PRACTICE ISSUES: New CPT codes causing headaches after implementation
At first glance, the new CPT codes that went into effect Jan. 1 involved swapping a set of old numbers for new ones. But the transaction has not been entirely smooth, or so we hear from billers and clinicians.
Among other issues, not all insurance companies have released new fee schedules. Others have said fees would transfer over from the old codes even though the new codes aren’t directly comparable. It’s almost like comparing apples and oranges.
Finally, a major concern has developed over what therapists should be billing for if they routinely do 60‑minute sessions. More on that below.
We do hear from Susan Frager of Psych Administrative Partners, however, that things could be worse. “In my neck of the woods, and I can’t speak for everybody, it’s not like I’m noticing a pattern of problems,” says Frager, who is based in Lacey, WA but also does work for therapists in other parts of the country.
Medicare, she says, “has been a little slow” on releasing it fees because Medicare acted at the last minute to avert the 27% rate cut that would have gone into effect under the Sustainable Growth Rate provision. That automatically puts fee cuts on the table unless Congress overrides them.
United Behavioral Health has released a new fee schedule, as have some of the Blue Cross carriers, according to Frager. “Others have just basically said they’re going to pay the same.” They include ValueOptions and Cigna.
But the session times for the new codes are slightly different, so there’s confusion about how they translate. For example, a 90806 was 45 to 50 minutes, and a 90808 75 to 80 minutes. Under the formula used to round up, you could go up to 62 minutes and still bill for a 90806. But once you went to 63 minutes, you needed to go up to a 90808.
Some therapists have found reimbursement rates transferred over to the new codes smoothly and easily. United Behavioral Health, for example, did an equitable transfer from 90806 to 90834 for LCSWs, but ended up paying psychologists in Virginia $1 less. “What the rationale is for that I don’t know,” Jean Thoensen says.
Blue Cross of Virginia and Anthem of DC announced rate increases last year and stuck with those increases under the new codes. Texas rates have gone down slightly.
Thoensen adds: “Coventry pays social workers in Virginia the least of anyone I have seen except Medicaid. But the first claim for a Coventry person came back with a note saying they have the new codes but haven’t priced them yet.
“The allowable they came up with, for that claim, is about twice what they usually pay for a 90806.
“They have not created a fee schedule, and I don’t know what they based it on. But it’s perfectly legitimate for a payer to do that. They can pay claims based on some temporary formula until they settle on fees.”
Note: If you find a payer who rejects a bill with the new CPT codes, you can file a HIPAA complaint with the Department of Health and Human Services (HHS). Go to: https://sei.cms.gov.
“When you look at the new codes, it actually lays out the minutes much more specifically” notes Jean Thoensen, of PsychBiller, in Centreville, VA. “In the behavioral health section a 908934 is 38 to 52 minutes.
“That fits the 45‑ to 50-minute category, but not the 60 minute. That now gets shoved up into a 90837, which is 53 to 90 minutes. We don’t have a 75‑minute or a 90‑minute code anymore.”
The problem is, there’s a widespread assumption among billers and providers that insurance companies won’t reimburse for the new 90837 - or at least they won’t reimburse without prior authorization. So therapists who regularly bill for a 60‑minute session are still unsure what they should do.
In fact, if they’re in-network they probably need to adjust their session closer to 52 minutes of they wan to avoid the pre-authorization hassle, Thoensen says.
She suggests that out-of-network clinicians who do 60 minutes bill for the 90837 and charge the client for the additional time. But here’s the caveat: “If you’re doing it with the knowledge that a 90837 is a difficult code to get reimbursed, you’ve just handed that person a receipt that you know they might have trouble getting reimbursed for.”
Contacts: Jean Thoensen in Centreville, VA at (703) 266-8612, firstname.lastname@example.org; Susan Frager is in Lacey, WA, at (360) 628-8612; email: email@example.com.