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90837 vs. 90834

With the changes we have been seeing recently, Health Assets is re-visiting the use of the psychotherapy procedure codes (CPT) 90834 (approx. 45 minutes) and 90837 (approx. 60 minutes). 

Some clinicians routinely see their patients for an hour session (greater than 53 minutes face to face with the patient).  This has caused some confusion and distress for clinicians who have received denials or requests for records regarding claims submitted with CPT code 90837.

Oxford, UBH, UHC, Beacon Health Strategies and Amerigroup/HealthPlus are among health plans that routinely deny 90837 coded claims.  Their guidelines do not consider this code to be medically necessary for the majority of cases. 

What are the options for a clinician whose practice mainly consists of hour long sessions? 

1.    Consider offering 45 minute sessions to patients with benefits from the above payers if you feel it will be sufficient for their care.

2.    Request prior authorization for hour long sessions (CPT 90837) for patients whose care you feel necessitate this amount of time.  Your request will be reviewed and a determination will be made regarding the frequency and duration of the authorized sessions, according to the health plan’s medical necessity guidelines.  In fact, they may deny your request altogether.

3.    Appeal any denied claims with documentation of the medical necessity of the CPT code used.  The payer’s appeals committee will determine if they will reverse the denial and pay the claim.

Some 90837claims for clinicians who are Out of Network with these health plans have been paid.  Out of network claims are paid at the discretion of the payer.

Documentation is key in cases where you are audited, you request an appeal, or request prior authorization.  Be sure that you indicate the start and end time of each session in the session note.

We will submit the CPT code listed on your transaction sheet.  We will not down code the claim at the time of claim submission.

Hint: If you plan on utilizing 90837 CPT codes for one of the above payers, be sure to check off that CPT code on the initial intake form that you send us for that patient, or email the staff to let them know that you are planning to submit a claim for 90837 for an existing patient.  We will attempt to get you a prior authorization.  You may have to submit an OTR (treatment report) to show why it is necessary to see the patient for the 53+ minute session.

As always, our staff is here to help you navigate the third party payer systems, including submitting claims, verifying patient benefits, maintaining credentialing updates and applying to Commercial insurance panels, Medicare and Medicaid, and following up on payments.

We Will continue to keep you up to date on any significant changes that may affect your billing procedures and practice.

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