Insurance Panels & Billing 101

[Therapist4Chnge]

Since the APA doesn’t require any training in practice management and billing, I thought it’d be helpful to start a thread. I’m hoping to hear from clinicians in all different settings to chime in because the more clinicians understand billing, the more we have an opportunity to advocate for ourselves.

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[Therapist4Chnge]

I’ll come back and update this post later this weekend when I have some time.

For those in practice, care to share your wisdom about insurance panels and billing?

 

[psych.meout]

Thank you so much for this! I really love my grad program and am receiving great training as a scientist and clinician, but there really is a dearth of training and education in the business and career sides of things outside of being TT university faculty or a researcher or clinician at an institution.

 

[Indiana_Jane]

Thank you so much for this! I really love my grad program and am receiving great training as a scientist and clinician, but there really is a dearth of training and education in the business and career sides of things outside of being TT university faculty or a researcher or clinician at an institution.

Same here! Looking forward to the responses.

 

[Sanman]

I’ll come back and update this post later this weekend when I have some time.

For those in practice, care to share your wisdom about insurance panels and billing?

My wisdom? Insurance panels suck and learn billing carefully. Small adjustments can mean big income changes. Learn to review and adjust billing quarterly.

Curious what you had in mind specifically T4C?

 

[singasongofjoy]

Small adjustments can mean big income changes

Sanman - I'm all ears. Care to elaborate? I assume you're talking about add-on codes?

 

[calimich]

Most of my work is as a tt assistant professor, however a year ago I started a small private practice on the side to which I usually devote 1.5 days/week. I'm a sole proprietor, do all my own billing/scheduling, and sublet an office from a psychiatrist. Currently I'm credentialed through Blue Cross of California and in the process of adding Blue Shield (I think in most states they are one entity, in CA they are separate), and Magellan. I was recruited to participate in the Blue Cross network, which led to a Blue Shield invite, but I applied to Magellan independently.

The process for getting on the BCross panel was generally very easy, although it did involve some tedious paperwork. Once I sent my application away it took about a month to process; I've been told to expect a similar timeline for BShield (actually just sent in my paperwork this afternoon). The Magellan process has taken much longer; they say up to 180 days and I've been waiting since late March. In addition to their own paperwork, all three networks required I have a CAQH account where my official documents (e.g., malpractice insurance, license) are stored.

I've been surprised and impressed at how easy the BCross billing has been and how quickly I'm reimbursed. BCross' billing is done through availity, it was fairly intuitive to learn, most of my claims are approved within 24 hours, and I typically receive direct deposits within a week after submitting the claim. At first I billed weekly, taking 45 mins or so at the end of the week to submit my claims, usually from my home computer. However, I quickly decided my time at home was more valuable and instead of taking this work home I now bill every 3 or 4 weeks by scheduling a 2-hour "billing hour" into my clinical day. Yes, I'm giving up revenue, but the trade off for me and family is worth it, and honestly I don't mind the break from seeing patients. I also learned that billing multiple sessions per client is much more efficient than billing single sessions each week -- once I input their info it's just a few more clicks to add multiple sessions.

some other thoughts...

I generally stick to the 50 minute therapy hour (90834), however I do not hesitate to bill 90837 when clinically necessary and we go 53 mins or longer. BCross/BShield do not need prior authorization for the longer time and I'm sure to document the time & clinical reasoning in the chart notes. The reimbursement rate isn't too much more, about 10%, but it all adds up. I also successfully negotiated a higher rate than what I was initially offered before agreeing to sign on with BShield.

Two factors that made this all easier for me are the reliable tt job and a solid referral source. About a month after opening I was booked solid and now routinely have a two month wait list. I've slowly been branching out to other niches and growing the % of full-fee clients, but I'd estimate about 90% of my clients use insurance and 75% come from a single referral source.

I have a website but not a Psych Today profile and don't do any marketing, although I did pay someone to design a logo and business cards. I use Simple Practice to manage notes & scheduling and did my own taxes this year. I have thoughts about expanding the practice by taking on supervisees, likely post-docs, but that's a few years away after tenure and I have no desire to do clinical practice full time.

I'm happy to answer specific questions if folks have them.

 

[Therapist4Chnge]

Curious what you had in mind specifically T4C?

I think it’d be helpful for trainees (and ECPs) to better understand some of the hoops they’ll have to jump through to get paid. Maybe cover some basics about pre-auth, explain a bit about CPT codes, etc. If ppl really want to make it interesting, someone (not me) can try and explain the new neuropsych billing.

I actually don’t take commercial or gov’t insurance, but i’ve sat through dozens of hours of billing talks and been active on a billing listserv for the last decade+, and I think sharing the info is important.

I’m also updating my biz talk lecture for a conference next year, so i’ll i’ll have more info that may be of use to ppl.

Ppl should feel free to post questions, as i’m not sure what ppl may want to discuss, but there is a ton of experience across members on here.

 

[Therapist4Chnge]

Calimich’s post is *exactly* the kind of post I was hoping to see in here. There is some great info in there.

Now i’m wondering why BC & BS are separate, but I can google that info; the other stuff is much harder to find.

 

[EPPP123]

Assuming that it is okay to mention here, there is a Facebook group called "Insurance Credentialing and Billing for Mental Health Clinicians" that is exactly for what you are discussing here. You must be a licensed clinician to join. TONS of information.

 

[ClinicalABA]

Here’s my process for autism evaluations with toddlers, almost exclusively seeing Medicaid clients-

- 1 hour intake session, billed under code 90791 (psych assessment without medical services. Pretty much automatically authorized by the insurance company. At the conclusion of this intake session (called a “standard clinical evaluation” by the ins. companies).
- If, at the conclusion of the intake, I want to do full testing (almost always what happens) I’ll need to request authorization for testing from the ins. co. This typically requires me to complete an ins. company specific form listing possible diagnoses, likely tests, and- in some cases- a reason why the intake wasn’t enough. Some ins. cos. request additional info, like a summary note of the intake. Some also require a referral from a physician (most of my referrals come from early intervention providers.
-authorization usually comes within a week of the request (in most cases they have 15 business days). I’m typically requesting authorization for CPT codes 96132, 96133, 96136, and 96137.
-denials by the ins. co. are rare with my population, and usually related to lapses in coverage or missing info. In some cases they will deny an annual reassessment based solely on my recommendations to come back in a year. Insurance won’t cover another assessment within a year unless there has been decline or lack of response to treatment (in which cases they typically will authorize). I’ve never appealed a denial that wasn’t subsequently authorized.
- I will bill out 5-10 hours for the assessment depending on age (generally older mean more differential dx, more tests, and more time per test. We don’t have issues in getting paid.

I have an insurance auth department and billing department in my company. We seem to be getting paid in a timely fashion, though I’d only know if something were wrong. They are good, but it still can be a crazy process at times.

