What is the purpose of this comparative billing report (CBR) on psychotherapy and evaluation and management (E/M) services?
CBR201607 was created to inform psychiatrists (specialty 26) about their billing and payment patterns on claims for psychotherapy and E/M services rendered in the office (place of service 11). This CBR examines Current Procedural Terminology (CPT®) codes 90832, 90833, 90834, 90836, 90837, 90838, and concurrently billed E/M CPT® codes 99211 through 99215. We reviewed claims submitted with dates of service from January 1, 2015 to December 31, 2015 and included only Fee-for-Service Medicare (Original Medicare) claims. To obtain more information about CBRs, please visit our website page at Comparative Billing Reports.
Why was this topic chosen?
Psychotherapy and E/M services was selected as a topic because various reports determined that Medicare has made improper payments for psychiatry and psychotherapy services. The findings indicate that numerous mental health services provided were medically unnecessary, insufficiently documented, rendered by unqualified providers, and/or billed incorrectly. The Office of Inspector General (OIG) estimates that Medicare allowed $185 million for inappropriately billed E/M services which did not meet Medicare Program requirements. Please visit the below OIG websites to view more detailed information:
- Medicare Part B Payments for Mental Health Services
- Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010
How many providers received the comparative billing reports?
The reports were sent to approximately 4,300 Medicare providers with the specialty of psychiatry (26), as submitted on their claims. Each CBR contains a provider’s billing history and patterns and compares them to his/her peers. If you did not receive a CBR and wish to review a mock provider’s CBR letter, see the following link: CBR201607 Sample CBR.
What specifically does the report focus on?
The report focuses on rendering providers with a specialty of psychiatry (specialty 26), who submitted claims with the CPT® codes covered in this CBR. The metrics examined:
- Percentage of Psychotherapy visits billed concurrently with E/M services
- Average minutes of Psychotherapy per visit
- Average Psychotherapy services per beneficiary
If you did not receive a CBR letter and wish to review a sample of a mock provider, please visit the CBR website at CBR201607 Sample CBR.
Does the information in the CBR change or alter the documentation and billing requirements established by the Medicare Administrative Contractors (MACs)?
No. The CBR does not alter, change or negate any of the documentation and billing requirements established by the MACs. The CBR is only for education and information. If you have questions about billing, please contact your MAC. A list of MACs is located on the Centers for Medicare & Medicaid Services (CMS) website page at the link titled, Review Contractor Directory – Interactive Map.
Did I receive a CBR as the result of an audit?
No. The CBR team does not conduct any audits. The CBR is disseminated to providers to offer insight into billing trends and allows a provider to compare his/her billing patterns to those of his/her peers. Providers are encouraged, however, to take advantage of the self-audit resources that can assist with setting up an audit process, which are available on the CBR website page at Self-Audit Help.
What is the definition of psychotherapy?
According to Wisconsin Physicians Service (WPS) Insurance Corporation’s LCD L34616, “Psychotherapy is defined as the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the patient and through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development or support current evaluation of functioning.” To read more about the different types of psychotherapy, select the following web link: WPS LCD L34616.
What is the difference between psychotherapy and psychoanalysis?
Wisconsin Physicians Service Insurance Corporation’s LCD L34616 states, “The practice of psychoanalysis is using special techniques to gain insight into and treat a patient’s unconscious motivations and conflicts using the development and resolution of a therapeutic transference to achieve therapeutic effect. It is a different therapeutic modality than psychotherapy…the provider using this technique must be trained by an accredited program of psychoanalysis.” To review the documentation requirements for psychoanalysis, see the website page at WPS LCD L34616.
Can elapsed time and/or counseling and coordination of care be used to bill E/M services rendered on the same date of service as psychotherapy?
No. When an E/M service is performed on the same date as a psychotherapy service, the E/M service must be chosen as the service to be billed based on the elements of history, examination and medical decision making. This information is found in the CPT® Manual instructions regarding psychotherapy. The CPT® Manual is available from the American Medical Association website page link at AMA Store.
Can prolonged service codes be billed when psychotherapy is billed without an E/M on the same date of service?
Yes, but only with CPT® code 90837 (psychotherapy, 60 minutes with patient and/or family), and only when the total time spent in psychotherapy lasts 90 minutes or longer. When the service occurs in an office or other outpatient setting, CPT® code 99354 should be billed for the first hour of prolonged service and CPT® code 99355 should be billed for each additional 30 minutes. When the service occurs in the inpatient or observation setting, CPT® code 99356 should be billed for the first hour of prolonged service with CPT® code 99357 for each additional 30 minutes. This information is found in the CPT® Manual under the description for CPT® code 90837 (psychotherapy, 60 minutes with patient and/or family). The CPT® Manual is available from the American Medical Association website page link at AMA Store.
Can prolonged service codes be billed with psychotherapy when an E/M is rendered on the same date of service?
