EHR and practice management for mental / behavioral health

CPT Code Changes: Additional Q & A

Many providers have questions about the CPT® Code Changes effective January 1st, 2013.  Here’s a list of additional Q&A, but first, a brief overview:

The codes used for billing common psychotherapy services are being changed, and the old codes can no longer be used as of January 1st, 2013. These changes are mandated on a federal level by HIPAA and can affect billing systems, contracts with payers and documentation requirements. Further research is required by each practice before the January 1st change date to make sure that practices code to their payers’ specifications, both public and private.

How do these changes affect me as a mental & behavioral health care provider?
The most commonly used codes for psychotherapy are affected, especially the 908 codes. The AMA 2013 CPT® code book (click here to purchase) is the final word on the changes, and there are a multitude of resources available.  Some examples are our overview blog and summary chart of the changes.  While this informational guide in intended to help practices make sense of the change regulations, it is the responsibility of each practice to insure compliance.

When should I start using the new codes?  What happens if I bill using the old codes?
You should start using the new codes as of January 1st, 2013.  If you bill using the old codes, you should expect the claims to be rejected by both private and public payers and may need to re-file.

What about old and new codes straddling the change-over date of January 1st, 2013?
If you have open authorizations that straddle the change-over period, you may need to apply for new authorizations. The former codes may not have been included in the maximum visit limits. Now, with psychiatrists using the E&M (evaluation & management) codes, if those codes are included in the maximum event limits, the authorizations will be exhausted more quickly.

I’ve heard that the contracts with my payers may need to be revised because of these changes–is that true?!  What about changes in fee schedules and payments?
Most provider contracts by managed care and other insurance companies review particular CPT® codes in the fee schedule only—typically, the payment amounts in this appendix are designed to be adjustable as rates change without creating the need for a revision of the main body of the contract.

Because of this, there may not be a need to revise your payer contracts, but this is some of the research that each provider will need to engage in as part of the code changes: you’ll have to contact your payers to confirm whether or not a new contract is necessary and if there will be any change in payment amounts.  You should also regularly check their websites for updates.  Some carriers will proactively issue new fee schedules, and you can expect to receive some documentation this fall.

Has Medicaid released their revised payment rates?
According to the APA Practice Organization, the Centers for Medicare and Medicaid (CMS) “declined to make a final decision about the value of the professionalwork associated with the new family of CPT®psychotherapy codes that take effect on Jan. 1, 2013.”

They have created estimated Medicare lists with 2 rates: One column lists the payment amount including the considerable Sustainable Growth Rate (SGR) cut of 26.5 percent across-the-board for all Medicare services scheduled to take effect Jan. 1, 2013, while the adjacent column has payment rates without the SGR cut.

What happens if I have problems with Medicare billing and reimbursement?
You can start by contacting your Medicare Administrative Contractor (MAC), but keep in mind that some of the MACs are changing by year’s end.  You can also contact the regional office of the Centers for Medicare and Medicaid Services (CMS).

I’ve seen some documents that list 90801 being replaced by 90791 and 90792, but others show 90801 only replaced by 90791.  Which is correct?
Both.  90801, psychiatric diagnosis evaluation, typically does not include medical services, so you will see charts that list only 90791 as the new code to be used: psychiatric diagnosis evaluation with no medical services.  However, if medical services are included in the diagnosis, 90792 is the appropriate new code to use: psychiatric diagnosis evaluation with medical services.

When changing the code from 90801, E/M (evaluation & medical) codes can be used in place of 90792.

When changing the code from 90802, interactive psychiatric diagnosis evaluation, 90791 or 90792 should be used, plus interactive add on code +90785.

What about other discrepancies that I see on different things I’m reading?  Not all of them have the same info listed. 
While many organizations have tried to provide helpful information & resources (PIMSY included!), the only true authority on the subject is the American Medical Association.  Your best bet is to compile your resources, note any differences that you’re seeing and verify all of it with the AMA 2013 CPT® code book (click here to purchase).  Ultimately, it is the responsibility of each practice to ensure compliance with the changes and contact their payers to confirm that they code to their payers’ specifications, both public and private.

I’ve noticed that the new codes are very specific about the time period covered.  What happens in my session falls in between the times specified?
The new basic psychotherapy codes are:

  • 90832: 30 minutes with patient and/or family member, no longer site specific
  • 90834: 45 minutes with patient and/or family member, no longer site specific
  • 90837: 60 minutes with patient and/or family member, no longer site specific
  • Between 1-15 minutes: not reported
  • 90832: between 16-37 minutes: patient must be present for all or some of service
  • 90834: between 38-52 minutes: patient must be present for all or some of service
  • 90837: 53 minutes and beyond: patient must be present for all or some of service
  • Note that the reimbursement for 90837 will be paid regardless of time over 53 minutes that the session lasts.  Be sure to check with your payers for this amount. 

How can I find out more?
Check out our CPT Code Resource Center for more complimentary tools.

Disclaimer: PIMSY EMR/SMIS has gathered information from various resources believed to be authorities in their field.  However, neither PIMSY EMR/SMIS nor the authors warrant that the information is in every respect accurate and/or complete.  PIMSY EMR/SMIS assumes no responsibility for use of the information provided.  Neither PIMSY EMR/SMIS nor the authors shall be responsible for, and expressly disclaim liability for, damages of any kind arising out of the use of, reference to, or reliance on, the content of these educational materials.  These materials are for informational purposes only.  PIMSY EMR/SMIS does not provide medical, legal, financial or other professional advice and readers are encouraged to consult a professional advisor for such advice.

Author: pehradmin

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