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Michelle Posted 3 month(s) ago
My question is in regards to correct billing of cpt code 96103 for a Psychiatrist (MD) provider. Could you bill 96103 as a stand-alone code and will insurances process and pay the claims without a visit? Normally provider sees patient and codes a visit and 96103. Can he bill 2 weeks later just a 96103, 2 weeks after that just a 96103 and 2 weeks later a visit and 96103? Is there a statute of limitations on the amount of times a psych provider can perform this code 96103? Our main objective is to find out if there is an amount of times a provider can bill a 96103 without sending a red flag while reducing the amount of visits billed to the insurance but, not reducing the amount of care a patient receives. In other words, 96103 provides a method for a doctor to remotely monitor a patient and see them as needed instead of routine follow ups that are unnecessary. Seems like it can be billed independent of an office visit and the ideal frequency is 2-4x monthly. However we know of no precedent for this and need insight on whether there will be any issues with billing it this often.
SuperCoder Posted 3 month(s) ago

Hi,

Here are some billing guidelines for CPT code 96103 :

a. CPT code 96103 describes tests administered by a computer and the interpretation and report performed by a qualified health care professional.

b. Billed one service regardless of the number of tests taken by the patient

c. The provider who interprets the report must be available during the time the patient is taking the test.

d. The interpretation of the test is included in the codes and is not separately billable. e. These codes may not be billed for scoring of tests.

Hence, the provider should be present and the test cannot be completed without the visit.

Additionally, insurance companies pay for this service, but there are some potential variations depending on the insurance company and their specific plan requirements. The details of coverage and requirements can usually be found in each insurance plan’s Local Coverage Determination (LCD).  It is advisable to research and review the LCD for each of their participating insurance plans so that their requirements can be built into your clinic’s processes.

  • In many cases, the test is not required to be repeated, but it can be repeated at some frequency, sometimes depending on clinical changes with the patient.  These tests may be repeated if the patient is considered a higher risk.  For example, an opioid abuser could be given assessments quarterly or even with each monthly visit to get their medications refilled.  

 

Michelle Posted 3 month(s) ago
My provider is asking for proof that this can not be billed as a stand alone code? Can you send me the guidelines you are finding this in? Thank you.
Michelle Posted 3 month(s) ago
Is it causing a red flag if provider is billing this code at each session with a visit code for the patient? This could be at times 4 to 6 times a year.
SuperCoder Posted 3 month(s) ago

 

 

Hi Michelle,

There is no guideline regarding the billing of CPT code 96103 by CMS. the only criteria stated is that sometimes depending on clinical changes with the patient.

Also, the neuropsychological evaluation requires 4-8 hours to perform, including administration, scoring, interpretation, report writing and interpretation to the patient and/or family. If the evaluation is performed over several days, the time should be combined and reported all on the last day of service. The red flag or the reimbursement limit is entirely payer specific.

In addition, when the code is billed by a hospital-based practice, there is no additional code that the hospital can bill unless a significant and separately identifiable E/M service was also done, in which case it could be billed in addition to 96103, although modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) would need to be appended to the E/M code to override the CCI edit that otherwise bundles the two services.

Hope this helps!

 

Michelle Posted 3 month(s) ago
When you are in the coding tools does it specifically show in the edits that 96103 can only be billed with an e/m code? My provider is asking why he can not bill in an office setting via computer 96103 only.
SuperCoder Posted 3 month(s) ago

Hi,

The directive to use E/M code will only be applicable when spearately identifiable evaluation and management is done. However, the use of CPT code 96103 can be done in facility and non-facility both as per the place at which the test is performed.

Michelle Posted 1 month(s) ago
Thank you for all your help. Do you know anything specific regarding Aetna coding rules for 96103? Aetna states auth is needed for 96103 so provider is nervous there are specific coding rules for payer. Provider is asking if there is a tool that can track the needed authorizations for Aetna insurance for the 96103. Thank you.
SuperCoder Posted 1 month(s) ago

Hi Michelle,

Kindly consider the following link :

http://www.aetna.com/cpb/medical/data/100_199/0158.html

Hope the above link helps!

Further query is welcome.

 

Posted by Michelle, 3 month(s). There are 9 posts. The latest reply is from SuperCoder.

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