Using testing codes requires great care

By Mitchell R. Slutzky, Ph.D.
May 31, 2019



Medicare testing codesI have discovered a significant problem with the new Medicare testing codes described by Paula Hartman-Stein, Ph.D., in the January/February issue of The National Psychologist.

She stated that the coding for the neurobehavioral status exam (96116) and psychiatric diagnostic interview (90791) has not changed. That needs some clarification.

On another front, psychologists must be careful in applying the new codes when working with patients in skilled nursing facilities (SNFs) during a Part A subacute-rehab stay to avoid lower reimbursement rates.

The neurobehavioral status exam now has two codes. The first hour is billed as 96116 (unchanged). The second hour is billed as 96121. There is a maximum of one unit of each. The 96121 gets paid at a slightly lower rate than the 96116.

Up until 90 minutes total time is billed as one unit of 96116. To bill for the 96121 unit, one needs to exceed the midpoint of that CPT code. Therefore, if the entire process took 91 minutes or more, the clinician could then bill one unit of each (96116 and 96121 respectively).

The other issue: When going through the reimbursement rates for the new codes in the Medicare Fee Schedule, I uncovered an interesting quirk and significant problem in the way psychologists are being reimbursed by Medicare for testing in “facility” settings (as opposed to “non-facility” settings).

This applies to only a few clinicians. That is because the vast majority of testing in a hospital setting is routed to the outpatient department to avoid the “facility” reduced charge. But it does affect all clinicians who work in SNF settings. Here is what I found out:

When evaluating a patient during a Part A stay in a SNF, there is a major penalty for clinicians who test their own patient instead of using psych techs.

Here’s why:

In a “facility” setting, the 96136 and 96137 codes have a vastly lower reimbursement rate than the 96138 and 96139 rates given to psych techs. The reasons for this are buried deep in the Relative Value Unit (RVU) calculations CMS uses to calculate the rates, but the net effect is that psychologists in this circumstance receive less than half of what psych techs receive for the equivalent procedure.

I have data that shows this. It is a shocker, and all clinicians who work in a long-term care setting need to be aware of this issue. Otherwise, they will see a very large reduction in pay for testing patients for whom “facility” rates apply.

Note that this applies to any patient for whom the Place of Service (POS) code is 31 (i.e., during a Part-A stay in an SNF). This does not affect patients seen in the long-term part of SNFs. Non-Part-A SNF patients are treated as “non-facility” for billing purposes (i.e., POS 32).

That too is a complicated story. I have had to master a lot of policy and billing rules in order to come up with this conclusion, but I see no reason to doubt my conclusion.

The short answer, as indicated above, is do not test patients during a Part A stay unless a psych tech is used for testing and scoring (or the rate you get will be too low.

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Mitchell R. Slutzky, Ph.D., is director of clinical and patient services for CHE Behavioral Health Services in the greater New York City area. He may be reached by email at mslutzky@cheservices.com.

 

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