 

[PsyDr]

Rambling, non-caffinated PsyDr's opinions on billing and insurance:

1) First you need an National Provider Identification nymber (NPI). Super easy to do. They ask for you name, address, license, speciality, etc. This will be relevant later.
2) IME, neuropsych disproportionately affects the older and younger crowds. Which means a lot of medicare/medicaid. These programs are run by CMS, in general, for our purposes.
3) CMS requires a referral from a physician for services. Because we are not "physicians". CMS also has a unique definition of physician, because but chiros, optos, etc are.
3) It is always better to bill under a medical code, rather than a psych code. Medical codes are pretty broad, and include ICD codes like "memory loss". Psych diagnositic codes are what you see in the DSM5.
4) If you ask your referral base to use ICD codes like "memory loss", it is a good thing.
5) When you submit a bill to insurance, it asks you for the diagnosis code. You ALWAYS want to use a medical code.
6) Non-CMS insurances tend to have a subsidiary company that does their mental health bills. This is why you could have BCBS insurance, but your mental health coverage is under Acme Insurnace CO. Even when you never paid for Acme. This is one of the HUGE problems with patients. They tell you they have BCBS, show up to their intake, and their specific BCBS plan actually uses ACME mental health, which you don't accept. Now you have a pissed off patient, who just didn't understand their own insurance, and have waited for nothing.
7) Non-CMS insurances use a rule of 3/4 or some number I forget. The relevant idea is that "are a majority of things psych on this bill?". Your NPI is always gonna be psych. So are your CPT codes. So you really want your diagnostic codes to be medical. Otherwise they get thrown over to mental health insurance, who are ridiculous and capitate things, or tell you how much testing you can do, or whatever. You can use the referral ICD code (e.g., memory loss).
8) Now you send that bill off.
9) Sometimes, the insurance company calls to complain. Maybe you billed too much, maybe you screwed up. If this happens too often, you're either taking bad insurances, doing a bad job in billing, or you're a pushover.

Preauth

1) some insurances want you to go through a preauthoriazation process before you see a patient. Common in commercial insurances and more so in workers comp.
2) This means you have to wait aroudn for a phone call, then explain why you need to test or treat someone whom you've never seen. It's a game, and basically you just learn what the insurance providers' handbooks or worker comp treatment guidelines say.
3) Oh yeah, this work isn't compensated. So.... hour on the phone with a jerkface might result in $0.00.

Audits:

1) Occasionally, insurance companies audit your practice. It's really a big nothing if you do things right. They select some files. Look through them. It's done. Only problem I ever had with that was when I tried to give a WAIS to a hyperverbal manic patient. So I had to explain why it took 3X as long as normal. But it was also repeatedly documented in the chart, and in test forms.

Insurances Hassles

1) If you have read ALL of the relevant documents I mentioned, and you're getting hassles from an insurance company, you can contact your state's insurance department. They have a public help line and are usually VERY nice. Insurance companies HATE when you do this. That's because the sate can sanction them millions of dollars for repeated screw ups. I wouldn't do it too often, or the insurance company will drop you, but it's not a bad move.

2) Sometimes they delay paying you. Especially if you move your office. Once I had a like 4-5 months where they didn't pay me because I moved offices. Had to cover staff and office overhead out of reserves, which suuuuuuuuucked. Big paycheck when it came through though.

Picking Insurance Panels

1) Okay, you got your NPI.
2) You need to sign up for medicare. It's a bunch of stupid forms.
3) If you have an LLC for your PP, you'll also need to get an NPI for it, and fill out clinic forms for CMS. But you have to attach your own personal NPI as well. So: PsyDr psychologist NPI + Psydr Clinic NPI owned by Psydr NPI. I dunno if that makes sense, coffee hasn't kicked in and I hate you.
4) If you DEFINITELY never want to accept medicare/medicaid, you're in luck! You have to write a letter with specific formating, and tell them you're "opting out" of being a CMS provider. Because the default in this country is that you are. Politicize that however you want. You're gonna have to redo this opt out letter every three years until you die.
5) Now that you're past all that, it's time to find some other insurances. You'll want to figure out what insurances the major employers in your area use. Maybe it's BCBS, United, Aetna,.... I dunno. Ask around. Family, friends, call the front desk at the major companies for all of an afternoon. This is not complicated.
6) 9/10, these insurance companies are gonna ask you to be on an automated credentialing service, the name of which I forget. So you sign up on that service, and it's frustrating and stupid.
7) Once you have #6 done, the insurance companies will look at your application. This can take anywhere from a few days to 6 months. Not even kidding. 6 months.
8) The response can vary from "we don't need any more providers in this area" to "here's a contract". The former being code for "go to hell".
9) The contract is usually the first time you'll see what they pay. One big insurance company offered me $40/hr.
10) You can call an negotiate these rates, but not always. So you call and say something like, "These rates are a lot lower than medicare. I'm sure you meant this number on top of medicare, right?". 8/10, they'll negotiate for a higher rate. How much higher is another issue.
11) I'd highly encourage you to never work with low paying insurances. They've already shown that they are bad, and unethical. It doesn't get better from there.
12) Unfortunately, people with crappier insurances tend to have more problems and are more difficult to deal with. I prefer to just do pro bono stuff, rather than have some mother screaming in my lobby about a $20 co-pay. True story, a neurologist friend of mine started takign a super crappy insurance because he got really interested in a condition/patient who only had that insurance. But he had to take all comers with that insurance once he got on it. Within 6 months, the patients had stolen everything in his waiting room. Weird stuff, like a leather bound version of some book.

Pro Bono Work
1) Totally not tax deductible. Which sucks.


Balance Billing
1) Illegal in some states, but not others. Look it up. Kinda a jerk thing to do, if you ask me.

Pointers
1) track your time and put it on reports. That's required.
2) Time tracker apps are key. Phone call, that's a tracking. Writing, that's a tracking. If you're diligent in doing this, you can make real money.
3) There are CPT and ICD codes for everything. Phone calls, file review, etc. Learn them. Submit bills for everything.
4) Don't take phone calls from patients unless it's an emergency. You're running a service business that's paid hourly. If they're using your services, they need to pay. If their insurance won't pay for a phone call, they need to come see you, or pay themselves.


@Therapist4Chnge
1) CRPS isn't real.
2) BCBS was originally two companies, both some of the first insurance companies. One was Baylor University's health insurance. One was a CA business health insurance. They joined up way back when. In states where BS was established before the merger, they still use BS.

 

[ImAFreudNot]

Just wanted to chime in to say thank you! I'm looking to enter into PP in a few years and so this information is all very helpful. I've been scouring the internet for billing and insurance info for psychologists and so far nothing has come close to this level of detail.

