Further Insights from the “Medicare Data”

Initial analyses of “What the Medicare data reveal about mental health services” were previously reported here. Watch this page for updates on information developed from the “Medicare Provider Utilization and Payment Data: Physician and Other Supplier” data released by CMS April 9, 2014. The data allow insights into health services provided to Medicare Beneficiaries in 2012 that go well beyond “how much Medicare pays your doctor” type of reporting widely emphasized in early press reports.

The “Medicare Data” shed some light on concerns about how the new therapy session codes implemented 1/1/2013 could be viewed. Were 75-80 minute sessions previously rare events for Medicare beneficiaries? Should the questionably “equivalent” code for 60 minute sessions routinely be interpreted as “not medically necessary” and therefore not reimbursable? Or were 75-80 minute sessions being provided with sufficient frequency to suggest these are standard care, reflecting the judgment by clinicians that such services are necessary? Was Medicare providing reimbursement for 75-80 minute therapy sessions, reflecting the determination that delivery of psychotherapy in these increments certainly was “reasonable and necessary”? Here is a look at the numbers.

    • 75-80 minute therapy sessions were the 12th most common mental health service, provided to nearly 23,000 Medicare beneficiaries in 2012.
    • The average charge for 75-80 minutes of therapy in an office setting was $173.
    • The average Medicare reimbursement for these sessions was $61.38 (60% of allowable in 2012).
75-80 Minute Psychotherapy Sessions in Medicare 2012
Office* Facility**
Number of Sessions Provided 190512 7011
Number of Clnicians Providing 894 119
Number of Beneficiaries Receiving 19687 2972
Average Charge Submitted $172.65 $194.66
Average Medicare Allowed $105.85 $96.50
Average Medicare Payment $61.38 $53.54
* CMS’s Methodological Overview reports Non-Facility Based Place of Service (place of Service =“O”) includes primarily office-based services and may also include include Pharmacy, School, Homeless Shelter, Indian Health Service Free-standing Facility, Indian Health Service Provider-based Facility, Tribal 638 Free-standing Facility,  Tribal 638 Provider-based Facility, Prison/ Correctional Facility,  Office, Home, Assisted Living Facility, Group Home, Mobile Unit, Temporary Lodging, Walk-in Retail Health Clinic, Urgent Care Facility, Birthing Center, Nursing Facility, Custodial Care Facility, Independent Clinic, Federally Qualified Health Center, Intermediate Care Facility/Mentally Retarded, Residential Substance Abuse Treatment Facility, Mass Immunization Center, Non-residential Substance Abuse Treatment Facility, Comprehensive Outpatient Rehabilitation Facility, End-Stage Renal Disease Treatment Facility, Public Health Clinic, Rural Health Clinic, Independent Laboratory,  or Other Places of Service
**Facility Based Place of Service (place of Service “F”) includes Inpatient Hospital, Outpatient Hospital, Emergency Room – Hospital, Ambulatory Surgical Center,  Military Treatment Facility, Skilled Nursing Facility, Hospice, Ambulance – Land, Ambulance – Air or Water, Inpatient Psychiatric Facility, Psychiatric Facility-Partial Hospitalization, Community Mental Health Center, Psychiatric Residential Treatment Center, Comprehensive Inpatient Rehabilitation Facility.


Who Provides Psychotherapy to Medicare beneficiaries?


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