Medicare Reimbursement Schedules 2013

Medicare has put out their reimbursement schedules for 2013.   DB Management configures these reimbursement schedules for the Behavioral Health Community and has them available for sale.  These schedules are calculated according to allowable, expectation of payment from Medicare and secondary or client responsibility.  The new CPT codes are included in these schedules along with Office EM codes that physicians and other prescribers will have to use.  These are available by sending us an email and requesting them.  If you would like one for your state and location, please contact our office via email at  Updates to these schedules for 2013 due to a rollback that will not occur until probably February will be provided at no extra cost.   Just an FYI the new Crisis Intervention codes are not covered by Medicare, however they are covered by some insurers.  Please feel free to leave a comment or a question in the comment section and we will get back to you.

All about 3rd Party Reimbursement for Mental Health

It occured to me this morning that I had been working in the field of 3rd Party Reimbursement for more than 31 years now.  I have seen the changes and watched it evolve.  In the early days there were not many insurance companies covering mental health.  Medicare did not even cover it when I first began.  There were a handful of insurance companies that would cover mental health services but usually on a very limited basis.  The changes have not all been good or bad and I have adapted to all of them.  Still there is a common problem that has not changed.  In the beginning the very wealthy could get mental health services and the very poor.  This has not changed.  The hard working middle class still has the problem of adequate coverage for mental health services.  

I recall a situation back in the 80’s where a young girl who had some sort of  explosive disorder.  I don’t recall the exact diagnosis but she had been place in a private inpatient unit.  After so many days the insurance benefits exhausted and the hospital was ousting her even though her treatment had not not been completed and she was still a danger to herself and others.  I worked with the mother and the insurance company on this case to get those benefits extended and we moved the patient to another hospital that was more reasonably priced and had a good success record.     The young girl was treated for several more months and then released to a halfway house.  I lost track of what occured next but this was the 80’s.     The first hospital has since gone out of business and it’s treatment or rather lack of treatment and high cost were very much publicized when it went bankrupt in the early 90’s.

 Some folks have good insurance through their employers while many are just struggling to get by and purchase a basic healthcare policy.  When an individual is looking for an insurance policy or even an employer the mental health benefits are not usually high on their list of priorities.  So as a result what we are seeing are large deductibles and large co pays which make the access to mental health services for those folks unaffordable.  A 45-50 co payment for a client is pretty much unreasonable considering the allowable in most plans is between 50-80 for a therapeutic hour session.   Some plans pay a little more some a little less in their allowable.  This all depends on geographics and the discipline of the provider.  But this is the general range of reimbursement. 

So as the tragedy in Newtown and the tragedy in Aurora weigh heavy on our minds these days and what we are going to do to address this growing problem, the discussion about better access to mental health services has to be on the top of that list.  I am not sure what has happened as a society that we are spawning these deeply disturbed and violent individuals,but if we are to attack this problem we must also attack the issues that many parents have concerning better reimbursement for mental health. 

The insurance reimbursement for mental health services though improved with the passage of mental health parity a few years back it still needs a lot of work.  It only applies to large employer groups and not individual policies.  I don’t know that I have any answers about what we need to do but I would share what I have learned through the years with those that can make a difference and stop all this pain.

More on CPT Coding Changes 2013

Many of my customers have been asking me about the new code changes and some of the answers are not quite clear.  You see most of the insurance industry has latched on to the idea that the former code of 90806 translates to 90834.  Well here is the problem with that 90834 is for 45 minutes.  Most of my customers will provide 55-60 minutes of therapy.   They more or less did away with the 90808 and they say they replaced it with 90837.  The other issue is that most of the insurance companies have latched on to this crosswalk and our fear is that they will not allow 90837 to be used routinely.  In fact the reimbursement for 90834 by Florida Medicare standard is about 43.00 for 2013.  This is extremely low.  So I would suggest using 90837 sparingly as we venture into 2013 and watch for indicators that your pay sources will pay for this code as opposed to using the 90834.   Just a suggestion and an experiment as we venture into these uncharted territories.

Medicare Reimbursement Changes 2013

There are a few things to be aware of for the coming year. The Medicare deductible goes up to $147.00 in 2013 and the Psychiatric deduction for reimbursement is now 81.25% instead of 75% as in recent years.  In addition the allowable for Medicare rates although the new published rates are down from last year will be reimbursed at 65% for service codes that begin with 908XX.  Hopefully Congress will intervene and correct this reduction of fees like they have every year since about 2003.  

