Psychotherapy - JE - Current Procedural Terminology (CPT) 90834, 90836 and 90837 Service Specific Targeted Review Final Findings

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs post-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings and closure of the case for CPT 90834, 90836, and 90837.

Summary of Findings

Since the last website posting, 275 claims were reviewed from December 2, 2020 through May 6, 2021 revealing an error rate of 19.31%. The breakdown of those findings are as follows:

  • 231 claims were allowed
  • 44 claims were denied in full for the following reasons:
    • The requested records were not received
    • The documentation submitted did not include a valid signature and/or credentials
    • The documentation submitted did not include a valid signature and a response to attestation or signature log request was not received
    • The documentation submitted was incomplete and/or insufficient
    • The documentation submitted was for the incorrect date of service
    • The documentation contains conflicting information
    • The documentation submitted contains cloned or altered information

The overall error rate since the initiation of this service specific targeted review is 19.31%. The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If you disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice, although this will not affect the error rate of the pre-payment review.

Education

Psychotherapy

CPT® 90837 is to be reported for one hour of face-to-face time spent with the patient. Any service that is performed via phone call should not be reported with this code. The documentation for this service must include one hour of documented time. If the documentation does not support one hour, it will be down coded to the appropriate CPT® code.

  • CPT® 90837
    • Psychotherapy, 60 minutes with patient and/or family member (53 minutes or longer)
  • CPT® 90834
    • Psychotherapy, 45 minutes with patient (38 to 52 minutes)
  • CPT® 90836
    • Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
  • CPT® 90832
    • Psychotherapy, 30 minutes with patient (16 to 37 minutes)

If time spent is not documented, no payment will be made. Do not report psychotherapy of less than 16 minutes. Refer to MLN Matters Psychiatry and Psychotherapy Services SE1407, Social Security Act 1862 (a)(1)(A), Medicare Claims Processing Manual, Medicare Program Integrity Manual Chapter 3, Section 3.3.2.6 and Medicare Benefit Policy Manual.

Cloned or Altered Information

While services provided to beneficiaries are expected to be documented at the time they are rendered, there may be times when services are not properly documented. When this happens and the record needs to be amended or corrected, it is vital the record keeping principles are followed. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5.

Failure to Return Records

When the MAC requests documentation for review, it is the provider's responsibility for the requested documentation to be received within 45 calendar days from the request. The MAC will not grant extensions to providers who need more time to comply with the request. Payment will not be made to any provider unless they have furnished the information as requested in order to determine the amounts due to the provider. Medicare will not pay for services unless they are deemed necessary and sufficient information is submitted that shows that services were provided. For payment, the services

must be determined to be reasonable and necessary for the prevention or treatment of illness. Refer to Social Security Act 1815(a), 1833(e), 1862(a)(1)(A).

Incorrect Date of Service

The date of service must be included on each page of the documentation and must correlate to the date of service billed. A claim will be denied, for example, when the date of service billed and the date of the service on the documentation are not the same. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, 3.6.2.2. and MLN Matters, Guidance on Coding and Billing Date of Service on Professional Claims, number: SE17023.

Resources

For additional educational resources, please visit our Education and Outreach department

Provider Action Required

Providers should review individual claim determinations.

To review individual claim comments via the Noridian Medicare Portal, complete the following steps:

  1. Log into Noridian Medicare Portal at https://www.noridianmedicareportal.com/
  2. Choose Claim Status from the menu bar.
  3. On the Claim Status Inquiry page:
    1. Fill in all Provider/Supplier Details.
    2. Select MEDB under Program drop down box
    3. Fill in all Beneficiary Details
    4. Fill in Claim Details.
  4. Click the Submit Inquiry button at the bottom of the form.
  5. On the Claim Status Results page
    1. Choose View Claim.
    2. On the right side of the page will the heading: Related Inquiries
    3. Choose Noridian Comments.
  6. Scroll down the page and under the Claim Status Line Details the comment will display.

Note: If documentation was sent late (>45 days from the date of the ADR), the claim may have been reopened by the examiner. These reviews are not currently available on the portal.

Initial documentation must be sent by fax, mail or esMD. Additional documentation requested can be submitted fax, mail or Noridian Medicare Portal

Further provider action recommended includes:

  • Provide education regarding errors noted to applicable staff members.
  • Verify documentation supports medical necessity of the psychotherapy visit.
  • Ensure ADR submissions are timely, complete, and include all documentation to support medical necessity and a valid physician order.
  • If records supporting the services on the claim are located at another facility, as the billing provider, your facility is responsible for obtaining those records for review.

Summary

Based on the improved error rate for this targeted review this case is now closed and Noridian will no longer request documentation for this review. Noridian will continue to monitor the utilization patterns of providers and perform medical review for medical necessity and appropriate coding practices. If, in the future, claims data indicates variances or high utilization, providers may be subject to a pre-payment or post-payment review.

If you would like to receive information regarding findings specific to your facility prior to the completion of the review, send an email to medicalreviewb@noridian.com. In order to facilitate the response, follow these instructions:

  • Complete the Subject line with the following information: Results request for CPT 90834-90837 widespread review
  • In the body of the email, include the following elements:
    • Your name, title, and telephone number
    • The facility name
    • NPI Number
    • Short description of information you would like to receive
  • Indicate if you would like to receive results via phone call, fax or US Mail and include a fax number or mailing address as applicable.

Upon request receipt, Noridian Medical Review will respond as timely as possible.. Requests may take up to two weeks to be completed.

If you have any questions, contact the Provider Contact Center

 

Last Updated Thu, 29 Jul 2021 13:23:37 +0000