Many therapists provide a 60 minute session but afraid of triggering an audit, they do not bill for it.
We love our work but unless we are independently wealthy, we need to be paid to do it. We don’t get paid for providing psychotherapy. We get paid for our time. Psychotherapy is what we spend our time doing. Other professionals charge for their time. We should too.
When CPT codes for psychotherapy were revised in 2017, it became possible to bill for longer therapy sessions. The one being addressed in this blog, is 90837, which is 53 minutes or more. Many of us spend 55 to 60 minutes with clients anyway because for many clients, the additional 10 -15 minutes makes a huge difference in what clients get out of their sessions. Now it’s possible to get paid for that time.
Reimbursement rate for 90837
Though it is not allowed to give the actual amount of payment by an insurance company because doing so violates the Sherman Antitrust Law, it is safe to say that payment is up to $30 more than what is paid for 90834. Not billing for the time you spend leaves a lot of money on the table.
Will all insurance companies accept or pay 90837?
Insurance companies have been reluctant to pay for 90837 and slow to get on board so it is best to check with the company. But BCBS does honor this code and so do many other insurance companies. According to Care Paths, the denial rate for BCBS in 2017 was 1.29%, which is a down from 3 to 4% in 2013 and 2015. Denial rates for Medicare and Medicaid are higher but have also come down. Current 90837 denial rates for Medicaid is 5.9% and for Medicare it’s 4.12%.
Will the use of 90837 trigger an audit?
It should not. But again, to be on the safe side double check with your client’s insurance company for their policy or discuss it with your biller, if you use one. This person should know.
Can I use 90837 for all my sessions?
Theoretically, yes. But practically, no. The CPT code is based on face-to-face time, meaning you can only bill for the time actually spent with the client. If the client is late, you need to bill at 90834 (38 – 52 minutes). Otherwise, you risk insurance fraud.
Is there specific documentation required when using 90837?
According to BCBS, using 90837 “cannot be for the convenience of the provider.” This means, though specific documentation is not required, play it safe by including justification on your progress note.
For example, let’s say:
- your client has an Adjustment D.O: “90837 is medically necessary to sort through complicated issues related to (what client is adjusting to) and clinical presentation.”
- your client may have a trauma history: “90837 is medically necessary because significant trauma hx necessitates taking time to create safe space for disclosure and then containment.”
- Or: “90837 is medically necessary to address complicated diagnosis and clinical presentation.”
- One of my Medicare clients is a lovely and highly intelligent and high functioning 72 year old gentleman who has few contacts outside his family and a LOT to process as he is makes sense of his life’s decisions, which, according to developmental theory, is exactly what he’s supposed to be doing at this stage of his life. For him, I write, “90837 is medically necessary because client has no friends with which to sort through complicated life issues. Having more social contacts is one of the goals but is taking a long time to achieve.”
Once you start thinking this way, you will be able to come up with the rationale that fits your client.
The bottom line is that it is possible to earn substantially more money by either spending a little more time with the client — or by getting paid for the time you already spend.
This is one of many tips I give in my training, Misery or Mastery® Essential Documentation for Psychotherapists.
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Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. Beth’s Documentation Wizard training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 2 attorneys, a bioethicist, and a billing expert and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years. Her newest initiative, Membership Circle, is designed to empower psychotherapists to master documentation with expert guidance, efficient strategies, and a supportive community.
Beth,
Thanks for this helpful article.
Question: I have an unstable patient requiring 90 minute psychotherapy sessions twice a week. I am an out of network provider for his insurance plan (Blue Cross). Since the max time allowed for psychotherapy session is 60 min (90837), what code(s) and/or modifiers would I use to identify the longer sessions?
Thanks
Hi David,
Thanks for your question.
Even though billing and clinical documentation are related, I’m not an expert in billing, which draws on a knowledge base that is so different than the clinical side, it has it’s own certification course! I’ve only used the ad-on emergency code one time and didn’t remember what I did, so I contacted my biller who reminded me.
Use 90839 (NOT 90837) for the 1st hour and then 90840 for each additional 30 minutes.
Here’s why: 90837 is used for sessions that are 53 minutes or MORE, meaning unlimited. So you want to use 90839 for the first hour and 90840 for every 30 minutes after that.
These codes should be used sparingly, not for each session and definitely not for 2 sessions each week because these codes are, by definition, used for emergencies. Repeated usage will draw attention you don’t want. Reserve the emergency sessions for when the client is suicidal, in high distress and/or under complex or life-threatening circumstances that demand immediate attention. It is also important to document why the use of this set of codes is important or medically necessary. Write a session note for 90839 and one for each 90840.
