Did the American Psychological Association give bad advice on Reimbursement?

Clinicians are increasingly using CPT code 90837 (which requires sessions of at least 53 minutes) in place of the 90834 (for sessions of less than 53 minutes). 90837 pays significantly better than 90834. Our data show that denial rates for this code are very low, but higher than for 90834 (see our prior post for data).

We have been told that BCBS of Massachusetts will not reimburse for 90837. It is reported (but not confirmed) that BCBS insurers of Pennsylvania and Utah do not reimburse differentially for this code.

It is also reported that some clinicians around the country have been receiving letters from insurance companies such as Anthem, Highmark and Medical Mutual of Ohio that indicate that their practice patterns are being scrutinized.

The tenor of some of these letters would seem to be an attempt to limit providers use of 90837. We are aware of one letter to a clinician from the mental health vendor for Mutual of Ohio that stated that the percentage of 90837 codes reported by that psychologist was greater than the expected billing distribution as determined by the average billing within the specialty of psychology.

In a recent webinar the president of the American Psychological Association, Tony Puente, Ph.D., warned psychologists about routinely using codes with higher reimbursement rates such as 90837. He stated that “the standard psychotherapy procedure historically and now is the 45-minute intervention,” and “there must be documentation that emphasizes the unusual nature of the procedure, such as difficulty in communicating with the patient or the distance the patient must travel to the therapy office.”

This is bad advice. The 45 minute session is not now, nor ever has been, a standard. Nor is there any evidence that says that 45 minutes is more appropriate than 48 minutes or 53 minutes. Clinicians who routinely use 90837 for longer sessions are perfectly justified in doing so, and do not have to provide documentation of the “unusual nature of the procedure,” unless required to do so by the insurance company.