Denials of 60-minute session payments at issue

The middle-aged patient was terrified of having blood drawn when the need to undergo medical tests to address a medical problem led to a late 2013 office visit with psychologist Julie G. Breskin, Ph.D.

Breskin, who practices in Salem, Mass., treated this individual for a simple phobia in two 60-minute sessions and billed insurance carrier Optum by United Behavioral Health using CPT code 90837. Providers use this code to indicate a 60-minute psychotherapy session with a patient and/or family member. Breskin says she did not seek pre-authorization.

For the first visit, Breskin conducted an evaluation, took a history, did some psychoeducation about anxiety avoidance and exposure and gave the patient homework challenging irrational fears.

For the second, Breskin had her patient practice muscle tension and release, with short, shallow breathing to ward off the possibility of fainting. She wrapped the patient’s arm with a TheraBand and they pretended a paper clip was a needle, going through the motions of an injection. The patient looked at phlebotomy images with the ability to switch back and forth to a backcountry skiing movie to calm down if necessary. The patient’s reported anxiety decreased from a six to one or two with repeated exposures.

The therapy worked. Breskin received a brief email from the patient: “I went for my blood draw and it was uneventful, no dizziness, no nausea, no spinning walls …. Next time I might even watch the vial fill up.”

Optum covered the first session and denied the second, because only a 45-minute treatment session was authorized for a simple phobia diagnosis. Rather than filing an appeal, Breskin resubmitted documentation using the CPT code for 45 minutes, 90834, and received approval.

Private insurers typically match the national Medicare payment rate, subject to geographic adjustment, which was $81 for code 90834 and $118 for 90837 last year.

“To appeal at that point as a solo provider … it was before the holidays, it was a time crunch, I had extended family health issues of my own and it was not worth me spending an hour to be paid for 15 extra minutes,” she explains.

Now the Massachusetts Psychological Association wants psychologists to take the time to appeal when turned down for reimbursement for 60-minute sessions by a carrier and if unsuccessful, pursue an appeal at the state’s Office of Patient Protection.

“Many psychologists are not aware that this would be a very fruitful thing for them to do and would result in eventually empowering us to serve our patients better,” says MPA Advocacy Committee Chair James Leffert, Ed.D. “If we keep doing it a number of times and the appeals are in fact upheld … then that creates precedent,” Leffert adds.

Optum’s coverage determination guidelines indicate outpatient psychotherapy sessions are generally provided in sessions up to 45 minutes. Coverage of extended sessions may be indicated for posttraumatic stress disorder, panic disorder or obsessive compulsive disorder treated with prolonged exposure therapy.

A UnitedHealthcare spokeswoman declined to comment on Breskin’s case but stated via an email: “We are committed to helping people receive the care they need at the right time and place, based on guidelines established by the medical and behavioral health communities. These guidelines include care leaders such as the Substance Abuse and Mental Health Services Administration, the American Academy of Clinical Psychiatrists and the American Psychiatric Association.”

MPA says the criteria UnitedHealth and other carriers consider acceptable for 60-minute sessions are overly narrow and should be expanded. Health plans that deny paying for 60-minute sessions ignore the significant volume of literature recognizing their effectiveness and may even violate the state’s Mental Health Parity Law, according to MPA Director of Professional Affairs Michael A. Goldberg, Ph.D. He recently wrote a letter to Tufts Health Plan protesting its policy of approving the same fee for both 60- and 45-minute sessions.

A Tufts Health Plan spokeswoman declined to comment on how contracted providers are compensated and issued the following statement: “We continually evaluate reimbursement rates for all codes and for all providers to assure that our members have access to care at affordable premiums, and to assure that these rates incentivize appropriate provider behavior with regard to coding and billing.”

Providers await details on Blue Cross Blue Shield of Massachusetts’s decision to add CPT codes for 60-minute sessions to its fee schedule effective Jan. 1. There are indications a paper authorization form may be required for pre-authorization and post-service audits may occur. Jenna McPhee, public relations manager for Blue Cross Blue Shield of Massachusetts, says the changes are still in the policy implementation phase and that there would be no public comment before Dec. 1.