A New Way to Bill for Extended Sessions?
by Barbara Griswold, LMFT (updated August 21, 2020, updates in red)
One of the most common questions I receive from therapists in consultations is how to bill insurance for “extended sessions” – that is, sessions longer than 60 minutes. These longer sessions are provided for a multitude of clinical and practical reasons, including the ability to do a more in-depth intake, to get more accomplished in couples or family sessions, for EMDR and other intensive or trauma-related treatments, or because the clients travel from a distance or aren’t able to come weekly.
Therapists billing for extended sessions were left high and dry in 2013 when the American Medical Association overhauled the Current Procedural Terminology (CPT) code list, and deleted the billing codes for these longer services. CPT codes, which are used on claims and statements to identify the types of services rendered, now offer only three, timed codes for individual psychotherapy, the longest one being 90837 for 60 minutes. With instructions to use the 90837 60-minute therapy code for any session over 53 minutes, there was no way to distinguish a 60-minute session from longer sessions, thus insurance reimbursement was based on the 60-minute rate.
However, therapists and clients quickly learned they might not get reimbursed more for a 60-minute session than for a 45-minute session. While many plans do allow ongoing, routine 60-minute sessions, and reimburse more than the 45-minute session (CPT code 90834), other plans reimburse at the same rate. As always, it’s a good idea to contact the plan to check their policy on coverage of 90837 sessions.
Worse yet, at least one major insurance plan (United Behavioral Health/OPTUM) up until December 2018 required preauthorization for use of the 90837; without it the claim will would be rejected. While UBH no longer requires preauthorization for 90837, it seems clear that they do not think this code should be used routinely. According to the OPTUM Provider Manual, the plan feels these longer sessions are appropriate for a client in acute crisis and is in need of stabilization, who has been diagnosed with Post-Traumatic Stress Disorder, Panic Disorder or Obsessive Compulsive Disorder and is being treated with Prolonged Exposure Therapy, or is being treated with Eye Movement Desensitization and Reprocessing (EMDR) for Post-Traumatic Stress Disorder (PTSD).
A New Billing Possibility
Another billing possibility for extended therapy sessions emerged in 2016 when the AMA allowed add-on codes for Prolonged Services, 99354 and 99355, to be used by non-medical personnel. Formerly allowed to be used only by doctors, physician’s assistants, and nurses, these “add-on codes” are used when billing for services that have gone longer than the usual service. According to the American Academy of Professional Coders (AAPC), the only individual psychotherapy service that may be billed with a Prolonged Service Codes is CPT 90837 (60 minute individual therapy).
UPDATE: What about family or couples therapy sessions? Let’s start with which initial CPT code to use for these sessions. The AMA clarified in 2016 that the CPT codes for family or couples therapy, 90847 (couples or family therapy with the client present) and 90846 (without the client present) were 50 minutes each, and that these codes should be used for ongoing family or couples therapy. Individual therapy codes (90832-90837) should only be used for a couples or family session if a family member comes into an ongoing individual therapy session, acting as an occasional or one-time “informant.” The identified client who is the focus of the individual sessions must be present for at least part of the session.
Now, here’s the good news: As of at least January 1, 2018, Prolonged Service codes are now allowed to be used for extended 90847 (family/couples therapy) sessions.
If you want to try billing for an extended session using the Prolonged Services codes, the session must be a minimum of 30 minutes beyond the original code. This means, for a 90837 (60 minutes) the session minimum would be 90 minutes; for a 50-minute 90847, the session must be a minimum of 80 minutes. It requires the use of multiple CPT codes for the same session (each having its own charge that you’ve chosen). Thus you will use multiple lines for the same date of service on the claim form or statement. When using these codes, it is recommended that you verify their coverage in advance with each insurance payer.
