Tag Archives: Medicare codes

Psychology has a Hero!

Pro Photo of Amy Rosett (2)      

Our hero’s name is Dr. Amy Rosett, a California psychologist who challenged CMS and won!

This is her story:   In 2014, Amy participated in PQRS, reporting measures via claims. While CMS required providers to report 9 measures to receive a bonus, Amy was only able to report 8 measures because there were a limited number of measures pertinent to psychology and her geropsychology practice that can be reported via claims.   Her reporting rate was 100% for each of the 8 measures she reported. She went through the MAV (Measure applicability process: CMS computerized process which attempts to fairly evaluate providers who do not have 9 available measures to report) . The MAV indicated that Amy did not meet 2014 PQRS bonus requirements because she should have used measure # 46 and #317.     Measure #46 (Medication reconciliation post-discharge) requires the provider to review a recent inpatient medication list and correct any discrepancies between the inpatient and outpatient medication list  (To fully reconcile errors, the provider must have the capacity to prescribe, adjust dosages or discontinue a medication).  Measure #317 (screening for high blood pressure) requires providers to measure blood pressure during a session and counsel patients about abnormal blood pressure readings.  While our initial assessment and psychotherapy CPT codes are connected to these measures, most psychologists agree (informal survey, Bischmann 2016) that the quality actions (taking a blood pressure and reconciling medications) required by these measures are not within most psychologist’s scope of practice.

Amy reached out to Diane Pedulla, JD, APAPO (APA provider organization) who specializes in Medicare.  Amy wondered if other psychologists were denied by the MAV review because they hadn’t used  the blood pressure and medication reconciliation measure.  There was little information regarding the experiences psychologists were having with PQRS and the MAV. Mostly, we heard that many psychologists were frustrated with PQRS and had given up on it. Diane helped Amy write an “informal review and submit it to the quality net help desk (qnetsupport@hcqis.org).

Per CMS protocol, the “informal review”  is a formal way to appeal the MAV results.   In her review, Amy aptly pointed out that most psychologists are not trained to measure blood pressure and this is outside our scope of practice.  She also pointed out that the medication reconciliation measure states the measure is to be performed by “physician, prescribing practitioner, registered nurse, or clinical pharmacist.” Psychologists are not included in the list nor do we have the prescribing capacity to correct a medication list.

Unfortunately, Amy’s informal review supported the original MAV results: CMS expected Amy to have performed the blood pressure and medication reconciliation measure.   Amy wasn’t willing to accept this.  With Diane Pedulla’s assistance, a request was made via APA for CMS to review the outcome of Amy’s informal review.  CMS reviewed the outcome and agreed that Amy’s informal review came to the wrong conclusion.  Amy won!

CMS is a large governmental organization. Various departments administer different portions of the PQRS, MAV and provider feedback process.  Amy’s initial denial via the MAV was an unintended consequence.  The issue is that providers such as nurses and others use the CPT codes psychologist’s use.  While it is appropriate for psychiatric nurse practitioners to measure blood pressure and complete a medication reconciliation, it is not typical for psychologists to perform these actions.   Through Amy’s determination, CMS recognized a flaw in the MAV system and they are working on correcting it.

CMS is asking that psychologists send examples (e.g. screen shots, copies etc) of reports they get via MAV so that CMS  can continue to correct any errors and make PQRS work as it was intended.  You might wonder why CMS cannot review information internally to identify errors. Apparently, the people who approve the measures and set up the formula’s for the MAV do not have access to the reports that providers receive.

APA asks that you send examples to pracgovt@apa.org.  You can also send things to me and I will make sure it gets to APA.


Written by:  Dori Ann Bischmann, PhD

WPA liaison to Medicare

Advocacy Cabinet


AMA (2015).  Measure #46 (NQF 0097): Medication Reconciliation Post-Discharge-National Quality Strategy Domain:  Communication and Care Coordination.

AMA (2015). Measure #317: Preventive Care and Screening:  Screening for High Blood Pressure and Follow-Up Documented-National Quality Strategy Domain: Community/Population Health.

