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Screening: An Overlooked Billing Opportunity

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Tuesday, May 22, 2018

At the end of April, I attended OPA’s convention, held annually each spring in the Central Ohio area.  Each time I attend, I am reminded of one of the greatest benefits of the event: opportunities for networking.  The experience of networking offers many benefits to psychologists, such as the chance to identify resources, get new ideas for our professional work, share our expertise, or just connect a face to a name.  Few other features of our association give these advantages. 

For example, at one point I was part of a discussion involving psychological services and billing codes.  As is often the case, the conversation began to focus on which services were reimbursed by insurance companies (a topic of discussions I am frequently involved in).  One of my colleagues reminded me that a separate billing for use of screening instruments was allowed by most insurance companies.  I realized that many psychologist, especially folks in private practice, were unaware of or taking advantage of this.  My next idea was that I need to make sure I am passing this information on to OPA members.

My hope is that more psychologists are becoming aware of the importance of measuring and documenting the effectiveness of their work through outcome measures, particularly those who are practicing psychotherapists.  The use of screening instruments can help accomplish this task.  Screening instruments such as Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), Alcohol Use Disorders Identification Test (AUDIT-C), are commonly used to detect the presence of symptoms and can be used pre, during, and post intervention.  While insurance companies vary on how frequently the use of these measures can be reimbursed, most provide some reimbursement for screening procedures when billed along with initial assessment or psychotherapy codes.  

As a result of requirements created by the Affordable Care Act, CPT Code 96127 was created in 2015.  Defined as brief emotional/behavioral assessment, with scoring and documentation, per standardized instrument, this code may be billed along with an initial assessment or psychotherapy code for each instrument administered.  Though in many cases the reimbursement rates are nominal, regular use of this procedure can create some added income for many practitioners.  Doing so also provides an incentive for clinicians to begin outcome measurement for their work.  For those of you who regularly use screening or brief assessment instruments, I encourage you to remember to bill CPT 96127 along with your regularly used code(s).  For those of you who do not make regular use of screening, I encourage you to start.  As always please reach out to me (jbroyles@ohpsych.org) with questions and comments.

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Retirement Checklist

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Thursday, April 12, 2018

Thinking of retirement?  You are not alone.  Questions about retirement are among those most commonly received by OPA staff.  Below is a checklist of important retirement considerations.  In assembling these guidelines, I have integrated more general ideas offered by APAPO with Ohio rules governing psychologists.  Some of the guidelines have links to other very helpful APAPO documents.  You may access these if you are a member.  (If you are not, I urge you to join!)

Clients and Their Records

  • Inform your current clients be sure to leave adequate time for termination or referral.
  • Talk to the psychologists to whom you will refer clients who need ongoing treatment — find out about their availability, insurance accepted, location, office hours and areas of expertise
  • Ensure continuity of care by providing referrals to clients who require ongoing services and helping them with the transition
  • Obtain informed consent and transfer a copy of your clients' records to the new providers
  • Inform your clients other health care professionals and keep them up-to-date on the status of closing your practice
  • Attempt to notify your past clients. There are a number of approaches you might take, including sending a letter and/or placing a notice in the local papers of the area you serve, on your website and in other community forums. Be sure to include information about how to contact you or access client records.
  • Be mindful of records you are required to maintain.  Ohio rule regarding this:

OAC 4732-17-01 (B) Negligence:
(7) Maintenance and retention of records.
(b) To meet the requirements of these rules, but not necessarily for other legal purposes, the license holder shall ensure that all contents in the professional record are maintained for a period of not less than seven years after the last date of service rendered, or not less than the length of time required by other regulations if that is longer. A license holder shall retain records documenting services rendered to minors for not less than two years after the minor has reached the age of majority or for seven years after the last date of service, whichever is longer.

  • Identify a person who will maintain current records you are required to keep and protect their confidentiality.  Make sure you have an updated written plan to facilitate the transfer of these records, and that the person who knows the location of this plan is identified by you to the Ohio Board of Psychology.  Ohio rule regarding this:

OAC 4732-17-01 (B) Negligence
(7) Maintenance and retention of records.
(c) A license holder shall store and dispose of written, electronic, and other records of clients in such a manner as to ensure their confidentiality. License holders shall prepare in advance and disseminate to an identifiable person a written plan to facilitate appropriate transfer and to protect the confidentiality of records in the event of the license holder's withdrawal from positions or practice. Each license holder shall report to the board on the biennial registration (renewal) form the name, address, and telephone number of a license holder or other appropriate person knowledgeable about the location of the written plan for transfer and custody of records and responsibility for records in the event of the licensee's absence, emergency or death. The written plan referenced in this rule shall be made available to the board upon request.

