Billing Psychological Services for Patients with Chronic Pain


Service

CPT code

Description

Approximate Medicare 2012 payment

Assessment – initial

96150

An assessment service that includes a clinical interview, behavioral and psychophysiological assessment, and the administration of health-oriented questionnaires

15 min (1 unit): $20.42

1 h (4 units): $81.68

Reassessment

96151

A reassessment to evaluate the patient’s condition and determine the need for further treatment

15 min (1 unit): $19.74

1 h (4 units): $78.96a

Intervention – individual

96152

Intervention services provided to an individual to modify the psychological, behavioral, cognitive, and social factors affecting the patient’s physical health and well-being

15 min (1 unit): $18.72

1 h (4 units): $74.88

Intervention – group (per person)

96153

An intervention service provided to a group

15 min (1 unit): $4.42

Group must be two or more people

60 min (4 units): $17.68

10 members (4 units): $176.80

Intervention – family with patient present

96154

An intervention service provided to family to improve patients health and well-being, with education and skills training of family members

15 min (1 unit): $18.38

1 h (4 units): $73.52

Intervention – family without patient present

96155

An intervention service provided to family members of a patient, designed to improve patient health, adaptation to illness, and enhance familial coping

15 min (1 unit): $0a

1 h (4 units): $0


aNote: Medicare and some private payors do not currently reimburse this service



In January 2002, the Centers for Medicaid and Medicare services adopted six new codes reflecting health and behavior intervention services, and these were added to the Current Procedural Terminology (CPT®) code book (Table 8.1) [1, 13]. These “health and behavior” (H&B) codes are designed to address the behavioral, social, and psychophysiological procedures to prevent, treat, or manage physical health problems and are intended for use by non-physician healthcare clinicians operating within their scope of practice. This includes psychologists (PhDs), nurses (RN, NPs), and other non-physician specialists.

The H&B assessment procedures are offered to patients with an established illness or medical symptoms. The codes make it possible for psychologists and others to provide services to patients with chronic pain without having to diagnose the patient with some type of psychological disorder. In contrast to traditional psychological services, which must be paired with psychiatric diagnosis for billing, the H&B codes are psychological services that are paired with a medical diagnosis for billing. Consequently, it has been noted that, “Clinically, for the first time, practitioners working inside of medicine now have a tool to conceptualize psychology as medical service and have a mechanism to pay for it” [14].

It is noteworthy that, prior to CPT 2002, there was no way for psychologists to adequately capture these types of services. This sometimes led to ethical and professional quandaries for psychologists who worked in medical settings [15]. Medicare and other insurance companies have disallowed psychologists from using evaluation and management (E/M codes, CPT 99201–99205; 99211–99215; all CPT codes ©2012 American Medical Association. All rights reserved) on the basis of their training and the fact that these codes require medical management. Neuropsychological test codes (CPT 96100–96117) are not appropriate because they reflect testing of cognitive function and response of the central nervous system, which does not necessarily pertain to physical illness. Psychotherapy codes (CPT 90801–90809) are designed for use by psychologists and psychiatrists, but require a mental health diagnosis, which may not be present in medical patients. “The difficulties associated with acute or chronic medical illness, prevention of physical illness and disability, and maintenance of health, in many instances, do not meet criteria for a psychiatric diagnosis” [15]. Nonetheless, traditional psychotherapy codes were often used in this context, which could create a clinical dilemma. In the past, some providers used psychotherapy codes to bill for behavioral medicine services, as it was “administratively mandated,” while observing that it was also “not an accurate reflection of the patient encounter” [14]. Counseling and risk factor reduction codes (CPT 99401–99429) are not useful in this context as they require the absence of a physical health diagnosis, illness, or symptoms, which is clearly contraindicated for health and behavior interventions. In any case, these procedure codes are generally not reimbursable for psychologists. Similarly, psychological assessment codes (CPT 90801 for the interview and 96101–96103 for testing and report) were also developed in the context of a mental illness/psychiatric diagnosis. While appropriate for some clinical assessments of medical patients, they may be problematic if the primary assessment is related only to the medical condition and its impact on functioning (e.g., herniated lumbar disc, cancer-related pain), as opposed to identifying psychiatric disorders (e.g., depression, anxiety, addiction, or PTSD) or psychiatric complications (e.g., malingering or symptom magnification). It should be noted here though that the ICD-9-CM, the ICD-10-CM, and the DSM-IV-TR all include a diagnosis for “pain disorder,” which includes those patients whose pain reports are judged to be affected by psychosocial factors. Thus, for those patients exhibiting chronic pain with symptoms that exceed what would be expected given the objective medical findings, a diagnosis of pain disorder coupled with psychological assessment CPT codes may be applicable. These are discussed in greater detail below.

