Claim denied with PR 172

[Adnare01]

Billing Question!

We keep getting denials on the claims from Medicare Michigan which are billed with CPT code 99358 (Prolonged E&M service) with denial reason as PR-172 (Payment is adjusted when performed/billed by a provider of this specialty). Provider is a Ph.D (Clinical Psychologist). I have no clue to get them paid. Any help would be highly appreciated.

Best Regards,

[kristin]

Is that code within the scope of practice for your provider? If so, you need to appeal using the guidelines set out by your MAC.

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[medwave]

The denial you're receiving (PR-172) indicates that Medicare doesn't recognize clinical psychologists as eligible providers for CPT code 99358.

CPT 99358 is typically reserved for physicians and certain non-physician practitioners who can bill E&M services independently. Clinical psychologists, while they can bill for psychotherapy and psychological testing, may not be recognized by Medicare as eligible providers for prolonged E&M services.

What you might want to do is verify provider enrollment status. Make sure to ensure that the psychologist is properly enrolled with Medicare as a clinical psychologist (not just as a mental health provider) and that their NPI is correctly registered. Also, check Local Coverage Determinations. Medicare policies can vary by region. Contact your local Medicare Administrative Contractor (MAC) to confirm if clinical psychologists in your area can bill 99358.

Or... consider Alternative Codes. Instead of 99358, consider using:
90834, 90837, 90847 (psychotherapy codes with appropriate time units)
90901 (biofeedback training)
Psychological testing codes if applicable

Incident-to billing
If the psychologist works under a physician's supervision, consider billing incident-to the physician's services (though this has specific requirements).

Appeal with Documentation
If you believe the service should be covered, file an appeal with detailed documentation showing the medical necessity and the provider's qualifications.

I'd recommend contacting your Medicare MAC directly to clarify the specific billing requirements for clinical psychologists in your jurisdiction regarding prolonged services.

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