Practice Solutions is a mental health billing service and Jeremy is going to talk with us today all about the nuances of billing insurance for testing services.
I think you’re going to enjoy this episode. We dive into some of the details that are very specific to testing practices and he gives us a lot of great information. So here we go.
Hey y’all, welcome back to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. Today you get a double dose of Jeremy. I have Jeremy Zug, who [00:01:00] is partner and co-owner at Practice Solutions here to talk with us all about billing in the mental health world and specifically billing for testing services.
We’ve talked a lot about testing and billing in the Facebook group and I get a ton of questions in individual consulting as well about how to bill insurance for testing services. And that’s our main game today.
So Jeremy, welcome to the podcast.
Zug: Hey, Jeremy. Glad to be here. Thanks for having me on.
Dr. Sharp: Thanks so much for coming on. I know the listeners have heard of y’all, before you sponsored two months of podcasts last fall, and I really appreciated that, but I feel fortunate to have you here in person so we can actually run through a ton of questions about how to bill insurance for testing services. So thank you so [00:02:00] much.
I know we have a lot to get into but I’m curious, so many people hate billing to be honest, what led you to start a billing company?
Zug: That’s a great question. I got involved in billing in Chicago when I was billing for two group practices and actually liked the puzzle. I liked being able to put together all the necessary guidelines of what equals reimbursement. I found that without billing, effective care can’t be delivered to patients a lot of the time, because you have to keep your lights on and people need to get paid and so that was the fascinating part of the gig as far as private practice. And so that sparked a passion for navigating billing in the murky waters of insurance.
Dr. Sharp: Got you. I like how you phrase that. It is a service to patients [00:03:00] ultimately, because if we’re not making money in our practices, that makes it really hard to continue serving folks.
Zug: Yeah, that’s right. If clinicians aren’t delivering quality care to patients, ultimately the society suffers as a whole. I view the role that we play as bigger than just CPT codes and diagnosis and EHRs. It’s serving society as a whole. It’s much more global than a lot of people think.
Dr. Sharp: Yeah, I think that’s true. Gosh, there are a lot of ins and outs to it and there’s a lot of technicality, but yeah, sure, underneath everything is just, how do we make sure to keep doing good work and provide access to people?
Zug: Yeah, and ultimately it’s about managing expectations to what the reality of the situation is, because it is complicated and it can be very frustrating to deal with insurance and hopefully Practice Solutions [00:04:00] exists as an antidote to the frustration that exists between health plans and billers and clinicians in private practice and you all have enough to think about already. So we’ll think about this.
Dr. Sharp: Yeah. Right. Exactly. We’ll talk at the end more about what Practice Solutions does. I think that y’all are offering something great. I want to focus today on some of the ins and outs of insurance billing so that we can do as much as we can on the front end to either do some of your own billing or make it easier on the billing company if you end up going that route.
Let’s just jump into it. A lot of these questions, honestly, I sourced from the Facebook group and from questions that my consulting clients have [00:05:00] asked. So I have a lot of rapid-fire questions. There’s going to be a lot of data. Does that sound okay if we just jump into it?
Zug: Yeah, let’s just do it and see where it goes. It’ll be fun.
Dr. Sharp: Okay. If you say so. All right, so first things first, starting at the initial interview, a lot of people ask how to account for an extended interview. So my question is, can you bill two units of 90791, the interview code and if so, how do you do that?
Zug: Sure. Generally, you can’t bill 90791 more than once per day and not on the same day as an evaluation and management service. So if they see their physician and they have evaluation and management service, your 90791 will deny. So if you [00:06:00] bill a 90791 once per day per patient, that’s all you get.
And so there aren’t extension sessions. So physicians have the option of adding time onto their codes, which I think is where some confusion here comes into play where it’s like, well, I know that some people can do additional time but for this code in particular, you can’t. It’s 90 minutes total for the session and then you have to add on an interactive complexity code or change it into a crisis session. And that’s your only other option for a mental health provider.
Dr. Sharp: It sounds like you could bill 90791 more than once but it would have to be on a different day. Is that right?
Zug: Correct. The most common use, I suppose, when I see this in clinicians is they’ll do a 90791 [00:07:00] and then do three or four therapy sessions and then bill it again to look back at the progress and see where the patient was in treatment before and where they’re progressing.
