Introduction
Traditionally, psychologists’ clinical scope of care across all settings is defined by assessment and psychotherapy. While we have access to Current Procedural Terminology (CPT) codes for mental health billing, by and large, our reimbursement is only for face-to-face clinical work. In addition to direct patient care, many psychologists engage in activities that support the needs of our patients including consultation and collaboration with other providers, as well as obtaining collateral information from families and varied systems. If you are a psychologist who works with insurance companies, there has historically been limited opportunity to bill for certain aspects of our services. We are reimbursed for our individual-, but not system-level work, which can ultimately be the difference in impact on a patient’s diagnosis and treatment plan. For many years, our psychiatrist colleagues have had access to a variety of Evaluation and Management (E&M) Codes where they can capture this non-face-to-face time and be reimbursed for their services. During this time, physicians can bill for evaluating or managing patient health, as well as for patient consultations, medical decision-making processes and care coordination oftentimes without having any face-to-face time with their patient. Psychologists are not able to utilize these codes because they are exclusively for physicians; as such, Center for Medicare Services (CMS) will not reimburse for these services even though psychologists engage in care coordination as well (Schmidt, Yowell & Jaffe, 2010). Psychologists need to be thoughtful in how they spend their time engaged in patient care to balance their billable versus non-billable time and ensure that they are aware of new CPT codes when they become available.
Billing code limitations with direct patient contact
One area where we see this limitation daily is within psychology consultation-liaison services in medical hospitals. Some patients require significant coordination with medical teams, nursing, family members and social work. In addition to individual assessment of the patient, a psychologist may be required to obtain collateral information to understand others’ observations, to create behavioral treatment plans, and to provide specific recommendations on how to manage patient care during hospitalization (e.g., describing behavioral reinforcement, verbal de-escalation, importance of consistency, and insight into function of behavior). For patients with significant behavioral concerns such as verbal and physical aggression, the assessment, collaboration with other providers, creation of a behavioral plan and delivery of such can take well over 3 three hours of time. However, there is no one code or extender that can be utilized to capture this work. We have been working through different ways to encapsulate this work from a billing perspective and recognize that the psychotherapy in crisis codes (90839 and 90840; American Psychological Association Practice Services, 2023) are most appropriate when working with patients under high distress and life-threatening circumstances that demand immediate attention. This code allows us to bill for assessment and intervention in an acute situation where collaboration with others and mobilization of resources is required to defuse the crisis and restore safety.
Billing codes for consultation with no direct patient contact
Another area for consideration is when we are consulted by our medical colleagues for recommendations on how to best manage patients psychologically or behaviorally but there is no direct contact with the patient. Historically, we spent our time and expertise to provide input and feedback without any billing opportunity. As of January 2023, psychologists are eligible to use the interprofessional telephone/internet/electronic health record consultations codes, which were previously specified to only be used by physicians (American Psychological Association Practice Services, 2023). With the ability to utilize these codes (99446-99449), there is now a new opportunity to capture this work and ensure appropriate reimbursement. When we communicate with and provide expertise to another treating provider regarding a diagnosis or management of a patient’s problem without having had face to face interactions, these codes, defined by time limits, can be utilized. To successfully utilize these codes, there are additional assumptions including that both a verbal and written report are provided to the referrer, complete with start and end times, and that the treating provider obtains advanced verbal consent from the patient to be discussed. Generally, these codes are used when a patient presents with a new problem or when an existing condition is exacerbated or not well managed (American Psychological Association Practice Services, 2023). There are additional limitations in how often these codes can be utilized; however, while we are permitted to use them, it is unclear if CMS will reimburse psychologists for these services at this time. If you are asked to review records and provide expert advice to a treating provider and all communication is digital, the 99451 code may be useful. Similar expectations are in place as the codes above, but this may prove useful for many who have been foregoing billing when providing this service.
In addition to the interprofessional consultation codes, CMS created a code (G0323) for care management services related to behavioral health in an effort to reduce barriers to mental health treatment (American Psychological Association Practice Services, 2023). Here, the psychologist (or clinical social worker) must spend at least 20 minutes of clinical time per calendar month engaging in assessment or follow-up monitoring using validated rating scales and engaging in behavioral health care planning in relation to psychological health problems that includes coordination of psychotherapy, pharmacotherapy, counseling, and continuity of care. Documentation of this by month is important and there are regulations in how often this code can be utilized, however, it is important to know that this is available to utilize (Bailey, 2020). Organizations and departments will have to continue to explore how to most efficiently document the total time spent across the month engaging in these tasks to support billing this code on a monthly basis.
