Comparative Billing Reports

CBR201807 Licensed Clinical Social Workers (LCSWs) FAQs

General
Clinical and Billing
Report Specifics
 
General
What is the purpose of a comparative billing report (CBR) on licensed clinical social workers (LCSWs)?

The purpose of CBR201807 is to inform LCSWs (specialty 80) about their billing and payment patterns on claims for psychotherapy. We analyzed claims submitted with dates of service from January 1, 2017 to December 31, 2017 and included only Fee-for-Service (FFS) Medicare claims. For more general information about CBRs, please visit our website page at Comparative Billing Reports.

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Why were LCSWs chosen as a CBR topic?

LCSWs were selected as a topic because the Office of Inspector General (OIG) has determined that improper payments were made for psychotherapy services. Per the OIG, Medicare “allowed $185 million in inappropriate outpatient mental health services, including psychotherapy.” The OIG also found improper payments for almost half of the psychotherapy services. Please select the following OIG web link to view more detailed information: Medicare Part B Payments for Psychotherapy Services.

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What is the focus of CBR201807? 

The report focuses on LCSWs with allowed charges for the claims with the CPT® codes below:

CPT® Code 

                Abbreviated Description

90785

Interactive complexity

90791

Psychiatric diagnostic evaluation

90832

Psychotherapy, 30 minutes

90834

Psychotherapy, 45 minutes

90837

Psychotherapy, 60 minutes

90839

Psychotherapy for crisis, first 60 minutes

90840

Psychotherapy for crisis, each additional 30 minutes

90845

Psychoanalysis

90846

Family psychotherapy, 50 minutes

90847

Family psychotherapy including patient, 50 minutes

90853

Group psychotherapy

If you did not receive a CBR letter and wish to review a sample, please visit the CBR website at CBR201807 Sample CBR.

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Did I receive a CBR as the result of an audit of my claims?

No. The CBR team does not review nor have access to medical records needed to perform audits. The CBR is disseminated to providers to offer insight into billing trends and allows providers to compare their billing patterns to those of their peers. Receiving this CBR is not an indication or precursor to an audit for all recipients.  Selected providers, however, may be referred for additional review and education. If you are concerned or have questions about an audit, please take advantage of the self-audit resources that can assist you with setting up an audit process. These are available on the CBR website at this link: Self-Audit Help.

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Clinical and Billing
What is the definition of psychotherapy?

The CPT® 2017 Professional Edition Manual defines psychotherapy as “the treatment of mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development.” For more information, please visit the American Medical Association (AMA) website link at AMA Store.

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Does Medicare require LCSWs to be licensed and/or certified?

According to the Medicare Benefit Policy Manual, a LCSW is “an individual who possesses a master’s or doctor’s degree in social work, has performed at least two years of supervised clinical social work, is licensed or certified as a clinical social worker by the State in which the services are performed; or, in the case of an individual in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post master’s degree supervised clinical social work.” To view more information about LCSW requirements, select the following web link: Medicare Benefit Policy Manual, Chapter 15, Section 170.

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What type of treatment do LCSWs provide during psychotherapy sessions?

Psychotherapy treatment includes ongoing assessment, adjustment of psychotherapeutic interventions, and may involve family members or others in the process. Since psychotherapy times are for face-to-face services, the patient must be present for individual therapy and for the majority of the time when family members are involved. More details about treatment are available in the CPT® 2017 Professional Edition Manual, which is available from the AMA website at AMA Store.

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How are psychotherapy notes defined?

According to Title 45 of the Electronic Code of Federal Regulations (e-CFR), “psychotherapy notes mean notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record.” The LCSW is responsible for separating these notes from the rest of the medical record. To view more details, select this web link: e-CFR Title 45, 164.501. 

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Are psychotherapy notes protected by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule?

Yes. Psychotherapy notes are treated differently from other health information in the medical record because they contain the personal notes of the LCSW, and may include sensitive information. The HIPAA Privacy Rule requires authorization of the patient prior to release of psychotherapy notes, except for those disclosures required by law (e.g., mandatory reporting of abuse; threats of serious and imminent harm made by the patient). For additional Information, select the following web link: e-CFR Title 45, 164.508, 164.512. 

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What information should LCSWs document in the medical records to file claims?

When billing claims for psychotherapy services, documentation should include the exact start and stop times of each session, a summary of the diagnosis, symptoms, functional status, focused mental status examination, the treatment plan, prognosis, and progress. The treatment modalities, as well as their frequency and effectiveness, should also be addressed at each visit. Healthcare providers should always sign, date the notes, and include their credentials. Psychotherapy notes should not be included when billing for services. For more information, select the following link: e-CFR Title 45, 164.501.