Dr. Sharp: Okay.
Zug: So that’s the most common but you get one 90791 per day per patient.
Dr. Sharp: Okay. Got you. Thinking about, let’s just say, a theoretical situation where someone, I know a lot of folks in the group do testing with kids or testing with adults where there might be additional parties interviewed or something like that. So let’s stick with kids though, to keep it simple. So for example, in my practice, I will meet with the parents first for two hours, and then I will interview the kid separately for usually an hour, maybe more than that on a different day. [00:08:00] So with that scenario, what would you consider the ideal billing setup?
Zug: According to what you just described, I would bill the evaluation as a 90791 and then I would bill the session separately with the child on a different day because it’s a separate procedure. How long are you seeing the child for normally?
Dr. Sharp: Usually an hour, maybe an hour and a half.
Zug: I would bill the 90791 again if you’re doing an hour and a half because essentially the child is a dependent on the insurance. So meeting with a parent or the parents for a psychiatric evaluation can we billed on their policy and then you can go over to the child’s policy with the insurance and bill a 90791 because you’re essentially doing the same service just with different individuals.
Dr. Sharp: [00:09:00] Oh, that’s interesting. I know y’all work a lot with TherapyNotes, would you put them into the system as different patients?
Zug: Correct, yeah, I would, for sure because that’s the most accurate… The thing we have to keep in mind with coding is it’s not about reimbursement. It’s about accurately reflecting the services that have been rendered because billing for the highest reimbursement is a fancy word called fraud. And so we don’t want to do that. We want to accurately represent the services being rendered.
So if you’re meeting with a parent, for example, for an hour and a half and you’re honest to goodness doing an evaluation, then you would bill that. And then if you meet with the child on a separate day, and you do the same service, then we should be billing the child’s insurance for 90791.
Dr. Sharp: Okay. That’s good to know. All right, so we’re off to a running start here. I’m already learning [00:10:00] some things. That’s great. Okay, so we got the initial intake down. So then from that point forward, we get into the testing codes. So as we get into testing codes, I think it’s worth talking about preauthorization and guidelines there.
So generally speaking, do you have any idea why the guidelines for preauthorization are so different among different insurance companies and why there’s such wide variation between what they approve or don’t approve?
Zug: Yeah, and that is an economic factor there. So the reason why some insurance companies say you need pre-authorization for psychological testing is because it’s expensive. They want to know and be able to budget and make sure that [00:11:00] they:
1. Can pay for it.
2. They want to ensure that it’s necessary because fraudulent abuse are prevalent in medical billing. People defraud the government and other insurance companies all the time by billing for services that were actually never rendered. And so that’s their precaution protecting against fraud or abuse as far as billing goes.
And so that’s why it varies from time to time and within the guidelines that Medicare sets forward, it’s up to the payer to set forth their own guidelines and then add it on to state and federal law. And so between state federal law and then your payer or whatever insurance company you’re in network with, you need to line up those guidelines in order to make sure everything’s being done properly.
Dr. Sharp: I understand that need to limit fraud. [00:12:00] It gets so frustrating for a lot of us when one insurance company doesn’t require pre-authorization at all for anything and then others require extensive pre-authorization for nearly everything. And then there’s a lot in between too. It’s hard to pin it down.
Zug: Yeah. Right. Some payers want to make sure their members are getting the best deal. So it’s like the Cadillac of insurance plans because they don’t refer to these as plans. The last time I spoke with a health director, he refers to all his plans as products. You know what I mean. This is that product and that product.
And so if we think about it as a product, some insurance companies offer a better product. It’s like, well, do you want to drive a 68 VW Bug or a Lamborghini or something? It’s like some plans offer a better product than others. And so that’s part of it as well, they want to offer a good product to their [00:13:00] market.
Dr. Sharp: Got you. Just thinking generally, when we’re looking at pre-authorization, there are those magic words, medical necessity. How does that apply to testing and do you have any thoughts on how to word a pre-authorization in a way that might be more likely to be approved based on medical necessity?
Zug: That’s a really good question. Practice Solutions is not involved a lot with the medical necessity part or even obtaining the prior authorization piece because they require clinical information. I do have several resources that I’d be more than happy to email or offer to folks that help with medical necessity.
