Q & As from APA’s Practice Management HelpLine

APA’s Practice Management HelpLine provides practical assistance to APA members on a wide variety of day-to-day issues that arise in managing a practice: reimbursement, relationships with managed care companies, coding, documentation, Medicare, Medicaid, establishing a private practice, closing a practice, and so on. Below are three recent questions that HelpLine staff have handled. APA members can submit their questions to the HelpLine by phone at (800) 343-4671 and e-mail at [email protected].

Q. I employ a social worker who provides psychotherapy to patients under my direction. Should the services she provides be billed under my National Provider Identifier? Does it matter whether the social worker is an employee or an independent contractor?

A: Medicare provides for “incident to” billing for care that is an “integral, though incidental, part of the service of a physician…in the course of diagnosis and treatment of any injury or illness.” When billing is done “incident to,” the claim is filed under the physician’s name, and the payment is made at the level paid to physicians (under Medicare, clinical social workers are paid at 75 percent of the physician’s fee schedule, while counselors may not contract with Medicare directly). The therapist providing the care must by licensed by the state where the treatment occurs. It does not matter if the social worker is an employee or an independent contractor.

As is often the case with rules that were created for all of medicine, rather than specifically for psychiatry, the “incident to” definition may not seem entirely accurate. While a tech wrapping an orthopedic patient’s sprained ankle can clearly be understood to be providing an incidental part of the doctor’s treatment for the patient’s injury, it is less clear that the psychotherapy indicated by the psychiatrist’s initial evaluation of the patient can really be considered “incidental to,” for example, the patient’s treatment for depression by the psychiatrist, who has prescribed an SSRI and meets with the patient periodically to determine how treatment should continue.

It is important to understand that under “incident to,” the patient is considered to be the psychiatrist’s patient, and the psychotherapy provided by another clinician must be directed by the psychiatrist. Even though the psychiatrist does not have to be in the room when the therapy is provided, he or she must be present in the same office space while the “incident to” care is provided and must be overseeing that care. The psychiatrist bears full responsibility for the patient’s treatment and is legally liable for any problems that should occur during the course of the treatment.

Q: I am an out-of-network provider. My patients pay me directly and file for reimbursement from their insurers. Several patients have been denied payment because although I am now using two codes—an E/M code for medical management and a timed-base psychotherapy add-on code—I list the two codes with one total fee, which is the same as before the CPT code changes went into effect. The insurer says I cannot be paid for my care unless I divide my fee between the two codes. Can you provide me with some rational way to do this?

A: Most insurers base their fee schedules on the same relative value units (RVUs) that are assigned to the CPT codes under Medicare’s Resource-Based Relative Value Scale (RBRVS). That being the case, a logical way to determine how your fee should be divided between the two codes is to find the RVUs assigned to each code and divide the total RVUs into your fee. (An RVU table with values for the codes most frequently used by psychiatrists can be found on APA’s website at http://www.psychiatry.org/cptcodingchanges; the column we recommend using is “Non-Facility RVU Total”). The quotient of the division is the dollar amount your practice charges for one RVU. Once you have that figure, you can multiply it by the RVUs assigned to each code you have used, and you will have the amounts you can assign to each code.

Q: I have been told that if counseling and coordination of care account for more than 50 percent of the time I spend with a patient for whom I am providing E/M services, I can select the appropriate E/M code based on the time of the encounter and its match to the typical time CPT assigns to the code rather than on the elements of the history, exam, and medical decision making the patient required. Why can’t I just define my psychotherapy with E/M sessions as counseling with E/M sessions and bill based on the time? It seems like the pay would probably be better and the documentation requirements less onerous.

A: There are a number of reasons why this is not an appropriate option. First, CPT defines “counseling” very specifically: It is a discussion with a patient and/or family concerning one or more of the following areas:

Second, psychotherapy is a group of defined treatment modes during which some of the elements of counseling may come into play, but it is not counseling. Payers understand that psychotherapy is generally an ongoing treatment that requires regular encounters with the patient. It would be very unlikely that one would have to counsel a patient and/or coordinate care on a weekly or even monthly basis.

Third, if you selected the E/M codes based on time, you would most likely be using the highest-level established outpatient codes, 99214, which has a typical time of 25 minutes, and 99215, which has a typical time of 40 minutes. Both codes are generally used only for patients who present with very complex conditions—in the case of 99215, probably life-threatening conditions. Medicare and most commercial insurers are concerned about the overuse of these two codes and would likely audit any provider who used them on a regular basis. ■