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  Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry  Biofeedback training by any modality

Biofeedback and Psychotherapy Combination Codes  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) minutes

Retired Biofeedback Codes  Prior to 1997 (the Golden Age) there were multiple codes specific for modalities of biofeedback – 90900, 90902, 90904, 90906, 90908, and

Alternative Codes For Biofeedback  Neuromuscular reeducation of movement, balance, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.

Alternative Codes For Biofeedback  Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training).  Formerly 97770

Health and Behavior Assessment And 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  Assessment RVU =.50  Reassessment RVU =.48  Intervention RVU =. 46  Group RVU =.10  Family (with pt) RVU =.45  Family (w/o pt) RVU =.44

Reimbursement Rates and Relative Value Units (RVUs)  Three components Physician Work Practice Expense Liability Insurance

Relative Value Units and Reimbursment (2)  The RVU is multiplied by a conversion factor to determine payment  Biofeedback codes have modest RVUs

Neurofeedback Evaluation Codes  Digital EEG recording  Digital EEG analysis  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  Limited diagnostic codes eligible.  Payment is less than $45 regardless of the length of session for