No. According to the CPT® Manual instructions regarding psychotherapy, prolonged services may not be billed when psychotherapy with E/M (CPT® codes 90833, 90836, 90838) are submitted on a claim for the same date of service. For coding assistance, see the CPT® Manual on the American Medical Association website at AMA Store.
Is a separate diagnosis required for each service when psychotherapy and an E/M service are billed on the same date of service?
No, according to the CPT® 2015 Professional Edition under the heading of Psychotherapy, “A separate diagnosis is not required for the reporting of E/M and psychotherapy on the same date of service.” For additional information, see the CPT® Manual that is available on the American Medical Association website at following link: AMA Store.
Can independently licensed social workers bill for psychotherapy with an E/M service?
No. According to the Medicare Claims Processing Manual, Chapter 12 (covering physicians and nonphysician practitioners), “Clinical psychologists and clinical social workers cannot bill for psychotherapy services that include medical evaluation and management services under Medicare.” Cahaba Government Benefit Administrators (GBA) LCD L35941 states that “Psychotherapy codes that include an evaluation and management component are payable only to physicians, NPs (nurse practitioners) and CNSs (clinical nurse specialists).” For more information, see the below links:
My patient walked out of the session after 10 minutes of psychotherapy. Can I bill the lowest level (CPT® code 90832) and append modifier 53, denoting a discontinued procedure?
A. No. Psychotherapy can only be billed if the session has passed the half-way point of the time described by the code. In order to bill CPT® code 90832, at least 16 minutes of the session must have elapsed. This is in accordance with the CPT® guidelines for timed services which states, “A unit of time is attained when the mid-point is passed.” The CPT® Manual is a resource for additional information on the American Medical Association (AMA) website link at AMA Store.
Is behavior modification a separately billable service?
A. No. According to LCD L35941 from Cahaba GBA, behavior modification is an adjunctive measure in psychotherapy that is not considered to be a separate service. To review documentation requirements for this intervention, select the web link at Cahaba LCD L35941.
What information should be included in the treatment plan, and how often should it be updated?
Cahaba GBA LCD L35941 states that the treatment plan should include measureable and objective treatment goals, descriptive documentation of therapeutic interventions, frequency of sessions, and estimated duration of treatment and should be updated on a periodic basis, generally at least every three months. For more information about documenting patients’ treatment progress, visit the following website: Cahaba LCD L35941.
What type of documentation must be submitted for psychotherapy services?
According to Novitas Solutions LCD L35101, psychotherapy services should include the following documentation:
- Time spent in the psychotherapy encounter and the therapeutic maneuvers used during the encounter
- Type of service (individual, group, etc.)
- Therapeutic techniques and approaches, including medications
- Identity of person performing the service
- For services that include an E/M component, the E/M service should be documented
- For interactive therapy, the medical record should indicate the adaptations utilized in the session and the rationale for employing these interactive techniques
More information is available on the website link at Novitas LCD L35101 . The CMS Medicare Learning Network® (MLN)also provides information on documentation requirements in an article at the link titled, Psychiatry and Psychotherapy Services.
Can I refuse to send documentation to the CERT contractor or Mac because the information is protected?
No. All of the information included in the record is not protected information. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and the Code of Federal Regulations (45 CFR 164.501) establish that the psychotherapy notes that are separate from the rest of the medical record do not include the following information (which should be part of the clinical note of the psychotherapy service): medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests and summary of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. The portion of the record that is protected would include information or facts of intimate personal content, topics of themes discussed in therapy sessions, details of fantasies and dreams, sensitive information about other individuals in the patient’s life, etc. Providers can find more information on documentation requirements in First Coast Service Options (FCSO) LCD and the CFR at the website links below:
How were providers selected to receive the comparative billing reports?
The CBR data team analyzed Fee-for-Service (FFS) Medicare claims with the CPT® codes covered in this CBR, and identified those with different billing patterns when compared to their peers (approximately 4,300 Medicare psychiatrists). Providers who did not receive a CBR and would like to review a sample letter are invited to visit our CBR website at the following link: CBR201607 Sample CBR.
How are the peers defined?
A single rendering provider was identified by National Provider Identifier (NPI). The peer groups for comparison with the individual provider are listed below:
- State: All Medicare Part B providers located in the provider’s state (as determined by NPPES), with allowed charges for the CPT® codes covered in this CBR
- National: All Medicare Part B providers in the nation with allowed charges for CPT® codes covered in this CBR
How was the data obtained for this report?
The data for this CBR includes Part B claims for the CPT® codes identified in the CBR. These claims, with dates of service January 1, 2015 – December 31, 2015, were downloaded from the CMS Integrated Data Repository (IDR), and loaded into the Palmetto GBA Medicare Data Warehouse. The analyses were based on the latest version of claims available from the IDR as of April 4, 2016. For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).
