One of the biggest concerns I hear from therapists surrounds audits and the use of the CPT code 90837. This billing code is used for individual therapy sessions 53 minutes and above.

So, what’s the concern? As documentation expert Beth Rontal of DocumentionWizard.com states in her blog, “the concern many therapists feel right now is not about whether 90837 is legitimate. It is about whether using it will trigger attention.” She’s talking about the kind of unwanted attention from insurance plans that leads to clinical reviews and record requests.

What triggers audits? While audit triggers vary between insurance plans, and most plans won’t share exact policies, I talk about some common audit triggers in my courses. Typically, it is anytime a clinician’s claim pattern falls outside the norm. And Rontal points out that AI is being used more frequently to identify these outlier claims.

Audits may be triggered when you see a client more than once a week for many weeks or months. Or when you see a client for a long period, especially for an Adjustment Disorder, or for some other diagnosis that is not considered major. Or when your claim patterns differ from those of your peers. In-network therapists are also more likely to be audited, though out-of-network therapists can be reviewed if a client submits a superbill.

Is 90837 an audit trigger? You may have heard that audits may be triggered when every session is billed with a CPT code of 90837. In this case, the insurance plan may suspect that you or your Electronic Health Record (EHR) are automatically billing for the 90837 no matter how long your session was. They may then request your records to look for proof in each session note that the session was at least 53 minutes long. This can give them an excuse to look for missing session times or any deficiencies in your notes that will allow them not to pay, or to ask for money back if they have already paid the claim for the session.

How are therapists handling this fear of 90837 audits?

• Occasional “downcoding.” This is when the clinician occasionally bills for a 90834, the code for 38-52 minutes, a shorter session than was provided. By varying the billed code, it is hoped the plan can see they are not billing a 90837 for all sessions regardless of length.
• Billing ALL sessions as 90834, the code for 38-52 minute sessions. Clinicians sometimes use 90834 even if the sessions run longer, believing that completely avoiding 90837 lowers (or eliminates) their audit risk.

So, what’s wrong with these options? For starters, in each case, there is income lost, which can be significant over the course of time. But many clinicians say they’d rather take the loss than risk an audit.

But there is more: “This is where many well-meaning therapists unintentionally increase their risk,” Rontal points out. “Billing lower codes does not reduce risk if your documentation reflects something different…. When progress notes consistently document 53 or more minutes of psychotherapy, but billing reflects 90834, that mismatch becomes visible during review.” It is possible that the plan could consider this to be a misrepresentation of the service rendered, and refuse to pay. So making sure your notes match your billing is an important consideration.

So, what’s to be done? While audits are a normal part of working with insurance, the best way to protect yourself from income loss in an audit is to:

• downcode to a 90834 only when a shorter session was provided, such as when a client is a few minutes late or leaves early
• write the actual THERAPY start and stop times in each session note (don’t include time spent scheduling or documenting). To be credible, times should vary between sessions
• make sure the total minutes documented matches the billing code used
• in each note, defend the medical necessity for the session. Keep in mind that some health plans consider 90837 a longer session than is needed for routine cases, so document why the longer session was necessary (for more on medical necessity and how to defend your 90837 sessions, take my on-demand course “What’s Missing From Your Charts: Writing Great Notes,” available at my store)

The takeaway: In an audit, reviewers aren’t checking to see if you provided bad therapy. You will generally fail due to poor, deficient, or missing notes. So having strong notes is a more effective strategy to prevent income loss than playing around with codes.

But Rontal also makes an important point that led me to write this article: Even if you have great notes, it can be problematic if your documentation doesn’t match your billing.

If you think a 90837 session is medically necessary and that is what you provided, document it and defend it. If you are billing for a 90834, then your session note should reflect that you actually provided a 38-52 minute session.

The good news: Let me remind you: 90837 is not in itself an audit trigger. So don’t let your fear lead you to lose money by avoiding 90837. You may use 90837 for years and years and never get audited. It depends on the health plan – some health plans rarely do audits, or you might never get chosen. While audits are a normal part of working with insurance, I practiced for 33 years with a full time insurance practice and only dealt with claim-related audits three times. May you have my same luck!

For more information on how to prevent income loss in an audit, see my training “Audits and Record Requests: What EVERY Therapist Should Know” available at my store.