Advocacy for new codes
While the addition of these new codes has been helpful in many psychologists’ settings, there are fewer occasions when we provide recommendations to our medical colleagues without having direct patient contact. In fact, as previously mentioned, our work is usually most effective when we are able to provide both individual- and system-level care. For this reason, ongoing advocacy by psychologists is required to ensure that all time spent in delivering and coordinating care to support a patient’s treatment goals is billable. The ability to capture direct patient care, as well as consultation with and recommendations for multidisciplinary team members, is necessary to address how the environment is interacting with a patient’s psychological presentation. Helping team members to understand how best to communicate with a patient, be consistent across shifts and providers, and set limits takes time and expertise to facilitate and execute successfully. This is demonstrated in the following case example:
Case Example. A psychology consultation-liaison team gets consulted for Mr. Smith because he is experiencing emotional dysregulation and has been disruptive on the medical floor (e.g., leaving his room and threatening nurses). The psychologist goes up to meet with the patient to assess history, current distress and barriers to participation in treatment, as well as offer interventions to target the dysregulation if possible (30-45 minutes billable). The psychologist then consults with the nurse, clinical director, Risk Management, and primary medical team to gather collateral information about the presenting concerns (30 minutes non-billable). The psychologist then leads a review of a patient safety agreement with the interdisciplinary team and patient to set expectations and review hospital policies (30 minutes billable). Next, the psychologist creates a tailored behavioral care plan for the providers and nurses which outlines recommendations for communicating with the patient (e.g., validation, de-escalation) and implementing strategies for behavioral reinforcement (e.g., setting clear expectations, leaving the room and setting limits when behavior is inappropriate, providing forced-choice options to participate in care). This is then reviewed with the physician, nurse and medical unit clinical director (30 minutes non-billable). This pattern often repeats itself throughout the week when other concerns come up with the patient in order to intervene individually by providing services to Mr. Smith, as well as systemic intervention to promote a consistent approach across numerous providers. With only 50% of the time spent on these tasks being billable, it is difficult for the psychologist to intervene effectively across these situations and meet their productivity requirements.
One pathway for exploring changes to these billing codes is through state-level advocacy to work with the Department of Human Services and/or state legislators through state psychological associations or organizations’ governmental affairs. Ultimately, if states’ Medicaid systems are able to work with psychologists to address these concerns, there may be opportunities to work on extending these efforts nationally with the support of the American Psychological Association. While there have been advocacy efforts by APA to include psychologists under the CMS definition of “physician,” these efforts have not yet been fully realized. Psychologists are recognized as independent licensed clinicians, but CMS defines “physicians” as “clinicians who medically diagnose patients, prescribe and manage medication, and supervise other medical staff” (Robezniek, 2020). This represents a scope of practice argument and the ultimate limitation for psychologists being able to access codes like E&M.
Board certified psychologists have specialty areas of focus, which can be used to advocate for, and leverage, our specialized clinical training with regional psychological organizations to prioritize initiatives. The ability to effectively communicate our unique set of skills (and what we view as gaps in mental health coverage) will ultimately allow for further consideration of new CPT codes to be created and acknowledged by the American Medical Association and the Center for Medicare Services.
References
American Psychological Association Practice Services, Inc. (2023, February). How to report interprofessional telephone/internet/electronic health record consultations. https://www.apaservices.org/practice/reimbursement/health-codes/interprofessional-record-health-consultations
American Psychological Association Practice Services, Inc. (2023, March). Expanding access to mental and behavioral health services in Medicare. https://www.apaservices.org/practice/reimbursement/health-codes/mental-behavioral-health-medicare
American Psychological Association Practice Services, Inc. (2023, August). Psychotherapy codes for psychologists. https://www.apaservices.org/practice/reimbursement/health-codes/psychotherapy
Bailey, D. (2020, September 1). Raising reimbursement. Monitor on Psychology, 51(6). https://www.apa.org/monitor/2020/09/raising-reimbursement
Robezniek, A. (2020, September 24). Congress plays name game to redefine “physician” under Medicare. American Medical Association. https://www.ama-assn.org/practice-management/scope-practice/congress-plays-name-game-Redefine-physician-under-medicare
Schmidt, C. W., Yowell, R. K., & Jaffe, E. (2010). Procedure coding handbook for psychiatrists (4th ed.). American Psychiatric Publication Inc.
Kelly Gilrain, PhD, ABPP
Board Certified in Clinical Psychology
Correspondence: gilrain-kelly@cooperhealth.edu
Ana Bullock, PsyD
Correspondence: bullock-anastasia@cooperhealth.edu