Prolonged Service Add-on codes now apply to outpatient mental health

The add-on codes for prolonged services, 99354 and 99355 are now applicable to face-to-face outpatient mental health as well as for E/M codes.  Previously these codes were only reimbursable if used with E/M codes.
+99354 – Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service, first hour
+99355  –  Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service, each additional 30 minutes
Previously CPT code 90837 was the longest code to report individual psychotherapy.  The 90837 indicates 60 minutes.  If a doctor or therapist saw a patient longer than one hour there was no way to report the additional time.  With this new rule, add-on codes can be used to report the additional time.
For example, if a psychologist spends 90 minutes with a patient face to face for individual psychotherapy they would report the 90837 and the 99354.  If they spent two hours and thirty minutes, it would be reported using the 90837, 99354, and one unit of 99355.
It is important that the patients chart is noted with the time spent with the patient.  Even though these add-on codes can be applied to outpatient mental health it doesn’t mean that all insurances or all plans will cover the add-on codes.  Also, prior authorization rules would still apply as well.
They have also created two new add-on prolonged service codes.  +99415 and +99416 are to report prolonged face to face services performed by a physician, NP or PA.  These prolonged service codes start at services > 45 minutes.
Note:  The + in front of a CPT code indicates that it is an add-on code and that a primary CPT code must be used.

New Mandates in Medical Billing

Recently we have seen more mandates regarding the medical billing field.  Our local Blue Cross recently offered direct deposit by signing up for ERAs and switched from Payspan to another service.  Most of our providers opted for the direct deposit but when the ERAs started coming through in a totally different format than providers were used to we had one provider in particular who didn’t like the new format and wanted to go back to the old paper checks and EOB.  We called Blue Cross to see if this was possible but were told that yes they could change back but soon it would be mandated and they would have to reapply then.

Also AETNA has announced that as of January 1, 2017 ALL claims must be submitted electronically.  They did send out a nice letter explaining what to do regarding appeals, attachments, secondary claims, corrected claims and COB information.

Patient Payment Collections

Even before the enactment of the ACA patient responsibilities were increasing.  However with the ACA plans we are seeing them climb ever higher.  It is not uncommon to see $40 or $50 co-pays and $2500 deductibles.  With patient responsibilities rising it is becoming crucial for providers to improve their patient payment collections.

In the past when most of a visit was paid by insurance this was not as important.  Now it is not uncommon for the entire allowed amount to be the responsibility of the patient so providers cannot afford to not collect the patient portions.

With the technology available, providers now have more options.

  1. Most important is sending patient statements on a regular monthly basis
  2. Co-pays should be collected at the time of service and should not require sending a statement except in unusual situations
  3. Patient statements can now be sent by email cutting down on costs
  4. Statements can be sent with a place for the patient to enter credit card information to pay the balance.
  5. A patient portal can be set up on a website to accept electronic payments over the internet.
  6. If time allows in the office patients should be called to remind them of past due balances and an attempt should be made to set up payment arrangements
  7. Providers can consider using “soft collections” through a collection agency where the collection agency makes several calls and sends letters over a brief period of time attempting to set up payment arrangements.

People are more accustomed to making payments by EFT or paying bills online with a credit card.  It is important that providers give patients convenient ways to make their payment.


Initial Encounters and Diagnoses Codes

Many practice management systems allow the storage of a patient’s diagnoses codes in their record.  Then when a claim is created the diagnoses codes are automatically populated.  This can be a huge short cut in some cases.  For example, a patient being seen for outpatient psychotherapy usually has the same diagnosis code visit after visit.  So every time the a claim is generated the diagnosis code is automatically entered saving the biller the need to add it.  However this can cause denials is certain situations.

Some diagnosis codes must be changed depending on whether it is an initial encounter or a subsequent visit.  For example; if a patient is seen for a right sprained ankle and the initial visit ICD10 diagnosis code of  S93.01XA is used, subsequent visits would be billed with ICD10 code S93.01XD.  The S93.01XD code is specifically for subsequent visits while the S93.01XA is specifically for an initial encounter.

So if a PMS system that allows storage of diagnoses codes is used make sure to check the claims over for accuracy.