New CPT Codes for Psych Testing

New CPT codes went into effect January 1, 2019 for psychological testing.  The codes offer an opportunity to more adequately describe the testing process and improve reimbursement for this service. Late in December different pay sources starting sending out updates to these procedure codes and the new fee schedules.  Previously there was a limitation on the description of these codes. In most cases, clinicians used only one code and that often times seemed inadequate. Payers would set one allowable for these procedures and that was it. Now as the coding is more descriptive and there is a finite division of psychological testing and neuro psych testing. Two very distinct modalities. In addition, there are now add on codes much like coding for crisis intervention. See the link to the American Psychological Association that has a very nice document with the descriptions of these new procedure codes and instructions on where and when they are used. Check out this website for more information.

Medicare Fee Schedules for Behavioral Health Providers

The Medicare Fee Schedules for 2019 are ready for Behavioral Health Providers for the following states and locations:

Florida     Colorado              Nevada                  Houston Texas        North Carolina               Virginia

If you would like a schedule for a different location or one of the locations mentioned above then contact our office at 877-891-9352  or email to  (subject line; Data List) to order one and we will be happy to take your information and provide the schedule for you.

Medicare Numbers Are Changing. Are You Ready?

Next year I know you all have heard that Medicare identification (HICN) numbers are changing but the way they are changing will have your head spinning.

The Medicare HICN will now be 11 digits and there is a formula for these.  It is really about time that they did because there is a security threat with the SSN being used for seniors and others on Medicare.  All other insurances changed that method some years ago when implementation of HIPAA was put in place but it has taken a long time for Medicare to change.

The identification numbers will all be a combination of alpha numeric and depending on the order as to which it will be.  They will not be using the characters, S, L,O, I, B, or Z.

Position 2,5,8,9  will always be uppercase Alpha characters.  There are additional rules about every position and you should make sure you know what these are.

Example of Current versus New

KEY Example
SSA HICN 123-45-6789-A1

There are a number of power point presentations and lots of information on the CMS Website about the transition and what to expect.  As of this month the Medicare RA’s will be returning both the old HICN and the new MBI of your current clients.  Effective April 2018 you must be using the new MBI’s for your existing clients.

Always changing is our healthcare system.  Some law makers have sought to simplify things while others just make it more complicated.  As always we try to stay abreast of what is happening in the industry in order to keep you informed.


Tricare Changes on the Horizon

In a  recent bulletin from Tricare it was announced that they would no longer be using the federal fiscal year and they are switching to a calendar year.   What this will mean is that instead of having to meet a deductible in October they will begin applying that deductible in January instead.  So for this year 2017,  if they had met that deductible early on they will not have to meet it again.  See the article below.

Extension of 2017 Fiscal Year TRICARE currently calculates beneficiaries’ enrollment fees, deductibles and catastrophic cap limits based on a fiscal year, which runs Oct. 1–Sept. 30. Under the new TRICARE contract which will start Jan. 1, 2018, TRICARE is shifting to a calendar year (Jan. 1–Dec. 31). Because of this shift, in 2017, your TRICARE patients’ deductibles and catastrophic caps will include October through December 2017 out-of-pocket costs.
In addition, Tricare is also changing to a new intermediary to manage their network for what was called the South and the North.  They are now referring to it as the East and the West.  New boundary lines are drawn and the North and South are all part of the same territory.    That network manager is Humana Military.  You have probably received information from them in the last 6 months but if you have not all existing contracts will be transferred but if you are new to Tricare you will have to submit the necessary paperwork to Humana Military to become an in network provider with Tricare.   This all goes into effect 01/01/2018.

Coding by Duration

Recently a clinician told us that providers had been audited for the use of 90837. The CPT codes have a duration associated with them and if the notes and the duration meet the criteria there is no reason for insurance companies to audit or for you to be afraid of utilizing that code. Most sessions go longer than 45 minutes, which is the CPT definition of 90834, and although in the crosswalks provided, back in 2013 they said that 90806 translated to 90834 they were incorrect.  The 90808 was supposed to translate to 90837 however, the 90808-code definition was 75 minutes or longer which does not equate.

The APA put out a guideline some time back regarding the durations for 90832, 90834 and 90837. Here is the guideline as proposed by the APA:

16-37 minutes use 90832

38-52 minutes use 90834

53 or more use 90837

In addition there are at least two insurance companies that we know of that do not allow the 90837 unless an authorization is obtained.  They are Optima/Sentara out of Virginia and Optum/United Behavioral.   After some research we noted that Optima had a published  allowable for 90837 which makes one wonder if this rule has been relaxed.    (The original rule was regarding the 90808 code for Optima/Sentara. )

For a fact the Blues in most all states allow the 90837 as does Medicare no questions asked.  Most of the insurances we have dealt with through the years do allow this code and there is no specific criteria or red flags.  This makes us wonder if those folks that were being audited also had some other item in their billing that set off red flags with the insurance industry.

