N.Y. Psychiatrists Win Dispute Over Medicare Payment Rule

The New York State Psychiatric Association (NYSPA) has convinced one of the country’s largest Medicare insurance carriers to correct the way it interprets rules for reimbursing psychiatrists conducting medication management or monitoring.

After two years of negotiations, Empire Blue Cross/Blue Shield agreed with the NYSPA’s contention that Medicare regulations allow psychiatrists to use an evaluation and management (E&M) code to bill Medicare for services that include psychotherapy and medication monitoring. The carrier wanted to impose a policy in which psychiatric medication management in conjunction with a psychotherapy session would be relegated to a lower-paying code such as 90806, which does not include E&M, rather than E&M codes such as 90805 or 90807.

This policy change, which became effective May 30, allows psychiatrists to be reimbursed at the higher rate used for services that include E&M.

The New York Medicare carrier’s interpretation of Medicare rules was that medication adjustment, but not medication monitoring, was necessary to qualify a service for billing with a higher-paid E&M code.

NYSPA Executive Director and general counsel Seth Stein, J.D., along with New York psychiatrists Edward Gordon, M.D., and Mark Russakoff, M.D., led the effort to get the carrier to alter its reimbursement policy on medication monitoring. Gordon and Russakoff are, respectively, the New York representative and deputy representative to the APA Medicare Carrier Advisory Committee. Gordon chairs the committee, which has a representative from every state, the District of Columbia, and Puerto Rico.

The carrier agreement means that New York psychiatrists who treat Medicare beneficiaries will be eligible for reimbursement about $6 higher per patient visit than they would have been under the policy the carrier proposed, Gordon said.

Gordon, who is also a member of the New York Medicare Carrier Advisory Committee, which includes physicians from all specialties, stressed in an interview with Psychiatric News that close and constant monitoring of the Medicare carriers “is the only way organized psychiatry can have input into local Medicare policy. It’s also the only way that the carriers know how psychiatry is practiced in the community and what the standards for psychiatric practice are.”

He also cited the assistance provided by Lloyd Sederer, M.D., director of the APA Division of Clinical Services, and Sam Muszynski, director of the APA Office of Healthcare Systems and Financing, during the months of negotiations with Empire Blue Cross/Blue Shield over its Medicare reimbursement policy.

One crucial reason psychiatrists can’t let up their vigilance over the local Medicare carrier, Gordon said, is that despite federal Medicare rules that cover many aspects of reimbursement and coding, “there are essentially 50 different Medicares,” since carriers have the freedom to set their own policies on several of these issues.

“Local Medicare policy is a work in process,” he emphasized. “By keeping after the local carrier in New York, we were able to bring about a significant improvement in coverage for psychiatry.” He suggested that psychiatrists in other states can also influence Medicare policy if they closely monitor what their local carrier is up to and get involved when they think they are being treated unfairly. ▪