The new evaluation code is 90791 for Initial Assessment w/o Medication Management and 90792 for Initial Assessment with Medication Management.   There are also some add on codes that become very confusing about when and where to use them.   This I would state will iron themselves out in the new year.  There are a number of places that are providing seminars etc… on the new coding and you would benefit your practice to read up and find out as much as you can.  

As always we are trying to stay ahead of the ever changing reimbursement environment.  We invite your comments and suggestions of information you would like to see discussed here.

NPI Updates

Attention Providers, did you know that when you went on line and obtained an NPI number that you were expected to keep that user name and password in a safe place because as you move through your life and times you are expected to update that information?  If you do not know your user name and password it would be prudent for you to call 800-465-3203 and obtain your user name and password.  Your information in NPI must match your information with Medicare.

CPT Coding Changes for 2013

During the past month or so we have received announcements from the Florida Federal Advocacy Coordinator for the APA and the National Council for Community Behavorial Health Care regarding changes for CPT Coding in 2013.   As we have reviewed this infomation it is noted that the most significant changes are for Psychiatrist and nurse practitioners.  A crosswalk regarding these coding changes is attached below.   It appears that beginning in 2013 those medication providers will be using a two code system.  The first code will be an evaluation and management code followed by an add on code.   For those providers who do not do medication management it is more of a simple change from 90804 to 90832.  For the Interactive codes you are permitted to use an add on code when complexity indicates the need for one but in general the crosswalk shows that the codes 90804, 90806 and 90808 will be deleted and replaced with 90833, 90836, and 90838.  


The Medicare rate schedule should be out by the end of November and perhaps at that time we will see some mention of this but at this time none of the Medicare MAC’s have mentioned this change nor have we seen anything coming from the different insurance carriers.  All this information is coming from the various associations and has not been implemented or addressed by insurance companies at this time.  We will have to wait an see how they intend to handle the transition.  More on this as things come up.

October 30, 2012     Update we have just received notification from New Directions who is the Managed Care for BCBS of Florida that these codes will be changing effective 01/01/2013.  We have yet to see anything posted for Medicare at this time.  More as these changes are recognized by the different insurors.

Medicare Fraud

Today in the news there was a flash across the screen concerning  the arrest of providers for Medicare Fraud.  Be aware of what constitutes fraud and what you can do to keep your practice ethical and legal.  Fraud is when services are either not considered necessary because the diagnosis and patient’s condition do not require the type of treatment that you are billing for or services that are billed were not provided.  The Medicare Population may not always have the best memory about the visits, so you need to protect yourself.  One of the ways I would suggest is that you maintain your records accurately and obtain a signature each and every time you see a client.  You can use a sign in sheet with removable labels so as not to compromise confidentiality.   I would also recommend that you make sure  clinical documentation backs up each and every visit.  The documentation should include a note that confirms your diagnosis and prognosis on each and every visit.  If Medicare comes knocking on your door you will be asked to produce this and because you are a Medicare participating provider you must comply.     Some of the things these providers that were arrested are clearly fraudulent and make it really bad for the rest of providers that are merely trying to make a living.  So my advice to you is keep good records.  Make sure that if you are billing for a service it was indeed provided and you have the documentation to support it.


Great West Health Information

Behavioral health benefits for your patients with a GWH-Cigna ID card are now being managed by Cigna. This change was effective May 1, 2012. Benefits for these patients had previously been managed by Value Options.

Contact Information
If you need to verify eligibility and benefits for your patients with a GWH-Cigna ID card, please contact us at 1.877.299.0656.
If you have questions regarding a claim, please contact us at 1.877.299.0658.

If you need an authorization, need to determine authorization requirements, or need to find a list of health care professionals for a referral, please contact us at 1.866.912.3339.
The claim address for your patients with a GWH-Cigna ID card is:
1000 Great West Dr
Kennett, MO 63857
If you submit claims electronically, the payer ID is 80705.
If you have contracting or credentialing questions, please contact your provider services department at 1.800.926.2273.

Mental Health Parity and the Affordable Healthcare Act

Currently the Mental Health Parity Act that was put in place in 2008 is only law for large group policies-those with 50 or more employees.  So a small group or an individual policy does not have to comply with this law.  In addition usually small groups or individual policies do not have to comply with most state laws concerning mental health.   This will change, in part, in 2014 when the Affordable Care Act requires such plans to cover an essential set of services including mental health and substance abuse.    Mental Health Parity only speaks to the limits that were in force the visit limits and dollar limits.  It does not speak to deductible but it is supposed to speak to out of network benefits.  If out of network benefits are a part of the policy for say Oncology they are not permitted to exclude mental health or substance abuse.   Bottom line is consumers need to pay attention to where they are getting coverage.