Wiki Group Psychotherapy Visits

[GSCoder07]

I work for a facility that frequently bills multiple, separate psychotherapy group visits per day for the same individual. For example, the patient attends a group visit at 10 am and will return later in the day for another meeting. Sometimes it's with the same facilitator and sometimes it's with a different facilitator. Medicare is paying the first visit but is denying the subsequent visit(s). We tried billing with modifiers -76, -77 & -XE but they keep denying the claims. We appealed some of the denials and the appeals were denied as well.
Is anyone else having this issue? If so, how are you handling it?

I appreciate the feedback!

 

[CBLENNIE]

If you are billing 90853 your problem is that the MUE units for this code is 1 per DOS for professional claims and 4 units per DOS for OP Hospital claims, and I believe based on my experience with FQHC claims for Medicare these are considered physician services, so you are limited to 1 unit of 90853 per DOS. So, the claims are going to automatically deny anything over 1 unit per DOS.

But there is hope of getting additional services paid based on the MUE Adjudication Indicator (MAI) assigned to this code. This code has an MAI of 3, which means it is a units per date of service edit. MLN Matters MM8853 with proper documentation of the medical necessity for the number of units you have billed you may be able to be reimbursed for more than 1 unit per DOS. It is quite difficult to win these appeals so I would strongly recommend you review this MLN Matters document paying particular attention to pages 2 & 3 which explain about an MAI 3 and what the workflow is for processing these claims by the MACs.

You may have to have your providers step up their documentation of these services in order to support the medical necessity of more than 1 unit of 90853 but it may be worth it depending on how much revenue you are losing to these denials.