I know there are some software out there where you can log in like EHR and have access to physicians that can review your pre-authorization so that you establish medical necessity faster. [00:14:00] Those tools do exist actually. I think they’re quite helpful because it’s physicians looking at other physicians’ work and making sure that you avoid denials and get those pre-authorizations.
I know that’s a limited answer. I’m not too well versed in obtaining an authorization piece or how to word it even but I’m certainly more than willing to offer some resources into the different tools that can help with navigating the medical necessity world.
Dr. Sharp: That’d be great. So you said that some EHRs offer almost a peer review before you submit the pre-authorization.
Zug: Correct. Right. Some EHRs do offer that. And then there are some standalone services where you can buy a one-time license. What happens is you essentially have a login and [00:15:00] then it gets peer-reviewed. You’re right. And that gets reviewed by other clinicians within your space and they offer feedback in general.
And those are becoming a lot more popular. And those are becoming endorsed by health plans across the country, those kinds of software tools or even consulting ones because it helps everybody. The patient needs the care and so going back and forth on a pre-authorization is not good for anybody.
Dr. Sharp: Right.
Zug: So those services are coordinating their efforts with the health plans in order to meet the medical necessity guidelines.
Dr. Sharp: Okay. That sounds great. I’ll list those resources in the show notes if you’re willing to send them to me. I think people would really get on board with that.
Zug: Sure.
Dr. Sharp: Now that we’re getting into the testing and the testing codes, can you talk at all about the difference of 96101 versus 96118?
Zug: Yeah, absolutely. So a [00:16:00] 96101 is obviously psychological testing which includes like an MMPI
type of test per hour of the physician’s or a psychologist’s time, both face-to-face tests to the patient and time interpreting the test results and preparing the report. So that code, 96101, is geared toward the psychologist. Nobody else can administer that test; computer or psych technicians.
But then 96102 is the same, it’s worded the same except for, it’s administered by a qualified health professional; interpretation of the report and administration but not preparation of the report. They leave that out. So they say the administering of the report and the interpretation but not preparing the report. And then 96103 is [00:17:00] administered by a computer.
Those are the big ones but then we jump over to 96118 which is a neuropsychological test which involves, you would know the different tests that fall within that type of test or the different tools that you use. And then again, is a psychologist’s time; both basically administering, interpreting and preparing the report.
And then you have 96119, which is a qualified healthcare professional, which is fairly ambiguous. And then a 96120 which is a computer administering the report.
Dr. Sharp: Well, there are a lot of nuances in there, let me dive into some of that. So the first question I have is, is there anything to distinguish neuropsychological testing 96118 from psychological testing 96101 because I tend to use those interchangeably, to be honest, because I haven’t found anything that [00:18:00] distinguishes them explicitly. So I’m curious if you have other information on that.
Zug: The only information that your biller knows is what’s listed in the code book. So neuropsychological testing, all they have is a parenthesis, for example, a Halstead–Reitan and then a Wechsler Memory Scales and a Wisconsin Card Sorting Test; that’s what your biller knows.
So if you have that type of billing model where you send the medical record to your biller and they see any of those listed, that’s what they’re going to code but a 96101, all they say here is it includes a psychodiagnostic assessment like an MMPI or it’s Rorschach, right?
Dr. Sharp: Rorschach, yeah.
Zug: Or a WAIS report.
Dr. Sharp: Oh, that’s wild.
Zug: Those are the only ways your biller knows how to distinguish those two.
Dr. Sharp: Okay. Yeah, [00:19:00] even talking through those, it seems like there’s a lot of overlap. I would certainly consider a WAIS getting at cognitive functioning, which you could consider neuropsychological. It sounds like there’s nothing, at least from a billing standpoint, from the billing manual to say that, yes, these particular tests are 96118, and these particular tests are definitely 96101, and there’s no crossover.
Zug: Correct. I wish they gave a bulleted list; they give those examples. I think they do that in order to leave it to the clinician’s discretion as far as what is medically necessary and what you’re actually going to be billing with. So what do you think is the most appropriate code for this service?
Dr. Sharp: That makes sense. So then we have this question of the [00:20:00] psychologist code versus the technician code or assistant code. And you have both of those with psychological testing and neuropsychological testing. Can you speak to what makes a psychologist versus a technician?