Finances

  • Talk to your attorney and accountant to determine whether selling your practice is a viable and worthwhile option. Also, be aware of ethical issues related to selling your practice, and seek appropriate consultation as necessary

  • If selling your practice, decide whether to work with a broker to help you navigate this potentially complicated process that requires a sophisticated understanding of local and state laws, business valuation, marketing strategy, tax implications and contracts

  • Collect any accounts receivable

  • Pay off any outstanding debts
  • Work with your accountant to organize your financials records (e.g., financial reports, tax documentation, contracts)

  • Talk to your accountant and/or tax professional about the tax implications of closing or selling your practice and strategies to reduce your tax liabilities

  • Once all of your finances have been reconciled, close bank accounts associated with your practice

Business Issues

  • Discuss the arrangements with your partners — if selling or transferring your ownership to your partner(s), be sure to work closely with your attorney to protect all parties involved

  • Inform your office staff far in advance

    Notify all your referral sources

    Inform other professional contacts and relevant entities, including the psychology board, professional organizations, insurance panels and other parties with which you contract, your billing and answering services and other practice consultants 

  • If you rent office space, give notice to terminate your lease in the manner and time frame that your leasing contract requires. If you own, take steps to sell or rent your office

  • Sell, donate or dispose of office equipment, such as photocopiers, fax machines, and furniture. Remember that if any of this equipment contains confidential information, that information must be deleted in line with HIPAA requirements.

  • Use up any remaining office inventory

  • Contact the issuers of any business licenses and permits you hold

  • Cancel any utilities (e.g., electric, gas, water, phone, Internet) you pay for your office

  • Submit a change of address form with the post office. Depending upon your privacy concerns and where you want your professional mail delivered, you may want to consider obtaining a post office box for a period of time to make sure you do not miss any important correspondence

  • Cancel or forward any publications or subscriptions you received at your office

  • Forward your office telephone number or keep you answering service for a period of time. Place an outgoing message informing callers of your closure and giving instructions for contacting you or accessing their records

  • Call your professional liability insurance carrier — make sure you are covered for complaints filed after you close your practice. If your current policy does not cover this type of complaint, find out about purchasing a "tail" to your policy 

I hope you find this helpful.  For those of you who are more experienced with this process, please feel free to contact me with more tips others might find helpful.


Jim Broyles, PhD, OPA Director of Professional Affairs

This information is also available in a pdf version in the Professional Resources section of our website located under the Member Services tab. 
Note... This is a members' only restricted area. You will need to login to gain access to the Professional Resources page.

Tags:  retirement 

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Medicaid Behavioral Health Redesign: Rejected Claims

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Tuesday, February 27, 2018

As many of you are aware, the Medicaid Behavioral Health Redesign was implemented in Ohio at the beginning of the year.  A few of the insurance companies are reporting systems issues that need to be worked out.  United Health Community Plan reports many claims are being rejected with the code A-17—NPI not Billed.  UHCCP requests that everyone be aware of the following:

Behavioral Health Redesign is now in effect as of 1/1/2018 and Optum has identified a growing trend of inappropriate billing according to the Ohio Department of Medicaid’s coding specifications. A significant number of claims are being submitted and denied “A17 | NPI not Billed” because the NPI is not being reported on each detail line. Behavioral Health Redesign coding specifications indicate this is a requirement. 

For specific reference to this requirement, providers should visit: http://bh.medicaid.ohio.gov 
Provider > Manuals, Rates & Resources > IT Resources (Final) > EDI/IT Q&A Document

UHCCP reports that providers are not able to submit claims with rendering NPI at the line level through the UHC claims portal. This portal does not have the capacity to submit claims in this format.  Claims in this format will have to be sent paper claim or through a clearinghouse.

If you bill United Health Care Community Plan and you have questions about this, please feel free to email me.