Somewhat related: For those who started their own PP/hung out their own shingle, are there any resources, books, software (for day-to-day tracking, etc), or other useful item available for purchase or consumption that you'd recommend for new clinicians starting out? I'm thinking business-savvy stuff, but interested to hear about anything others have found useful.

 

[msgeorgeeliot]

As part of my due diligence to set up a PP, I had already planned to spend a day (or however long it takes) to read every @PSYDR post ever about this general topic. This summary is killer. Thanks, “I hate you”

Rambling, non-caffinated PsyDr's opinions on billing and insurance:

1) First you need an National Provider Identification nymber (NPI). Super easy to do. They ask for you name, address, license, speciality, etc. This will be relevant later.
2) IME, neuropsych disproportionately affects the older and younger crowds. Which means a lot of medicare/medicaid. These programs are run by CMS, in general, for our purposes.
3) CMS requires a referral from a physician for services. Because we are not "physicians". CMS also has a unique definition of physician, because but chiros, optos, etc are.
3) It is always better to bill under a medical code, rather than a psych code. Medical codes are pretty broad, and include ICD codes like "memory loss". Psych diagnositic codes are what you see in the DSM5.
4) If you ask your referral base to use ICD codes like "memory loss", it is a good thing.
5) When you submit a bill to insurance, it asks you for the diagnosis code. You ALWAYS want to use a medical code.
6) Non-CMS insurances tend to have a subsidiary company that does their mental health bills. This is why you could have BCBS insurance, but your mental health coverage is under Acme Insurnace CO. Even when you never paid for Acme. This is one of the HUGE problems with patients. They tell you they have BCBS, show up to their intake, and their specific BCBS plan actually uses ACME mental health, which you don't accept. Now you have a pissed off patient, who just didn't understand their own insurance, and have waited for nothing.
7) Non-CMS insurances use a rule of 3/4 or some number I forget. The relevant idea is that "are a majority of things psych on this bill?". Your NPI is always gonna be psych. So are your CPT codes. So you really want your diagnostic codes to be medical. Otherwise they get thrown over to mental health insurance, who are ridiculous and capitate things, or tell you how much testing you can do, or whatever. You can use the referral ICD code (e.g., memory loss).
8) Now you send that bill off.
9) Sometimes, the insurance company calls to complain. Maybe you billed too much, maybe you screwed up. If this happens too often, you're either taking bad insurances, doing a bad job in billing, or you're a pushover.

Preauth

1) some insurances want you to go through a preauthoriazation process before you see a patient. Common in commercial insurances and more so in workers comp.
2) This means you have to wait aroudn for a phone call, then explain why you need to test or treat someone whom you've never seen. It's a game, and basically you just learn what the insurance providers' handbooks or worker comp treatment guidelines say.
3) Oh yeah, this work isn't compensated. So.... hour on the phone with a jerkface might result in $0.00.

Audits:

1) Occasionally, insurance companies audit your practice. It's really a big nothing if you do things right. They select some files. Look through them. It's done. Only problem I ever had with that was when I tried to give a WAIS to a hyperverbal manic patient. So I had to explain why it took 3X as long as normal. But it was also repeatedly documented in the chart, and in test forms.

Insurances Hassles

1) If you have read ALL of the relevant documents I mentioned, and you're getting hassles from an insurance company, you can contact your state's insurance department. They have a public help line and are usually VERY nice. Insurance companies HATE when you do this. That's because the sate can sanction them millions of dollars for repeated screw ups. I wouldn't do it too often, or the insurance company will drop you, but it's not a bad move.

2) Sometimes they delay paying you. Especially if you move your office. Once I had a like 4-5 months where they didn't pay me because I moved offices. Had to cover staff and office overhead out of reserves, which suuuuuuuuucked. Big paycheck when it came through though.

Picking Insurance Panels

1) Okay, you got your NPI.
2) You need to sign up for medicare. It's a bunch of stupid forms.
3) If you have an LLC for your PP, you'll also need to get an NPI for it, and fill out clinic forms for CMS. But you have to attach your own personal NPI as well. So: PsyDr psychologist NPI + Psydr Clinic NPI owned by Psydr NPI. I dunno if that makes sense, coffee hasn't kicked in and I hate you.
4) If you DEFINITELY never want to accept medicare/medicaid, you're in luck! You have to write a letter with specific formating, and tell them you're "opting out" of being a CMS provider. Because the default in this country is that you are. Politicize that however you want. You're gonna have to redo this opt out letter every three years until you die.
5) Now that you're past all that, it's time to find some other insurances. You'll want to figure out what insurances the major employers in your area use. Maybe it's BCBS, United, Aetna,.... I dunno. Ask around. Family, friends, call the front desk at the major companies for all of an afternoon. This is not complicated.
6) 9/10, these insurance companies are gonna ask you to be on an automated credentialing service, the name of which I forget. So you sign up on that service, and it's frustrating and stupid.
7) Once you have #6 done, the insurance companies will look at your application. This can take anywhere from a few days to 6 months. Not even kidding. 6 months.
8) The response can vary from "we don't need any more providers in this area" to "here's a contract". The former being code for "go to hell".
9) The contract is usually the first time you'll see what they pay. One big insurance company offered me $40/hr.
10) You can call an negotiate these rates, but not always. So you call and say something like, "These rates are a lot lower than medicare. I'm sure you meant this number on top of medicare, right?". 8/10, they'll negotiate for a higher rate. How much higher is another issue.
11) I'd highly encourage you to never work with low paying insurances. They've already shown that they are bad, and unethical. It doesn't get better from there.
12) Unfortunately, people with crappier insurances tend to have more problems and are more difficult to deal with. I prefer to just do pro bono stuff, rather than have some mother screaming in my lobby about a $20 co-pay. True story, a neurologist friend of mine started takign a super crappy insurance because he got really interested in a condition/patient who only had that insurance. But he had to take all comers with that insurance once he got on it. Within 6 months, the patients had stolen everything in his waiting room. Weird stuff, like a leather bound version of some book.

Pro Bono Work
1) Totally not tax deductible. Which sucks.


Balance Billing
1) Illegal in some states, but not others. Look it up. Kinda a jerk thing to do, if you ask me.

Pointers
1) track your time and put it on reports. That's required.
2) Time tracker apps are key. Phone call, that's a tracking. Writing, that's a tracking. If you're diligent in doing this, you can make real money.
3) There are CPT and ICD codes for everything. Phone calls, file review, etc. Learn them. Submit bills for everything.
4) Don't take phone calls from patients unless it's an emergency. You're running a service business that's paid hourly. If they're using your services, they need to pay. If their insurance won't pay for a phone call, they need to come see you, or pay themselves.


@Therapist4Chnge
1) CRPS isn't real.
2) BCBS was originally two companies, both some of the first insurance companies. One was Baylor University's health insurance. One was a CA business health insurance. They joined up way back when. In states where BS was established before the merger, they still use BS.

