More FAQs on payment for psychotherapy codes

This new installment of frequently asked questions focuses on interactive complexity and crisis codes for 2013

By Government Relations and Legal & Regulatory Affairs staff

Jan. 31, 2013—Members continue to raise important questions with the APA Practice Organization as Medicare Administrative Contractors (MACs) and private insurers begin to implement the 2013 psychotherapy codes. Here are answers to several such questions.

When should the new “crisis” codes be used? Why have Medicare Administrative Contractors (MACs) and some private insurers not assigned a payment rate to these codes for 2013?

The psychotherapy codes for 2013 include two codes for use with a patient in crisis. Code 90839 is a standalone code for a 60-minute crisis psychotherapy session, while code 90840 is an “add-on” code used for each additional 30 minutes of crisis psychotherapy. A psychologist should use the crisis codes when psychotherapy services are provided to a patient in high distress with complex or life threatening circumstances that require the psychologist’s urgent and immediate attention.

Because 90840 is an “add-on” code it must be billed along with code 90839. Psychologists should also be aware that 90839 can only be used when the service lasts for at least 30 minutes. Use code 90832 when providing psychotherapy for a crisis situation less than 30 minutes.

Because the crisis codes have not completed the Relative Value Update Committee (RUC) process overseen by the American Medical Association, the Centers for Medicare and Medicaid Services (CMS) did not assign Medicare payment values to these new codes. As a result, both public and private carriers will make their own decisions about whether and what amount to pay for these codes.

As of Jan. 25, not all MACs had updated their 2013 fee schedules, so what Medicare will pay for the crisis codes is still undetermined in many parts of the country. At this time, First Coast Service Options in Florida lists 2013 payment amounts of $134.56 for 90839 and $67.28 for 90840 when the services are provided in a non-facility setting. At least three MACs — Cahaba GBS, Palmetto GBA and Novitas Solutions — do not list the crisis codes in their currently posted fee schedules. Psychologists are advised to monitor announcements from their regional MAC regarding payment for the crisis codes. Among private insurers, some have included these codes and associated payment amounts in their fee schedules for 2013, while others have not.

Psychologists looking to submit a code for crisis services to Medicare should list the fee they believe is appropriate with the understanding that a MAC might reimburse less than the billed amount or not cover the service at all. Practitioners who have contracts with private insurers may face contractual limitations on the amount they may bill.

How often can I bill the interactive complexity code? How is payment for interactive complexity determined?

The new add-on code for interactive complexity, 90785, is designed for use with specific and recognized communication difficulties for different types of patients and in situations where significant complicating factors may increase the intensity of the primary service.

Add-on code 90785 may be billed along with a diagnostic evaluation (90791), an individual psychotherapy service (90832, 90834 or 90837) or group psychotherapy (90853). In order to use code 90785 at least one of the following factors must exist: 

  1. Maladaptive communication (for example, high anxiety, high reactivity, repeated questions or disagreement) 

  2. Emotional or behavioral conditions that inhibit implementing the treatment plan 

  3. Mandated reporting (for example, in cases of neglect or abuse) 

  4. Play equipment, devices, interpreter or translator required (see relevant guidance from CMS)

These factors are typically present when psychologists treat patients who:

  • Have others legally responsible for their care (for example, minors or adults with guardians) 

  • Request others to be involved in the psychotherapy sessions (for example, family members, interpreters, translators) 

  • Require the involvement of other third parties (for example, child or senior welfare agencies, probation officers, school personnel)

More detail regarding when and how often psychologists can bill code 90785 will be determined by the coverage policies of public and private carriers. Psychologists who participate in Medicare are advised to check their MAC website for local coverage determinations (LCDs) on the new psychotherapy codes. Practitioners who accept private insurance should monitor relevant coverage policies on private carrier websites.

CMS has assigned an interim work value to the interactive complexity code for 2013. Actual payment will differ based upon the geographic locality, but the national Medicare rate for 90785 is $4.76. Some private insurers have published rate sheets for 2013 that include 90785, while rate lists for certain other private insurers do not include the interactive complexity code.

For both the crisis and interactive complexity codes, APA and other mental health associations will conduct member surveys early in 2013 as part of the process that is expected to result in CMS assigning new work values for 2014 and beyond.