PhD/PsyD Neuropsychology Practice Question

[Workup]

I am a neurologist. My practice would like to hire a neuropsychologist to work with patients with memory impairment, multiple sclerosis, concussion, etc.

Can someone give me a rough idea how many patients a neuropsychologist sees in a day?

For example, how many new patients could a neuropsychologist see in a day and perform a standard or flexible battery of tests + interpretation? And then how many do think you one could see if a testing assistant/psychometrist was used?

I realize everything depends -- but I could estimate that my average patient visit takes about 30 minutes -- so I am just trying to ballpark that to see if this is even feasible. I'm looking for qualified respondents - not guesses. And if there is a better resource I'd be happy to read into that as well.


Thanks,
me

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[WisNeuro]

Depends on the referral question. The testing itself takes anywhere between 2-6 hrs depending on what needs to be assessed. 30-60 mins per interview. Bout an hour for scoring. 1-2 hours for interpretation and report writing. If it was just them, 1 patient a day, maybe 2 if it was a straightforward memory disorder, but then they have no time for scoring and report writing. Could easily see 2 patients a day if they had a psychometrist for all testing, maybe 3. Rough ballpark considering the time involved with my usual patients and whatnot.

 

[erg923]

I am a neurologist. My practice would like to hire a neuropsychologist to work with patients with memory impairment, multiple sclerosis, concussion, etc.

Can someone give me a rough idea how many patients a neuropsychologist sees in a day?

For example, how many new patients could a neuropsychologist see in a day and perform a standard or flexible battery of tests + interpretation? And then how many do think you one could see if a testing assistant/psychometrist was used?

I realize everything depends -- but I could estimate that my average patient visit takes about 30 minutes -- so I am just trying to ballpark that to see if this is even feasible. I'm looking for qualified respondents - not guesses. And if there is a better resource I'd be happy to read into that as well.


Thanks,
me

4-6 full evaluations/batteries per week would be a busy neuropsychologist in an outpatient setting if they are doing their own testing.

 

[WisNeuro]

4 full evaluations/batteries per week would be a pretty busy neuropsychologist in an outpatient setting.

If they are doing their own testing, yes. If they have a psychometrist, easily more.

 

[PsyDr]

The general rule of thumb is a full practice is 4 assessment per week. Initial interview + completing one test to adhere to cms standards will run 1.5 hrs.

A patient will take 4-6 hours to test, with approximately 4 hours to score, and dictate. Figure one a day, with one day a week to catch up on dictation and admin stuff. Adding tech can increase efficiency, but 2 is the optimal number. However, the start up costs are higher because you need at least two sets of test materials, which can run in the 5-6k range per.

With one Psychometrician, you could squeeze two pts a day in. But the np would need a day a week to catch up on dictation . Burn out would be high and reports would lag. Pt A: Start with np at 9, hand off to tech at 10, test until noon. Lunch. Return at 1. Finish at 3ish. Tech scores until 5. Pt b: start at 10, test till noon with np. Return, test till 4ish. Np scores till 5-6pm. Notice where the dictation time comes in? Yeah. Not sustainable long term unless there is a day off.

With 2 Psychometricians, figure 2 pts per day with no day set aside as dictation and admin. There are easier ways to schedule with 2 techs.

I have never heard of a neuropsychologist using more than 4 techs, and the only ones I have ever met that used more than 2 were willing to do so because they were in private practice, were incredibly seasoned, and making physician salaries. I would estimate that you are looking at less than 5% of the profession who could do this long term. After 2 techs you are going to have a severe burnout/turnover problem and/or an incompetent person who does not understand what they are doing. The only people who could actually handle such a workload competently are going to ask for physician scale salaries. I mean, we do stats for a living, we can calculate the revenue we bring in.

Source: I have several techs.

 

[Pragma]

The most I have seen done in PP is 4 patients per day with 2 techs. Short dementia evals. More would turn you into a Psydr apparently!

 

[PsyDr]

The most I have seen done in PP is 4 patients per day with 2 techs. Short dementia evals. More would turn you into a Psydr apparently!

Then you wind up going to cardiology, allergy, internal medicine, and sleep medicine to figure out why you are tired all the time and they all tell you that you work too much! Bonus points for getting competitive on the stress echo.

But seriously, I know a guy in his 60s who uses 4 techs, 4 days per week. Has them all exchange protocols and restocked in Friday's. I had 4 (2 at hospitals, 2 in the office). Never heard of anyone else using 4. Know the high number in the sweet survey who used 3 techs for a HUGE lawsuit at that time. He now uses 2.

 

[Workup]

Thank you - that was very helpful. We are looking to hire a colleague so I'm hoping to make it a workable situation to avoid burnout and job hate.

It seems to me that . . .

96116 is the initial interview with the NP. One unit on first visit (maybe another on follow-up?)
96118 or 96119 x 4-6 units (based on 4-6 hours of testing).

Which means that NP + psychometrist could see at max 8 patients per week and bill 96116 x 8 + 96118/9 x 40 (8 pts x average of 5 hours of testing).

Do you find that insurances have hard stops on how many units of 96118/9 a NP can bill for a patient? I am (luckily?) in a BCBS, Medicare environment.