 

[PsyDr]

As part of my due diligence to set up a PP, I had already planned to spend a day (or however long it takes) to read every @PSYDR post ever about this general topic. This summary is killer. Thanks, “I hate you”

God help you.

 

[erg923]

Some may have some misunderstandings about psych testing preauthorization requests (the ones that are "reviewed" for "medical necessity"). This is not my job, but I do work for a large behavioral health manged care company.

1. There is no "administration time" allotted for instruments that the patient fills out themselves such as MMPI, MCMI and most any rating scale or symptom inventory. Time for scoring, interpretation and report write-up is of course allotted for these instruments, however.

2. Asking for 5-6 units/hours or more of the testing service codes (e.g., 96130/96131) is often going to be seen as excessive for even a fairly lengthy test battery. 2, 3, maybe 4 units/hours of the service codes (96130/96131) will be seen as much more reasonable and acceptable for most any psych/npsych testing battery.

3. Time requested for projective instruments, for most patients/clinical situations, is likely to be excluded from the authorization ("not medically necessary"). A primary reason being their poor psychometrics, variable interpretation, and lack of empirical evidence that they translate into more a accurate diagnosis or significantly alter a typical treatment plan.

4. Testing to "confirm" a diagnosis or diagnoses that have already been made or are already highly suspected based on your psychiatric interview (90791) or prior exams is unlikely to be seen as medically necessary. Probably a term to avoid using.

5. Test batteries that are heavy on rating scales but light on, or absence of, more objective instruments/data will probably be more heavily scrutinized for medical necessity and the time requested.

6. With some disorders, comorbidity is the rule rather than the exception, Requesting 4, 5, 6 hours of testing to see if its "ADHD or depression or anxiety disorder" is often quite excessive because if your interview, collateral info/rating scales and clinical judgment suggest alot of symptoms of both...its probably just both, plain and simple. Some testing may be be useful at times, but a giant battery??? Probably not much ROI or increased individual diagnostic accuracy there.

7. Requests for billing psychological testing for every patient is/would be cost prohibitive in the current set-up. Psych testing is thought of by the manged care industry as adjunctive to the psychiatric eval/interview, not as a primary part (or a standard part) of the diagnosis and treatment planning.

8. As flawed it may be, the DSM is there for a reason and should used as a primary guide for diagnosis. Use of structured or semi-structured interviews such as SCID, SADs or many others is probably more the "gold standard" for diagnosing most psych disorders as opposed throwing a MMPI, PAI and various other tests or rating scales, etc at everything.

9. If doing actual neuropsych evals (not just mixing in some traditional neuropsych tests for your own curiosity or for subjective co-morbid complaints of "memory problems"), use medical codes and bill thru medical plan. Otherwise it will go in as psych testing and, right or wrong, will be subjected to many of these points.

10. With all honesty, I think we sometimes request psych/npsych testing time/instruments to satisfy our own clinical curiosity (or because that's how we were trained) rather than because it is needed or objectively helpful to the patient. I am reminded of Meehl's autobiography quote:
-"I did some T.A.T.’s on Dr. B. C. Schiele’s well-heeled private patients, which was interesting and paid well but left me wondering just how much it helped the patient."

 

[madpsych78]

I'm a post doc in a pediatric neuropsychology private practice. Most of our referrals are for concerns surrounding Autism, ADHD, learning disorders such as dyslexia, anxiety, etc. Yet Autism and ADHD are typically not regarded as medical. What would be more acceptable ICD codes that we could use to bill medically when there is no history of things like head injury, medical conditions, etc.?

 

[erg923]

I'm a post doc in a pediatric neuropsychology private practice. Most of our referrals are for concerns surrounding Autism, ADHD, learning disorders such as dyslexia, anxiety, etc. Yet Autism and ADHD are typically not regarded as medical. What would be more acceptable ICD codes that we could use to bill medically when there is no history of things like head injury, medical conditions, etc.?

Those are all psychiatric diagnoses, at least to the managed care industry. Although Interqual criteria can/does consider ASD a diagnosis that can billed for neuropsych testing evaluations due to the likelihood of specific and sometimes global impairments in cognitive functioning that accompany/are comorbid with the diagnosis and its common rule-outs.

Psychological/Neuropsychological testing for learning disorders, or for academic performance concerns or issues, even if thought to be co-morbid with other psychiatric diagnoses, is generally not considered "medically necessary" to plan medical/psychiatric treatment and is generally not a covered benefit of any insurance plan. The school/school system is allotted tax dollars to do those types of evals. My experience is you will get comprehensive eval authed for ASD and its various mimics, but just don't expect to be given specific time for a WIAT or a WRAT for the reasons I mentioned above.

 

[PsyDr]

Just wanted to chime in to say thank you! I'm looking to enter into PP in a few years and so this information is all very helpful. I've been scouring the internet for billing and insurance info for psychologists and so far nothing has come close to this level of detail.

Somewhat related: For those who started their own PP/hung out their own shingle, are there any resources, books, software (for day-to-day tracking, etc), or other useful item available for purchase or consumption that you'd recommend for new clinicians starting out? I'm thinking business-savvy stuff, but interested to hear about anything others have found useful.

(Disclaimer: I apparently was running a fever while writing all this, so it's not exactly organized).

Other weird thoughts:


Mart's book on forensic psychology PP is decent.
Pepping's book on neuropsychology PP is decent, but I just summed up a decent amount of that for you and added.

Hire an attorney to create an LLC. DO NOT USE ONLINE COMPANIES TO CREATE YOUR LLC. This is what protects you forever. You do not want to cheap out on this. IME, solo practice young attys will work with you in a paymnet plan or something if you explain you're just starting out and are poor as hell. Mine has made a lot more money off of me over the years because he did this.

Paper tracking is where I started out. Literally printed a schedule with 15 min increments off of Outlook, wrote what I did, and then entered it later.

I forget the software we used to submit bills. I had an old school one that was like $600/yr. We submitted paper bills, which meant we had to order CMS form 1500 to print. We ordered this crap from Amazon. One of the moves to stop the PP was the requirement to submit electronically.

I ordered the state mandated WC/Minimum wage posters to go in the break area from amazon. There was a scam where some atty was threatening to come after small business if they didn't have these posters, but would conveniently offer to sell them for like $300. They're $50 from amazon.

Create an Amazon prime account for your business. I buy our stamps from here. And our paper, because I am lazy and am not carrying that crap from my car to my office.

Once you have an LLC, and an EIN, you can get a business credit car. I suggest AMEX business platinum. I use it, I've seen many PP guys throw that card down.

Your business credit does not mess with you personal credit. They are different, even though your SSN is attached.

You'll need a fax or electronic fax, because HIPPA requires a fax. Cheap monthly thing.

You can buy used file cabinets from used office supply stores. I don't know why you'd want to pay full price for those.

