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Maximizing Reimbursement with the 90837 CPT Code

Michael Reider

Oct 24, 2024

In the world of mental health billing, understanding the 90837 CPT code is crucial for maximizing reimbursement. This code, which represents psychotherapy sessions lasting 60 minutes, has a significant impact on your practice's financial health. As a mental health professional, getting familiar with the ins and outs of the 90837 CPT code can help you optimize your billing practices and ensure fair compensation for your services.

This article will guide you through the essentials of the 90837 CPT code, including its description, time range, and reimbursement rates. You'll learn best practices for billing with this code, strategies to boost your reimbursement rates, and ways to overcome common challenges. We'll also explore how the 90837 code affects therapeutic communication and progress notes, giving you a comprehensive understanding of its role in your practice.

Understanding CPT Code 90837

Definition and description

The 90837 CPT code is a crucial billing code for mental health practitioners, including psychologists, psychiatrists, counselors, and social workers. It represents a 60-minute individual psychotherapy session, with at least 53 minutes of documented face-to-face time 1. This code is designed for longer, more in-depth therapy sessions that focus on treating mental illnesses and behavioral disturbances.

The American Medical Association (AMA) defines 90837 as "Psychotherapy, 60 minutes with patient" 2. During these sessions, the healthcare professional uses definitive therapeutic communication to alleviate emotional disturbances, change maladaptive behavior patterns, and encourage personality growth and development 2.

Time requirements

To bill using the 90837 code, you must spend at least 53 minutes of face-to-face time with the client 1. It's important to note that this time should be devoted solely to therapy, excluding wait time, scheduling, or documentation 3. Accurate tracking and documentation of the session duration are essential to ensure proper billing compliance and avoid potential insurance fraud 3.

The CPT manual provides flexibility by identifying time ranges for different psychotherapy codes. For 90837, the time range is 53 minutes or longer . This means that if your session extends beyond 53 minutes, you should rightfully bill for the full session using the 90837 code .

Comparison with other psychotherapy codes

The 90837 code is part of a set of time-based codes for individual psychotherapy sessions. The main difference between these codes lies in the duration of the therapy sessions they represent . Here's a comparison:

90832: Used for 30-minute sessions (16-37 minutes of face-to-face time)
90834: Used for 45-minute sessions (38-52 minutes of face-to-face time)
90837: Used for 60-minute sessions (53+ minutes of face-to-face time)

It's crucial to select the code that most closely matches the actual time you spent with the patient . For instance, a traditional 50-minute therapy hour should be billed as 90834, while sessions lasting 53 minutes or longer should use the 90837 code .

Understanding these distinctions is vital for maximizing reimbursement. Some insurance companies, like United Healthcare, pay about USD 50.00 more for a 90837 session compared to a 90834 session . However, it's important to note that using 90837 "cannot be for the convenience of the provider" 5. Your documentation should reflect both the accurate amount of time spent with the client and the services performed during the full duration of the session .

By mastering the nuances of the 90837 CPT code and its related codes, you can ensure accurate billing, maximize reimbursement, and provide extended therapy services with confidence.

Billing Best Practices for 90837

To maximize reimbursement and avoid potential issues when using the 90837 CPT code, it's crucial to follow best practices for billing. Here are some key considerations:

Proper documentation

Accurate and detailed documentation is essential when billing with the 90837 CPT code. Your session notes should include all standard elements of a progress note, such as session details, person-centered observations, clinical interventions used, progress towards goals, and risk assessment. Additionally, your documentation should clearly justify the need for a longer session.

To support the use of the 90837 code, include specific details about the client's need for additional clinical intervention. This may include information about the severity of symptoms, acuteness of issues, diagnosis with modality combination, or chronic conditions impacting functioning. For example, you might document recent suicidal ideation, a traumatic event, or how generalized anxiety disorder is interfering with the client's health or vocation.

Remember that insurers are more likely to scrutinize the use of the 90837 code. They want to confirm that the nature of the treatment justifies the longer session and that the care provided is medically necessary. By providing thorough documentation, you can demonstrate that no less frequent or equally effective treatment plan could meet the client's goals and address their symptoms based on their diagnosis.