Given your particular client, you may want to be try the proactive approach and call the insurance company. See if you can get extended sessions pre-approved. If you don’t, your client could be responsible to pay for them. Or get three weekly sessions approved without extended sessions. If you insurance company will not pay for extended sessions or multiple sessions per week, you may consider having a conversation with the client about cost sharing. Insurance pays for the 1st 53 minutes and the client pays for anything over that.
I hope this is helpful. Good luck with this!
Beth
Explain the difference in using the codes? please
90834 is the code used for sessions. This code is for sessions that last between 38 – 52 minutes.
90837 is used for sessions that are 53 minutes and longer.
Hi Beth, a CMS document (LCD L31887) suggests that every encounter note should include:
* Diagnosis
* Symptoms
* Functional status
* Focused mental status exam
* Treatment plan, prognosis, and progress
* Name, signature, and credentials of the person performing the service
Do you put all of these in every note? Much of it would be quite repetitive, particularly for clients who are seen frequently.
Thank you.
Yes, they all need to be in every note. Having a template with these items on there helps cut down on how repetitive this process can be. You might want to check out Master Clinical Forms. These forms let you create a master for each client with all the info that does not change from session to session.
Hi Beth, I am currently being audited and did not put start and end times on my notes, they are requesting clawback of 2600. as a result. Can I appeal this? Thank you,
Sheila
Hi Sheila,
I’m so sorry to hear about the results of this audit. The actual start and stop time are a required part of the note. Unfortunately, insurance companies don’t tell you until you fail an audit. You can appeal but you might want to consult with your professional organization first and see if you can get any guidance. They may recommend speaking with an attorney who works with therapists on these matters. A lawyer will often provide a 15-20 minute free consult to see if your case has any legal merit before taking you on. You are not the only therapist who has been caught in this lousy trap. I wish you the best.
you might want to consult with an attorney who specializes in working with psychotherapists first.
Hi Sheila, I too am experiencing an audit and clawback for 2400. I was wondering how things turned out for you?? my e-mail is lisab@olypen.com.
Lisa
Hi Ray,
Good that you asked. Yes, I include all this info in my notes even though it seems redundant because it’s the standard. What cuts down on time is using a template that cues you to write all this information, plus the other mandatory elements of a note. Writing the “redundant parts” in a “master note” and them copy and paste that note into a new document. Then you are not re-writing the redundant stuff every time you write a note. That is how my notes work and what I do. It takes me 3-7 minutes to write a note using my templates, depending on how complex the session is. I hope this information helps clarify the process for you.
Beth
Hi Ray,
Yes, I absolutely include all these elements in my progress notes. And more. Not including them could incur a claw back. With the right kind of notes, you can make a master that includes all the redundant information that auto populates into each new note. If you want notes that cue you to cross all your T’s and dot all your I’s, you might want to check out my Master Clinical Forms.
Beth
Thank you for this clear and insightful explanation of the nuances of 90837! With gratitude and cheers💕
HI Lisa! Glad you found this helpful. Thanks for letting me know.
Hello Beth,
I need to know which insurance companies has the highest reimbursement rates for 90837 in Colorado.
HI Aaron,
I wish I could help you but I can’t for a couple of reasons. 1) I’m not from Colorado and don’t know the insurance companies there. 2) It’s actually illegal to share the reimbursement rates of insurance companies. It has to do with the Sherman Antitrust Act.
WHAT IS THE SHERMAN ANTITRUST LAW
According to Britannica, “The Sherman Antitrust Act (the Act) is a landmark U.S. law, passed in 1890, that outlawed trusts—groups of businesses that collude or merge to form a monopoly in order to dictate pricing in a particular market. The Act’s purpose was to promote economic fairness and competitiveness and to regulate interstate commerce.” Oct 20, 2020
My commentary: Unfortunately, insurance companies use this law to keep us, the psychotherapists, from banning together to price fix and negotiate collectively.
WHO THE LAW AFFECTED
“Federal courts ruled that unions were essentially trusts, limiting competition within businesses. The Sherman Anti-Trust Act was created to help workers and smaller businessmen by encouraging competition. While it did assist these two groups, the act eventually hindered workers in attaining better working conditions.”
DID THE LAW WORK?
For more than a decade after its passage, the Sherman Antitrust Act was invoked only rarely against industrial monopolies, and then not successfully. Ironically, its only effective use for a number of years was against labor unions, which were held by the courts to be illegal combinations.” Apr 21, 2016
My commentary: In other words, the law was meant to help us but it hurts instead. Because it is illegal to discuss what the insurance companies pay us, we cannot engage in collective bargaining.
Yes, the law needs to be changed. But who has the time when we are serving clients?