Update on 59 Modifier

Barbara Griswold researched and wrote an article about the new CPT code changes for mental health effective January 1, 2017 and graciously allowed us to reprint her article which you can read here.

Since then a kind reader sent us more information on her experience with using the 59 modifier.  She states that they have had good experience getting paid using the modifier XE in place of the 59 modifier when billing the CPT code 90847 along with 90832, 90833, 90834, 90836, and 90837 and 90838.

I checked back with Barbara and she researched further and sent me the following information.

The 59 hasn’t been deleted but I found that some codes that have come out that should be used instead since they are more specific, most notably XE in the case we are talking about when a therapist does a couples and individual session in the same day.  I’m not sure if this is just Medicare, or if private plans will accept this,  but a few websites seemed to verify this.  Here is one of them that explains it well.

Thanks for clarification Barbara

Author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should” www.theinsurancemaze.com

New CPT Codes for Mental Health

Barbara Griswold researched and wrote the following article about the new CPT code changes for mental health effective January 1, 2017 and graciously allowed us to reprint her article.

While you may know that psychotherapy CPT codes underwent radical changes in 2013, on January 1, 2017, more changes quietly went into effect.  According to the American Psychological Association, in the American Medical Association’s new 2017 CPT manual the following was clarified:

·         The descriptions of codes 90846 (couple/family therapy without patient present) and 90847 (couples/family therapy with patient present) have been changed so they now have stated time lengths of 50 minutes.  These codes should be used when providing family or couples therapy, with a minimum of 26 minutes.

·         Psychotherapy codes (90832, 90834, and 90837) are now for individual therapy only.  The description “psychotherapy with patient and/or family member” has now been changed to simply “psychotherapy with patient.”  Yes, the AMA says these sessions may occasionally involve “informants” such as family and caregivers, but these codes are to be used when the therapist is primarily providing individual counseling, and the patient is present for the majority of the session.

·         Codes 90832, 90833, 90834, 90836, 90837, 90838 can be reported on the same day as 90846 or 90847.  Include modifier 59 to emphasize the services were separate and distinct.  (Note: this doesn’t mean the insurance plan will cover them both, but this is how to code them).

by Barbara Griswold, LMFT, Author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should” www.theinsurancemaze.com

Telemedicine changes

We received the following article from Barbara Griswold and she graciously allowed us to reprint it.

The CPT manual also introduced a new CPT modifier, 95, for “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.”  While this will cover video sessions, you’ll notice this description doesn’t apply to phone sessions.  This modifier follows the code for the service provided — ex. If you provided 60 minutes of telemedicine, you would code 90837 with modifier 95. (Note: Many clients don’t have coverage for telehealth.  Also, payers have previously asked providers to use the GT modifier to indicate a telehealth session, so it is a good idea to check with plans before billing).

In addition, the manual clarified that the only codes appropriate for telemedicine are 90832, 90834, 90837, 90845, 90846, and 90847.

What is the Place of Service Code for Telehealth? The APA article suggests when recording the Place of Service code for telehealth sessions that you use the originating code for where the provider is located (typically 11 for office).  However, since the article was written, a new Place of Service Code, 02, took effect (January 1, 2017) to identify “The location where…services are provided or received, through a telecommunication system.”   As always, it is a good idea to check with the insurance plan to see which should be used.   For a complete list of Place of Service codes, click here.

by Barbara Griswold, LMFT, Author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should” www.theinsurancemaze.com


What is Fee-splitting

Fee-splitting laws were enacted many years ago in several states including NY to protect patients from unscrupulous physicians.  Fee-splitting occurs when a physician splits part of the professional fee he earns with someone else.  It was enacted to prevent harm from a small minority of physicians who were looking to strictly line their pockets.  It was meant to keep doctors from referring services to another doctor who was getting paid for the referrals.

In the strictest sense of this law, it also pertains to doctors who take credit cards as a form of payment as the credit card companies are charging a percentage to the doctors.

Medicaid admits that charging a provider a percentage is very common but still illegal.  Most medical professionals prefer to pay a percentage as it is easier for them to compare to other services.  All are now required to find another method of payment or risk losing their medical license.

NY Medicaid demands repayment of Millions of Dollars

NY Medicaid has been sending letters to physicians in New York State demanding providers pay back huge amounts of money.  These demands are not for any overpayments or errors in billing.  The Medicaid Fraud Control Unit has found a new way to take millions of dollars away from doctors based on an article in Volume 16 Number 3 of a Medicaid update issued in March of 2001.

The article states that billing agents are prohibited from charging Medicaid providers a percentage of the amount claimed or collected.  They state it is prohibited by the antiquated fee splitting laws.