Avoiding common billing errors

One of the most common errors when using the 90837 code is incorrect time tracking. The 90837 code represents a 60-minute psychotherapy session, with at least 53 minutes of documented face-to-face time. It's crucial to accurately track and document the time spent with the client to ensure proper billing compliance and avoid potential insurance fraud 3.

Another common mistake is using the 90837 code for sessions that don't meet the time requirement. Remember to use the code that most accurately reflects the time you spent with the patient. If a session lasts less than 53 minutes, you should use the appropriate code for a shorter session, such as 90834 for 45-minute sessions.

Be cautious about routinely using the 90837 code for all sessions. Some insurance companies, like United Behavioral Health/OPTUM, have indicated that 45-minute sessions should generally be sufficient for routine therapy. Using the 90837 code too frequently may increase the chance of an audit .

When to use add-on codes

In certain situations, you may need to use add-on codes in conjunction with the 90837 code. For example, if you're providing services outside your normal work schedule, you can use the 99050 or 99051 add-on codes. However, it's important to note that these codes should only be used for appointments that start outside your normal office hours, not for sessions that extend beyond your regular hours.

For crisis situations, different codes apply. If the session meets the criteria for a crisis session, you might use the 90839 code for the first 60 minutes and the 90840 code as an add-on for each additional 30 minutes. These codes are appropriate when the presenting problem requires immediate attention due to high distress or life-threatening situations.

By following these best practices, you can ensure accurate billing, maximize reimbursement, and minimize the risk of audits or claim denials when using the 90837 CPT code.

Maximizing Reimbursement Rates

Average reimbursement rates

Understanding the average reimbursement rates for the 90837 CPT code is crucial for maximizing your practice's financial health. While specific rates can vary depending on factors such as location and insurance provider, it's important to note that the 90837 code typically offers higher reimbursement compared to shorter session codes. For instance, some therapists report that the 90837 code can pay between USD 9-20 more on average than a 90834 appointment, which amounts to approximately 13-20% more per session 1.

Medicare, a significant payer for mental health services, has published their reimbursement rates for 60-minute individual therapy sessions using the 90837 CPT code. In 2024, the Medicare reimbursement rate for CPT code 90837 is set at USD 149.64 2. This represents an increase from previous years, with rates of USD 147.07 in 2023 and USD 164.84 in 2022 2.

Factors affecting reimbursement

Several factors can impact the reimbursement rates for the 90837 CPT code. These include:

Geographic location: Rates can vary significantly based on where you practice, with some areas offering higher reimbursement than others.
Insurance provider: Different insurance companies have varying policies and rates for the 90837 code. Some may require pre-authorization or have specific criteria for its use.
Provider credentials: Your level of education, licensure, and specializations can influence reimbursement rates.
Medical necessity: Proper documentation demonstrating the need for longer sessions is crucial to justify the use of the 90837 code.
Frequency of use: Some insurance companies may scrutinize frequent use of the 90837 code, so it's important to use it judiciously and with proper justification.

Negotiating with insurance companies

To maximize your reimbursement rates, consider negotiating with insurance companies. Here are some strategies:

Timing: The best time to negotiate rates is when you initially credential with a panel. Review the fee reimbursement schedule before signing any contracts 3.
Preparation: Create a list of differentiating factors that set you apart, such as specializations, continued education, or unique services offered 3.
Justification: Highlight factors that justify higher rates, such as serving underrepresented populations, offering crisis treatment, or having specialized training in high-demand areas 3.
Reasonable requests: When negotiating, consider asking for a modest increase, such as a 5% raise, which can make a substantial difference in your income without seeming unreasonable 3.
Documentation: Maintain thorough documentation of your services, including detailed progress notes, to support your claims and demonstrate the value you provide.

By understanding average reimbursement rates, considering the factors that affect reimbursement, and strategically negotiating with insurance companies, you can work to maximize your reimbursement rates for the 90837 CPT code. Remember that while focusing on reimbursement is important, providing quality care to your clients should always remain your top priority.

