In an effort to expand care and secure more reimbursement for psychologists, APA is stepping up its work with the key players who define and set values for the Current Procedural Terminology (CPT) codes that psychologists rely on for reimbursement. The enhanced work is focused not only on advocating for higher reimbursement rates but also on identifying new opportunities for psychologists to be paid for their services and ensuring that psychologists understand the codes that are currently available to them.
“Psychologists typically bill a handful of codes,” says Stephen Gillaspy, PhD, senior director of APA’s Office of Health Care Financing. “We want to make sure they not only have access to these bread-and-butter codes but also to other options.”
By ensuring that psychologists are better reimbursed for their work, APA can help increase the number of practitioners who can provide services, whether through Medicare, Medicaid or private health insurance.
“Expanding access to reimbursement codes helps make sure psychologists can provide their patients and clients with the services they really need,” says Gillaspy.
Exploring new structures
A multilayered process determines which codes psychologists can bill for and their value. An American Medical Association (AMA) group, the CPT Editorial Panel, defines CPT codes, rules and guidelines. Its guidance and the specific placement of codes within the CPT manual influence whether psychologists can use certain codes.
Then, a second AMA body, the Specialty Society Relative Value Scale Update Committee (RUC), recommends reimbursement values to the Centers for Medicare and Medicaid Services (CMS). CMS decides whether to accept or amend those values and determines the rates for Medicare for the next calendar year. Medicare’s reimbursement rates often influence how private health insurers reimburse psychologists and other health-care providers, but ultimately private health insurers and state Medicaid programs make their own decisions on which CPT codes to cover and at what values.
As a professional association, APA doesn’t have direct control over any of these bodies’ decisions, but it proactively works with all of them to advocate for the role of psychologists in patient health and mental health. The association is increasing its efforts to monitor this landscape, provide input during public comment periods, and proactively push for reimbursement structures that benefit patients and psychologists.
For example, last fall APA sent a letteropens in new window to CMS highlighting a number of concerns and recommendations for the 2020 Physician Fee Schedule, which is the annual list of CPT codes and their values for Medicare. Among them: a recommendation that CMS adopt the RUC’s recommended values for the revised Health Behavior Assessment & Intervention (HBAI) codes, which allow psychologists and other providers to bill for services that help patients cope with or manage physical health conditions. The revised codes include increases in value, putting them in line with payments for psychotherapy services.
APA also formed an advisory group to develop specific guidance for payers as they developed their payment policies for the new HBAI codes. This group also informed the association’s work to support psychologists on how the new codes should be used—because the rollout of any new code typically includes some bumps in the road.
“APA helped to create changes with the new codes that improved reimbursement for individual treatment,” says advisory group member Ravi Prasad, PhD, clinical professor and director of behavioral health for the Division of Pain Medicine at the University of California, Davis. “It’s also done a great job of putting out materials to help people understand what those new billing practices should look like.”
Other changes for 2020: The CPT manual added new online assessment and management services codes—G2061, G2062 and G2063 (see below). These codes cover specific non-face-to-face services that require professional patient assessment and decision-making when an existing patient contacts the provider through an online patient portal that meets certain standards, including HIPAA compliance. For example, a mother contacts her child’s psychologist with concerns that her child’s anxiety is worsening, the psychologist replies requesting more information to assess, the psychologist reviews the mother’s response and then replies to the mother with treatment recommendations, saving the clinical documentation in the electronic medical record.
“Psychologists are already providing this service, but they usually eat that cost,” says Gillaspy. “These codes offer a way to capture that work, especially for those in large health systems.”
The CPT manual added two sets of these codes—one for physicians and one for nonphysician health-care providers. During Medicare’s public comment period, APA advocated for psychologists to be able to use the nonphysician codes, giving concrete examples of how psychologists interact with patients between visits. Ultimately, Medicare decided in psychologists’ favor. Now, APA is closely monitoring the rollout of these codes in Medicare and beyond. It’s not yet clear whether Medicaid and private carriers will add them. If payers reimburse for the physician codes, then APA will advocate for reimbursement for psychologists using the nonphysician health-care provider codes.
Additionally, psychologists can now bill for time spent on audio-only telephone services if a Medicare beneficiary calls because they are experiencing mental health issues or symptoms. During these calls, the psychologist engages in assessment of the problem (not formal testing) and then provides an intervention service.
These services, and their accompanying CPT codes, do not replace traditional psychotherapy and reimburse at a lower rate because they were built for brief and directed services.
To bill for assessment and management services, psychologists would use the following codes: 98966, 98967 and 98968 (see below).
This change is unrelated to the temporary regulation changes that allow psychologists to bill for audio-only telehealth, including psychotherapy services, during the COVID-19 public health emergency. For more on that and other temporary telehealth regulation changes, see the July/August Monitor.
APA is also increasing its efforts to educate members about codes that psychologists might not have been aware they have access to. For example, the Screening, Brief Intervention, and Referral to Treatment (SBIRT) codes are used to identify, reduce and prevent problematic alcohol or substance use, and psychologists can bill for SBIRT services in conjunction with psychotherapy by using CPT codes G2011, G0396 and G0397 (see below).
“If you think about the opioid epidemic, these services are critical to help patients before the person may need more extensive or specialized treatment,” says Gillaspy. “It’s clearly within psychologists’ scope to screen for substance use and intervene.”
Psychologists should talk with their carriers and billing department before billing a new code, advises Kevin Arnold, PhD, ABPP, director of the Center for Cognitive and Behavioral Therapy in Columbus, Ohio. Arnold also advises psychologists to pick up a new copy of the CPT manual each year.
“Read the descriptions of the codes and the APA advisories that have been published,” says Arnold, “so you understand the codes you are billing and what those descriptions mean.”
Expanding opportunity
Meanwhile, APA is advocating to expand psychologists’ access to other CPT codes for services they’re well trained to provide. Two areas in particular are codes for time spent assessing and addressing social determinants of health and in assessing and monitoring treatment outcomes.
APA is working with other nonphysician professional groups to advocate for access to codes for these services. “As physicians and other health-care providers develop codes for new ways to deliver services, we want to make sure psychologists can also receive reimbursement,” explains Gillaspy.
At the same time, APA is tracking how shifts in the marketplace are affecting patients and providers. For example, APA staff recently talked with Jennifer Birdsall, PhD, clinical director of CHE Behavioral Health Services in California, and her team to hear their concerns about shifts in long-term care.
Enrollment in Medicare Advantage plans has doubled over the last decade, and the number of available plans has also increased, according to the Kaiser Family Foundation. The result is that Birdsall’s billing department tracks hundreds of commercial plans and product lines with differing co-pays and coverage limits.
“Older adults need access to behavioral health and psychologist services,” says Birdsall, pointing to the host of difficult life transitions, losses, and mental and physical health challenges that this fast-growing and underserved population faces. “We have to figure out a way to make the reimbursement fair for psychologists so that they continue to select to be Medicare providers.”
This spring, APA formed a health-care financing advisory group to help the association develop long-term strategies that take into account such marketplace realities and to plan a long-term strategy for financing psychology practice. The group’s work will include exploring how alternative payment models, such as value- and outcomes-based reimbursement, will affect psychologists’ financial framework.
“We still have to pay attention to fee-for-service and individual CPT codes, even as we work with other health-care providers on alternative payment models,” notes Gillaspy. “We need to live in both worlds.”