The principle advantage of health and behavior coding is that they allow psychologists to provide behavioral medicine services without utilizing psychiatric diagnoses. These codes were intended to be funded through medical, not mental, health carve outs, and this offers several advantages over traditional psychological service codes (CPT 90801–90806 and 96101–96103). Most importantly, health and behavior codes are not subject to Medicare’s “Outpatient Mental Health Treatment Limitation,” whereby Medicare reduces its copayment for mental health services from 80 to 50 %. This reduction only applies to services provided to outpatients with a “mental, psychoneurotic, or personality disorder identified by an ICD-9-CM diagnosis code between 290 and 319” [16]. As such, reimbursement for H&B codes occurs at a rate of 80 %, as it is considered a covered service under the medical portion of insurance. By 2014, though, it is expected that mental health services will be paid at the same 80 % level as physical health services [17]. Secondly, outside of Medicare, the use of psychological codes by psychologists will generally involve billing the mental health insurer, not the medical insurer, and the involvement of a second insurance company can add an additional complication administratively. Third, as above, the use of psychological codes requires a psychiatric diagnosis, and while psychiatric disorders are common in patients with chronic pain, they are not always present.



Logistics of Code Use


There are six H&B codes: two for assessment (initial and reassessment) and four for intervention (individual, group, family with and without patient present). All health and behavior codes only account for face-to-face time spent between a provider and patient. H&B codes are billed in 15-min increments, with no “rounding up.” Therefore, if less than 15 min of services is provided the lesser increment must be used (e.g., 28 min of intervention  =  1 unit  =  15 min). Under Medicare rules, psychiatric treatment codes (CPT 90801–90809 and 96101–96103) and H&B treatment codes cannot be billed on the same day. If both services are needed on the same day, only the predominant service should be billed. With respect to identifying physical health diagnosis, only existing medical diagnoses as reported by the patient’s physician should be reported. These codes rely on coding a physical health diagnosis from the International Classification of Diseases, 9th Edition [18]. Obtaining the physical diagnosis requires a review of medical records or communication with the patients’ referring physician. While multiple ICD-9-CM diagnoses may also be present (e.g., 722.81 post laminectomy syndrome, lumbar, 723.1 cervicalgia), the physical diagnosis that is primary focus of treatment that day should be reported. While a direct referral from a physician is not necessary to utilize these codes, non-physician practitioners should not attempt to diagnose a patient’s medical condition without medical collaboration as that is outside the scope of practice. Table 8.2 provides a description of Axis I diagnoses codes that are typically used with these codes.


Table 8.2
Commonly used diagnoses for patients with pain



















































ICD-9-CM/ICD-10-CM diagnosisa

DSM-IV-TR diagnosisb

ICD-9-CM/ICD-10-CM diagnostic code

Pain disorder related to psych. factors/pain disorder with related psych. factors

Pain disorder with associated [psychological factors] and [medical condition] (code physical diagnosis on Axis III)

307.89/F45.42

Psychogenic pain/pain disorder exclusively related to psychological factors

Pain disorder associated with psychological factors

307.80/F45.41

Somatization disorder [Briquet’s disorder]

Somatization disorder

300.81/F45.0

Undifferentiated somatoform disorder

Undifferentiated somatoform disorder

300.82/F45.1

Other specified psychophysiological malfunction/somatoform autonomic dysfunction
 
306.8/F45.8

Unspecified adjustment reaction

Adjustment disorder unspecified

309.9/F43.20

Psychic factors associated with diseases classified elsewhere/psychosomatic disorder, NOS

[specified psychological factor] Affecting [indicate medical condition]

316.00F45.9

Other unknown and unspecified causes of morbidity and mortality

Diagnosis deferred

799.90

Noncompliance with medical treatment

Personal history of noncompliance with treatment, presenting hazards to health

V15.81
 
DSM 5c: Proposed Complex Somatic Symptom Disorder will incorporate previous diagnoses of somatization disorder, undifferentiated somatoform disorder, hypochondriasis, pain disorder associated with both psychological factors and a general medical condition, pain disorder associated with psychological factors, and factitious disorder, and has no equivalent in the ICD-9 or ICD-10


DSM-IV-TR © 2000 American Psychiatric Association. All rights reserved

DSM 5 © 2010 American Psychiatric Association. All rights reserved

aNote: ICD-10-CM scheduled to become effective October 1, 2013 [44]

bNote: All DSM-IV-TR Dx use the equivalent ICD-9-CM Dx codes

cNote: DSM-IV-TR is current APA manual for psychiatric disorders. DSM 5 is currently in revision and expected to become effective in 2013