How were allowed charges calculated in this CBR?
Allowed charges for this CBR were calculated based on the Medicare Physicians Fee Schedule (MPFS). Payment can vary depending on factors such as the carrier locality and the number of units billed. In most instances, Medicare pays the provider 80 percent of the fee schedule allowed amount and the patient is responsible for the balance of the payment; however, there are some exceptions to this rule. To search for payment rates in the MPFS, see the following link on the CMS website page: Physician Fee Schedule Look-Up Tool.
My allowed charges are higher than the national averages because I am in a region with a higher cost of living and, thus, a higher allowed amount. Are my allowed charges being compared to providers in other states with lower allowed charges?
We are aware that the MPFS allowed amounts vary from area to area. A geographic practice cost index (GPCI) has been established to account for the variation in practice expenses across the states and nation. For the purposes of this CBR, averages were calculated by state and nation for all psychiatrists (specialty 26), who submitted claims for psychotherapy services with or without an E/M service. This CBR is only for educational purposes; variations may be justifiable due to location or other supporting documentation. More information on the GPCI is available on the CMS website page at Documentation and Files - National Physician Fee Schedule and Relative Value Files.
How is a “visit” defined?
For the purposes of this CBR, a “visit” is defined as every service provided to a beneficiary on a particular date of service from a particular provider. For example, if a provider provided a beneficiary with one service of 99211 and one service of 99212 on the same date of service, both services would be considered as the same visit.
What does Table 1 mean?
Table 1 is a listing of the CPT® Code and Abbreviated Description and time assigned for each psychotherapy CPT® code included in this CBR. To review an illustration of Table 1, refer to the example on the CBR web page at CBR201607 Sample CBR.
What does Table 2 mean?
Table 2 serves as a Summary of Your Utilization for Psychotherapy CPT® Codes included in this CBR. Each row contains a CPT® code and the provider’s allowed charges, allowed services, and number of distinct beneficiaries for the year analyzed. The Total row shows the sum of the provider’s allowed charges, allowed services, and number of distinct beneficiaries for all CPT® codes used in this CBR. It is important to note that the totals for each column may not be equal to the sum of the rows, as it is likely that the same beneficiary has billings for more than one CPT® code and is, therefore, counted only once in the total. A sample of Table 2 can be found at CBR201607 Sample CBR.
What does Table 3 mean?
Table 3 is an example of the comparison of a provider’s Percentage of Psychotherapy Visits Billed Concurrently with E/M Services. Table 3 compares a provider’s percentage psychotherapy visits billed concurrently with E/M services to that of his/her peers. The provider’s percentage of visits with an E/M, as well as the percentages for the state and the nation, is provided with comparisons. A sample of Table 3 and a further explanation can be found at CBR201607 Sample CBR.
What does Table 4 mean?
Table 4 is an example of the analysis of a provider’s Average Minutes of Psychotherapy per Visit, using the CPT® codes in this CBR. The provider’s average minutes per visit, as well as the averages for the state and nation, are provided with comparisons. A sample of Table 4 and a further explanation can be found at CBR201607 Sample CBR.
What does Table 5 mean?
Table 5 is an example of the analysis of a provider’s Average Allowed Psychotherapy Services per Beneficiary. The psychotherapy codes were matched to the established patient office E/M services (CPT® codes 99211-99215) by the same provider, beneficiary, and date. The provider’s average services, as well as the averages for the state and the nation, is provided with comparisons. A sample of Table 5 and a further explanation can be found at CBR201607 Sample CBR. The results for each state and the nation can be reviewed at the following link: CBR201607 Statistical Debriefing.
What does Table 6 mean?
Table 6 is an example of the Distribution of Established Patient E/M CPT® Codes. It is the proportion of services for each E/M CPT® code for a provider, his/her state, and the nation. Also included is a distribution of established patient E/M CPT® codes for the year being analyzed. The analysis can be found at the following link: CBR201607 Statistical Debriefing.
What does “Comparison to Your State” and “Comparison to the Nation” mean?
There are four possible outcomes for the comparisons between the provider and the peer groups:
- Significantly Higher - This means that the provider’s value is higher than the peer value, and the statistical test confirms a significance
- Higher - This means that a provider’s value is higher than the peer value, but either the statistical test does not confirm a significance or there is insufficient data for comparison
- Does Not Exceed - This means that a provider’s value is not higher than the peer value
- N/A – This means that the provider does not have data for comparison
A provider’s value may be greater than the value of his/her peer group. The statistical test gives the provider the benefit of the doubt since significance is based on the total number of visits or beneficiaries and the variability of those values.
Are other references and resources available about psychiatry and E/M services?
Yes. Providers may benefit from the CBR201607 Statistical Debriefing which describes the Tables used, located at CBR201607 Statistical Debriefing. Also, the references and resources for this CBR are found at CBR201607 Recommended Links.