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My patient walked out of the session after 10 minutes of psychotherapy. Can I bill the lowest level (CPT® code 90832) and append modifier 53, denoting a discontinued procedure?

No. Psychotherapy can only be billed when the patient is present for all or the majority of the session. Per the 2017 CPT® Professional Edition Manual, “Do not report psychotherapy of less than 16 minutes duration.” Additionally, it is inappropriate to report modifier 53 with psychotherapy services, as modifier 53 is reported for a discontinued procedure after induction of anesthesia. For more information, please visit the American Medical Association (AMA) website link at AMA Store.

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Report Specifics
What are the criteria for receiving CBR201807? 

 There are more than 43,000 LCSWs nationwide with allowed charges for the CPT® codes included in this study. This CBR was sent to approximately 10,000 of these providers. The criteria for receiving this CBR are:

  • Provider is significantly higher in at least two of the peer comparisons
  • Provider is near or above the 50th percentile in allowed charges ($5,000)
  • Provider had at least 10 beneficiaries

If you did not receive a CBR letter and wish to review a provider’s sample, please visit the CBR website at CBR201807 Sample CBR.

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How were providers selected to receive the comparative billing reports?

The CBR data team analyzed Fee-for-Service (FFS) Medicare claims with the CPT® codes covered in this CBR, and identified those with different billing patterns when compared to their peers. Providers who did not receive a CBR and would like to review a sample letter are invited to visit our CBR website at the following link: CBR201807 Sample CBR.

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What does ‘comparison to your state’ and ‘comparison to the nation’ mean?

There are four possible outcomes for the comparisons between the provider and the peer groups:

  • Significantly Higher - This means that the provider’s value is higher than the peer value, and the statistical test confirms a significance
  • Higher - This means that a provider’s value is higher than the peer value, but either the statistical test does not confirm a significance or there is insufficient data for comparison
  • Does Not Exceed - This means that a provider’s value is not higher than the peer value
  • N/A – This means that the provider does not have data for comparison

A provider’s value may be greater than the value of his/her peer group. The statistical test gives the provider the benefit of the doubt since significance is based on the total number of visits or beneficiaries and the variability of those values.

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How are the peers defined?

A single rendering provider was identified by National Provider Identifier (NPI). The peer groups for comparison with the individual provider are listed below:

  • State: All Medicare Part B providers located in the provider’s state (as determined by NPPES), with allowed charges for the CPT® codes covered in this CBR
  • National: All Medicare Part B providers in the nation with allowed charges for the CPT® codes covered in this CBR

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How was the data obtained for this report?

The data for this CBR analysis includes Part B claims for the CPT® codes identified in Table 1 of the CBR. These claims, with dates of service January 1, 2017 – December 31, 2017, were downloaded from the CMS Integrated Data Repository, and loaded into the Palmetto GBA Medicare Data Warehouse. The analysis was based on the latest version of claims available as of May 15, 2018. For more information, see the following link: CMS Integrated Data Repository (IDR).

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What does Table 1 mean?

Table 1 is a listing of the CPT® codes and abbreviated descriptions (and times) assigned for each psychotherapy CPT® code included in this CBR.  To review an illustration of Table 1, refer to the example on the CBR web page at CBR201807 Sample CBR. 

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What is indicated by Table 2?

Table 2 is a summary of a provider’s utilization of the psychotherapy CPT® codes included in this CBR. Each row contains a CPT® code, allowed charges, allowed services, number of visits, and number of distinct beneficiaries for the year analyzed. It is important to note that the totals for each column may not equal the sum of the rows, as it is likely that the same beneficiary has billings for more than one CPT® code and is, therefore, counted only once in the total. A sample of Table 2 can be found at CBR201807 Sample CBR. 

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What does Table 3 show?

Table 3 represents a provider’s average minutes per psychotherapy visit based on the typical times listed for CPT® codes 90832, 90834, 90837, 90839 and 90840. Table 3 compares a provider’s average psychotherapy visits to those of his/her peers in his/her state and the nation.

A sample of Table 3 is available on the CBR website at CBR201807 Sample CBR. The results for each state and the nation can be reviewed at the following link: CBR201807 Statistical Debriefing.

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What is the meaning of Table 4?

Table 4 is a provider’s average number of visits per beneficiary, using the CPT® codes in this CBR. A sample of Table 4 and a further explanation can be found at CBR201807 Sample CBR. The results for each state and the nation can be reviewed at the following link: CBR201807 Statistical Debriefing.

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What is the significance of Table 5?

Table 5 is a provider’s average allowed charges per beneficiary. A sample of Table 5 can be found at CBR201807 Sample CBR.  The results for each state and the nation can be reviewed at the following link: CBR201807 Statistical Debriefing.

 

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