Zug: Yeah. And this is such a moving target, Jeremy. This is where knowing your state and health plan regulations come into play. I think if you’re a licensed psychologist from an accredited university, you fall into the psychologist category, which to me seems unambiguous; a psychologist is anybody with a PhD or a PsyD from an accredited university that has passed licensure. That’s pretty universal. Actually, I’ve yet to come across a state or a health plan that says that’s not a psychologist.
Dr. Sharp: Okay.
Zug: But when we get into a qualified health professional, [00:21:00] that’s where it gets really sticky because these code books aren’t written to just the private practice world, they’re written to a variety of settings with a variety of applications. So here’s the general principle; a board-certified psychometrician can be used for the administration and scoring of the tests under the supervision of a clinical psychologist or a clinical neuropsychologist. If I had a master’s degree or something and I were a board-certified psychometrician, that word is so hard for me, psychometrician.
Dr. Sharp: It’s hard for everybody.
Zug: It’s too many syllables. I couldn’t just create a practice doing that on my own. I need to be under the supervision of a clinical psychologist. And so there are qualifications for what makes a board-certified psychometrician but basically, it varies by [00:22:00] state. A physician assistant would be considered somebody who’s qualified to do that. They’re required to accept assignments for payment and they’re required to follow the same guidelines as a clinician would.
So that’s what I would say is definitely check your guidelines for your state regulation but not everybody passes muster on that. There are some community college courses you can take and then take a test but generally, there’s a test associated with that qualification.
Dr. Sharp: The psychometrician qualification.
Zug: Correct.
Dr. Sharp: Okay. I know that a lot of folks use, I do this as well, I have graduate students, PhD students to administer tests and can bill or have billed that under [00:23:00] the technician code. Is there anything to say that that is not appropriate?
Zug: There’s not. I haven’t read much about that but I believe that there are guidelines for a PhD student would be the same as you providing supervision for somebody in therapy. As for the literature and the folks I’ve asked; the principle remains the same. That’s a good question, actually. I’ll have to clarify that a little bit more but there’s nothing to suggest that that would be inappropriate.
Dr. Sharp: Okay. And what about states that have master’s level licensure for psychologists? There are some states, maybe even Michigan, that’s where y’all are.
Zug: I know Arizona for sure. And those are becoming more common but there’s certainly not there, the [00:24:00] rule.
Dr. Sharp: So could those folks bill a 96101 or 96118 or does it have to be PhD level?
Zug: What I’ve read as far as the qualifications goes by state and by health plan, I think it does have to be a PhD level clinician but if you are in one of those states, I would absolutely check because there may be a provision since that’s not very common, that maybe the health plans in those states have altered their policies. Those policies change every year. So you definitely want to stay current but in general, the principle is a PhD or PsyD, is considered a psychologist.
Dr. Sharp: Yeah. Got you. There are so many nuances, it sounds like, with state regulations and different …
Zug: Yeah, you’re absolutely correct. It’s pretty incredible actually, because you could spend a [00:25:00] whole lifetime learning this stuff and still not hit the end of it.
Dr. Sharp: Right. Well, thank goodness other people are doing it. I don’t want to have to spend a lifetime on it.
Zug: That’s right.
Dr. Sharp: So we’ve got all these different codes; we’ve got psychological testing, neuropsychological testing, both with and without a technician, can you bill those codes on the same day for the same patient?
Zug: You mean a 96101?
Dr. Sharp: Yeah. Like say, what if my …
Zug: Oh, sorry. Go ahead.
Dr. Sharp: A scenario might help. What if my technician administered, let’s say, three hours of tests and then I jumped in and administered two more hours, could I bill both the 96101 and the 96102 on the same day?
Zug: Oh, good question. I believe that it has to be [00:26:00] contiguous. My understanding of the general principles of how these things are laid out or best practices is that if you’re going to do the testing, 96101 should be brought to completion by the psychologist or 96102 should be brought all the way to completion by the psych technician or the qualified health personnel.
And so that’s what I would say just to stay safe because the risk that you run there is when you get audited, it’s like, well, who is the rendering provider on this? Well, the psych tech was doing it and then I jumped in. And then that makes billing and audit trail pretty fuzzy, I would say, because then at what point do you say that you jump in versus your psych tech or whatever?
