Author Topic: Mental Health: 90834 vs 90847  (Read 4034 times)

CarnationMB

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Mental Health: 90834 vs 90847
« on: May 09, 2013, 02:30:38 PM »
My therapist is wondering what code to use for a client...

The couple has used their EAP sessions this year, and the therapist feel it is absolutely medically necessary to continue their sessions. This clients specific plan denies 90847 sessions.

What options do we have?

*Can we use 90834 for each client and the other is in the session as a support person/family member? (of course, she would then also focus the session on the one that it is billed on. We are NOT looking for a way to "trick" the insurance company)

*Should I call insurance and request an exception and bill for 90847? (Im new at this and don't even know if that is possible) 

Do you have any suggestions?

Thanks

PMRNC

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Re: Mental Health: 90834 vs 90847
« Reply #1 on: May 09, 2013, 04:41:05 PM »
First it's important to know EAP is NOT a part of a patient/insured's Major Medical Benefit. There are employers who only HAVE EAP/CAP programs. If they have MAXED coverage there are no appeals as this is NOT insurance it's a program. You can request the insurance card for the patient's major medical if they have one and if not it would be up to the patient to pay in full and continue if they wish. You might get additional EAP sessions in the next incidence or annually (depends on the EAP).    IN NO WAY, SHAPE OR FORM, SHOULD the major medical carrier have any knowledge of an EAP benefits. These are STRICTLY confidential and violating those terms are worse than violating HIPAA.

Have patient give you their major medical benefit card and verify benefits there if they have one.
Linda Walker
Practice Managers Resource & Networking Community
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www.billerswebsite.com

CarnationMB

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Re: Mental Health: 90834 vs 90847
« Reply #2 on: May 09, 2013, 07:38:18 PM »
I'm sorry if I was unclear. 

I have the Insurance info on the client and their plan does not cover 90847 sessions.
I was wondering about the rules or restrictions to having two people in a 90834/37 session. If they can only be there as a support person/translator, or if they can be active in the session?
 
I just it put it in the question that they have used their EAP sessions as a couple up until now, and need more sessions.


About your other remark about the insurance company not knowing about the EAP: Where does this come from? I'd like to learn more about it (about everything really, since I'm still/always in a learning phase). My personal insurance (Premera Blue Cross) knows that I have EAP sessions and can tell me if they are used or not. I think the employer does not know if or why I have used them, but the insurance knows how many I used (probably not why though...).   

PMRNC

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Re: Mental Health: 90834 vs 90847
« Reply #3 on: May 10, 2013, 07:57:09 AM »
Quote
I have the Insurance info on the client and their plan does not cover 90847 sessions.
I was wondering about the rules or restrictions to having two people in a 90834/37 session. If they can only be there as a support person/translator, or if they can be active in the session?

With the 90847 you still established ONE patient on record correct? To bill the individual therapy codes, the patient of record would be the ONLY one who can participate in the session and the diagnosis has to support the therapy as individual. If this is for marriage counseling, problems in marriage in general, most likely they carrier is not going to cover it and using the individual therapy code would not be appropriate.  When you said the insurance wouldn't cover the 90847 most likely they don't cover "marriage or family counseling" it's not the CPT that's not covered it's the supporting diagnosis with a patient. Now if one of the patient's has a diagnosis that could support an individual session it would be fine to bill that, it's even ok for the spouse to be IN the session but may not participate at all and you want your client to cover themselves with additional documentation in the file because it is highly inappropriate as a general rule of thumb for more than one person to be in an individual session.. once yes, twice would raise a flag.  JMHO

Bottom line is that if traditionally the therapist wants to continue the way the record has been established that would be the appropriate coding (90847) and have the patient pay up front or bill them. I'd say to change the coding to get the insurance to pay would be asking for trouble.

Quote
About your other remark about the insurance company not knowing about the EAP: Where does this come from? I'd like to learn more about it (about everything really, since I'm still/always in a learning phase). My personal insurance (Premera Blue Cross) knows that I have EAP sessions and can tell me if they are used or not. I think the employer does not know if or why I have used them, but the insurance knows how many I used (probably not why though...).   

An EAP is a privately purchased organization/service from the employer.  It is not insurance, it's an extra confidential benefit. There is NO sharing of any information between an EAP and the Employer NOR is there any sharing of information or need to know between the EAP and the major medical benefit. The EAP will know of the Major Medical benefit to refer you to once EAP sessions are exhausted. The major medical carrier should not have any information on the EAP aside from possibly knowing one exists which is also really NOT appropriate. The reason is simple, there is to be no BIAS in claim determination based on EAP benefits. EAP will cover and pay benefits for any mental health illness, alcohol, substance abuse.  If the major medical carrier knows about the EAP then there is a chance of a breach and bias.  My major medical carrier could not tell you anything about our EAP or even if it exists or not since they would NOT NEED this information to process claims on our behalf.  The insurance carrier should not be able to tell if the EAP was accessed if they know there is an EAP, it's NOT information they need and could result again in bias.   

Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com