Practice Directorate contests Medicare payment limits

Psychologists may find that certain claims for health and behavioral services, as well as testing services, routinely paid by Medicare in past years are now being denied.

by Government Relations Staff

The American Psychological Association (APA) Practice Directorate is contesting limitations on psychologists who bill Medicare for health and behavior services as well as testing services in 2008.

Psychologists may find that certain claims that Medicare routinely paid in past years are now being denied. Payment for testing services is now limited to eight hours per patient per day. Claims for health and behavior interventions cannot exceed 4 units (1 hour) per patient per day.

These limitations were established as part of the National Correct Coding Initiative's (NCCI) Medically Unlikely Edits (MUEs). According to the Web site for the U.S. Department of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS) developed the NCCI to "promote national correct coding methodologies and to control improper coding."

MUEs are intended to prevent Medicare from paying for Part B claims that CMS considers incorrect. The agency's Web site indicates that "the MUE program was developed to reduce the paid claims error rate for Medicare claims. MUEs are designed to reduce errors due to clerical entries and incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment."

Psychologists whose Medicare claims are denied because they exceed the MUE time limits for testing and health and behavior codes may appeal the denials through their local carrier.

The Practice Directorate believes that these billing limitations are inappropriate in part because the time restrictions placed on these services bear no direct relationship to the likelihood of errors in claims submission. For example, it is not "medically unlikely" that a patient might require more than one hour of a health and behavior intervention in a single day.

The coding edits that have been applied to these services exceed several of the limitations in local Medicare coverage determinations. While some Medicare carriers allow for up to ten hours of testing, the MUEs automatically trigger a denial if a claim exceeds eight hours of testing.

Another concern is that the limitations on health and behavior codes imposed by the MUEs fail to recognize the diverse needs of patients who benefit from the services. For example, pain management patients might not be able to withstand more than 15 minutes (1 unit) of an intervention on a given day, while a cardiac rehabilitation patient may need 90 minutes of care on one day and 45 minutes on another. Yet the MUEs limit billing for health and behavior services to one hour per day regardless of a patient's circumstances.

The Practice Directorate's government relations staff is advocating for the NCCI medical director to remove the time limits applied to testing and health and behavior codes. The directorate is challenging the use of MUEs pertaining to psychological services delivery as overly restrictive and an inappropriate way to determine correct coding for these services.

Watch for news of developments in future issues of this e-newsletter.