHIP) and Medicaid. OHIP and Medicaid agree that there is no concern or restriction with special educators or other non-healthcare professionals from utilizing HCPCS codes for Early Intervention service claiming...The following HCPCS codes have recently been added to NYEIS and may be appropriate for special instruction or other non-healthcare professional services:
G0176 - Activity therapy (such as play, etc.) for care and treatment of patient's disabling mental health problems, per session (45 minutes or more)
G0177 - Training and education services related to care and treatment of patient's disabling mental health providers per session (45 minutes or more)
G0451 - Development testing, with interpretation and report, per standardized instrument form
H0004 - Behavioral health counseling and therapy, per 15 minutes
H2000 - Comprehensive multidisciplinary evaluation
H2014 - Skills training and development, per 15 minutes
H2027 - Psychoeducational service, per 15 minutes
H2037 - Developmental delay prevention activities, dependent child of client, per 15 minutes
S9445 - Patient education, not otherwise classified, non-physician provider, individual, per session
V2799 - Vision service, miscellaneous
T1016 - Case Management, each 15 minutes
T1017 - Targeted Case Management, each 15 minutes

Now that might seem innocuous, and providers may simply think that there are now more options for coding, but let's review some realities before people jump to using these new codes.

If you use a Level II code (and you are not a specified DMEPOS provider) on a standard HCFA-1500 billing form to just about any commercial insurance company that I know of you will not get paid for services.  Additionally, you will most certainly NOT be paid for maintenance, developmental, or educational Level II codes.

Last year I documented that New York State had an 85% denial rate for reimbursement from commercial insurers, and even a 22% denial rate for simple intra-agency billing to the Medicaid program - which is pathetic.  I am struggling to understand why the state would encourage use of codes that are KNOWN to be denied by commercial insurers when they already have a gigantic billing/collection problem.  Now they can make whatever rules they want to make their own Medicaid program pay those codes but that will do nothing for the commercial insurance aspect of billing.  Using Level II codes will contribute to more commercial denials.

Promoting use of Level II HCPCS codes can only mean they are incredibly misinformed and clueless OR they are throwing in the towel with trying to get reimbursement and they intend on replacing skilled services with services provided by non-licensed people with 'generic' developmental training.

What's that again?

Yes, other states around the country have replaced occupational, physical, and speech therapy services with paraprofessional services provided by non-licensed human service professionals who usually hold generic child development degrees/training.  Those paraprofessionals certainly are not entitled to bill standard CPT codes to insurance companies.  They certainly ARE entitled to use Level II HCPCS codes - and now it seems that NY State is paving the way for it to happen.  It is much less expensive to have paraprofessionals provide services than licensed professionals.  The States don't bother trying to collect the commerical side of things, write rules for Medicaid to eat as much cost as possible, and just go the paraprofessional route.  However, the larger question is whether or not it really meets the needs of children and families.

Bottom line is that we (as a society) probably can't afford all of these programs, and the only way to even try to afford them is to either tax people into oblivion or develop cost saving models like the use of paraprofessionals.  Is that coming to NY State Early Intervention?  Talk to your colleagues around the country in Florida, New Jersey, Colorado, and many other places and see how the use of paraprofessionals has impacted care delivery in their Early Intervention Programs.

Either way, use of Level II HCPCS codes will contribute to continued inability to collect reimbursements and will collapse the system, or it is reflecting a mood-shift where we are setting up a system that will make greater use of paraprofessionals.

Be ready.


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