Jim Broyles, Ph.D.,  OPA Director of Professional Affairs

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Prior Authorization Law Now In Effect

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Thursday, January 11, 2018

As many of you may remember, the “Prior Authorization Law,” which was passed in 2016, will begin its impact this year. The Ohio Psychological Association’s Advocacy Team worked very hard to contribute to the passage of this law (it was a featured priority for past OPA Legislative Days), and we should now see the benefits of its requirements.

Among other things, the law states:

For health insurance policies issued on or after January 1, 2018, the insurance company must: 

  • Make preauthorization forms available electronically
  • Allow preauthorization forms to be submitted electronically
  • Respond to requests for authorization within
    • 48 hours for urgent situations
    • 10 days for nonurgent situations
  • List preauthorization requirements on the company’s website 
  • Provide a streamlined appeal process including reasonable timelines for denied authorizations
  • Prohibit retroactive denial of authorizations granted

In the past, I have provided support for a number of psychologists who were requesting help with obtaining preauthorization for testing or for an extended therapy session time. This law would affect the processes involved here, requiring them to be clear and accountable. 

Please feel free to give me feedback about what you are encountering as you interact with insurance companies. Are you finding these features available from insurance companies on their websites?  Are you aware of law violations?  

I welcome your questions as well as your feedback.

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Anthem Offers CPT 90837 Documentation Guidelines

Posted By Karen J. Hardin, Tuesday, November 7, 2017
Updated: Tuesday, November 7, 2017

Several OPA members who are also panel providers for Anthem Blue Cross Blue Shield have reached out to me regarding letters they have recently received. The letter is similar to communications received from other insurance companies in the past, addressing the providers use of CPT Code 90837. Psychologists who receive the letter are informed that their use of CPT Code 90837 (60-minute psychotherapy session) is “higher than the expected billing distribution as determined by the average billing behavior of other physicians within your specialty and peer group.” The letter goes on to state, “Our goal is to help providers ensure that the documentation and reporting guidelines are followed and that their documentation supports the level of care billed for each service.”

Letter recipients have reached out to me expressing concern and confusion regarding the purpose of the letter.  Most feel confused about the meaning of the above statements. In an effort to help, I reached out to Anthem and asked for more information. In their response, Anthem clarified: “our letter is strictly educational in nature and its purpose is to ensure that your documentation supports the codes that are being billed.” Their response continues by outlining the documentation they would expect to see to support the CPT 90837 service billed:

  • Date of service
  • Length of session (start/end time), therapy time with patient and/or family
  • Therapeutic maneuvers utilized
  • Diagnosis -for each visit- related to treatment and therapy for the visit 
  • Progress or lack of progress to the goals
  • Updates to treatment plan if necessary
  • Provide signature (Electronic or written)

Also to note, these services are NOT included in the “time” for the session:

  • Time spent arranging services/appointments
  • Time spent in communication with other healthcare providers
  • Time spent documenting or providing reports

The intent of the letter, then, is to remind recipients to follow documentation guidelines for CPT Code 90837. No information was given on whether record audits should be expected at some point in the future. However, it seems clear that following these guidelines should help Anthem providers pass audits with no issue. I would also like to note that these record keeping guidelines are very similar to current standard accepted practices for the insurance industry and to recommendations I have given in the past.  

I hope you find this helpful.  Please feel free to stay in touch should you have other issues or concerns.

Jim Broyles, PhD
OPA Director of Professional Affairs

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Adjustments of Previously Paid Claims

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Thursday, October 12, 2017

I was recently contact by an OPA member who was encountering a difficult situation with an insurance company.  He received notice from the company in question stating a prior reimbursement they made was invalid, and they were therefore asking for the payment to be returned.  The initial payment had been made more than two years prior to the date the determination notice had been sent.  The psychologist contacted me about the legitimacy of this determination and request.  Like so many of us, he vaguely recalled there are limits to such “take back” requests, but he was unsure of the specifics.  (Apparently the insurance company making this determination was somewhat lacking in understanding, also). 

I reminded him of Ohio law on this topic, which I am copying below.  Insurance companies may look back and make a new determination about previously paid claims, but they are limited to a two-year period.  In other words, a request for return of paid claims is limited to the two-year period immediately preceding the notice requesting the return of funds.  The following is taken from the Ohio Department of Insurance website:

Adjustments of Previously Paid Claims

Claim payments that are made on or after July 24, 2002, are deemed final two years after the payment is made. After that date, the amount of the payment is not subject to adjustment, except in the case of fraud by the provider. 
 