Word of caution for all providers you should always ensure that the documentation matches what was billed.  So whether using an Electronic Health Record or some sort of manual system this is as important as the records maintained for the IRS. Keeping these records in synch provides the best method for keeping your practice ethical and out of arms way for those auditors.


Large Deductibles and Co Pay Tips

Large Deductibles can be resolved in a couple ways

In our business we get asked how to deal with a client that has a large deductible.  Our responses are listed below.

  • Client can waive usage of their insurance
  • The provider may charge the client and expect to be paid the allowable or some portion of that until the deductible is satisfied.
  • If under contract with the insurance company it states that you may not charge the client more than the allowable not that you have to collect it.
  • If in a group the client can be assigned to a non contracted provider with that insurance.  Then the client may be put on a  sliding fee.
  • If out of network with the insurance the client may be charged the standard fee and the client may go elsewhere or decide to pay for that service in full.

Co Pays

With a lot of non profit agencies they struggle with how to work with co pays when the client states that they cannot afford to pay 60.00 per session.  If this is an in network provider than the contract says the client must be  charged the co pay.  It does not say that the client must pay the co pay.   So keeping this in mind what we often advise our groups is that which is stated above.  The client must be charged the co pay, a negotiation may be made with the client to accept a lesser fee and write off the difference.  The client ledger must show the 60.00 charge but it is not necessary to show a payment of 60.00.

Words of Caution

Always keep in mind that often the allowable for a service may only be 60 or 65 so that co pay may be the only reimbursement.   There are a number of Aetna policies out there with a 70.00 co pay.  Master’s level providers allowable is almost always less than that.  So the best bet may in some cases be not to use the insurance but to negotiate with the client for a reasonable fee.   Be mindful of the allowable whether  in network or out of network when co pays or deductibles are involved to ensure that you get the reimbursement you deserve for the clients you serve.

**Medicare deductible is a different animal and it is only 183.00 for Part B.  The advice is not to charge the client the deductible and wait for the explanation of benefits to come back before pursuing this with your client because they may have a secondary that picks it up.


PQRS Medicare

Just in case you missed it the latest and last revision to the rules for PQRS are listed below:

Major highlights include:

  • Individual eligible professionals and group practices that meet the criteria for 2016 PQRS satisfactory reporting/participation will avoid the PQRS negative payment adjustment in 2018
  • PQRS group practices can participate in 2016 PQRS via the Qualified Clinical Data Registry mechanism in 2016
  • There are 281 measures in the PQRS measure set and 18 measures in the group practice reporting option web interface for 2016

The 2018 PQRS payment adjustment is the last adjustment that will be issued under the PQRS. For more information about participating in PQRS in 2016, visit the PQRS website.

Medicare Fee Schedules 2016

Medicare Fee Schedules will be available for 2016 by the end of the week.  Be aware that the new deductible for 2016 is 166.00 for Part B.  Place your order now to get one sent to your office.  Information provided on the fee schedules is by discipline


Medicare Expected

Secondary or client responsibility

The expected amount will differ due to sequestration and PQRS reductions for 2016.     Please do not hesitate to contact us at for your new 2016 Fee schedule.


Fee Schedules

Medicare Regional Reimbursement Schedules are normally made available every year towards the end of January when all the fee issue shake out.  Every year since I have been doing this there is always a change and a rollback on the Medicare fee schedules.  As soon as those fees are available we update our fee schedules and make these available for you.

You can go and get your fee schedules on the internet yourself or you can subscribe to obtain them from us.  We go a few steps further in figuring out what you should be expecting Medicare to pay and what you should be expecting from your client or their secondary.  Our fee schedules also compute the allowable amount for LCSW’s because that is not published on the internet.  This is a service that you do not have to be a contracted customer with DBMA in order to obtain these schedule.

In addition, we also have other insurance fee schedules available and we have recently added Tricare to our list of companies that we calculate how the coverage will play out according to the Tricare plan the individual is on.   If you are interested in any of this, please feel free to send us an email or contact our office.  We are always happy to serve this community.

Who’s Who?

Who’s on first?  This is my new saying as I try to work with the different insurances only to find out they have been bought by one entity or another.  Recently I was invited to go to a meeting in Houston and the speakers were going to be Beacon Health Strategies.  When asked who they were I remarked I think they bought PsychCare.  I was right but they also bought Value Options and although I think the two will maintain their names for awhile they pretty much have shut down the PsychCare website where I used to check eligibility on Humana clients.  We were having to call which is a big hassle trying to get through to the right place at PsychCare because you have to be intuitive to know which number to choose to get to Eligibility and Benefits because it is not an option.  Pet peave.  Always has been for me that the choices with the IVR do not include Benefits and Eligibility.  But I digress.  In addition Coventry bought MH Net last year or maybe the year before and Aetna bought Coventry so they are all operating with the different names but when you dig deeper you find that the credentialing is all done by Aetna.  Payments still come from the different entities. We keep trying to stay ahead of that ball to make sure our claims and credentialing information go to the correct place.  It is always a challenge.