They go on to state that they understand that these practices are very common but it is not acceptable under the Medicaid program.

The letter then goes on to state that during the period of 1/1/2010 to present time Medicaid paid out $XXXXXXXX to the provider, and that the provider paid the billing service $xxxxxx.  They then demand that one half of the amount the provider paid to the billing service during that time frame be repaid to Medicaid.  The amounts Medicaid is demanding are staggering.  We were sent a copy of one letter demanding $48,151.66.  To add flame to the fire Medicaid is charging 9% interest on top of this.
What can we, as a medical community, do about this?  Some are hiring attorneys to fight it.   Some are checking into it with their professional associations.   We know of one family practice that is going out of business.  They have notified their patients and are closing up.  Other doctors will drop out of the Medicaid program.  How will all this affect Medicaid patients if doctors give up participation with the program?

We have been saying for several years that charging a percentage is considered fee splitting in several states including New York.  The problem is that most providers want to be charged a percentage because they feel that this is the best way to make sure that the billing service is doing their job.  They are only paid if and when the provider is paid.  However, at the end of the day it is still considered fee splitting.

At this time it appears that it is only straight New York State Medicaid however we have heard rumors that the Medicaid Managed Care Plans may follow.   Commercial insurances could also decide to follow suit.  The letter sent out by NYS Medicaid indicates that providers can actually lose their license for violating fee splitting laws.

If you or one of your providers have received a letter from Medicaid requesting a refund due to percentage billing please let us know what your office is doing about this.  What are you hearing?  We will post responses anonymously to let others know what is happening.

MACRA in a Nutshell


A provider’s fee schedule will be based on their composite score.

Penalties take effect in 2019 but are based on actions taken in 2017.

There are three exceptions.  They are:
1.    Physicians billing less than or equal to $30,000 in charges to Medicare for 100 or fewer patients
2.    Physicians in their first year of enrollment
3.    Physicians participating in APMs

For 2017 & 2018 Requirements are for  Physicians (MD/DO and DMD/DDS), Physician Assistants, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists

In 2019 it is expanded to include physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dietitians/nutritional professionals

So mental health, physical therapy, audiologists, and a few others are not affected until 2019

There are 4 performance categories:
1.    PQRS  –  60%
2.    EHR  –  25%
3.    Clinical Practice Improvement  – 15%
4.    Resource Use  –  0%  (not used in 2017, but will be in 2018 and on)
This means that a huge 85% of the score is based on PQRS and EHR.

#1 Marketing Idea for Today

Marketing is the hardest part of starting or growing your medical billing business.  We are often asked for suggestions on marketing from billing services.   There are many changes in the medical billing field that are opportunities for marketing your business.  Right now we have a great suggestion for you.

Many times there is a change or new information in the field of medical billing that is important to providers but they may not be aware of.  When such information is available, it can be a great marketing tool.  And right now we do have such information available that you can use to grow your business.

I know you probably have heard a lot about MACRA, but the surprising fact is that many providers’ offices have not yet understood how this is going to affect their income in the next few years.  Not only will their income be affected but they will be scored by Medicare and their score will be published on a website.

Here’s how to use this information to market:

First of all you need to totally understand MACRA so you can explain it to a doctor.  You need to know specifically how it will affect their income.  You need to know which medical providers will be affected when.  Also many doctors will be concerned about how they are being scored when it is available for anyone to look at on a website.   For more information on understanding MACRA, see our article MACRA in a Nutshell.

Once you are confident that you understand the information, you can build a marketing campaign by calling, writing, or dropping in offices.  If you decide to go directly to offices to try to talk to them, you may find it difficult to find a decision maker who can stop to talk to you.  Be prepared by having written information you can leave behind explaining how you can help them understand this information.  Make sure to leave your contact information.   As with any marketing campaign make sure to keep track of everything.

Another idea is to offer a luncheon to cover this important information.  Either send out invitations that are enticing with the information they will be receiving or advertise what you are offering.

You could also offer to come in to do an analysis of how MACRA will impact their office.  This may seem difficult but it really isn’t.  You just need to find out:

1. Do they report PQRS?

2. Do they demonstrate Meaningful Use? Those are the two biggest areas for scoring.

If they are already doing both of those then their score should be pretty good.  If not, then you can give them information on how to fix that.

The problem with MACRA is that most providers see “2019” and think, “We don’t have to worry about anything yet”.  But the reality is that the 2019 income will be determined but what the providers do in 2017.  Ignoring MACRA is not an option.

So back to marketing, you can use MACRA to get the provider’s attention.  Design a flyer or other informational packet and use it to get your foot in the door.  Once in, you may discover other areas that are problems and will have the opportunity to talk to them about your services.