With respect to goals of these codes, “The elements of a health and behavior assessment and intervention are designed to improve a patient’s health, ameliorate specific disease processes, and improve overall well-being” [15]. Performance of an H&B assessment may include a health-focused clinical interview, behavioral observations, psychophysiological monitoring, use of health-oriented questionnaires, and assessment data interpretation. Elements of a H&B intervention may include cognitive, behavioral, social, and psychophysiological procedures that are designed to improve the patient’s health, ameliorate specific disease-related problems, and improve overall well-being. A detailed description of these services is provided below in clinical vignettes. The patients with chronic pain who may benefit from use of these codes include those with needs for monitoring adherence to medical treatment and medication regimens, overall adjustment issues secondary to pain diagnosis, and those suffering from the physical and emotional discomfort of chronic pain. In addition, patients suffering from chronic pain with a need for training in adaptive coping behaviors (i.e., relaxation, biofeedback, pacing, problem solving), and/or reduction in potentially harmful or risk taking behaviors (including overmedicating, excessive sedentary behavior, and social isolation), would also be excellent candidates for treatment with these codes. Established illnesses that may benefit from use of these codes include cancer, low back pain, neck pain, shoulder pain, postsurgical pain, post laminectomy syndrome, fibromyalgia, phantom limb pain, and myofascial pain, to name a few.

Since 2006 almost all medicare-assisted contractors reimburse H&B codes. In addition, although many private carriers also reimburse these codes, there are exceptions, so it is always recommended to check with the specific carriers in the state of practice. It is notable that Medicare, and most private carriers, does not reimburse for services provided without the patient present (CPT 96155), despite the fact that a fee has been established for this code. As a guideline, nationwide Medicare reimbursement rates, without geographic adjustments, are listed in Table 8.1.


Troubleshooting Issues


Psychiatric Comorbidity. Use of the H&B codes is not precluded in a patient with an existing mental health diagnosis. However, H&B treatment in a patient with comorbid psychopathology must focus on the physical illness/disease that is present and the patients’ biopsychosocial adjustment to their disease/illness, not their needed mental health treatment. A general rule of thumb is that if you spend greater than 50 % of time discussing concerns and offering treatment for physical illness, bill the H&B code. Conversely, if greater than 50 % of time is spent in counseling and providing support and techniques for treatment of mental illness, then the psychotherapy codes should be used, and the documentation should reflect this.

Assessment. When using the H&B assessment or reassessment codes (96150, 96151), a variety of health-oriented questionnaires can be included along with a clinical interview. These can include traditional standardized psychological measures, along with a variety of nonstandardized checklists and physical and coping strategy measures. A few examples of nonstandardized measures specific to pain assessment are included in Table 8.3, and standardized measures are listed in Table 8.4. Note that this code does not include indirect, or non-face-to-face time, and as a result, measures used in this assessment are generally brief and focused and may include nonstandardized clinical checklists. When more extensive testing (personality, psychopathology) is warranted, the psychological testing codes (96101–96103) should be employed.


Table 8.3
Commonly used non- and partly standardized assessment tools


























































Assessment tool

Abbreviation

Beck Anxiety Inventory

BAI

Beck Depression Inventory – II

BDI-II

Brief Pain Inventory

BPI

Coping Strategies Questionnaire

CSQ

Current Opioid Misuse Measure

COMM

Chronic Pain Acceptance Questionnaire

CPAQ

McGill Pain Questionnaire

MPQ

Multidimensional Pain Inventory

MPI

Numerical Rating Scales

NRS

Opioid Risk Tool

ORT

Oswestry (Low Back Pain) Disability Questionnaire

ODQ

Pain Anxiety Symptoms Scale

PASS

Pain Catastrophizing Scale

PCS

Patient Health Questionnaires

PHQ

Screener and Opioid Assessment for Patients in Pain – Revised

SOAPP-R

Visual Analog Scales, Verbal Rating Scales

VAS, VRS



Table 8.4
Resources for psychologists













APA Practice Directorate: Phone number: 202-336-5889. For advocacy and support with claims denials of H&B codes by managed care companies

APA Practice Central: www.​apapractice.​org includes section on H&B coding, psychological testing, and practice tips. Look under the “Reimbursement” and “Billing and Coding” subsections

Health Psychology and Rehabilitation: www.​healthpsych.​com go to the “Practitioner’s Toolbox” for valuable strategies about “Resolving Issues with Medical Payors”