A third-party payer may recover the amount of any part of a payment that the third-party payer determines to be an over-payment if the recovery process is initiated not later than two years after the payment was made to the provider. 
Upon determination of an over-payment a third-party payer shall send a notice to the provider that contains the following:

  1. The full name of the beneficiary who received the health care services for which over-payment was made;
  2. The date or dates the services were provided;
  3. The amount of the over-payment;
  4. The claim number or other pertinent numbers;
  5. A detailed explanation of basis for the third-party payer's determination of over-payment;
  6. The method in which payment was made, including, for tracking purposes, the date of payment and, if applicable, the check number;
  7. That the provider may appeal the third-party payer's determination of over-payment, if the provider responds to the notice within thirty (30) days;
  8. The method by which recovery of the over-payment would be made, if recovery proceeds under division (B) of this section.

Please note number seven above which allows for an appeal of the re-determination.  I urged the psychologist who reached out to me to appeal the adjustment determination, including a copy of the above information.

I hope you find this reminder helpful.  Please feel free to let me know whether you have encountered similar difficulties and about any problems you had responding to such requests.  

Jim Broyles, PhD
OPA Director of Professional Affairs

 

 

 

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Insurance Core Issues: Ohio's Prompt Payment Law

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Wednesday, August 23, 2017

I have received a number of questions and requests in the past two months regarding difficult insurance issues encountered by OPA members.  The problems involved range from delayed reimbursement to challenges with prior authorizations. Since many of these difficulties stem from a few basic core issues, I thought it might be helpful, now and in the next few weeks, to remind everyone of a few important consumer and provider protection laws which give needed support for nearly every practicing psychologist who must interact with health insurance companies.  

The first of these is Ohio’s Prompt Payment Law, which establishes strict time frames for the processing and payment of claims by insurance companies.  Specifically, the law states:

  1. A third-party payer has fifteen (15) days from receipt to notify a provider when a materially deficient claim is received. Examples of materially deficient claims include claims with an incorrect patient name or benefit contracts number, a patient that cannot be identified, a claim without as or treatment code or a claim without a provider's identifying number. The fifteen (15) day time period and the time spent correcting the deficiencies do not count toward the calculation of time in which a claim must be processed.
  2. A third-party payer has thirty (30) days to process a claim if no supporting documentation is needed.
  3. A third-party payer has forty-five (45) days to process a claim if the third-party payer requests additional supporting documentation. However, third-party payers must request supporting documentation within thirty (30) days of the initial receipt of the claim. The time period of forty-five (45) days is suspended until the third-party payer receives the last piece of information requested in the initial thirty (30) day period.
    • The time period is not suspended if a third-party payer requests additional supporting documentation after receiving initially requested information.
    • A request for additional supporting documentation that is made outside the thirty (30) day time period and that is based on information received in the initial request regarding a previously unknown pre-existing condition may suspend the forty-five (45) day processing time.
  4. A third-party payer may refuse to process a claim submitted by a provider if the provider submits the claim later than forty-five (45) days after receiving notice from a different third-party payer or a state or federal program that that payer or program is not responsible for the cost of the health care services, or if the provider does not submit the notice of denial from the different third-party payer or program with the claim.
  5. A third-party payer that has a timely filing requirement must process an untimely claim if all the following apply:
    • The claim was initially submitted to a different third-party payer or state or federal program;
    • The provider submits the claim to the second payer within forty-five (45) days of receiving notice that the first payer denied the claim; and
    • The provider submits the notice of denial along with the claim
  6. When a claim is submitted later than one year after the last date of service for which reimbursement is sought, a third-party payer shall pay or deny the claim not later than ninety (90) days after receipt of the claim or, alternatively, pursuant to the requirements of sections 3901.381 to 3901.388 of the Revised Code.

Many reimbursement issues encountered by psychologists may be eligible for a complaint under this law.  For example, an insurance company may review a claim to determine whether it was medically necessary.  However, they may not withhold payment, beyond the time frames stipulated, while making this determination.  The timelines above still apply.  