Will insurance reimburse for Prolonged Service Codes? Some therapists who have used these codes have reported they were reimbursed for the extra time, yet others only got reimbursed only for the 90837 or 90847. One billing manager reported, “we have been using 99354 in combination with 90837 and 90847. The payers seem to be allowing the use of the 99354 and in fact reimburse at a higher rate for the 99354 than the original procedure code. BlueCross BlueShield, HealthPartners, Aetna, PreferredOne and Cigna have all reimbursed for the service.” Thus, it seems like you have nothing to lose by giving it a try. You can also contact your plan and ask if these codes are covered by your contract, or ask that it be added.
Other Billing Options
If the session meets the criteria for a crisis session, the choice might be made to bill using the crisis CPT codes that were introduced by the AMA in 2013: 90839 for the first 60 minutes of a crisis session, 90840 as the add-on for each 30 minutes of additional time after the 60 minutes. In order for the new crisis codes to apply, the presenting problem must require immediate attention to a client in high distress, including life-threatening or at least highly complex crisis clinical situations.
Can you bill one 45- or 60-minute session to insurance, and contract privately with the client to pay any additional time out of pocket? There is a lot of discussion online about this option, both sides confident about their opinion. To me, this option seems a credible one, if not forbidden in your plan contract. Why shouldn’t the client retain the right to pay for services that are not covered by his plan? If you are a network provider, insurance plans may want you to charge the client your usual network rate for the additional time, and collect any copayments or deductible for the first part of the session. I had one insurance network executive suggest that the client sign a Private Pay Agreement stating he understands that this additional time will be his responsibility, and how much he will owe; “if you get that, we would back you,” he said.
Can you break the session into two parts and bill for both? I’ve talked to therapists who have done this, ex. billing for one 90834 and one 90832 (a 30-minute session) on the same day, or billing for 2 units of 90834 or 90837. In my experience, these scenarios are rarely reimbursed, as most plans only allow one hour of therapy per day (unless the two services are separate and distinct, such as a couples therapy session and an individual therapy session on the same day, in which case, modifier 59 may need to be used to indicate this).
While we can look for different ways to code and bill for these longer sessions, it must be acknowledged that our discussions are the result of an industry-wide trend toward encouraging briefer treatment, and disincentivizing longer sessions.
American Medical Association, CPT® 2019 Standard Edition. Chicago, IL; American Medical Association, 2018.
OPTUM 360 (2018). Current Procedural Coding Expert.
APA Office of Health Care Financing. (2016, November 16). Psychotherapy coding clarifications, telemedicine code modifier added to CPT manual. Retrieved March 20, 2018, from http://www.apapracticecentral.org/update/2016/11-17/telemedicine-code.aspx
OPTUM by United Behavioral Health. (2014, February), Coverage Determination Guidelines, Extended Outpatient Sessions, Retrieved March 20, 2018, from https://providerexpress.com/trans/html/pdf/extendedOutpatientVisits.pdf
Dustman, R. (2016, February 16). Prolonged Services Update and Other 2016 E/M Changes. Retrieved March 20, 2018, from https://www.aapc.com/blog/33732-prolonged-services-updates-and-other-2016-3m-changes/
Specific criteria must be met to use prolonged services code. American Academy of Pediatrics News (January 10, 2018); Retrieved Feb 10, 2019 from http://www.aappublications.org/news/2018/01/10/Coding010518
American Academy of Child and Adolescent Psychiatry. (2018) CPT Training Manual. Retrieved Feb 11, 2019 at https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/business_of_practice/cpt/2018_CPT_module_revised_March_2018.pdf
Direct Prolonged Serices: Inpatient and Outpatient Coding. American Academy of Pediatrics (2016). Retrieved Feb 11, 2019 at https://www.aap.org/en-us/Documents/coding_prolonged_services.pdf
The 2013 Psychotherapy Codes: An Overview for Psychologists. (n.d.). Retrieved March 20, 2018, from http://www.apapracticecentral.org/reimbursement/billing/psychotherapy-codes.aspx