Business cards have been weirdly useful. People like seeing an expensive card carrying case.

Websites were useless and directed a lot of business that I didn't want.

 

[PsyDr]

I'm a post doc in a pediatric neuropsychology private practice. Most of our referrals are for concerns surrounding Autism, ADHD, learning disorders such as dyslexia, anxiety, etc. Yet Autism and ADHD are typically not regarded as medical. What would be more acceptable ICD codes that we could use to bill medically when there is no history of things like head injury, medical conditions, etc.?

I don't think it's right, but the ped neurologists use "static encephalopathy" or variants thereof as the diagnostic code.

 

[ClinicalABA]

I'm a post doc in a pediatric neuropsychology private practice. Most of our referrals are for concerns surrounding Autism, ADHD, learning disorders such as dyslexia, anxiety, etc. Yet Autism and ADHD are typically not regarded as medical. What would be more acceptable ICD codes that we could use to bill medically when there is no history of things like head injury, medical conditions, etc.?

Note that many states have specific "autism mandates." These are regulations that require insurance companies to cover services related to the diagnosis and treatment of ASD (de facto identifying ASD as a medical condition, as thus all diagnostic and therapy services as medically necessary). States will differ as the the scope of the mandate. Also, not all insurance plans are subject to state laws- for example, self-funded plans (usually found in bigger companies with many employees contributing to the "premium pool") are subject to federal law, and thus don't have to cover ASD related services (though i have found that many do). Medicaid plans may also be exempt from state autism mandates. In my state, the ASD mandate came on line in 2010 for private, non-self funded insurance plans. The state Medicaid program (MassHealth), came on board around 2015/16, and this let to an exponential increase in insurance funded referrals in my area.

As ERG notes, insurance will not cover things that are the school's responsibility or are related to academic progress. As an example, they will typically fund cognitive testing as part of an ASD eval (using neuropsych CPT codes) for kiddos younger than 5. After age 5, that part of the fee for our testing is paid by the school or family.

 

[madpsych78]

Note that many states have specific "autism mandates." These are regulations that require insurance companies to cover services related to the diagnosis and treatment of ASD (de facto identifying ASD as a medical condition, as thus all diagnostic and therapy services as medically necessary). States will differ as the the scope of the mandate. Also, not all insurance plans are subject to state laws- for example, self-funded plans (usually found in bigger companies with many employees contributing to the "premium pool") are subject to federal law, and thus don't have to cover ASD related services (though i have found that many do). Medicaid plans may also be exempt from state autism mandates. In my state, the ASD mandate came on line in 2010 for private, non-self funded insurance plans. The state Medicaid program (MassHealth), came on board around 2015/16, and this let to an exponential increase in insurance funded referrals in my area.

As ERG notes, insurance will not cover things that are the school's responsibility or are related to academic progress. As an example, they will typically fund cognitive testing as part of an ASD eval (using neuropsych CPT codes) for kiddos younger than 5. After age 5, that part of the fee for our testing is paid by the school or family.

I think that's where things can get messy because in the states where I have practiced in the schools (I started off as a school psychologist), ASD can also be evaluated within the school setting as Autism is a special education category. So one can argue that the school may be responsible for testing for Autism, at least as a special education category. I'd say the difference is in the types of interventions that are identified as needed - you often need a clinical diagnosis of ASD to receive ABA therapy, rather than the special education eligibility of Autism. School-based evaluations are only going to include recommendations that either the school can provide, or things the parents can do at home. In other words, they are not going to recommend outside programs or services, such as ABA therapy, because then the district would be liable for paying for that.

We've received many referrals from neurologists with diagnostic codes of encephalopathy (G93.40), but it's not sufficient to bill G93.40 if the only diagnosis from the neuropsych testing is, say, ADHD.

For what it's worth, my supervisor's practice is in Texas, and we are in-network with some private insurance companies but not Medicaid.

 

[ClinicalABA]

I think that's where things can get messy because in the states where I have practiced in the schools (I started off as a school psychologist), ASD can also be evaluated within the school setting as Autism is a special education category. So one can argue that the school may be responsible for testing for Autism, at least as a special education category. I'd say the difference is in the types of interventions that are identified as needed - you often need a clinical diagnosis of ASD to receive ABA therapy, rather than the special education eligibility of Autism. School-based evaluations are only going to include recommendations that either the school can provide, or things the parents can do at home. In other words, they are not going to recommend outside programs or services, such as ABA therapy, because then the district would be liable for paying for that.

We've received many referrals from neurologists with diagnostic codes of encephalopathy (G93.40), but it's not sufficient to bill G93.40 if the only diagnosis from the neuropsych testing is, say, ADHD.

For what it's worth, my supervisor's practice is in Texas, and we are in-network with some private insurance companies but not Medicaid.

Most states have some sort of autism mandate (see http://www.ncsl.org/research/health/autism-and-insurance-coverage-state-laws.aspx). This often (always?) requires a dx by an MD or doctoral level psychologist, which can cause a problem when the dx is given by a school psychologist or social worker. As a general rule an in line with the OP, it’s wise for clinicians to familiarize themselves with all regs and insurance co policies pertaining to their specific areas of practice, as well as the ramifications of not doing things in line with such regs or practices.

 

[calimich]

The Magellan process has taken much longer; they say up to 180 days and I've been waiting since late March.

So yesterday I started getting Magellan referrals which was strange because I hadn't received official work I'd been accepted into their network. First referral came around 5pm...then another about 30 minutes later. At 7:30pm I got the email confirming I'd been added to their panel and by 9am today I had two more referrals.

I knew there was demand but I didn't expect so many this quickly and certainly not before receiving the official word. Unfortunately, I don't have much room for new folks. Any other Magellan CA providers here?

 

[AbnormalPsych]

Hire an attorney to create an LLC. DO NOT USE ONLINE COMPANIES TO CREATE YOUR LLC.

Any advice on how to find one based on your experience? Word of mouth?

 

[PsyDr]

Any advice on how to find one based on your experience? Word of mouth?

You don’t need to get fancy with this. I just called solo practices and asked if they could do what I needed. Like most professionals, the people who said no were able to give referrals. The solo practice preference is just my idiosyncratic anticorporatism; has little to do with business sense.

You can look up what the basic filing fee is for your state, on your states’ website. Add in a few hundred to have the actual documents drawn up. I think LLCs in my state cost like $500 just to file with the state. I used a young attorney who created this stuff, filed with the state, and got EIN stuff for the irs filed.

Used a much higher priced attorney for some of the more complicated tiered structure.

 

[erg923]

Seems more can be done with this thread?

I see billing/coding misunderstandings everyday that cost providers many headaches.

Beyond requests for psych testing, I would have to assume there are questions related to outpatient therapy services, caps on the 90837 code, CBS services, IOP services, the appeal and peer-to-peer process, BH carve-out companies, the parity issue, etc.?

