NYSPA/APA Successful in Reversing Improper Denials of Claims Submitted To UBH/Optum

NYSPA was recently contacted by two members who had been receiving improper denials from United Behavioral Health/Optum for claims for the new combination psychotherapy CPT codes (e.g., 99212+90836), Optum was refusing to provide reimbursement for the psychotherapy add-on code because the provider had failed to document start and stop times for the psychotherapy portion of the session alone (as opposed to the E/M portion). This practice, clearly in violation of CPT, was being applied to both in-network and out-of-network benefits. 

When discussions with Optum provider relations representatives proved fruitless, NYSPA contacted the APA for assistance.  The APA in turn contacted Deb Adler, Senior Vice President for Network Services at UBH/Optum, to address our concerns.   As a result of conversations with Ms. Adler, the APA was able to confirm the following: 

1.  Recording of Time – UBH/Optum has acknowledged that the new combination psychotherapy codes represent the provision of a single integrated service that cannot and should not be separated out.   As a result, UBH/Optum will discontinue its requirement that psychiatrists record the time spent providing psychotherapy alone.  If any member has had claims denied for this reason, these claims should be appealed or sent back for re-processing.   Please note, however, that proper documentation of psychotherapy must include session start and stop times and/or the total face-to-face time spent with the patient.

2.  Counseling and Coordination of Care – Optum recently sent a letter to all participating providers confirming guidelines for documentation of E/M services.  (A copy of this letter may be downloaded here).  However, in its letter, Optum failed to recognize the documentation approach based on time when counseling and/or coordination or care represent more than 50% of face-to-face time with the patient.  Optum has agreed to amend the provider letter to include this alternative method of documenting E/M services, in addition to documentation based on the elements (e.g., history, exam or medical decision making).   Please note that the time-based documentation approach may not be utilized in connection with the new combination psychotherapy codes. 

3.  The Optum letter also reminded providers that it plans to commence audits of the new combination psychotherapy codes as of December 1, 2013.   However, as a result of discussions with APA staff, Optum has agreed to work internally to encourage the removal of the name and title of Amanda North, Director of the Special Investigations Unit, from future provider letters of this nature.   Optum intended the letter to be educational in nature and did not intend to imply that fraudulent activity was suspected.   

We would like to thank the members who brought this concerning situation to our attention so that we were able to advocate on behalf of our entire membership to ensure proper processing and reimbursement of all CPT codes submitted by psychiatrists. 

Please contact NYSPA Central Office if you or your patients continue to receive improper denials for psychotherapy and/or E/M services submitted to UBH/Optum.