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Update on Blue Cross problems affecting accurate payment of new psychiatric codes



April 19, 2013
Area(s) of Interest: Payor Issues and Reimbursement Public Payors 

The California Medical Association (CMA) began receiving calls earlier this year from psychiatrists with concerns about the way their claims were being processed by Blue Cross.


Following significant changes to the psychiatry category of the Current Procedural Terminology (CPT) manual, many practices reported that when they submitted a claim for an Evaluation and Management (E/M) code with a psychotherapy add-on code, the Blue Cross system was deducting two copays, one on the E/M and one on the add-on code. Additionally, physicians reported that they believed the pricing methodology Blue Cross used undervalued some of the new psychotherapy codes.


CMA raised both concerns with Blue Cross in early March and learned that the system problem causing a double copay to be deducted was corrected on March 5. Blue Cross is in the process of automatically reprocessing the affected claims.


Blue Cross also notified affected physicians on April 12 of its decision to increase rates for several of the new psychotherapy codes, including CPT 90833, 90836 and 90838. For psychiatrists who are on the standard Prudent Buyer fee schedule, Blue Cross has also increased pricing for E/M codes (99202-99205, 99212-99215, 99223, 99232-99233). The new pricing went into effect on March 13 and is retroactive to January 1. Blue Cross is in the process of reprocessing the affected claims.


Physicians who are on the standard Prudent Buyer fee schedule can review the new pricing on the Blue Cross website through Provider Access (login, then select “Mental Health Practitioner Fee Schedule Update”). Physicians who have non-standard contracts with Blue Cross received a copy of the new pricing as “Exhibit B,” which was enclosed with the Blue Cross notice.


Blue Cross expects to complete the reprocessing of affected claims between May and June. The payor has assured CMA that interest would be paid automatically as required by law.


While physicians do not need to resubmit claims in order to receive the additional money due, CMA encourages physicians to create an internal list of all affected claims to ensure they are eventually paid correctly.


Physicians with questions can contact Blue Cross Network Relations at (855) 238-0095 or networkrelations@wellpoint.com.


Questions: CMA’s reimbursement helpline (888) 401-5911 or economicservices@cmadocs.org.

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