APA Practice Organization obtains clarification from Anthem on EquiClaim letters
Anthem has assured us that this is an educational process without financial consequences.
Practice Organization members have reported receiving letters about the frequency of their use of CPT® code 90837 (psychotherapy, 60 minutes with patient and/or family member). These letters, sent by EquiClaim on behalf of Anthem Blue Cross Blue Shield, were addressed to psychologists allegedly using 90837 more than average for Anthem psychologists.
The letters indicate they are for informational purposes; however additional language states EquiClaim’s monitoring of the psychologist’s 90837 billing practices may lead to a request for “medical records of members with the intention of identifying any improper coding and recovering associated overpayments.” Members expressed concern that continued use of 90837 might result in an audit and refund demands.
Practice Legal and Regulatory Affairs staff has developed a good relationship with leaders at Anthem. Using a collaborative approach (which proved successful with the Santé Analytics and Inovalon audits), we contacted Anthem to clarify the meaning and intent of the EquiClaim letters. Anthem promptly provided a statement (PDF, 102KB) assuring us that this is an educational process without financial consequences.
In response to our concerns about these letters, Anthem has made changes internally to ensure further reviews of these types of communications occur in advance of distribution.
Why did I get a letter?
Anthem asked EquiClaim to survey use of therapy codes 90832 (30-minutes), 90834 and 90837. We understand that based on Anthem’s directions, EquiClaim sent letters to psychologists who billed 90837 more than 50 percent of the time. EquiClaim determined that psychologists’ average usage of 90837 was 45.5 percent.
Thus, for example, you were likely to receive the letter if your therapy billing to Anthem listed 90837 51 percent of the time, 90834 49 percent of the time, and never listed 90832.
Can I continue to bill Anthem 90837?
Psychologists should use their clinical judgment to determine the health care needs of their patients, including the length of a psychotherapy session. At this time, we are not aware of Anthem limiting the use of 90837. We recommend that psychologists frequently billing 90837 with Anthem follow Anthem’s billing guidelines in the next section.
According to official guidance for CPT codes, 90834 (psychotherapy, 45 minutes with patient and/or family member) is to be used for sessions lasting 38-52 minutes. Code 90837 is to be used for sessions that are 53 minutes or more in duration.
How should I bill 90837?
We recommend that psychologists submitting claims to Anthem follow the guidance from Anthem as outlined in its statement, as well as the additional “Criteria for submitting a 90837 code” which appears on the report page from EquiClaim. That guidance states:
- Psychotherapy times are for face-to-face services with the patient and/or family member.
- The patient must be present for all or some of the service.
- In reporting, choose the code closest to the actual time (i.e., 53 or more minutes for 90837).
- Document start and end times.
Following this guidance should put you in a good position if Anthem later decides to review your records and/or practices. Insurance company provider contracts generally give them the right to review records. (But remember that you must have appropriate consent or authorization under your state’s confidentiality law.)
Contact Legal & Regulatory Affairs staff or your state psychological association if you experience actions by Anthem or EquiClaim that are inconsistent with Anthem’s explanations above.
Please note: Legal issues are complex and highly fact specific and require legal expertise that cannot be provided by any single article. In addition, laws change over time and vary by jurisdiction. The information in this article does not constitute legal advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.
Current Procedural Terminology (CPT®) copyright 2015 American Medical Association. All rights reserved.