Review Results For Service Specific Postpayment Review of Psychotherapy, 60 Minutes With Patient

Background

In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post payment review of CPT code 90837 (Psychotherapy, 60 minutes with patient). The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.

National Government Services randomly selected 323 claims billed for CPT 90837 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• 90837 Psychotherapy, 60 minutes with patient

Results

Decision	Number of claims
Allow	101
Deny	168
Non-Response Denial	54

• 157 claims from Illinois with 66 allowed and 91 denied for a claims error rate of 57.2%
• 78 claim from Minnesota with 23 allowed and 55 denied for a claims error rate of 70.5%
• 34 claims from Wisconsin with 12 allowed and 22 denied for a claims error rate of 64.7%

Key Reasons Services Were Denied

• Documentation did not support medically necessity due to one or more of the following: The documentation was missing an Initial treatment plan; updated plan of care; includes (type, amount, frequency, duration, goals, medical history, focused exam modalities); amount of time spent with the patient (length of session, patient diagnoses; prolonged services; updated treatment and progress).
• Documentation was insufficient or incomplete
• Failure to respond to the request for documentation

Recommendations

• Send the requested records within the requested time frame to avoid a denial for no documentation
• Familiarize yourself with available Psychotherapy guidelines and other CMS publications listed below
• Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare.
• If you feel your application of this code is correct, ensure your documentation supports your usage.

Related Content

• CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 6
  • 20.5.2 Coverage of Outpatient Therapeutic Services Incident to a Physicians Service Furnished on or after January 1, 2010
  • 70.1 Outpatient Hospital Psychiatric Services (General)
  • 70.2 Coverage Criteria for Outpatient Hospital Psychiatric Services
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15
  • 60 Services and Supplies
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12
  • 150 Clinical Social Worker (CSW) Services
  • 160–160.1 Independent Psychologist Services
  • 170–170.1 Clinical Psychologist Services
• LCD L33632 – Local Coverage Determination: Psychiatry and Psychology Services
• LCA A52825 – Local Coverage Article: Psychological Services Coverage and the Incident to Provision for Physicians and Non-Physicians – Medical Policy Article
• LCA A56937 – Local Coverage Article: Billing and Coding: Psychiatry and Psychology Services

Posted 7/6/2021