 

[LadyHalcyon]

Also, don't forget to stack! Interactive complexity, prolonged service codes, etc. Be familiar with what you can bill, and as a QHP we can bill.

 

[LadyHalcyon]

But requesting more than 4 units for testing isn't ridiculous when the new codes factor in interpretation/scoring time. I easily spend 10 to 2pm testing someone (can go longer, depending on patient, patient's parents). I can bill a 90791 for the clinical interview, and I do. But once again, I do thorough clinical interviews bc, imo, that is almost more important than the data. If there is a talkative teen, plus a talkative parent, that interview can take 2 hours. Then the scoring and interpreting... And then WE DON'T EVEN GET PAID TO WRITE THE REPORT.

Some may have some misunderstandings about psych testing preauthorization requests (the ones that are "reviewed" for "medical necessity"). This is not my job, but I do work for a large behavioral health manged care company.

1. There is no "administration time" allotted for instruments that the patient fills out themselves such as MMPI, MCMI and most any rating scale or symptom inventory. Time for scoring, interpretation and report write-up is of course allotted for these instruments, however.

2. Asking for 5-6 units/hours or more of the testing service codes (e.g., 96130/96131) is often going to be seen as excessive for even a fairly lengthy test battery. 2, 3, maybe 4 units/hours of the service codes (96130/96131) will be seen as much more reasonable and acceptable for most any psych/npsych testing battery.

3. Time requested for projective instruments, for most patients/clinical situations, is likely to be excluded from the authorization ("not medically necessary"). A primary reason being their poor psychometrics, variable interpretation, and lack of empirical evidence that they translate into more a accurate diagnosis or significantly alter a typical treatment plan.

4. Testing to "confirm" a diagnosis or diagnoses that have already been made or are already highly suspected based on your psychiatric interview (90791) or prior exams is unlikely to be seen as medically necessary. Probably a term to avoid using.

5. Test batteries that are heavy on rating scales but light on, or absence of, more objective instruments/data will probably be more heavily scrutinized for medical necessity and the time requested.

6. With some disorders, comorbidity is the rule rather than the exception, Requesting 4, 5, 6 hours of testing to see if its "ADHD or depression or anxiety disorder" is often quite excessive because if your interview, collateral info/rating scales and clinical judgment suggest alot of symptoms of both...its probably just both, plain and simple. Some testing may be be useful at times, but a giant battery??? Probably not much ROI or increased individual diagnostic accuracy there.

7. Requests for billing psychological testing for every patient is/would be cost prohibitive in the current set-up. Psych testing in particular is thought of by the manged care industry as adjunctive to the psychiatric eval/interview, not as a primary part (or a standard part) of the diagnosis and treatment planning.

8. As flawed it may be, the DSM is there for a reason and should used as a primary guide for diagnosis. Use of structured or semi-structured interviews such as SCID, SADs or many others is probably more the "gold standard" for diagnosing most psych disorders as opposed throwing a MMPI, PAI and various other tests or rating scales, etc at everything.

9. If doing actual neuropsych evals (not just mixing in some traditional neuropsych tests for your own curiosity or for subjective co-morbid complaints of "memory problems"), use medical codes and bill thru medical plan. Otherwise it will go in as psych testing and, right or wrong, will be subjected to many of these points.

10. With all honesty, I think we sometimes request psych/npsych testing time/instruments to satisfy our own clinical curiosity (or because that's how we were trained) rather than because it is needed or objectively helpful to the patient. I am reminded of Meehl's autobiography quote: "I did some T.A.T.’s on Dr. B. C. Schiele’s well-heeled private patients, which was interesting and paid well but left me wondering just how much it helped the patient."

 

[LadyHalcyon]

Here's my question: I see CPT codes pertaining to reviewing charts, consulting, etc. Anyone have experience using those? When, where, why, how? Did they get paid? Besides prolonged codes, interactive complexity etc, what should I be coding that varies from the typical 90834/90837?

 

[LadyHalcyon]

Caps on 90837 codes, please explain more about this to me. Only one insurance company has an issue with it and it seems to pertain to how often our company uses them.

Seems more can be done with this thread?

I see billing/coding misunderstandings everyday that cost providers many headaches.

Beyond requests for psych testing, I would have to assume there are questions related to outpatient therapy services, caps on the 90837 code, CBS services, IOP services, the appeal and peer-to-peer process, BH carve-out companies, the parity issue, etc.?

 

[erg923]

But requesting more than 4 units for testing isn't ridiculous when the new codes factor in interpretation/scoring time. I easily spend 10 to 2pm testing someone (can go longer, depending on patient, patient's parents). I can bill a 90791 for the clinical interview, and I do. But once again, I do thorough clinical interviews bc, imo, that is almost more important than the data. If there is a talkative teen, plus a talkative parent, that interview can take 2 hours. Then the scoring and interpreting... And then WE DON'T EVEN GET PAID TO WRITE THE REPORT.

I said, generally, not more than 4 of the 96130/96131 codes. I didn't say not more than 4 total units. Hint: shorten your reports, noone reads 10 page reports.

If you aren't finding something like 12 units (7, 8, 9 hours depending on the code combo) to be adequate for most clinical situations, then you probably need to shorten your test battery or your reports. Maybe both?

I don't understand what you mean about not getting paid to write the report??? That's what 96130/96131 is for. Even the CPT code definition of the old 96101 code included report writing.

https://www.apaservices.org/practice/reimbursement/health-codes/testing/psychological-testing.pdf

"Evaluation services include interpretation of test results and clinical data, integration of patient data, clinical decision making, treatment planning, report generation, and interactive feedback to the patient, family member(s) or caregiver(s)."

 

[erg923]

Caps on 90837 codes, please explain more about this to me. Only one insurance company has an issue with it and it seems to pertain to how often our company uses them.

I know several, UBH being one, that require demonstration of medical necessity to bill this code.

 

[PsyDr]

Here's my question: I see CPT codes pertaining to reviewing charts, consulting, etc. Anyone have experience using those? When, where, why, how? Did they get paid? Besides prolonged codes, interactive complexity etc, what should I be coding that varies from the typical 90834/90837?

Patient family consultation with patient present pays. Without patient present does not. You should still submit these cpt codes.

Chart review rarely pays, but you should submit it anyway so that there is data to make this reimbursed in the future.

Inpatient/outpatient patient observation can pay.

Professional consultation pays. Includes phone consultation.

 

[WisNeuro]

Patient family consultation with patient present pays. Without patient present does not. You should still submit these cpt codes.

Chart review rarely pays, but you should submit it anyway so that there is data to make this reimbursed in the future.

Inpatient/outpatient patient observation can pay.

Professional consultation pays. Includes phone consultation.

