2013 has marked a significant year for coding changes for psychiatry and psychology. As with other specialties, the AMA provided a clear division of coding for psychotherapy services as opposed to medical management of patient problems. CMS has adopted most of the new coding regulations put forth by the AMA yet, many State Medicaid plans have narrowed the scope of coverage within the code series.
As with all insurance plans, the key to getting proper payment is understanding covered services, provider credentialing and appropriate coding/documentation to support the claim. Psychologists have numerous coding limitations that are regulated on both a State and Federal level. Gill Compliance Solutions researched several northwest states to compare Medicare rules against Medicaid based on the new changes. In a Medicaid Information Release for Idaho(MA12-12), applicable to, the uses of codes 90791 and 90792 have different time requirements as compared to both AMA and CMS rules. For most payors, a time requirement is irrelevant for submitting these codes. Yet, for this plan, a “unit based” time criteria is required to quantify the patient benefit eligibility and level of reimbursement for each 15 minute increment. This State plan provides a 4-hour annual benefit for both assessments and reassessments. The unit value is the quantifiable measure to track this member benefit. Further, as the AMA provided a new code for crisis management (90839) as a stand-alone service, many Medicaid plans are not recognizing this code for credentialed psychologists. These are only a few examples of how State and Federal plans may complicate billing outside of the new coding requirements.
Another guideline, relevant to both psychiatrists and psychologists, is the new time requirement for psychotherapy services 90832. AMA guidance requires a minimum time of 16 minutes for this service to be reported. A provider should be extra cautious about time documented in the permanent medical record and checking Medicaid guidelines on psychotherapy under the 16 minute increment. Many plans will not reimburse for any code if this minimum criteria is not met.
As a reminder, keep tabs on MAC decisions along with CMS updates as they will continue to develop regulatory criteria.