National Psychologist March/April 2013, Vol 22, 2, pp 3, 20.
Psychotherapy code changes confuse providers and payers
By Paula E. Hartman Stein, Ph.D.
January brought changes in the business of psychotherapy with a new family of Current Procedural Terminology (CPT) codes that are wreaking havoc, and APA underestimated the confusion that would ensue. A Sept. 13 email to members said, “The changes are minimal.”
“We have total chaos out there on these codes with both the providers and the payers,” said James Georgoulakis, Ph.D., APA’s representative to the AMA’s Relative Update Committee (RUC). “I think we may have underestimated the problems and the challenges. This is the first revision of the psychotherapy codes in many years. A lot of psychologists do not read the CPT manual and did not even know the codes were being changed.”
He said the American Psychiatric Association told its members there is little information available about how the new codes should be interpreted by Medicare or private insurers and to expect that each company will have its own rules and interpretations. He also noted that the Local Coverage Determinations (LCDs) have not yet been developed.
Antonio Puente, Ph.D., the only psychologist on the voting panel of the AMA’s CPT committee, said he worries that insurance companies do not understand the new codes. “Some companies did not load up the codes quickly enough, and there were kickbacks from some of the companies.”
Insurers had about five weeks to make changes after The Federal Register published reimbursement rates. “We have over 40 codes with changes, which is a paradigm shift of seismic proportion,” said Puente. “If providers get a code kicked back they should be patient, track carefully, assume nothing and educate profusely,” he said. “They may be able to quickly and easily solve the problem.”
Georgoulakis suggested that psychologists who experience claims rejections not easily resolved contact Randy Phelps, Ph.D., who heads a new department in APA involving economic issues.
On the provider side, Puente said psychologists are erroneous who believe that the new 60-minute psychotherapy code, 90837, is the same as the old 45-minute code. “I think that is one of the largest mistakes occurring in the professional world right now,” Puente said. “The old 45-minute code equals the new 45-minute code. People should not code by the income they want; they should code by the service that is necessary.”
Currently there is no 90-minute code. Puente suggested that in cases when extended time is needed, providers may use the 60-minute code with modifier 22, which means an extended service. “APA is very interested and the American Medical Association (AMA) is very receptive to the development of a new 90-minute code, but right now it is only conceptual in nature,” Puente said.
Several already accepted psychotherapy codes have not yet been surveyed, part of the reason that Medicare reimbursement has not increased despite higher work values for many psychotherapy codes.
According to Georgoulakis, “The codes must be surveyed and reviewed between the April and September meeting of the RUC. If they don’t, the values we have of the codes will be frozen in 2014. It must be done.”
Georgoulakis was recently appointed to the research subcommittee of the RUC that oversees surveys of work values of services reimbursed by Medicare. Work value is based on time involved, technical skill, physical and mental effort, judgment and stress due to potential risk to the patient. Codes that still need to be valued are crisis intervention, interactive complexity and pharmacological management for psychologists.
“We will allow an expert panel with members from psychiatry, psychology and social work to do a modified survey that is not as extensive as the one last year,” Georgoulakis said. “The three groups will make a proposal to the research subcommittee.”
Georgoulakis said that the RUC makes reimbursement recommendations to the Center for Medicare and Medicaid Services (CMS) and the CPT committee determines definitions of codes. “Just because there is a CPT code does not mean there is reimbursement behind it. For example, at this point CMS has not made a decision as to whether they are going to pay at all for the medication management code for psychologists.”
Another caution relates to the use of psychiatric diagnostic evaluation codes, 90791 and 90792. The 2013 CPT manual indicates these codes “may be reported more than once when separate diagnostic evaluations are conducted with the patient and other informants.”
According to Georgoulakis, there is no guarantee that Medicare or any payer will adhere to the CPT definition. “The issue of the number of times a code will be paid is a payment policy issue, not a CPT issue.”
Puente and Georgoulakis want psychologists to be better informed. Puente put up a website, www.psychologycoding.com. He also conducted a three-hour webinar for the North Carolina Psychological Association with the goal of having it disseminated to other state psychological associations.
Georgoulakis is critical of APA for not devoting significant time to the issues at the upcoming August convention. At press time only a one-hour session about CPT coding sponsored by Division 40 is scheduled. “The topic of coding and billing ought to be a keynote, not a footnote,” Georgoulakis said.
Paula E. Hartman Stein, Ph.D., a clinical geropsychologist in Kent, Ohio, was on the Technical Consulting Group that helped determine work values for psychology services. Her website, www.centerforhealthyaging.com, offers webinars on the pay for reporting system, PQRS, and free powerpoint slides produced with Cameron Camp, Ph.D., on CPT coding when treating persons with memory impairment. She plans a webinar this spring on payment issues affecting psychotherapy codes.