As for chart review, I fold most of it into my 96132/33 time. Initial look through I'll tag onto my 96116/121, but when I'm scouring things later, it's the former, just happens to be the higher RVU codes. As far as the documentation I've seen, things are pretty vague with the description CMS gives to the new testing codes, I plan to maximize the value until seeing otherwise.

As to chart review for more therapy type stuff, don't know what to tell you, it just gets folded into the 90791, which is unfortunately just a unit code, reinforcing a clinician to do the shortest possible interview to get it done.

 

[PsyDr]

As for chart review, I fold most of it into my 96132/33 time. Initial look through I'll tag onto my 96116/121, but when I'm scouring things later, it's the former, just happens to be the higher RVU codes. As far as the documentation I've seen, things are pretty vague with the description CMS gives to the new testing codes, I plan to maximize the value until seeing otherwise.

As to chart review for more therapy type stuff, don't know what to tell you, it just gets folded into the 90791, which is unfortunately just a unit code, reinforcing a clinician to do the shortest possible interview to get it done.

I did this before the new CPT codes. Used them for when I was called for an inpatient consult, reviewed the chart, and then patient refused to see me. I'm getting paid somehow.

 

[WisNeuro]

I did this before the new CPT codes. Used them for when I was called for an inpatient consult, reviewed the chart, and then patient refused to see me. I'm getting paid somehow.

Yeah, at the moment I don't do any billing for the refusal type things. I haven't pushed it yet as no one is hounding me about productivity and such. could change in the next few years. I'm wondering if there is a way to document for productivity means, with likely no reimbursement for these pts.

 

[PsyDr]

Yeah, at the moment I don't do any billing for the refusal type things. I haven't pushed it yet as no one is hounding me about productivity and such. could change in the next few years. I'm wondering if there is a way to document for productivity means, with likely no reimbursement for these pts.

I'm hourly. If I'm working, I'll have find a way to get paid for my time.

 

[WisNeuro]

I'm hourly. If I'm working, I'll have find a way to get paid for my time.

I feel you. My salaried position has its benefits and drawbacks. One benefit is that they want me available for inpatient, so I leave a chunk of my schedule open for inpt work. If I don't get any consults, I get a 25-30 hour work week. There are likely changes coming down the pipe in the next year or two, so I imagine I'll have to start playing more of the numbers game heading forward.

 

[LadyHalcyon]

I know several, UBH being one, that require demonstration of medical necessity to bill this code.

Aren't they being sued?

 

[singasongofjoy]

I know several, UBH being one, that require demonstration of medical necessity to bill this code.

I have a huge degree of billing naivete - fairly recently licensed and billing what the others in my clinic are billing but I'm beginning to realize no one knows all that much about the billing process and I think we probably leave off a lot that we could be billing for. So a few questions:

What does one need to do to show medical necessity for 90837? I don't do much therapy but I'm working with one young adult who has ASD, Tourette's, slow processing and I was told by the admins here I needed to stick with 98034 because 90837 wouldn't be approved, so I often just find myself going over (last appt of the day) but not billing for it and I'm not happy about it.

What code to use for professional consultation? I found this: https://www.nixonlawgroup.com/nlg-b...essional-internet-consultations-new-cpt-codes but that leads to another (naive) question: can (non-neuro)psychologists bill E/M codes and when? I generally know little about billing assessments for anything other than the usual 90791, 96130/1, 96136/7.

My evals are fairly often with interpreter, and (EDIT: and as a separate point/scenario, meaning I personally assist parents by reading the questions to them- not meaning that the interpreter is assisting) it is not uncommon to need to assist parents in filling out rating scales due to their own reading difficulties. What to do about when parents need assistance filling out rating scales, since typically rating scales don't get admin time? (we usually give them to parents to fill out while we're conducting the cog and ADOS). How would/shoul- that be billed? 96131 time?

Re: translation/interpretation: I am confused by 90785. I see that it is ok to use it for "use of play equipment, physical devices, interpreters or translators to communicate with a patient who has a language barrier" but also "shouldn't bill the 90785 code solely for the purpose of translation or interpretation services" if it would take the form of higher beneficiary payments and copayments for the same service, based on disability or ethnicity." I have never used 90785 for any interpretation, alt communication devices, etc (seems unfair, per point 2). What situations other than mandated reporting (or the unlikely event of a really emotionally dysregulated family member who needs to be asked to leave) do folks use this code for? How (or is) "use of play equipment" different than toys brought in to entertain while talking with parents, or ADOS/developmental testing materials (that might need to be cleaned afterwards)- is that something people use 90785 for?

Above poster comments re: cog testing over age 5 not getting reimbursed makes me wonder if we're just not getting reimbursed for some of the testing in the 5+ crowd - we do cog testing if the client has not had it through teh school / we can't get records / it seems insufficient (e.g., school just did core sections of the DAS; I want to look at processing speed). How might one best make an argument for the cog testing in the 5+ crowd?

 

[PsyDr]

I have a huge degree of billing naivete - fairly recently licensed and billing what the others in my clinic are billing but I'm beginning to realize no one knows all that much about the billing process and I think we probably leave off a lot that we could be billing for. So a few questions:

What does one need to do to show medical necessity for 90837? I don't do much therapy but I'm working with one young adult who has ASD, Tourette's, slow processing and I was told by the admins here I needed to stick with 98034 because 90837 wouldn't be approved, so I often just find myself going over (last appt of the day) but not billing for it and I'm not happy about it.

What code to use for professional consultation? I found this: https://www.nixonlawgroup.com/nlg-b...essional-internet-consultations-new-cpt-codes but that leads to another (naive) question: can (non-neuro)psychologists bill E/M codes and when? I generally know little about billing assessments for anything other than the usual 90791, 96130/1, 96136/7.

My evals are fairly often with interpreter, not uncommon to need to assist parents in filling out rating scales due to their own reading difficulties. What to do about when parents need assistance filling out rating scales, since typically rating scales don't get admin time? (we usually give them to parents to fill out while we're conducting the cog and ADOS). How would/shoul- that be billed? 96131 time?

Re: translation/interpretation: I am confused by 90785. I see that it is ok to use it for "use of play equipment, physical devices, interpreters or translators to communicate with a patient who has a language barrier" but also "shouldn't bill the 90785 code solely for the purpose of translation or interpretation services" if it would take the form of higher beneficiary payments and copayments for the same service, based on disability or ethnicity." So I have never used 90785 for any interpretation, alt communication devices, etc. What situations other than mandated reporting (or the unlikely event of a really emotionally dysregulated family member who needs to be asked to leave) do folks tend to use this code for? How (or is) "use of play equipment" different than toys brought in to entertain while talking with parents, or ADOS/developmental testing materials (that might need to be cleaned afterwards)- is that something people use 90785 for?

