EquiClaim Reviews Claims for CPT Code 90837 (by Barbara Griswold, LMFT; February 19, 2016)

Providers contracted with Blue Cross and other health plans nationwide may have received a letter this week from EquiClaim (a Change Healthcare Company). EquiClaim was hired to review claims, and to notify providers if they are billing for CPT code 90837 significantly more often than their peers.

Why is this happening? In 2013, the American Medical Association issued new CPT codes, including 90834 (37-52 minutes face-to-face with the client) and 90837 (53 minutes or more).  Prior to 2013, the typical psychotherapy “hour” was billed using a code for 45-50 minutes. However, Blue Cross reported in a provider update, “with the release of the new CPT codes, [we have] observed that over half of the billing for this type of psychotherapy is now claiming 53-60 minutes spent face-to-face with the patient.”

What is the intent of this program?  In an e-mail response to my questions, EquiClaim VP of Operations Dave Cardelle stated that “recent studies by the Office of the Inspector General have determined that inaccurate billings are contributing significant losses to the US healthcare system.  It is our goal to work with providers to help educate, in a non-punitive manner, with the intent to ensure accurate coding for future submissions.  This approach helps providers address coding inaccuracies before claims get received by the Payer, providing an opportunity to avoid the traditional audit or investigative approach as well as reducing the payment reimbursement timeframes. Overwhelming feedback has been that this program is a preferred alternative to traditional audit or investigation of outlier providers.”

What will happen?  The letter states that updated provider coding profiles will be sent periodically, presumably to give you a chance to correct any improper use of the 90837 code.  If the above-average use of 90837 continues, a request for medical records may be made, to determine if the code being used is appropriate.  The letter suggests that overpayment requests will be made only in the cases of continued improper use of the codes.

 Are they trying to pressure me to stop using 90837? The letter denies this specifically, saying there is no “intent to pressure you as a provider to under-report services legitimately provided to a member.”

 What do you recommend?  Be calm, don’t read between the lines, and don’t take it personally.  There is no accusation of unethical billing.  Just make sure you are using the 90837 code correctly:

• Use 90837 only for sessions 53 minutes and longer
• Record session start and stop times in the clinical notes — for example, 1:02 to 1:57pm (in addition, medical records should include date of service, diagnosis, treatment goals/plan, interventions, and progress. Be sure notes are legible).
• When choosing the CPT code, include only face-to-face client time (ex. do not include post-session note writing).
• 90837 can be used when a family member joins the client in session, but only when the identified client is present for at least part of the session, and should not be used for ongoing couples or family therapy
• If you have historically billed primarily with the 45-50 minute code and have switched to primarily the new 60-minute code, plans may ask you to explain this
• Consider: What factors might explain why you are doing longer sessions than your peers?  Is session length a personal clinical choice, or do you have complex or crisis cases? Are you treating severe diagnoses? Clients with a high level of trauma? High-conflict couples or families?  Does your treatment type require a longer session (ex. EMDR or play therapy)?

Do they have the right to ask for records? While you can challenge the request, Blue Cross (or any payer) “retains the right, based on a provider’s agreement, to conduct reviews and audits of services rendered to our members to ensure coding guidelines have been followed.”

Will other insurance companies follow suit?  We’ll have to wait and see. But this is not an issue for many plans, including those that reimburse the same amount for 90834 and 90837, or require preauthorization for 90837 sessions.

Stay tuned — I’m hoping to interview some folks at Blue Cross to get more information….