Medicare Improper Payment Report for Behavioral Health Services

The following information is from the 2014 Medicare Improper Payments Report by the Department of Health and Human Services.

This table shows the Improper Payment Rates by Provider Type and Type of Error for Medicare Part B claims:

    Provider Type

    Improper Payment Rate

    Type of Error

    No Doc

    Insufficient Doc

    Medical Necessity

    Incorrect Coding

    Other

    Clinical Social Worker

    33.9%

    0.7%

    99.3%

    0.0%

    0.0%

    0.0%

    Clinical Psychologist

    24.4%

    0.0%

    93.9%

    0.0%

    3.5%

    2.6%

    Psychiatry

    21.0%

    0.0%

    59.9%

    0.5%

    39.4%

    0.2%

    Average for all provider types

    26.4%

    0.2%

    84.4%

    0.2%

    14.3%

    0.9%


This 2014 report does not include information that is specific to billed codes. The following information refers to specific codes for a single MAC, however, this report is based on the old psychiatry services codes.

A review by Noridian, revealed that 46% of claims for codes 90804-90829 were denied (this review took place before the 2013 code changes were implemented). This information is included in an effort to help reverse that trend. Understanding the following report will ensure better documentation and payment.

    In an effort to review data for billing practices, patterns or trends, Noridian Government Services commenced a process of reviewing psychiatric claims.  It includes the following CPT Codes:

      90801, 90804, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90862

    The Review Results indicate:

      Code

      Paid

      Denied

       Reduced/Partially Paid

      90801

      72.5%

      22.75%

        4.75%

      90804-90829

      37%

      46.25%

       16.75%

      90862

      65%

      28%

      7%

    Review results indicate a 28 percent denial rate of claims submitted with 90862. The documentation submitted supported dispensing medications and giving injections.  Procedure code 90862 (pharmacological management, including prescriptions, use and review of medication with no more than minimal medical psychotherapy) should not be used for the following purposes:

    • Dispensing medications
    • Giving injections
    • Filling medication boxes for patients
    • By non-practitioners as ‘incident to’

    Non-physician practitioners are required to submit claims using their own Provider Identification Number (PIN), if the CPT code 90862 is within their scope of practice.

    Review results also indicate 7% of reduced or partially paid claims submitted with the CPT Code 90862; the documentation actually supported M0064.