2006 Psychological Testing Codes Toolkit from the APA Practice Organization, available at http://www.apapractice.org/apo/toolkit.html#

Group Therapy. H&B groups provide psychoeducation and social support as relating to physical health, health behaviors, and medical illness (e.g., distinguishing acute from chronic pain, explaining the pathophysiology of pain signal, teaching how to increase activity level despite pain), not mental health (e.g., management of depression, anxiety, trauma). H&B group therapy is reasonable in medical or psychological settings that already use group-based treatments, including intensive outpatient pain management settings, multidisciplinary pain programs, medical or mental health-based office-based settings, and hospital settings. H&B groups often have a cognitive behavioral component, instructing patients how to practice psychological coping skills for modulating chronic pain, improving quality of life despite pain, or for coping with functional limitations. This treatment is different than mental health groups (CPT 90853) that focus on mental illness and may use non-evidence-based methods (e.g., process, support, or psychodynamic approaches).

Payor Issues. While H&B services are sorely needed in the field of pain medicine, in practice, reimbursement problems can occur. In most insurance policies, mental health reimbursement has been “carved out” of the medical insurance contract and provided for under a separate contract. This sometimes creates a problem when attempting to get H&B services authorized, as H&B services can violate contractual boundaries. The mental health insurer will say “We can’t reimburse you for this because [contractually] we can’t pay for medical diagnoses or medical CPT codes. You should call the medical insurer.” Similarly, the medical insurer will say “We can’t reimburse you for this because [contractually] we can’t reimburse psychologists. Call the mental health insurer.” If these problems occur, several resources are available to support and advocate for practitioners and are listed in Table 8.4 and are also available online [19]. In practice, handling this issue sometimes entails educating the payors about these codes and their purpose and pointing out any discrepancy in their policy. In particular, it is ironic that while many payors now require psychological evaluations prior to spinal surgery, spinal cord stimulator implants, or inrathecal pump implants, these same payors may not have made arrangements to reimburse these evaluations. When this type of difficulty is encountered, it is often useful to begin by speaking with the payor’s provider relations representative and to inquire about gaining in-network status for providing health and behavior services or making other arrangements for reimbursement. In the case of some private payors, reimbursement of H&B services for psychologists must go through the mental health payor. Paradoxically, this will require the assignment of a DSM-IV-TR psychiatric diagnosis for a medical patient who may have no known psychiatric condition. A method of addressing this matter suggested by some payors is to assign a DSM-IV-TR diagnosis as follows: On Axis III, list the medical diagnosis and ICD-9-CM code. On Axis I and II, list “DSM-IV 799.90 Diagnosis Deferred,” as the purpose of H&B services are neither to assess nor treat psychiatric disorders. Having this DSM-IV code on the forms, however, may facilitate the mental health payor’s ability to process the claim.



Clinical Vignettes



96150 Initial Evaluation


A 42-year-old male, military veteran, undergoing treatment for irritable bowel syndrome and fibromyalgia pain is referred for biopsychosocial assessment of pain and psychological distress that developed after fibromyalgia diagnosis. Reduced quality of life due to pain and inability to return to work are also noted.

A 56-year-old male who fell 200 ft off of an oil rig, sustained injuries to both cervical and lumbar spine regions, and is status post two cervical spine surgeries and a lumbar discectomy. He is referred for persisting distress and refractory pain that has not optimally responded surgical and pharmacological interventions. The patient feels worthless and useless as he has never been unemployed before and strongly identifies with his work.

A 16-year-old female is referred for chronic pelvic pain secondary to endometriosis and has dropped out of school due to constant pain and embarrassment over her condition. She has trouble tolerating short-acting opioid analgesics, and her family also has cultural discomfort with the use of pain medicines.


Procedure Description


Patients are assessed with either standardized tests or less formal clinical questionnaires, and a structured clinical interview, which includes both the patient and family members. The clinician assesses the impact of pain condition on activities of daily living, sleep, mood, and quality of life in the following ways. During the interview, medical, psychiatric, and substance abuse histories are assessed, and behavioral observations are made. Medical records are also reviewed, and the overall impressions are formulated into a case conceptualization and treatment plan that is made explicit in the documentation. When appropriate, patients are recommended for individual and/or group cognitive behavioral therapy services emphasizing non-pharmacological coping skills, psychological adjustment to chronic pain and disability, and relaxation training or biofeedback for chronic pain.

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Oct 21, 2016 | Posted by in PAIN MEDICINE | Comments Off on Billing Psychological Services for Patients with Chronic Pain

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