Did you get a letter from Blue Cross or another insurance plan, saying something about your use of  the 90837 CPT code (Psychotherapy 60 min)?

       Why are you getting this letter?   The letter states you are receiving it because you use this code more than peers, but isn’t clear about what they want from you, other than to contact them. I  interviewed Alma Granados, Anthem Provider Reimbursement Administrator, for the lowdown.

       Granados states that Anthem Blue Cross reviewed one year of all their paid claims.  They then calculated an average utilization of the 90837 CPT code for different provider specialties within each market.  Individual providers then were compared to their specialty’s baseline.  Providers whose claims showed a higher-than-typical use of the 90837 code received the letter.

       What does the plan want from you?  According to Granados, “our letter is strictly educational, the intent is to draw attention to the documentation guidelines for Psychotherapy Services. Our goal is to ensure that providers are following the documentation and coding guidelines set by the AMA and current CPT coding books, and that their documentation supports the level of care billed for each service.”

       “Please be assured that we are in no way asking you to change the way that you provide care to your patients,” says Granados.  “We recognize that each service is billed dependent on your clinical judgement and the nature of the presenting problem.”

       While Anthem says the purpose of the letter is educational, the letter is not informative, so it leaves providers feeling confused and worried.  Out of this fear, many therapists are choosing to “downcode” sessions, using the 90834 45-minute psychotherapy code instead, which typically represents lower reimbursement.

         Here’s my view:  The real issue here is that many health plans think providers are just billing for 90837 routinely, even if they do shorter sessions.  In other words, they suspect fraud.

And there is one insurance plan — OPTUM/UBH/UHC — that states in their policies that 90837 should be used only for complex cases, or when the treatment itself takes extra time, such as EMDR, Systematic Desensitization, or some Trauma Informed Treatments, and perhaps some DBT protocols.  In fact, providers have received notice of claims being held up, awaiting notes to defend the use of the 90837.  So you might choose to minimize your use of 90837 with OPTUM/UBH clients when doing routine therapy — or just know that it is more likely that you will receive a request for a clinical review or a request for your progress notes for those sessions.

I would also say that with Medicare, the routine use of 90837 can increase your audit risk.  In these cases, your progress notes need to be excellent — if they aren’t, see my Progress Notes webinar “What Should Be In Your Charts…”)

          So, what about health plans other than Medicare and OPTUM/UBH?  They are NOT forbidding the use of the 90837 code.  They are NOT telling you it is a problem that you use it more frequently than your peers.  They are NOT saying you need to change your treatment.  And you are NOT being singled out — the letter is being sent to thousands of therapists each year, in different waves.

          What matters is whether you are using the code correctly.  They are looking for fraud. If you aren’t committing fraud, why should you change anything?

       What you should do: If you got this letter, email them back.  YOU CAN CUT AND PASTE THE FOLLOWING INTO THE EMAIL:  

1. 1. I understand the session length must be 53 minutes or longer.  If the session starts late or ends early,  a 90834 code (38-52 minutes) or 90832 code (16 – 37 minutes) must be used.
   2. In each progress note, the actual start/end times of the therapy portion of the session has been documented to back up my billing.  I understand this does not include time spent waiting, scheduling, communicating with others, or documenting the session or writing reports.
   3. I know 90837 may be used only for individual sessions, or when family comes into a session to serve as informants for ongoing individual treatment.  When a 90837 is used for a family visit, the client must be present for all or most of the session. I know this code should not be used for ongoing couples or family treatment.
   4. I document all sessions according to the health plan’s documentation criteria, including capturing the date of service, length of session (start/end time), client problems and symptoms presented, therapeutic maneuvers utilized, diagnosis, progress or lack of progress to the goals, updates to the treatment plan if necessary, and my signature (electronic or written).
   5. I know all sessions must meet the health plan’s medical necessity criteria– that insurance can only be billed when a client has a diagnosis (usually more than a DSM-5 Z code), when the treatment is not aimed solely at personal growth, is deemed necessary and not just desired, and aimed at least in part on reduction of a mental health symptom, such as anxiety or depression.

Please let me know if I can provide any other information.

Sincerely yours,

[Your Name]

[Your License and License #]

[Your Tax ID and Your NPI]

[Your Address]

[Your Phone Number]”

What will they do? In my own experience (and the experience of many others I’ve coached), after emailing the plan with this information, they respond via email some form of “OK, thanks, we see you know how to use the 90837” and indicate you need to take no further action and they no longer need to talk to you.

A final note:  Insurers will expect to see that you have downcoded to a 90834 on occasion.  They will also expect your start and stop times to believably vary from one session to the next to reflect real life. While it may not be required, it’s a good idea to document in those cases you feel there is a reason you feel the need for sessions longer than 52 minutes (if the case is complex, you are working with more severe diagnoses, you are doing EMDR or trauma work, or some treatment that may take longer than routine talk therapy).

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