Tele Health Neuropsychologist evaluation

[GretchenC123]

Hello, I am auditing a medical record and the neuropsychologist billed $2,250.00 for a 96116 (did not use the modifier 95 even though the evaluation took place via video). When I do a search for the UCR reimbursement, the amount is $198.11 for November of 2021. I use Find-a-code for my UCR numbers. How can these numbers be so far apart? Any thoughts? The outpatient facility UCR is closer to $2,000.00 but I am assuming that is for patients who go to a neurobehavior outpatient clinic.

 

[CBLENNIE]

According to Encoder Pro for Montana the Medicare allowance for non-facility services is $97.00 for November 2021. Did the provider bill multiple units by chance even though this code is for the first hour of testing and each additional 30 minutes should be billed with 96113, which has a non-facility allowance of $58.62 per unit with the MUE units allowed per DOS of 6.

Providers are free to charge as much as the market will bear if they are non-contracting; so, if patients or the responsible party is willing to pay $2250.00 for 1 hour of 96116, assuming they billed just 1 unit, then that is what the provider can charge.

 

[GretchenC123]

This was in Colorado, and no, there were no units listed. Because this is a personal injury case and the patient is represented by an attorney, the providers usually bill extremely high. When I called the place of service they said that their evaluations can run up to 8k for one day and I bet they don't contract with insurance companies. They do this stuff for "forensic" cases. Thank you for the information.