I literally have never used an add-on code and I am relatively sure I've missed out on billing at some point. Folks who do assessments- what are some of the more commonly used add on codes that might be seen for assessment of IDD & the common comorbidities (from toddlers through adult)?

Above poster comments re: cog testing over age 5 not getting reimbursed makes me wonder if we're just not getting reimbursed for some of the testing in the 5+ crowd - we do cog testing if the client has not had it through teh school / we can't get records / it seems insufficient (e.g., school just did core sections of the DAS; I want to look at processing speed). How might one best make an argument for the cog testing in the 5+ crowd?

All of these are my opinions:

1) Medical necessity is defined by each individual insurance policy. You'd be well served to request the insurance's provider handbook.
2) Billing for unsupervised form filling out is basically a no go. Have a tech sit in the room and you can use 96138. Patients hate this crap. I've explained that it's an insurance thing so I'm not the bad guy .
3) 99451 or 99452 for physician phone consultation. Remember to document and include start/stop time.
4) Because of ADA, you are responsible for interpreters for pure language differences. You absolutely cannot ask family members to translate. You absolutely cannot bill for translators. The code you are referring to is used for the use of EQUIPMENT, it is not for translating. This is for like those talk type devices, in damn near aphasic patients. This is not for giving a toy to a kid, or using toys for therapy. I've seen exactly one autistic kid use one of these devices, but I'm not a peds guy.
5) standard add ons include extended time.
6) You can get cognitive testing approved for kids IF the diagnosis is not covered under academic stuff. In ASD, the insurer will likely say that because the school treats this, it's the schools issue. In learning disorders, this will never be covered, because the insurer will always say this is an academic issue. HOWEVER, other medical codes will be covered. I'm not saying it's right, or that I've ever done it, but the ICD10 code "static encephalopathy" or "unspecified encephalopathy" are commonly used by peds neurologists to bill for ADHD and ASD diagnoses.
7) Psychologist cannot bill E/M codes under CMS. There have been some rare individuals that claim to have been paid for E/M codes from private insurers. This is a big thing, and why the APA is requesting that CMS change this. If you see the term "physician" in the APA policy stuff, this is what this is referring to. The title "Physician" under CMS is very odd ball and includes physicians, optometrists, audiologists, chiropractors, etc.
8) Look into 99483-99494 for case management.

 

[singasongofjoy]

All of these are my opinions:

1) Medical necessity is defined by each individual insurance policy. You'd be well served to request the insurance's provider handbook.
2) Billing for unsupervised form filling out is basically a no go. Have a tech sit in the room and you can use 96138. Patients hate this crap. I've explained that it's an insurance thing so I'm not the bad guy .
3) 99451 or 99452 for physician phone consultation. Remember to document and include start/stop time.
4) Because of ADA, you are responsible for interpreters for pure language differences. You absolutely cannot ask family members to translate. You absolutely cannot bill for translators. The code you are referring to is used for the use of EQUIPMENT, it is not for translating. This is for like those talk type devices, in damn near aphasic patients. This is not for giving a toy to a kid, or using toys for therapy. I've seen exactly one autistic kid use one of these devices, but I'm not a peds guy.
5) standard add ons include extended time.
6) You can get cognitive testing approved for kids IF the diagnosis is not covered under academic stuff. In ASD, the insurer will likely say that because the school treats this, it's the schools issue. In learning disorders, this will never be covered, because the insurer will always say this is an academic issue. HOWEVER, other medical codes will be covered. I'm not saying it's right, or that I've ever done it, but the ICD10 code "static encephalopathy" or "unspecified encephalopathy" are commonly used by peds neurologists to bill for ADHD and ASD diagnoses.
7) Psychologist cannot bill E/M codes under CMS. There have been some rare individuals that claim to have been paid for E/M codes from private insurers. This is a big thing, and why the APA is requesting that CMS change this. If you see the term "physician" in the APA policy stuff, this is what this is referring to. The title "Physician" under CMS is very odd ball and includes physicians, optometrists, audiologists, chiropractors, etc.
8) Look into 99483-99494 for case management.

Thanks so much- very helpful. For clarification, when talking about assisting parents in filling out forms, I mean that I am sitting there reading the questions to them. (I realize that was confusing because I put it next to also mentioning we often had translators but I meant them to be separate things that come up). So if I am personally reading the questions to someone, what code woudl it make the most sense for it to fall under?

 

[PsyDr]

Thanks so much- very helpful. For clarification, when talking about assisting parents in filling out forms, I mean that I am sitting there reading the questions to them. (I realize that was confusing because I put it next to also mentioning we often had translators but I meant them to be separate things that come up). So if I am personally reading the questions to someone, what code woudl it make the most sense for it to fall under?

Testing by psychologist. There is no equipment there.

 

[singasongofjoy]

Testing by psychologist. There is no equipment there.

Well yes, I know, that's not what I meant - I meant would reading questions aloud to a client fall under 96130/1 or 93136/7 since test admin time is understandably not typically approved for rating scales, but thanks for the reply.

 

[erg923]

You are translating the content of the rating scale verbally into a different language for them? If so, the 96136/96137 codes (test admin my a psychologist). I think this would be somewhat dicey though, ethically and clinically?

If not the above, why are you reading it to them? Literacy issues? If that's the case, I also think its slightly dicey since they may or may not really get what you are reading to them.... thus skewing/perverting data you get from the standardized norms you are using for comparison?

 

[singasongofjoy]

You are translating the rating scale verbally into a different language? If so, the 96136/96137 codes (test admin my a psychologist). I think this would be somewhat dicey though, ethically and clinically?

If not the above, why are you reading it to them? Literacy issues? If that's the case, I also think its slightly dicey since they may or may not really get what you are reading to them?

No, not translating. Reading in English to parents who can't read (or can't read very well). It's come up more often than I expected.

 

[erg923]

No, not translating. Reading in English to parents who can't read (or can't read very well). It's come up more often than I expected.

Do you check their oral and aural comprehension then? How do you know they "get" what the scale is asking?

I don't think using standardized assessments with normed data in a non-standardized way would fly with most insurance companies unless you made a clinical justification for it in writing that made sense, was justified, and was tailored to that specific case?

 

[LadyHalcyon]

Last week I was informed one of my Medicare patients has a very large bill. It seems this bill is because of co-insurance. She used to also have Medicaid but hasn't had it since 2017. We recently switched EHRs and this is now just being caught. In terms of co-insurance, aren't we required to attempt to collect?

 

[PsyDr]

Last week I was informed one of my Medicare patients has a very large bill. It seems this bill is because of co-insurance. She used to also have Medicaid but hasn't had it since 2017. We recently switched EHRs and this is now just being caught. In terms of co-insurance, aren't we required to attempt to collect?

It’s a federal crime to not send a bill/attempt to collect. There’s almost no statutes about how aggressive you have to make that attempt...