1 Way to Increase Your Revenue
Earlier this week, Practice Solutions and Blueprint teamed up and presented a webinar on the benefits of measurement-based care and how you can use measurement-based care to increase your revenue in private practice. This blog is meant to inform you about how you can use measurement-based care to the benefit of your practice, your clients and your bottom line.
First, we need to understand that our mental healthcare system is faulty. In the current system of mental healthcare treatment, most clients with depression fail to reach remission after five months of treatment, and in most cases providers lack the data to learn from these failures, so we are unable to improve client outcomes over time.
According to a recent study mental and behavioral disorders cost the United States an estimated $210.5 billion per year. In fact, depression is one of the reasons for truancy in the workplace. There is a way to make data-driven decisions and increase your revenue in private practice.
With measurement-based care, everybody wins!
What is measurement-based care?
Measurement-based care is the practice of basing clinical care on patient data collected through treatment.
With measurement-based care, clients, providers, and payers all benefit.
Clients benefit because they can achieve better therapeutic outcomes quickly, improve their self-awareness, and they receive personalized care. Measurement-based care provides the same level of benefit that any fitness tracker does. It allows the client to have full visibility into their treatment at all times. The Blueprint platform as well as others enable this capability!
Providers benefit from measurement-based care because they can make precise therapeutic interventions based on the data, they can increase their revenue and rates, and they can become more effective in their clinical work.
The insurance companies benefit because measurement-based care lowers the cost of care, through better outcomes their members are more satisfied, and they can allow for outcomes-based bonuses and incentives.
In fact, to incentivize measurement-based care, payers created, unbundled, and adopted new billing codes starting in 2016.
The list of payers that has taken this stance on measurement-based care includes:
Aetna
Anthem
Blue Cross Blue Shield of Illinois
Blue Cross Blue Shield of North Carolina
Beacon
Carefirst
Caresource
Cigna
CMS
Horizon BCBS
Kaiser Permanente
Magellan
Medical Mutual
Medicare
Moda
Molina Healthcare
Pacific Source
Paramount
Regence BCBS
Trillium Health
Triwest
United Healthcare
Wellcare
Humana
Wellmark BCBS
And many more than these!
Not only does measurement make clinical sense, it also makes financial sense for payers.
Measurement-based care been widely proven to improve clinical outcomes (Fortney et al., 2017) and can also reduce the cost of care (The Kennedy Forum, 2015).
Payers can save $1000s of dollars per year for each patient that receives measurement based care as opposed to “treatment as usual.”
Reimbursing providers $10 for each administered measure is like investing a penny to earn a dollar. Not only does measurement-based care make clinical sense, it also makes financial sense.
What CPT Code(s) can I use to bill for measurement?
There are a number of CPT codes that you may qualify for if you’re practicing measurement-based care.
CPT 96127: Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder scale), with scoring and documentation, per standardized instrument.
CPT 96136: Psychological test administration and scoring by physician or other qualified healthcare professional, two or more tests, any method.
CPT 96138: Psychological test administration and scoring by technician, two or more tests, any method
CPT 98970: Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes
CPT 99484: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified healthcare professional time, per calendar month, with the following required elements: (a) Initial assessment or follow-up monitoring, including the use of applicable validated rating scales; (b) Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes (c) Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation (d) Continuity of care with a designated member of the care team
General CPT coding guidelines
There is a TON of variation with these codes across states, plans, provider types, and more. For the majority of providers, we recommend the following baseline guidelines:
1 outcome measure completed on a given date of service: CPT 96127
2 or more outcome measures completed on the same date of service: CPT 96136 or 96138, depending on provider type, state, plan guidelines.
Psychological test definition difference from a clinical vs billing perspective is not prescriptive but rather descriptive. From a billing perspective you don’t have to administer an MMPI to do psychological testing.
Each plan has its own edits, coverage guidelines, limitations, and more. To reduce trial-and-error, check your fee schedules (2019 or later) and/or consult with your network representative to understand what is covered in your contract and any plan-specific guidelines or limitations that may be in place.
Blueprint and Practice Solutions can help! Collectively, we’ve helped practices submit over 30K measurement-related claims.
Common CPT coding questions
What should the date of service be? If you’re billing CPT 96127, 96136, or 96138, the date of service should be the day the measure was administered. This can be the same day as an existing appointment or a different day.
Should this be submitted as an add-on code? Do I need any special modifiers? Usually not. These are standalone codes that can be submitted as a new line-item on an existing claim and/or on their own claim. Sometimes, plans will also accept them as an add-on code but the CPT Coding Manual does not list the codes above as “add-ons.”
Is there patient responsibility on these services? Just like all other services or CPT codes, it depends. Some insurance plans treat these as preventative services so there is no patient responsibility. Other plans may include a small copay or coinsurance along with a payment. And others put 100% of the cost on patients. At Blueprint, across all claims we’ve helped submit, only about 20% of the total allowable is deemed “patient responsibility.” The rest is paid by insurance.
How much should I expect to earn for these codes? Again, it depends. On average, across all codes, provider types, states, and plans, we see an average of $10 per measure. Generally, CPT 96136 and 96138 will pay more than 96127, but at least two measures are required and occasionally these codes are only covered for psychologists and physicians.
What if this code is not on my fee schedule? Often times, managed care and government payers cover this code, but if you are credentialed with a commercial insurance and you don’t see these codes on your fee schedule then you will want to contact the insurance company and see if these are covered.
Case Study – What does $10 per outcome measure look like at scale?
Clinic XYZ
Based in Washington D.C. Metropolitan Area. Staff consists of two psychologists, 12 LCSWs
300 patients completing 4 outcome measures per month (e.g. 2 measures bi-weekly)
Clinic is in-network with CareFirst BCBS and Aetna and has contracted coverage for CPT 96127, 96136, and 96138.
CareFirst BCBS Blended Average Allowable amount is $12.49 per measure
Aetna Blended Average Allowable amount is $6.18 per measure
Approximately 80% of patients have CareFirst BCBS insurance, 20% have Aetna insurance
300 patients
x 4 outcome measures per month
x $10.92 reimbursed per measure
x 12 months
= $157,248 in new annual reimbursement revenue
If you’re interested in learning more about MBC or want to see a demo of how Blueprint and/or Practice Solutions can help you implement MBC and start maximizing insurance revenue, please reach out!
