Professional Affairs News: Expected Updates to BCBS-MA Policy on Psychotherapy Coverage for 90837
Wednesday, September 14, 2016
Professional Affairs News
Expected Updates to BCBS-MA Policy on Psychotherapy Coverage for 90837 - Expanded List of Treatments for Certain Diagnoses
Michael A. Goldberg, Ph.D.
Associate Director of Professional Affairs
We are pleased to report some positive outcomes from MPA's continued advocacy, for psychologists in the BCBS-MA network. Before summarizing these positive changes, here is some relevant historical context on CPT 90837.
When the AMA revised the behavioral health services codes in 2013, they included CPT 90837, Psychotherapy for 53 minutes or more. Medicare set a relative value for 90837 that is nearly 50% greater than what is paid for CPT 90834, Psychotherapy for 38-52 minutes.
BCBS-MA set their rates based on a fixed multiplier applied to Medicare relative values; however, they chose to leave this service off of contracts for providers, meaning that 90837 was unavailable to consumers. MPA advocated for a change of this policy, arguing that consumers were being denied access to the most scientifically based treatments. In response to MPA's advocacy, BCBS-MA began covering this service in 2015. However, the use of 90837 was restricted to a very limited list of diagnoses and treatments with science supporting better outcomes for longer treatment sessions (e.g. behavior therapy for OCD and PTSD, EMDR for PTSD, etc.). Likewise, prior authorization was required for all managed plans.
Since 2015, MPA has been advocating to expand the policy to cover 90837 for more diagnoses and more treatments. We recently learned that BCBS-MA has agreed to change their policy in this regard, effective January 1, 2017. We expect that the official detailed policy will be published and sent to providers in October 2016, and we anticipate that policy will include the following changes:
• Discontinuation of any requirements for prior authorization.
• Expansion of the list of evidence-based treatments for which 90837 may be billed, to include more Exposure-based therapies, CBT applications, Parent-Child Interaction Therapy (PCIT), and Short-Term Dynamic Psychotherapy.
• These therapeutic modalities will be approved for an expanded list of covered diagnoses to include every diagnosis that MPA advocated for. At the very least, that list will include:
Oppositional Defiant Disorder
Unspecified Anxiety Disorder
Providers can request a prior authorization for any situation that is not covered by the policy as an individual consideration.
In practice, claims submitted for the covered treatment modalities and applicable diagnoses or with an approved individual consideration will be paid regardless of the treatment type. However, BCBS-MA intends payments to be limited to the specific treatments that are covered and providers may still be subject to post-service audits for compliance with the medical policy.
This is just one example of the value of MPAs advocacy work with health plans. MPA will continue to work on behalf of its members and those they serve, to increase access to effective and scientifically-based treatments.