53+ Minute Psychotherapy Sessions Remain a Standard of Care

Reports are emerging that insurance companies are directly or indirectly pressuring clinicians to decrease their use of CPT Code 90837 (for a psychotherapy session 53+ minutes in length), or outright refusing to reimburse for these. Clinicians are once again alarmed about potential bias against coverage of reasonable lengths for psychotherapy sessions for appropriate conditions.

I previously reported “baseline” conditions in terms of the number of “extended length” therapy sessions clinicians were providing to the large population of Medicare beneficiaries in 2012, the year before psychotherapy CPT code revisions were implemented. Indeed, many mental health professionals would consider 60 minutes to be the typical amount of time required for a psychotherapy session. Up to 2012, psychotherapy visits could only be categorized in 20-30 minute (90804), 45 to 50 minute (90806) and 75-80 minute (90808) increments with CPT. Technically, there was no way to code for a 60 minute visit. This implies that, prior to 2013, clinicians either were consistently “downcoding” 60 minute visits to the 45 to 50 minute code or “upcoding” a 60 minute visit to the 75 to 80 minute code. Of course neither would have proper. The best possible spin would be that the vast majority of clinicians were actually providing 45 to 50 minute visits and were coding and billing those accurately, and that sessions that were coded with the 75 to 80 minute code were actually provided for that length of time. If that is what was occurring, alarms about 60 minute sessions being the standard session length of time would seem to be potentially disingenous.

Nevertheless, there is concern now that insurers will begin to deny coverage for sessions that are coded with the 53+ minute code — or require preauthorization or other unusual oversight — and insist that the code for 45 minutes of therapy (90834, technically 38-52 minutes) will be the generally accepted procedure code.

With this background in mind, I wanted to understand how many “extended” sessions were being provided after the psychotherapy code revision in 2013 — the most recent year for which data are available — compared to the baseline year 2012. This would give an initial look at whether there might have been covert or overt pressure to reduce the use of codes for extended sessions. To some extent this compares apples and oranges, with the 2012 code representing 75-80 minutes of therapy and the 2013 code representing any session of 53 minutes or longer. But it is the 53+ minute code clinicians now fear insurance companies will pressure them to stop billing, or simply stop paying for.

Here are what the data look like for 2012 and 2013.

90808 and 90837 Comparisons
90808 in 2012 90837 in 2013
Number of Sessions Provided 197523 2149958
Number of Clinicians Providing* 1013 11485
Number of Beneficiaries Receiving 22659 293743
Average Charge Submitted $175.23 $162.11
Average Medicare Allowed $104.75 $102.01
Average Medicare Payment $60.46 $62.34

Source:  https://data.cms.gov/*Number of clinicians includes those providing services in multiple locations.

Results show that almost 11 times as many 53+ minute sessions were provided by more than 11 times as many clinicians to almost 13 times as many Medicare beneficiaries, at 7.5% lower charge on average, a 2.6% lower amount allowed by Medicare, though with a 3.1% increase in the average amount reimbursed, in 2013, relative to 75-80 minute sessions in 2012.

It’s hard to argue that the change in CPTs was bad for Medicare beneficiaries from 2012-2013. Many more beneficiaries received many more sessions of 53+ minutes in length by many more clinicians in 2013 than received 75-80 minute sessions in 2012. It’s possible the change in coding for therapy session length has actually greatly increased the number of longer sessions beneficiaries received the year after the coding change relative to the year before. It would be interesting to see if this occurred in the private insurance market setting as well, though of course insurers will hide that information as ‘proprietary and secret.’

It’s also difficult to argue that the change negatively affected clinicians’ bottom lines to a substantial degree, at least in the first year during which the new codes were available. Clinicians continued to be able to provide treatment visits of 53 minutes or greater duration, receiving a 3.1% increase on average in reimbursement per session, without the need to continue to provide a minimum of 75 minutes of therapy in order to obtain the higher rate.

Most importantly, payers will be hard pressed to argue that 53+ minute sessions are ‘atypical’ and ‘outlier’ events, and therefore ought not be used regularly and/or will not be reimbursed. With more than 11,000 clinicians providing more than 2.1 million such treatment sessions to nearly 294,000 Medicare beneficiaries, 53+ minute treatment sessions could hardly be characterized as an ‘outlier’ procedure. In fact, in the context of the very large Medicare population, it looks downright standard of care. Clinicians might do well to keep this in mind when for-profit insurance companies try to sell that fiction.


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