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.

https://www.apaservices.org/practice/reimbursement/health-codes/testing

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 dbmabill@dbmafl.com  (subject line; Data List) to order one and we will be happy to take your information and provide the schedule for you.

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.

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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.

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 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

Allowable

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 dbmanagement@dbmafl.com for your new 2016 Fee schedule.

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 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.

This was in a newsletter from ValueOptions and I believe it responds to an age old question I have received for many years as to why Clinicians are taught in school to diagnose with DSM when the standard for billing has always been ICD.

Both DSM and ICD codes are used for diagnosis, but per HIPAA, ICD must be used for billing purposes. DSM-5 utilizes ICD-9-CM and ICD-10-CM coding depending on the date of service. The move from ICD-9 to ICD-10 is a rather large change. Some highlights include:

• · The number of characters are increasing from 3 to 5 characters to 7 characters
• · Codes can be alpha or numeric on any character
• · The number of codes is growing from approximately 14,000 to 69,000 codes
• · The concept of one to many is introduced with the possibility of a single ICD-9 code now having multiple ICD-10 codes and descriptions
• · Some concepts will be retired – an example is substance dependency where dependency is replaced by use and specific substances are documented vs. polysubstance

Overall, by using ICD-10, documentation should improve

Claims Implications

For purposes of claims payment, the correct ICD diagnosis coding should be utilized based on the date of service. For dates of service prior to October 1, 2015, the ICD-9 coding format should be utilized. For dates of service October 1, 2015 and later the ICD-10 diagnosis coding should be the format utilized. Claims will need to be split between these two dates if submitting for a range of dates.

This applies to all claims regardless of the method of submission.

In Addition, I found this little crosswalk that I thought might be useful.  For more information on this, contact our office at 877-891-9352

We are often asked this question about Co pays, Coinsurance and Deductibles.  We must talk on this topic at least 5-10 times a week to one customer or another.

1) Can you charge the client less than the co pay?

The answer is No you must charge the client the co pay on your ledger but what you accept is between you and the client.  If you are contracted with an insurance company the specific wording in your contract says that you may not charge your client more than the allowable or expect them to pay more than the allowable.  It does not say you cannot accept less than the allowable.  Be aware of what your allowable is for a specific service and do not shortchange yourself.  For instance many times I find that the co pay exceeds the allowable.  So your client comes to you and says I cannot afford 60 per visit so you slide it down to a more reasonable amount for this client and then the insurance comes along and applies all to the co pay and you get whatever you got from the client.  This is something I try to help our customers be aware of when we do the verification of benefits.

2) What is the fee for this client when the client has a coinsurance?

Co pays are a flat amount each service, but coinsurance is a percentage of the allowable for that service.  This amount will differ from service to service.  If you do 45 minutes or 60 minutes the coinsurance amount will change so you can’t set a flat amount for each service unless you intend to do the same service each time.   You must show on their ledger that you charged them the correct coinsurance and no more.  Again what you decide to accept as payment from your client is your business.  The accounting just needs to show that you did indeed charge them that amount.

3) How should I handle the deductible?

Here is the problem with deductibles,  other providers can meet that deductible it is not just your practice.  Be aware if your client is going to other types of providers because if I was to tell you that it will take 10 visits @60.00 per visit to meet that deductible it may take less because the client has seen another provider for a different service and it has been applied to their deductible.  Again if you are contracted with this insurance you do not want to charge the client more than the allowable until they meet that deductible.  If you are not contracted with the Insurance you may charge them your full fee.

These items tend to trip providers up a lot and we try to warn our customers against charging a customer a flat rate to meet the deductible it may be better to take a percentage of the allowed amount and advise them that once the claim has been processed by the insurance there may be a difference that they will be responsible for at a later date. Or you may choose to eat that it is entirely up to you.   Some of our customers use this method if the deductible is less than 1000.00 they will charge the client 50% each visit until deductible is met and if it is more that 1000 but less than 2500 they will charge the client 70-80% your choice until that deductible is met.  If more than 2500 then they charge the client 100%.  But of course it is your practice you can decide which way to do it.  Your billing person should advise you when the insurance starts paying and the client fee can be adjusted.