 

[WisNeuro]

Thank you - that was very helpful. We are looking to hire a colleague so I'm hoping to make it a workable situation to avoid burnout and job hate.

It seems to me that . . .

96116 is the initial interview with the NP. One unit on first visit (maybe another on follow-up?)
96118 or 96119 x 4-6 units (based on 4-6 hours of testing).

Which means that NP + psychometrist could see at max 8 patients per week and bill 96116 x 8 + 96118/9 x 40 (8 pts x average of 5 hours of testing).

Do you find that insurances have hard stops on how many units of 96118/9 a NP can bill for a patient? I am (luckily?) in a BCBS, Medicare environment.

96118 is also used for scoring, interpretation, and report writing, if done by the neuropsychologist. 96118 is also use for feedback provided. Anything the psychmoterist does is billed under 96119, unless there is some computerized testing, which I think is 96120 or something. As for insurance companies, yes and no. Usual hassles. Hopefully you have a billing department who can keep up with them.

 

[Pragma]

90791 for interview in some contexts works too.

 

[sunshine008]

all these billing things...when does a neuropsych student learn this? I'm in my 5th year and no one has ever taught me this...

 

[Therapist4Chnge]

all these billing things...when does a neuropsych student learn this? I'm in my 5th year and no one has ever taught me this...

Hopefully on fellowship, but mostly when they get out and are forced to learn it. I had minimal exposure on fellowship, so I had to learn via list servs, colleagues, presentations, etc.

I try and teach all of my fellows the basics of billing (e.g. CPT Codes, what is needed in each note from a billing perspective, diff between being panels on medical v. MH, diff types of insurance plans, etc). It is often actively avoided, but at the end of the day it is directly related to bring paid for your work.

Tony Puente offers free power points and videos about CPT Codes (the reference codes used to specify the service provided). If you google his name and "billing codes", his coding website should show up. Be warned, his slide deck is dense, so you'll need to go over it a few times and read outside sources to understand everyhing.

 

[Pragma]

Tony Puente offers free power points and videos about CPT Codes (the reference codes used to specify the service provided). If you google his name and "billing codes", his coding website should show up. Be warned, his slide deck is dense, so you'll need to go over it a few times and read outside sources to understand everyhing.

Yep, very helpful stuff.

You could in theory just do a 96118 for everything if you do your own testing, or at least for your own work on the case (interview and report writing included). You have to give at least one test. 96119 for any face time with a tech.

90791 can also be used instead of just all 96118 if you do a full diagnostic interview before the eval, and an alternative to that is a 96116. Those are the only billing variations that I am aware of.

 

[AcronymAllergy]

90791 for interview in some contexts works too.

Yep.

Yep, very helpful stuff.

You could in theory just do a 96118 for everything if you do your own testing, or at least for your own work on the case (interview and report writing included). You have to give at least one test. 96119 for any face time with a tech.

90791 can also be used instead of just all 96118 if you do a full diagnostic interview before the eval, and an alternative to that is a 96116. Those are the only billing variations that I am aware of.

Ditto. 96116 is what I typically use, but if it's a more in-depth interview with significant mental health components, that's when I lean toward 90791 instead. I believe both bill higher than 96118 (96116 slightly, and 90791 significantly); or at least their RVU returns are greater.

 

[WisNeuro]

I think with 90791 you actually need to be offering up a psych diagnosis, or at least rule outs. Not sure if it's appropriate for things like your run of the mill dementia case with a clean psych history. But may be appropriate for a referral question of substance abuse, unclear history of bipolar/borderline, complaining of cog px, and primary care would rather not deal with them.

 

[Therapist4Chnge]

It also depends on your provider contract (with the insurance company. If it is cash, you can put whatever CPT code down or more likely not include any). Many private insurers authorize 90791, 96118, 96119, and a feedback session..which can be one of a few codes. In 99% of my cases I use 90791 because there is a psych component (even if it is just adjustment following neurologic injury, though YMMV). Dr. Puente leans towards 96118, though does specify to check with the payor/insurance company. It behooves us as a profession to differentiate to ensure we are paneled under medical, as being paneled under behavioral health is a PITA because "parity" is a joke in practice. I'm only paneled on the medical side, which helps cut down on some of the issues. It creates another issue if an insurance company tries to force the case through behavioral health, but that is when the patient gets involved because my cost is far higher out-of-network, so the issue tends to resolve itself.

From my understanding, the use of 90791 (and 90801 before that) in neuropsychological assessment came out of psychiatric eval, where many insurance companies would require a full intake prior to approving psychological testing. I can't recall if Dr. Puente told me this or I talk w. someone else, though it is my understanding that the development of 96118+96119 was meant to differentiate neuropsychological assessment and were meant to be inclusive (and not in conjunction with 90801), though as with many things…insurance companies influence practice, greatly.

I believe Medicare (MC) explicitly lists 90791 to be used for evaluation of a psychiatric referral, so that needs to be considered when billing Medicare. I see probably 3 MC cases a year in my out-pt practice, so I'm less familiar with them directly, though more familiar with them as an influence on how private insurers set policy.