Comparative Billing Reports

CBR201808 Psychologists FAQs

General

Clinical and Billing

Report Specifics

 

General

What is the purpose of a comparative billing report (CBR) on psychologists?

The purpose of CBR201808 is to inform psychologists about their billing and payment patterns on claims for psychotherapy. We analyzed Fee-for-Service Medicare claims submitted with dates of service from April 1, 2017 to March 31, 2018. For more general information about CBRs, please visit our web page at Comparative Billing Reports.

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Why were psychologists chosen as a CBR topic?

We selected psychologists as a topic because the Office of Inspector General (OIG) has determined that high amounts of 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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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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What is the focus of CBR201808? 

The report focuses on psychologists (specialty 62) and clinical psychologists (CP) (specialty 68) who submitted charges for claims with the CPT® codes below:

 

 

CPT® Code

 

Abbreviated Description

 

90785

Interactive complexity

90791

Psychiatric diagnostic evaluation

90792

Psychiatric diagnostic evaluation with medical services

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

90846

Family psychotherapy, 50 minutes

90847

Family psychotherapy including patient, 50 minutes

90853

Group psychotherapy

96101

Psychological testing with interpretation and report by psychologist or physician per hour

96102

Psychological testing with interpretation and report by technician per hour

96103

Psychological testing with interpretation and report by computer

96105

Assessment of expressive and receptive speech with interpretation and report per hour

96111

Developmental testing

96116

Neurobehavioral status examination, interpretation, and report by psychologist or physician per hour

96118

Neuropsychological testing, interpretation, and report by psychologist or physician per hour

96119

Neuropsychological testing by technician with interpretation and report by a qualified healthcare professional per hour

96120

Neuropsychological testing by a computer with interpretation and report by a qualified healthcare professional

96150

Health and behavior assessment each 15 minutes

96151

Health and behavior re-assessment each 15 minutes

96152

Health and behavior intervention, individual each 15 minutes

96153

Health and behavior intervention, group each 15 minutes

96154

Health and behavior intervention, family and patient each 15 minutes

 

If you did not receive a CBR letter and wish to review a sample, please visit the CBR website at CBR201808 Sample CBR.

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Clinical and Billing

 

What are the qualifications of a clinical psychologist (CP)?

According to Chapter 15 of the Medicare Benefit Policy Manual, “To qualify as a clinical psychologist (CP), a practitioner must meet the following requirements:

  • Hold a doctoral degree in psychology
  • Be licensed or certified, on the basis of the doctoral degree in psychology, by the State in which he or she practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals.”

Medicare only covers services that are reasonable and necessary and does not cover services that are “excluded from Medicare coverage even though a clinical psychologist is authorized by State law to perform them.” To find more information about clinical psychologists, select the following web link: Medicare Benefit Policy Manual, Chapter 15, Section 160.

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Can a psychologist (who is not a CP) perform psychological tests?

Yes. The Medicare Benefit Policy Manual states that “psychological and neuropsychological tests performed by a psychologist (who is not a CP) practicing independently of an institution, agency, or physician’s office are covered when a physician orders such tests” and can bill directly for these services. When diagnostic tests are performed by a psychologist (who is not a CP) who is not practicing independently, but is on the staff of an institution, agency, or clinic, that entity bills for the psychological tests. To view more information, please select the following web link: Medicare Benefit Policy Manual, Chapter 15, Section 80.2.

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How are qualifications determined for psychologists in States that do not require licensing or certification?

Per the Medicare Benefit Policy Manual:  “In States or territories that lack statutory licensing or certification, the A/B MAC (B) checks individual qualifications before provider numbers are issued. Possible reference sources are the national directory of membership of the American Psychological Association, which provides data about the educational background of individuals and indicates which members are board-certified, the records and directories of the State or territorial psychological association, and the National Register of Health Service Providers. If qualification is dependent on a doctoral degree from a currently accredited program, the A/B MAC (B) verifies the date of accreditation of the school involved.” More detailed information is found at the following web link: Medicare Benefit Policy Manual, Chapter 15, Section 80.2.

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Can other non-physician practitioners (NPPs) perform psychological testing?

Yes, however, some procedures performed by NPPs may require the supervison of a physician. In addition to CPs and IPPs, the NPPs listed below can bill for diagnostic psychological and neuropsychological tests:

  • Nurse practitioner (NP)
  • Clinical nurse specialist (CNS)
  • Physician assistant (PA)
  • Physical therapist (PT), occupational therapist (OT) and speech language pathologist (SLP)

Specific qualifications for the above NPPs can be found at the following web link: Medicare Benefit Policy Manual, Chapter 15, Section 80.2 .

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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 mental health professional  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 psychologist, 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 psychologists document in the medical records when filing psychotherapy 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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Report Specifics

 

How were providers selected to receive this comparative billing report?

The CBR data team analyzed Fee-for-Service (FFS) Medicare claims with the CPT® codes covered in this CBR. The providers with different billing patterns as compared to their peers were selected to receive this letter. 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: CBR201808 Sample CBR.

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What are the criteria for receiving CBR201808? 

There are more than 30,000 psychologists nationwide with allowed charges for the CPT® codes included in this study. 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 25th 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 CBR201808 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 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?

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

  • State: All Medicare psychologists practicing in the provider’s state billing the selected CPT® codes included in this analysis
  • National: All Medicare psychologists practicing in the nation, billing the selected CPT® codes included in this analysis

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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 the CBR. These claims, with dates of service April 1, 2017 – March 31, 2018, were downloaded from CMS Integrated Data Repository, and loaded into the Palmetto GBA Medicare Data Warehouse. The analyses were based on the latest version of claims available from the IDR as of July 9, 2018. For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).

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My allowed charges are higher than the national averages because I am in a region with a higher cost of living and, thus, a higher allowed amount. Are my allowed charges being compared to providers in other states with lower allowed charges?

We are aware that the Medicare Physician Fee Schedule (MPFS) allowed amounts vary from area to area. For the purposes of this CBR, averages were calculated by state and nation for all psychologists (specialty 62) and clinical psychologists (specialty 68) who submitted claims for the CPT® codes included in this CBR. This CBR is only for educational purposes; variations may be justifiable due to location or other supporting documentation. More information on the GPCI is available on the CMS website page at Documentation and Files - National Physician Fee Schedule and Relative Value Files.

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What does Table 1 mean?

Table 1 is a listing of the CPT® codes and abbreviated descriptions  assigneddescriptions assigned for each CPT® code included in this CBR.  To review an illustration of Table 1, refer to the example on the CBR web page at CBR201808 Sample CBR.

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What is indicated by Table 2?

Table 2 is a summary of a provider’s utilization of the 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 due to rounding. The visit and beneficiary counts are unduplicated counts for each row and the total. A sample of Table 2 can be found at CBR201808 Sample CBR.

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What does Table 3 show?

Table 3 represents a provider’s average minutes per individual psychotherapy visit based on the typical times listed for CPT® codes 90832, 90834, 90837, 90839 and 90840. Table 3 compares a provider’s average minutes per psychotherapy visit 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 CBR201808 Sample CBR. The results for each state and the nation can be reviewed at the following link: CBR201808 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 listed in Table 1. A sample of Table 4 and a further explanation can be found at CBR201808 Sample CBR The results for each state and the nation can be reviewed at the following link: CBR201808 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 CBR201808 Sample CBR. The results for each state and the nation can be reviewed at the following link: CBR201808 Statistical Debriefing.

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