Overcoming Challenges with 90837

Addressing insurer scrutiny

Using the 90837 CPT code can sometimes lead to increased scrutiny from insurance companies. Some insurers, like United Healthcare, have historically required preauthorization for this code, although this requirement has been lifted as of 2019 1. To address this scrutiny, it's crucial to maintain meticulous documentation of your sessions. Ensure that your progress notes clearly reflect the exact start and end times of each session, excluding any administrative tasks 2.

Justifying medical necessity

Demonstrating medical necessity is paramount when using the 90837 code. Your documentation should provide a compelling justification for why a 60-minute session is necessary for the client's treatment. Include detailed progress notes that outline specific treatment goals, interventions used, and the patient's progress 2. It's also essential to link the correct and specific diagnosis code to CPT 90837, as this strengthens the validity of your claim 2.

Handling audits and reviews

If you find yourself facing an audit or review, it's important to approach the situation calmly and systematically. First, obtain the original claim ID for any denied claims 3. Update the claims data with corrected information if necessary, and refile the claims as corrected on a CMS 1500 form, specifying the resubmission code ('7') and the original claim ID 3.

To prevent claim problems from the outset, conduct thorough eligibility and benefits verification calls before providing services 3. This proactive approach can save you time and frustration in the long run. When addressing benefits payment issues, having a reference ID from an eligibility and benefits verification call can be invaluable 3.

Remember that while the 90837 code is a popular choice and can be a significant income source, some insurance plans, including Medicare, may only approve 1-3 weekly sessions . Exceeding these boundaries can trigger audits and reimbursement fees, so it's crucial to tread carefully .

To maximize your chances of successful reimbursement and minimize the risk of audits, consider the following best practices:

Bill for 90837 only when the session lasts at least 53 minutes of face-to-face time with the client .
Never bill for a 90837 session twice on the same day for the same client .
Include supporting documents, such as session notes or the client's diagnosis, to justify your use of 90837 .
Meet any preauthorization requirements before submitting claims for 90837 .

By following these guidelines and maintaining thorough, accurate documentation, you can navigate the challenges associated with the 90837 CPT code more effectively and ensure fair compensation for your services.

Conclusion

Mastering the intricacies of the 90837 CPT code has a significant impact on a mental health professional's ability to maximize reimbursement. By understanding the time requirements, documentation needs, and billing best practices, practitioners can ensure fair compensation for their extended therapy sessions. This knowledge also enables them to navigate insurer scrutiny and justify medical necessity effectively.

To wrap up, the strategic use of the 90837 code, coupled with thorough documentation and skilled negotiation with insurance companies, can lead to improved financial outcomes for mental health practices. As the landscape of mental health billing continues to evolve, staying informed about coding practices and reimbursement strategies remains crucial to provide quality care while maintaining a thriving practice. Remember, while maximizing reimbursement is important, the primary focus should always be on delivering effective treatment to clients.

FAQs

What are the typical reimbursement rates for CPT 90837?
The reimbursement rates for CPT 90837, which is used for extended therapy sessions, can vary based on the payer and geographic location. For instance, in New York, the rate is approximately USD 144.83.

Is it possible to bill two units of 90837 for a single session?
Yes, you can bill two units of 90837 if you provide prolonged psychotherapy services face-to-face with a patient for 91 minutes or more, starting from January 1, 2023.

How should longer therapy sessions be billed?
To bill for therapy sessions that extend beyond the typical duration, you should not add more units but rather use an add-on code. For a 90-minute session, you should bill using CPT 90837 along with an appropriate add-on code listed separately in box 24 of the CMS1500 form.

Does Medicare provide coverage for CPT code 90837?
Yes, Medicare covers CPT code 90837. The national average reimbursement rate by Medicare for this code is USD 147.07. However, the rates can vary significantly by location, such as USD 200.00 in Palo Alto, CA, and USD 150.00 in Los Angeles.