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Coding, Billing, Claims And Reimbursement Issues
How will MFTs and counselors know which codes are reimbursable and the amounts they can bill for when they treat Medicare clients?
The Medicare Physician Fee Schedule will not provide detailed information on coding and reimbursement amounts. To get an idea on what codes are generally accepted by Medicare please see the link below on page 22-25.
https://www.cms.gov/files/document/mln1986542-medicare-mental-health.pdf
At what rate will MFTs and counselors be reimbursed?
With respect to marriage and family therapist services and mental health counselor services, the amounts paid shall be 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for payment of a psychologist.
How will co-insurance be applied?
Because Medicare Part B covers physician and other practitioner services, a beneficiary’s $236 deductible for Part B in 2023 applies before most coverage begins. If your doctor accepts assignment, then beneficiary generally pays 20 percent of the Medicare-approved amount for the service, called coinsurance, after you’ve paid the annual deductible.
All providers who accept assignment must submit claims directly to Medicare, which pays 80 percent of the approved cost for the service and providers can bill the beneficiary the remaining 20 percent.
In addition to MFTs and counselors directly billing Medicare for services provided to older clients in their private practices, will there be other opportunities for counselors to participate and receive reimbursement in other settings?
Yes. MFTs and Counselors are now eligible Medicare Part B providers in Federally Qualified Health Centers (FQHCs). FQHCs are safety net providers that primarily provide services typically furnished in an outpatient clinic. FQHCs provide comprehensive services including preventive health services and mental health and substance abuse services. Counselors also are now eligible Medicare Part B providers in Rural Health Clinics (RHCs). The Rural Health Clinic (RHC) program increases access to primary care services for patients in rural communities. RHCs are required to provide outpatient primary care services such as behavioral health care. As part of the Mental Health Access Improvement Act counselors are now required team members for Medicare hospice interdisciplinary teams. The hospice interdisciplinary team includes physicians, nurses, mental health providers, chaplains, and trained volunteers who work together to address a hospice patient’s physical, emotional, and spiritual needs.
How should a provider submit Medicare claims if they have more than one license (e.g., if a psychologist is also a LPMHC or LPMFT would Medicare reimburse them based on the psychologist rate or the LPMHC or the LPMFT rate?
This question will be addressed in the 2024 Medicare Physician Fee Schedule Final Rule, but it is likely that if the practitioner has already been billing Medicare as a Psychologist, he/she will continue to bill as that provider designation. The MPFS will include several provisions on enrollment, coding and billing issues that go into effect on January 1, 2024 for MFTs and counselors.
Are pre-licensed MFTs and counselors under appropriate supervision eligible to provide services and seek reimbursement? If yes, what are the requirements?
No.
What is the time frame for Medicare to process claims?
For clean claims that are submitted electronically, they are generally paid within 14 calendar days by Medicare.
Are providers required to submit electronic claims?
The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be sent electronically unless a provider qualifies for an exception waiver.