If you need to file a Prompt Pay Law complaint or any other complaint with the Ohio Department of Insurance (ODI), the best way is to establish an ODI Provider Gateway Account.  Once established, filing complaints with ODI becomes streamlined.  Instructions for establishing this account with ODI may be found here:
https://legacy.insurance.ohio.gov/ODILogon/Legacy/content/Documents/PC/ProviderGatewayAccount.pdf

I encourage all psychologists who interact with insurance companies to establish this account with ODI.  Providers may also use a printed form:
http://www.insurance.ohio.gov/forms/documents/INS0505.pdf

It may be helpful to share this information with office managers.  They may contact me directly for questions and support, providing they work for an OPA member.  In the next few weeks, I will be providing information on more laws associated with these core issues of difficulty affecting many of us.  In many cases, the solution may involve interacting with ODI, so following the above suggestion will facilitate my recommendations in the future. (Please note: ODI does not govern Medicaid or Medicare plans.  Please contact me directly for help with these).

Please let me know if you have comments or questions.

Jim Broyles, PhD
OPA Director of Professional Affairs

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OPA Insurance Committee Survey: CPT Codes and Session Length

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Wednesday, June 28, 2017

Many psychologists who work in private practice have become well familiar with the many difficulties which continually develop as they interact with insurance companies. Policy and procedures imposed by these entities constantly evolve, creating an ever-moving target so difficult for many psychologists to follow. The most recent difficulty encountered by most of our members involves our use of the psychotherapy CPT (Current Procedural Terminology) codes. For those who are less familiar, these are codes which describe, through their definition, the type of psychotherapy provided (individual, family, etc.)  Individual psychotherapy codes are further specified by session time (30, 45, or 60 minutes). Most psychologists who are experienced at psychotherapy emphasize that a variety of factors, including patient need, diagnosis being treated, and clinical judgement, are considered when choosing the most appropriate procedure.

Recently, a number of insurance companies have begun to restrict or limit the use of certain codes. For example, some require preauthorization for the 60-minute code, while others have sent warning letters to clinicians who “overuse” this longer session time. Together with OPA’s insurance committee, I have been monitoring this circumstance and have felt considerable concern about the reasoning behind the emergence of these newer policies. Specifically, many of the insurance companies have justified these restrictions by reasoning that most clinicians do not use longer session times routinely. This idea stands in direct contradiction to information gathered informally by OPA’s Insurance Committee and me. Through conversation and email, many of you have reported you consider the 60-minute psychotherapy session crucial to your treatment approach with clients. Others have stated they would use the 60-minute session much more often, but are unable to due to insurance company restrictions.

In response to these confusing and contradicting circumstances, OPA’s Insurance committee has developed their own survey. The purpose of the survey is to gather accurate, objective information about psychotherapy CPT codes commonly used by psychologists and others. The survey takes only a minute or two to complete, and the results will be used to help advocate for our members on this issue. It would be enormously beneficial to our efforts if you will take that minute to participate in our survey now:

https://www.surveymonkey.com/r/XKLMWQ9

It would also be quite helpful if you would pass along the link to the survey to other mental providers in your practice or community. I will be happy to report survey results as well as other efforts related to this issue as they develop. 

On a related note, many psychologists who are Medicaid providers have been experiencing confusion regarding the implementation of Medicaid Behavioral Health Redesign. The proposed redesign changes were initially scheduled to be implemented July 1 of this year. Due to a number of concerns expressed about readiness by community mental health providers, the implementation of the redesign has been postponed.  Ohio Department of Medicaid will continue the existing mental health and substance use disorder service codes, billing logic, rates and policies until a future date for Behavioral Health Redesign implementation is determined. However, qualified Ohio hospitals who offer outpatient community behavioral health services may begin implementing the new behavioral health code set and policies beginning August 1, 2017. Please let me know if you would like further details. The Ohio Department of Medicaid will also continue staffing its Rapid Response telephone lines (1-800-686-1516, Option 9) in order to respond to questions from providers.

Jim Broyles, PhD, OPA Director of Professional Affairs

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APAPO Survey on the valuation of CPT codes

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Wednesday, May 24, 2017

You may be receiving a very important survey soon from the American Psychological Association Practice Organization. The surveys will be emailed to APAPO members, and will be gathering vital information regarding the valuation of Current Procedural Terminology (CPT) codes commonly used by psychologists, which directly affects reimbursement rates set by all insurance companies. The survey is developed by the American Medical Association /Specialty Society Relative Value Scale Update Committee (RUC). Click here to view an article from a recent APAPO Practice Update which explains the survey. It is very important for you, if you are a member of APAPO, to be on the lookout for the survey and to set aside the 2 hours it may take to complete it. If you have questions feel free to contact me.

