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.