Dr. Sharp: Oh, let me clarify a bit. Sorry, maybe I worded the question kind of good. Let’s say the technician does three hours of testing. They wrap up and then the [00:27:00] patient comes down to my office for two more hours of additional testing. Does that make any difference?
Zug: Oh, yeah. You have to bill those as two separate procedures.
Dr. Sharp: Okay. And you can do that on the same day?
Zug: Yeah, there’s nothing in here that says you can’t for sure.
Dr. Sharp: Okay.
Zug: The book or the guidelines doesn’t give any direction as far as not being able to bill those on the same day. They have to do though, is that if you do that, you may have to append a modifier to the claim to show that, look, these were done on the same day but they were different and medically necessary.
It’s like if I were to do a 60-minute therapy session and then the same day they come in for a crisis session;
crisis session is getting an add-on code because there was already a [00:28:00] mental health code being billed that day. And so the insurance company needs to know, was this separate? Was it separately identifiable procedure that we have to process?
And so I would say if you’re going to do that kind of thing where somebody in an upper office is going to see them for that code and then they’re going to come down and see you, you’re going to have to append a modifier to that claim to show that it was a significantly and separately identifiable procedure and therefore falls under, they’re going to look at those as two different things.
Dr. Sharp: Okay. That makes sense. These modifiers, that’s a whole other world that’s relatively new.
Zug: It is a whole other world.
Dr. Sharp: I’m just making a note here. I think it’d be helpful to maybe give a resource for finding modifiers as well because I think we don’t deal with that a whole lot in testing but there are these occasions where it might come up.
[00:29:00] Zug: Modifiers are slippery because different health plans are going to require different modifiers. Modifiers, they distinguish procedures but then that shouldn’t be confused with a modifier distinguishing education level. There are certain health plans that require you to put a modifier to show that you’re a clinical psychologist versus a master of social work but that’s not everybody. And then there are modifiers to distinguish between procedures.Dr. Sharp: Yes. Gosh, that’s all I want to keep track of. Thank goodness you’re out there.
Zug: And the modifier that you’d want to put there for the scenario that you just described is 59. So Modifier 59 distinguishes between two separate procedures.
Dr. Sharp: Okay. That sounds good. I’ll put that [00:30:00] in the show notes as well.
Zug: Perfect.
Dr. Sharp: Great. One more question with billing codes on the same day. Can you bill a 90791 and a testing code like 96101 and/or a therapy code like 90837 all on the same day?
Zug: So the 90791 can’t be billed on the same day as a 90837. Most likely those will get denied. The coding book distinguishes between psychotherapy codes and testing codes. So it is very likely that you could do a psychiatric diagnostic evaluation, 90791 with a 96101 in the same day.
When they don’t like codes billed in the same day, they’ll say [00:31:00] that, they’ll say, do not report a 90791 in conjunction with these codes. And indeed, a 90791 does not have that distinction, so you can fill a 96101 with a 90791.
Dr. Sharp: Okay, that’s good to know. I think that’s a fairly common model where folks will do the interview first in the morning and then do testing throughout the day. So just making sure that’s okay to bill both of those on the same day. Great.
I’m just looking through; I know there are a lot of things to get at. What about this question, people ask a lot about, can I bill on a day that I’m not actually doing the work? The example here is with report writing, [00:32:00] can you bill that 96101 for report writing on a different day than you actually sat down and wrote the report in front of the computer?
Zug: Yeah. Just to clarify your question, so it’s like you did the testing and then report writing and then something happened and you had to come back and continue to prepare the report. Is that what you’re asking?
Dr. Sharp: Yeah, something like that where some report writing happens on a different day than the actual appointment on your calendar or in your EHR.
Zug: All the guidelines really say are that you prepare the report with that code, so whatever time you spent preparing that report, it doesn’t say on the same day. To the best of my knowledge, you can start a psychological test this afternoon and then finish the report over the course of a week and then bill it that way
as long as those are coded to that date of service.
[00:33:00] I think that’s the real key there. People get confused about, well, do I have to do 72 hours of report writing on today? It’s like, well, we know that’s just not possible. So the date of service is when the report was administered.And then you also bill the time spent preparing the report, which can take time and the authors of the code books know that. They know that if you see three testing patients today, it’s going to take you a long time to write those reports. They expect you to have a life in some ways.
