August 2023 Update: A New Way to Bill for Longer Sessions?
By Barbara Griswold, LMFT (July 12, 2023; update Sept. 30, 2023, updates in red)
As I reported in a previous article, therapists and clients nationwide got an unexpected punch in the gut (and the wallet) when the AMA deleted Prolonged Services CPT codes on January 1, 2023. These Prolonged Services codes — 99354 and 99355 — could previously be added to a 90837 (60-minute individual therapy) or 90847 (Family/Couples therapy) to seek additional reimbursement for individual therapy sessions of 90 minutes or more, or family / couples sessions of 80 minutes or more.
While some health plans never covered these codes, many did, so many therapists and clients have enjoyed a significant increase in reimbursement when used. Deletion of these codes has led many therapists to resign from insurance networks due to the inability to get adequately reimbursed for longer sessions, which may be essential to the type of treatment they provide.
So, what options were left? As I reported, after a reading of the CPT code manual and in my conversations with other coding experts, there seems to be agreement that the replacement code — 99417 — cannot be used with psychotherapy codes 90837 or 90847. And there were no other obvious options. It looked like we were out of luck.
But just when things looked hopeless, other options may have appeared. On June 22, 2023, alert reader Keith Elias, LCSW forwarded this article from the National Association of Social Workers (NASW), excerpted below (brackets and underlines are mine):
“… Beginning January 2023, deletion of the prolonged service codes became problematic for private practitioners who used them to report … services requiring 90 minutes or more. After several months of research and meetings, the [NASW] and other mental health associations were able to discover a solution through contacts with the Centers for Medicare and Medicaid Services (CMS) and other third-party payers. To report prolonged services, [therapists] may now report two units of 90834, individual psychotherapy for 45 minutes, for … 90 minutes. When providing prolonged services beyond 50 minutes for 90847, family therapy with the patient present, report two units also. Although reporting two units of time is the preferred method of reporting prolonged services for psychotherapy, not all third-party payers are using this model. Therefore, [therapists] should contact third-party payers…to learn their preferred method of reporting prolonged services….” 1
So, just to be sure you caught that: Even if there is a way to bill for longer sessions, that doesn’t mean insurance will cover it, just as many plans never covered Prolonged Service codes. Or they may not cover it right away.
Then, I got more hope from another source: Alert reader J.W. in Minnesota shared this from Minnesota Medical Assistance / Medicaid plan, dated March 6, 2023 (underline/emphasis mine):
“The American Medical Association discontinued prolonged services CPT code 99354 on Jan. 1, 2023. We used the procedure code to report prolonged psychotherapy services provided face to face with the member. You can bill two units of 90837 for prolonged psychotherapy services provided face to face with the member for 91 minutes or more effective Jan. 1, 2023.“ 2
IMPORTANT NOTES:
- Note here that while the NASW is encouraging the use of two units of 90834 (45-min. individual therapy) for an individual session 90 minutes or more, Minnesota is encouraging the use of two units of 90837 (60- minute individual therapy) for a session 91 minutes or more.
- While the NASW post states that 2 units of 90847 can be used for extended couples/family sessions, Minnesota does not seem to allow this.
- The NASW doesn’t state the minimum length of an extended couples/family therapy when two units of 90847 are billed.
So, is billing for two units of 90834, 90837 or 90847 worth a try? Maybe. Reports are starting to trickle in from therapists across the country, sharing their experiences:
- A reader in Florida reported “Optum told me that we can use two 90834 a day, but we cannot use two 90847 a day.”
- Another reader in Florida reported “I just billed Aetna in Florida for two 90834 in one day for a 90 minute session. It was not accepted.”
- A reader in Northern California reported she billed Noridian Medicare for two units of 90837 and was paid. However, she tried the same with with Kaiser Medicare (Northern California), but they rejected it, only paying for a single unit of 90837.
- One Texas clinician reported that Blue Cross Blue Shield of Texas paid for two 90837 sessions, while AmBetter (a Marketplace plan) denied two units as a duplicate service.
- And in an 8/4/23 email from LyraHealth, it was stated, “Lyra does not cover extended couples therapy sessions or back to back couples therapy sessions.” But when queried, they said extended individual therapy sessions could be covered if pre-approved by their Clinical Quality team, so the therapist would need to explain the need for this type of care and anticipated length of treatment.
- And a 5/17/23 post from Blue Cross Blue Shield Michigan gave this interesting option: “For Blue Cross and BCN commercial members, use HCPCS code G2212 in place of procedure codes 99354 and 99355 for dates of service on or after Jan 1, 2023. The G2212 code can now be billed with procedure codes 90837 and 90847“: Click here for the full post (this link only worked for me in Chrome)
- But most sources I’m reading are saying that G2212 and 99417 can only be used by medical providers with Evaluation and Management codes 99205 and 99215: Click here to see 5 pages of G2212 and 99417 research
- And OPTUM/UnitedHealthcare came out with this policy statement: “OPTUM will not reimburse G2212 for commercial [non-Medicare] members. You must bill the appropriate prolonged services code for commercial CPT code 99417 and only bill … G2212 for Medicare with the …[Evaluation and Management] codes 99205 or 99215.” So it seems for OPTUM, both 99417 and G2212 can be used only by medical doctors and can only be combined with with Evaluation and Management codes (that start with 99-). Click here to read full policy.
So, I’d recommend contacting the health plan beforehand to see if billing for two units might be covered (but, good luck reaching a human, and one who is knowledgeable about this level of detail). Once clinician suggested getting a formal preauthorization from the plan (where a health plan gives you advance permission in writing to bill for a service) might be a good idea.
What is the risk? There is a risk that the health plan could deny payment for the entire session instead of just paying one unit. But even if the health plan pays, billing for two units on one day could increase your risk of an audit. On closer inspection, the health plan may decide they shouldn’t have paid, and may request money back. And remember, depending on your state law, they can often go back a year or more when inspecting previous payments.
A final important point that you’ve heard from me before: The NASW post stated “It is also important to document in the clinical record why the prolonged service was necessary. The rationale must be related to the patient’s needs… For example, a trauma related treatment modality generally requires a prolonged service.” 3 This means each progress note should explain why it was clinically necessary to do a longer session — especially when billing insurance.
Have you received guidance for billing for longer sessions from health plans or your professional association? Please contact me to share (and please share article citations and links, when possible!)
This is an ongoing story, so stay tuned — I’ll continue to update you on this important topic.
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Citations:
1 -For the full NASW article, click here
2 -To read the Minnesota Assistance provider manual, click here
3 – NASW article, click here