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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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Insurance Audits: How to be Prepared!

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Wednesday, April 12, 2017

I have spent considerable time in the last couple of years providing OPA members help and support with insurance issues. Often, concerns from psychologists arise when an insurance company questions individual psychologist’s billing or record keeping practices. When these questions are raised, psychologists often feel confused about whether, what kind, or how much information an insurance company may need, what they are entitled to, and how to provide this. This past month has been no exception to this ongoing need for clarification. Many who follow the listserv or read my emails know that Medical Mutual recently contacted several Ohio psychologists through an auditing company, Change HealthCare, to raise questions regarding billing codes used by psychologists. My experience with these issues continually leads me back to some basic suggestions for most of us who provide clinical services: a little bit of preparatory work can go a long way toward being ready for audits or other kinds of scrutiny from insurance companies. With this in mind, I would like to make the following suggestions:

  1. Make sure the initial consent document used in your practice includes language designed to provide consent for releasing patient information in response to a broad array of insurance company requests.

    For example:
    You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record.... By signing this Agreement, you agree that I can provide requested information to your carrier.

    This allows for the release of basic clinical information which may be required by the insurance company.

  2. HIPAA allows for psychotherapy notes to be kept separate from the rest of a client’s clinical record, and offers a greater level of protection for these notes.  I suggest psychologists maintain this separate record. This allows for less sensitive, more basic clinical information to be easily released in response to an insurance company audit while offering greater protection for client privacy.

  3. Most insurance companies require that we follow basic record keeping guidelines set primarily by Medicare. When billing time based CPT codes, the more general clinical record should include documentation which supports the procedure (separate from the psychotherapy note) for each session billed including:
  • Session start and stop time
  • Modality
  • Diagnosis
  • Symptoms
  • Functional Status
  • Focused Mental Status Exam
  • Treatment plan goal addressed, prognosis, and progress
  • Name, signature, and credentials of the person performing the service

Following these suggestions will help many psychologists to readily respond to most audits conducted by insurance companies for the variety of reasons that I am familiar. More detailed guidelines on record keeping will be provided during my workshop at OPA’s upcoming convention (Thursday, April 27 at 9:00 a.m.). I hope to see you there! 

Jim Broyles, PhD
OPA Director of Professional Affairs

Tags:  insurance  Insurance audits 

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