Why can't NC Psychologists be paid for the 80/20 Behavioral Health Codes ? : working w/ APA to solve this mystery for NC psychologists

I am trying to figure out why NC psychologists are not being paid for Behavioral Health Codes e.g., 96152.

Why does this matter? Because the Behavioral health Codes (please see: http://www.apa.org/practice/cpt_2002.html) pay at the 80/20 rate vs the therapy rate of 60/40.

American Psychological Association obtained 'privileging' for American psychologists as associated with this 'medical arm' of the billing structure, in 2002.

However, NC psychologists are not being paid when they bill using a Behavioral Health Code.

I have talked w/ Diane Pedulla (dpedulla@apa.org) at APA in D.C. re: non payment of Behavioral Health Codes in NC.

This non-payment is associated with Medicare, not Medicaid.

I understood Ms. Pedulla to state that 'just because it is not listed as not being paid for, does not mean it will not be paid for.'

I also understood her to state that Medicaid does not commonly pay for the behavioral health codes, which is in keeping with the document that was passed to me by a member of the NC Executive Board on Friday, June 6, 2008, in Asheville, NC (http://www.dhhs.state.nc.us/DMA/bh/8C.pdf

This is not a problem for NC psychologists as Medicaid pays quite well when it is the primary carrier.

It is only the primary carrier for clients receiving SSI (this means they did not vest enough into the social security system to receive SSDI, which would give them Medicare as primary carrier, w/ Medicaid as secondary).

Medicaid is also the primary carrier for those under 21 deemed to be 'disabled.' What I turned up is the following as associated with looking at the below documents on the CIGNA government web page, utilizing the descriptor '96152.'

I understood Ms. Pedulla to state that 'just because it is not listed as not being paid for, does not mean it will not be paid for.'

What I turned up is the following:

1. CORF, Comprehensive Outpatient Rehabilitation Facilities, can utilize 96152, behavioral health code, which pays at 80/20, medical side of payment 'tree.'

2. It appears, per Item 5 below, that physicians can be paid for 96152.

Thanks for your help, Tony (Puente) and Diane (Pedulla). marsha hammond, phd__________________________________________________________________________________________________________________________________item 1: http://www.dhhs.state.nc.us/DMA/bh/8C.pdfpdfThis is associated w/ Medicaid only. thus, there being no Behavioral Health Codes for Medicaid is not new. This is the document you bought w/ you to the executive board meeting on friday, Dr. Dick Rumer. Ms. Pedulla stated that this is the usual re: Medicaid

___________________________________________________________________Item

2: the psychologists in the room at the executive board meeting on friday stated, as we spoke about the matter, that none of them were being paid for Behavioral Health Codes, that in order to be paid, they gave up and simply ran thru the 60/40 therapy codes e.g., 90806.

There was agreement that this was so from the 25 people that were there, at least some who knew exactly what we were talking about. ___________________________________________________________________item

3: CIGNA, jurisdiction 11, is contractor for Medicare for NC. We researched at the CIGNA site, LCD, Local Coverage Determination. Pedulla and I both looked at it online. http://www.cms.hhs.gov/mcd/results_index.asp?from= ***********************

Item 3a. L6442 Psychiatry and Psychology Services 09/15/2005 10/01/2006 N/A 11/15/2007 LCD for Psychiatry and Psychology Services (L6442) http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=6442&lcd_version=31&show=all

no mention of 96152 anywhere in the above doc **************************************************************

Item 3b: L6460 Psychological Services Coverage Under the “Incident To” Provision for Physicians and Non-physicians 01/31/1999 02/09/2005http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=6460&lcd_version=8&basket=lcd%3A6460%3A8%3APsychological+Services+Coverage+Under+the+%E2%80%9CIncident+To%E2%80%9D+Provision+for+Physicians+and++Non%2Dphysicians%3ACarrier%3ACIGNA+Government+Services+%2_________________________________________________________________________________________________________________Item

4: PDF] Bulletin Number: xxxxxx... for Social Work and Psychological Services in a CORF - CORF providers should billsocial work and psychological services using only CPT code 96152; Health and ... www.cms.hhs.gov/MLNMattersArticles/downloads/MM5898.pdf - 2008-02-25 - Text Version96152 can be billed in a CORF:

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5898.pdf

Comprehensive Outpatient Rehabilitation Facilities (CORF)Billing for Social Work and Psychological Services in a CORF - CORF providers should bill social work and psychological services using only CPT code 96152; Health and Behavior Intervention, Each 15 Minutes, Face-to-Face; Individual. CPT 96152 may only be billed with revenue code 0560, 0569, 0900, 0911, 0914 and 0919. _____________________________________________________________________________________________________________________Item 5: seems to indicate that physician can bill to carrier; no mention of psychologistProgram Memorandum Department of Health &Human Services (DHHS)Intermediaries Centers For Medicare & MedicaidServices (CMS)Transmittal A-01-135 Date: NOVEMBER 30, 2001http://www.cms.hhs.gov/SNFPPS/downloads/a01135.pdf

page 396152 Intervene hlth/behave, indiv Yes NA NA Code Effective 1/1/2002Physician billing to Carrier