Private insurers’ implementation of the 2013 psychotherapy CPT® codes: Answers to psychologists’ questions

Jan. 23, 2013 — This article addresses several frequent questions from practitioners regarding private insurers' implementation of the new psychotherapy codes for 2013 that took effect on January 1. This information elaborates on the extensive materials about the new CPT® codes already provided by the APA Practice Organization.

Questions and Answers

Question 1: What 2013 psychotherapy code is intended to replace the old 90806 code?

Answer: APA Practice views 90834 as the 2013 code equivalent replacing 90806.

APA Practice considers 90834 as the applicable replacement for 90806. It represents the same basic time period, despite the change in description from 45-50 minutes (90806) to 45 minutes (90834). Consistent with the way that CPT codes are now written, the new codes have specific quarter-hour times instead of time ranges. We do not see this change as providing a basis for private insurers to reduce rates when transitioning from 90806 to 90834, and we will make that argument with insurance companies if necessary.

We are aware of some members’ concern that, in light of the change from a 45-50 minute range to a specific reference to 45 minutes in the code descriptions, companies will view services billed under 90834 as a 10 percent decrease in service and value, and they will cut reimbursement under 90834 accordingly.

Yet, CMS has assigned to 90834 a payment value for 2013 that reflects the equivalence of 90834 and 90806. The national Medicare payment rate (subject to geographic adjustment) for code 90834 in 2013 is $81; the national payment rate in 2012 for code 90806 was $82, merely one dollar higher.

Initial reports indicate that, in switching from 90806 to 90834, some private insurers are reducing the rate by a dollar or two —similar to the change in Medicare payment. This comparison suggests that these insurers do not view the new code as representing less time.

We are gathering information on how other companies are reimbursing code 90834, along with the other new psychotherapy codes. To assist us in gathering this information, psychologists should send new rate sheets or correspondence from private insurers about psychotherapy payment, along with the corresponding prior rate sheet, to our Legal and Regulatory Affairs Department. As discussed in question three below, some companies have had difficulty with transitioning to the new codes, so the rate picture may not yet be clear for those companies.

Question 2: Is it a violation of the federal mental health parity law for private insurers to require pre-authorization for the new 60-minute psychotherapy code?

Answer: This parity argument appears to have a limited chance of success.

Some private insurers have announced that they will require pre- or post-authorization for use of the new 60-minute code 90837, which applies to psychotherapy sessions of 53 minutes or longer. Some members see the authorization requirement as a violation of the federal mental health parity law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Others believe that an authorization requirement violates federal parity requirements unless the company similarly requires authorization for extended primary care visits.

APA Practice does not consider it promising to challenge pre-authorization for the new 90837 (60-minute) psychotherapy code as a violation of the federal mental health parity law, and at this time we are doubtful that making the parity argument with insurers would produce the desired result. Even so, we do think it is important for any companies that mandate pre-authorization on 90837 to provide clear, reasonable and transparent guidelines for when they reimburse for these longer therapy sessions.

When billing a private insurer that does not require authorization for 90837 and has not indicated that this code should be used infrequently, you should bill this code if your session time falls into the 53-minute or more time frame that pertains to 90837. We recommend, however, that you record your exact session start and stop times in your clinical note (for example, 1:02 to 1:57) when billing the new codes, as Medicare providers must do. At any point, a company can ask you for appropriate documentation or explanations. Also be mindful that if you have historically billed a company primarily the 45-50 minute code and switch to primarily using the new 60-minute code, that company may ask you to explain this change.

Question 3: Why have some private insurers had difficulty with adopting the new psychotherapy codes?

Answer: Several factors may be responsible, but we believe prompt payment laws should still apply.

We have heard several reports of difficulty with private insurers’ adoption of the new CPT codes. For example, one company reportedly told providers that the company was not ready to use the new CPT codes and that providers should continue to bill under the old codes until further notice. Another company indicated that psychologists should bill using the new codes, but has not yet announced the corresponding reimbursement rates. Yet, another company retracted reduced rates issued around January 1 and announced that it will not reduce rates.

One factor underlying such difficulties may have been the Sustainable Growth Rate payment cut in Medicare rates of 26.5 percent that had been scheduled to take effect on Jan. 1. The drastic cut was averted for 2013 on January 2 when Congress passed the “fiscal cliff” legislation, which included a provision postponing the huge SGR payment cut. Companies that had not yet prepared for this possibility would have been forced to scramble in order to adjust payment rates for 2013.  

We are hoping that those private insurance companies that have not yet completed their conversion to the new codes will do so in the very near future. APA Practice believes, regardless of the cause of difficulty thus far, private insurers should not be excused from complying with applicable prompt pay laws.

Psychologists who continue to have issues after February 1 with private insurers’ transition to the new psychotherapy codes should contact APA Practice Organization or call Practitioner Helpline at (800) 374-2723.

Current Procedural Terminology (CPT) copyright 2011. American Medical Association. All rights reserved.

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.