Dr. Sharp: Oh, well, that’s nice. Wow. Thank you coding book authors. That’s really tough.
Zug: Yeah, right.
Dr. Sharp: Okay. That sounds good. I know that comes up a lot in the Facebook group. So what about other, let’s say, common, I guess these are common situations, particularly working with kids but also adults to some degree, what about this question of [00:34:00] educational testing? How do we bill for educational testing? Is there a way to bill insurance for it or is that a no go or what?
Zug: Educational testing, you mean like doing tests in a school? Is that what you mean?
Dr. Sharp: Well, that’s a good question. All I know is that a lot of the guidelines mention educational testing and don’t really give a whole lot of detail as to what that actually entails. So maybe I would turn that back to you to see if there’s anything that specifies what is educational testing and when is it covered? When is it not covered?
Zug: Right. The terminology in the code book is essentially just a psychological test and a neuropsychological test. And so there’s nothing in the code book, there’s no verbiage to say, this is an educational test and this isn’t right. And so my understanding of the guidelines is that the school pays first for psychological testing. My [00:35:00] understanding additionally to that is that schools won’t test unless it’s absolutely necessary or in an extreme case. So in my estimation, it’s up to the clinician in a sense.
In some of the other articles I’ve read or whatever, say that any tests administered for educational or vocational purposes that do not establish medical management performed when abnormalities of the brain or emotional function are not suspected, are not considered reasonable and necessary. And so I think that you run a risk there as far as educational testing. And of course you can always ask or refer to your contractor or whoever you’re in network with, but generally not considered reasonable and necessary. It has to be paired a little bit with medical management, it seems like anyway.
Dr. Sharp: [00:36:00] Sure. I know that we’re getting into the weeds a little bit with this, but I think it’s important where, my understanding is that if you are doing testing solely to determine the presence of a learning disorder, which is meant to be under the purview of the school system, then that is really never okay to bill to insurance but if you include some academic testing in the context of a larger neuropsychological evaluation where there is some suspected medical management issue or neuropsychological problem, then that might be doable. Do you have any sense of that?
Zug: Yeah, I completely agree with that, because then you’re doing the educational test within the scope of a greater medical management. By medical management, we don’t mean like [00:37:00] pharmacological management, it’s just behavioral disorders. And if the educational test falls within the scope of the behavioral disorder, then I think it would be fine to do according to most regulations.
Dr. Sharp: Okay. I think that’s a really important distinction but that also raises the other question of, if we are only testing for learning disorders, we know that that’s the primary diagnosis. That’s the only concern the parents have or the adult has, then that’s a case where we can’t bill it to insurance and we have to bill out of pocket for that.
Zug: Yeah, correct. You can always bill insurance but if they deny and you’re in network, you can’t balance bill the patient. And that’s why it’s really important on the front end to know what codes you’re going to administer essentially, and then see if that’s covered by [00:38:00] the company you’re in network with, or if their health plan covers it. So if the product your patient has doesn’t cover it, then that’s something to discuss. That’s something to look into.
Dr. Sharp: So where does the burden of proof lie? Does it lie with us to not try to get reimbursed for things that we know aren’t reimbursable or does it lie with the insurance company to verify that? Because like you just said, it’s psychological testing or neuropsychological testing. How do they determine if someone does this bill for a learning disorder evaluation through insurance?
Zug: So burden of proof …
Dr. Sharp: I’m not sure if that’s the right term.
Zug: That’s a tough term to use but I understand what you’re trying to say. So it’s up to the clinician to bill to the greatest degree of accuracy, what was administered. [00:39:00] And then if that’s not what you’re doing, then the insurance company has the legal bounds to come in and actually check, to actually verify or audit what was done. So it’s really challenging, Jeremy.
If you know you’re doing a strictly psychological test that the insurance doesn’t cover, if you’re out of network, I would just say bill it and then whenever they deny, you balance bill a patient because you can do that kind of thing. But it gets really tricky when you’re in network because like, what if they don’t cover it and you’re in network and you submit a claim and they deny and you can’t balance bill the patient. Well, then you just did a ton of work for no money.
