Psychiatric Practice and Managed Care
 DOI: 10.1176/appi.pn.2013.11a27
Q & As from APA’s Practice Management
Psychiatric News
Volume 48 Number 21 page 1-1

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, including reimbursement, relationships with managed care companies, coding, documentation, Medicare, Medicaid, establishing a private practice, closing a practice. Below are three recent questions that HelpLine staff have handled and the corresponding answers. APA members can submit their questions to the HelpLine by phone at (800) 343-4671 or e-mail at hsf@psych.org.

Q. I am in-network with an insurance company that has not increased my fees for many years. A number of my patients are insured through this carrier so I don’t want to drop out of the network, but is there anything I can do to get my reimbursement updated?

A. Yes, you can try to renegotiate the terms of your contract. Begin by checking the current contract to see whether it describes the renegotiation process. Since it appears that your contract has been renewing each year without any input from you, you need to contact the insurer and let the company know you are not satisfied with continuing the contract under the current terms. We recommend doing this in writing. If the company is willing to negotiate, don’t hesitate to ask for exactly what you want. Remember, this is a negotiation, and if the company doesn’t agree to your request, you can decide whether you are willing to accept its offer—don’t be embarrassed to continue working under the current payment schedule if that’s how it turns out. It’s good to remember that insurers are required to have a large enough provider network to serve their subscribers, so you may have more clout than you think, especially if you’re in a community with few psychiatrists who take insurance.

Q. What CPT code is appropriate for a psychiatrist to bill for the evaluation of a patient in the emergency room(ER) setting? Would the ER evaluation and management CPT codes (99281-99291) be appropriate if the patient was already seen by a clinical social worker and the clinical social worker is billing for the psychiatric evaluation by using CPT code 90791? Or would the psychiatrist be allowed to bill for CPT code 90792 on the same day the clinical social worker used CPT 90791?

A. Usually the ER codes are billed by the ER physician who sees the patient in the ER. The psychiatrist who sees the patient in the ER is doing so as an outpatient consultation. The psychiatrist could use the E/M outpatient consult codes (99241-99245) or 90792. (If the patient has Medicare, you can’t bill the consult codes, but can use the new patient office visit E/M codes, 99201-99205, or 90792). If a social worker and a psychiatrist each did a complete evaluation of a patient, the social worker could bill a 90791 and the psychiatrist a 90792. Although you could code this way, it is likely that many payers would question why it was necessary for both clinicians to do an initial evaluation, and they may not be willing to reimburse for both. If the patient is admitted to the inpatient psychiatry service, the psychiatrist can use the initial hospital care E/M codes (99221-99225), which would cover both the consult and initial psychiatric evaluation.

Q. I am in-network for several insurance companies, and they don’t seem to be handling the new coding correctly. One of them is paying me less than it did last year even though I am providing the same service, albeit using different coding, and another is saying I should collect two copays from my patients even though I know this is wrong. What can I do?

A. Many insurers were handling claims inappropriately at the beginning of 2013 but have since adjusted their systems to comply with the new coding system. If you are still having problems, please contact APA’s Practice Management HelpLine by phone at (800) 343-4671 or e-mail at hsf@psych.org. ■

Ellen Jaffe is a Medicare specialist in APA’s Office of Healthcare Systems and Financing.

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