On a related note, I received many positive comments about my last communication with OPA members regarding the letters from Change Healthcare. This group contacted psychologists regarding their billing practices and use of certain CPT codes. In that communication, I outlined concerns expressed by APAPO and OPA to Change, as well as gave specific recommendations on how to respond to their requests. During our recent OPA Convention and through email, many of you pointed out how helpful this information was. I feel compelled in response to point out to everyone that the guidance from that communication would have been impossible if not for the considerable efforts of APAPO’s office of Legal and Regulatory Affairs, specifically attorneys Alan Nessman and Connie Galietti. Both expended considerable time and effort communicating with the organizations in question, drawing on their considerable legal experience and expertise, to produce the guidance you received. This is only a small example of the ongoing advocacy and support Ohio psychologists receive from APAPO. Many psychologists today remain unaware of the vital support they receive from APAPO, and how our more local advocacy efforts are dependent on their help. I urge all Ohio psychologists to be mindful of this when making a decision on whether to become a member of this organization.

Tags:  apapo  cpt codes  survey 

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Can Psychologists Continue to Bill Medical Mutual 90837?

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Sunday, April 23, 2017

In March of this year, many psychologists in Ohio received letters from Change Healthcare, acting on behalf of insurance company Medical Mutual concerning the frequency of their use of CPT® code 90837 (psychotherapy, 53+ minutes with patient and/or family member) billed to Medical Mutual. These letters were addressed to psychologists allegedly using 90837 at a high rate compared to other Medical Mutual psychologists. Change Healthcare defines “high rate” as anyone using 90837s 70% of the time compared to 90834s or 90832s. Although these letters stated that they were for informational purposes only, some members read them as implying the possibility of onerous audits (and the possibility of refunds) unless the utilization of 90837 codes by the psychologists began to decrease. 

In the past, the Legal and Regulatory Affairs staff of the American Psychological Association’s Practice Organization (APAPO) has reached out to Change Healthcare to seek clarification of their intent in sending these letters in other states. During those discussions APAPO raised many issues about the letter. For example, APAPO staff noted that outpatient mental health practice lends itself more to the use of the longer 90837 code, while codes representing shorter time periods are more likely to occur in nursing homes or integrated care facilities. As a result, those psychologists who were allegedly high users of 90837 might not necessarily have been high users if they were compared to other psychologists in a typical outpatient practice. Furthermore, APAPO staff noted that the nature of these letters could give a chilling effect and dissuade psychologists from using the procedure codes most appropriate for their patients. 

Change Healthcare clarified for OPA and APAPO that the intent of these letters was truly to be educational (although we believe that this educational project was unnecessarily anxiety producing). Change Healthcare does not presume that a higher use of 90837 involves inappropriate billing. We learned that here will be no routine audit of those who use 90837 at a higher rate than other psychologists. Nor will Change Healthcare initiate any unusual efforts toward seeking refunds from psychologists who use the 90837 codes more frequently than others. 

Can Psychologists Continue to Bill Medical Mutual 90837?
Psychologists should continue to use their clinical judgment to determine the health care needs of their patients, including the length of a psychotherapy session. At this time, we are not aware of Change Healthcare limiting the use of 90837. We recommend that psychologists billing 90837 with Medical Mutual continue to use its billing guidelines as described in the next section. According to official guidance for CPT codes, 90834 (psychotherapy, 45 minutes with patient and/or family member) is to be used for sessions lasting 38-52 minutes. Code 90837 is to be used for sessions that are 53 minutes or more in duration. In addition, 

  • Psychotherapy times are for face-to-face services with the patient and/or family member.
  • The patient must be present for all or some of the service.
  • In reporting, choose the code closest to the actual time (i.e., 53 or more minutes for 90837).
  • Document start and end times.

Following this guidance should put psychologists in a good position if Change Healthcare later decides to review their records and/or practices. 

Finally, OPA members can contact me if their experiences with Highmark appear contrary to the guidelines described above.

Please note: Legal issues are complex and highly fact specific and require legal expertise that cannot be provided by any single article. In addition, laws change over time and vary by jurisdiction. The information in this article does not constitute legal advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.

Current Procedural Terminology (CPT®) copyright 2015 American Medical Association. All rights reserved.

Tags:  Change Healtcare  cpt code 90837  Insurance audits 

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