So it’s really up to the clinician to do as much work on the front end as possible to ensure that the health plan will cover it or at least applies to the deductible.
Dr. Sharp: That makes sense. So it is on our shoulders to [00:40:00] not misleadingly bill. We need to know.
Zug: Yeah. That’s a good way to put that. So it’s up to the clinician, but ultimately it’s up to the patient to know what their health covers.
Dr. Sharp: I see. Yes. Gosh, I think that’s a place we all get stuck. I think very few of us are willing to put that back on the patient. We assume it’s our responsibility to know that, which is good customer care to some degree. And that’s important to keep in mind that ultimately, it is the patient’s responsibility.
Zug: Yeah. I totally agree with you but as far as who’s eating the cost, it’s the clinician’s responsibility.
Dr. Sharp: Right. You bring up this idea of balance billing and especially in network balance billing. So this is something that we’ve talked about a lot and something [00:41:00] that happens even in our practice that I’ve advocated is this, if insurance denies a service and calls it a non-covered service, can you still bill that patient additionally, if they agree to that and are made aware of that scenario?
Zug: Generally, no, but some people clear it with the health plan. If you go to the health plan or your provider consultant for your region, and a lot of the times you can get that kind of thing approved, but in general, Jeremy, if you’re in network and they deny and they say non-covered, what they’ll say on the EOB is, you cannot bill a patient for this amount. And so then they would be considered illegal to balance bill the patient.
Of course, everybody has their informed consent, then I’m going to bill you for whatever the insurance doesn’t cover. So this [00:42:00] is a case that; I would check with the health plan to see if that’s okay, because sometimes they’ll approve it actually, because we live in a just ask world in a lot of ways. And then I would just check with your state laws to see like, if I have it in my informed consent, then they have to pay for it.
Dr. Sharp: Yeah, sure. I think that’s important, just to make that clear, in the cases where we are able to do that, I have cleared it with insurance plans that we’re in network with and made it very explicit and sought guidance around what kind of form do we need to have the patient sign to make sure it’s on the up and up. I’m glad you reinforced that to not just go off balance billing but to make sure you got your bucks in a row because …
Zug: Because you can get in a lot of trouble for that, but if you clear it, like what you’ve done, if you can clear it and prove [00:43:00] that you’ve cleared it and all that good stuff, then I would say go for it. It’s business sense to do that.
Dr. Sharp: Sure. A lot of plans have the provision I found, where you, in order to be able to balance bill for testing, you have to “inform the client of the reason testing was denied”. They have to be made aware of that before you balance bill them. So that might be, it wasn’t deemed medically necessary or it’s for educational purposes or for exploratory reasons, things like that.
Zug: Right. You just can’t hit them with a huge bill. That’s not reasonable. Hopefully, people would understand that but not everybody does.
Dr. Sharp: We haven’t talked about feedback. There’s a lot of back and forth about that. What would you say is best practice for billing for feedback sessions? Is there [00:44:00] any flexibility?
Zug: Yeah, sure. Absolutely. We get this question a lot too. So feedback sessions, I would call the health plan and clarify if they cover a 90887. The description for that code is the interpretation or explanation of a medical procedure or a psychiatric procedure or even other accumulated data to family or other responsible persons, or even advising them how to assist the patient. So in my mind, that’s the most accurate code for that service.
So if I’m going to provide a feedback session and I’m going to explain a medical procedure to somebody, hence the word feedback, I would code that. However, if it turns into a therapy session, Jeremy, which is up to the discretion of the clinician, then I would bill a 90837. I don’t know about you, but it [00:45:00] seems like and often a lot of the time those feedback sessions turn into therapy. I don’t know. Does that ring true for you?
Dr. Sharp: Yeah, certainly.
Zug: So if that, in your mind, is the more accurate code, I would bill a 90837, but 90887 is the “feedback” They don’t say that. They don’t say feedback; they say explanation of the procedure. And then how to assist the patient and care, whether that be family or other interested parties or the patient themself, then I would bill that code but if it’s turning into a therapy session, I would bill the 60-minute session for sure.
Dr. Sharp: Sure. That makes sense. Let me ask you about maybe a different scenario, what if the feedback session ends up turning into more of an information gathering session? Would that then lead you in the direction of billing like a 96101 for gathering more data?
