Coding and Billing in a

Biofeedback Practice

Ronald L. Rosenthal, Ph.D.

…authorization is not a

guarantee of payment

Contextual Background

Federal Policy State Statutes Insurance Regulations/LMRP Business Practices Clinical & Theoretical Orientation

Practice Models(or how to get the money)

Third Party Reimbursement

Fee for Service

Mixed Collection Methods

Section 403(c)

Provider Panels

Restricts your ability to set fees

Can increase the number of patients

Billing Prerequisites

Procedure Code

Diagnostic Code

Diagnostic Coding

ICD-10 for physical disorders

DSM IV for psychological disorders

Procedure Codes

Primarily oriented to physicians and treatment of physical ailments

Current Procedual Terminology (CPT code book)

Biofeedback Codes

90911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry

90901 Biofeedback training by any modality

Biofeedback and PsychotherapyCombination Codes

90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face to face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy) 45-50 minutes

Retired Biofeedback Codes

Prior to 1997 (the Golden Age) there were multiple codes specific for modalities of biofeedback – 90900, 90902, 90904, 90906, 90908, 90910 and 90915.

Alternative Codes For Biofeedback

97112 Neuromuscular reeducation of movement, balance, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.

Alternative Codes For Biofeedback

97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training).

Formerly 97770

Health and Behavior AssessmentAnd Intervention Codes

These codes describe services to patients who present with established illnesses or symptoms, who are not diagnosed with mental illness, and may benefit from evaluations that focus on the biopsychosocial factors related to the patient’s physical health status.

Rationale: Specific Examples

Patient Adherence to Medical Treatment Symptom Management & Expression Health-promoting Behaviors Health-related Risk-taking Behaviors Overall Adjustment to Medical Illness

Overview of Codes

New Subsection Six New Codes

Assessment

Intervention Established Medical Illness or Diagnosis Focus on Biopsychosocial Factors

Relative Values for Health & Behavior Codes

96150 Assessment RVU = .50 96151 Reassessment RVU = .48 96152 Intervention RVU = . 46 96153 Group RVU = .10 96154 Family (with pt) RVU = .45 96155 Family (w/o pt) RVU = .44

Reimbursement Rates and RelativeValue Units (RVUs)

Three components

Physician Work

Practice Expense

Liability Insurance

Relative Value Unitsand Reimbursment (2)

The RVU is multiplied by a conversion factor to determine payment

Biofeedback codes have modest RVUs

Neurofeedback Evaluation Codes

95816 Digital EEG recording

95957 Digital EEG analysis

99090 Reference EEG database access

Modes of Claim Submission

Electronic Transmission

Hard Copy--Mailed

Modes of Claim Submission

Electronic Transmission

Hard Copy--Mailed

Electronic Submission of Bills and HIPAA

Small offices are exempted from HIPAA compliance if they do not use electronic transmission of information.

HIPAA compliance mandated when an office engages in electronic transmission of information.

Problems with Biofeedback Codes

Not universally covered.May require prior authorization.Limitations on number of sessions.Limitations on types of

patients/disorders eligible for reimbursement.

Poor reimbursement rates.Time consuming to get authorization.

Medicare and Biofeedback

Requires the use of a modifier (GP for physical therapy) for payment.

There is a cap on outpatient rehabilitation services (less than $2000/year).

Medicare and Biofeedback

Rehabilitation professionals are trying to have the cap eliminated (The Medicare

Access to Rehabilitation Services Act of 2007).

Medicare and Biofeedback

Medicare standards often adopted by other insurance companies.

Coverage only for muscular retraining.Excludes 90876.Limited diagnostic codes eligible.Payment is less than $45 regardless of

the length of session for 90901.