[00:46:00] Zug: Yeah, I would probably put that under a 90889 because you intended for it to be the feedback code or the feedback session and it turned into not that. So 90889 is also another preparation of the report. It reads like this, preparation of report of patient psychiatric status, history, treatment or progress for other individuals, agencies or insurance carriers but it can also apply to the patient itself.And it gets a little tricky again because you don’t slide back into a psychological testing procedure because it’s not a separate psychological test, is what you’re saying?
Dr. Sharp: No, if anything, it’d be almost probably similar to a collateral interview, gathering more.
[00:47:00] Zug: I would say a 90887. If that turns into therapy in any way that lends itself toward treatment and not just the collection of data, I would bill the psychotherapy session. I would probably always lean back to a psychotherapy session in general because that’s a more accurate code to show that we’re moving toward treatment. It’s not educating you on psychological testing, it’s actually about your treatment. That’s what I would say in general.Dr. Sharp: That makes sense. This has been chock-full of great information. I want to be conscious of time also. So anything in terms of closing thoughts, situations that we might get tripped up on that you think we should be aware of as testing folks in particular?
Zug: No, as testing folks, I think [00:48:00] psychologists are fairly well equipped on the clinical end. I wouldn’t even recommend buying a copy of the new code books, just so that you know, and I know you only need about four pages out of that book and so you don’t need a thousand-page reference but it would be a value to stay informed on the updated regulations because the book changes every year. We always get the updated books and it helps us to stay informed with what’s going on. So that’s what I would say for sure.
Dr. Sharp: Okay. And what is this book? Where does someone get this book?
Zug: I think you can get them on the Amazon, but it’s the American Medical Association CPT book, the Professional Version, the 2018 book. It is the entire current procedural terminology for what’s considered a valid procedure code for 2018. [00:49:00] So I would say to get a copy of that and to review the psychotherapy codes as well as the testing codes because what you don’t want to get caught is with like a 2005 book and then you’re billing the wrong thing. That’s not good.
Dr. Sharp: Absolutely not. I really appreciate all of this. It’s been fantastic. Can you just talk a little bit about your company and what y’all do?
Zug: Yeah. Practice Solutions exist only in the behavioral and mental health space. We’re a billing company. We are eight employees at this point. So small, I suppose. We exist to provide a high touch feel to our clients and we integrate well with TherapyNotes, obviously, quality care being delivered to patients through effective and compliant [00:50:00] billing services.
And that’s really our goal is to remain compliant with laws, as well as enable people to get care because it benefits everybody, like we said at the beginning. So that’s who we are, it’s what we do and that’s all we do. We’re not looking to expand to any other niche anytime soon, actually, so we’ll always exist in the mental and behavioral health world, and we’re passionate about that space, and we’ll continue to foster and grow our knowledge in the space so that we can provide services in a more potent manner.
Dr. Sharp: That sounds great. Thank y’all. It’s a needed service and it certainly helped us a great deal.
Zug: Oh yeah, it’s great. It’s fun to work with you.
Dr. Sharp: Good. If people have questions or want to learn more, what’s the best way to find you and get in touch with you?
Zug: Through our website is always a good way to get in touch with me. [00:51:00] And then I know that there’s a learning page for The Testing Psychologist, and that’s a great way to get ahold of me because those emails go directly to me. I don’t know if you can attach the link to the notes or whatever, but if folks want to reach out, please go through that link and you’ll get a direct response from me.
Dr. Sharp: Okay. That sounds good. I will put that link in the show notes just so people can make sure to go right to you.
Zug: Yeah. Great. Well, thanks for having me on today.
Dr. Sharp: Yeah, of course. Thank you. I appreciate it. I know it’s some time out of your schedule and I think this will be super helpful for a lot of people listening. So thanks so much, Jeremy.
Zug: Great. No problem. You’re welcome. Thanks for having me on.
Dr. Sharp: Yes. Bye bye. All right, thanks again for listening to this episode with Jeremy Zug. Jeremy gave us a ton of good information about billing insurance for testing services. I know that this is a pretty [00:52:00] nuanced and detailed conversation but hopefully, you took away some pretty important information. I think that he helped address some questions that we face on a daily basis about how to bill insurance for testing services.
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