APAPO (winter 2016).  Participating Successfully in the Medicare PQRS Program:  What to know and do for the 2015 and 2016 reporting years.  Good Practice:  Tools and information for Professional Psychologists, 12-15.

Rosett, A. (2015/2016) personal communications regarding PQRS.  California. http://www.dramyrosett.com.

QualityNet Help Desk (1-866-288-8912, qnetsupport@hcqis.org).




Its a New Year for PQRS: Are You Ready? Updated Addendum.

The dawn of a new year should be your reminder to update your PQRS (Physician Quality Reporting System) measures. Each year, some measures are retired and new measures are introduced.  This year psychologists don’t necessarily have more measures to use, but we do have more reporting options.

APA has partnered with Healthmonix, a registry company, to provide a registry specifically  for psychologists.  The registry is available at http://apapo.pqrs.com.  I used the registry this year and I will share my experiences later in this post.

PQRS Basics for 2015:  There are 6 different ways to report PQRS data.  Most psychologists have two reporting methods available:  Claims-based and registry.  Some psychologists, particularly if employed by large systems, may be able to report via GPRO (a registry based reporting system for group practices) and EHR (directly through electronic heath records).

Claims-based reporting remains the most popular way for providers to report, according to CMS.  Nevertheless, CMS plans to phase out Claims reporting (federal register, 11/13/14) and thus they retired more claims-based measures this year.  There are 6 measures psychologists can report via claims:

#128 body mass index,

#130 documentation and verification of current medications in the medical record,

#131 pain assessment prior to initiation of patient treatment,

#134 screening for clinical depression,

#181 elder maltreatment screen and follow-up plan

#226 preventive care and screening:  tobacco use-screening and cessation intervention.

SEE ADDENDUM below for an additional measure.

CMS is encouraging providers to use registry reporting (or EHR), although no definitive end-date has been established for claims reporting.  Claims-based measures available to psychologists are also available via registry. There are 4 measures only reportable via registry:

#173 unhealthy alcohol use,

#325 adult major depressive disorder (MDD):  coordination of care of patients with specific comorbid conditions,

#383 adherence to antipsychotic medications for individuals with schizophrenia

#391 follow-up after hospitalization for mental illness.

Note that APA also included # 9 major depressive disorder: antidepressant medication during acute phase, but this is an error.  Measure #9 is only available via EHR reporting.  There is also a Measure Group on Dementia available via registry.

Participate in PQRS during 2015 to avoid a 2% payment adjustment (AKA cut, penalty) to your Medicare reimbursement in 2017.  CMS requires that providers report 9 measures covering 3 NQS (national quality strategy domains) on 50% of all FFS (fee for service) Medicare beneficiaries.  PQRS does not apply to Medicare replacement plans.  According to CMS, a provider who see’s at least one FFS Medicare beneficiary, must report at least 1 cross-cutting measure.  A cross-cutting measure is a measure that is reportable via most, if not all, reporting methods.  Several of the claims-based measures are on the cross-cutting measures list.

If a provider does not have 9 available measures (as is the case for psychologists using claims-based reporting), he/she should use as many measures as possible (6 for psychologists reporting via claims).  The reporting will be subject to MAV (measure-applicability validation), which is a system that CMS uses to determine if the provider used all available measures.  If the MAV determines that the provider fulfilled his/her obligation, the provider will get credit for successfully reporting PQRS data and avoid the 2% payment adjustment.

The Measures Group on Dementia is only available via registry.  A “measures group” includes a number of related measures that must be completed on each patient.  CMS requires that measure groups be reported on at least 20 patients, the majority of which need to be FFS Medicare Part B beneficiaries.  When reporting measures groups, you can report data from Medicare replacement plans.

I am pleased that APA set up a registry for psychologists, especially since CMS plans to phase out claims-based reporting.  I found the registry easy to navigate and it provided good feedback about duplicate reports and if I met CMS criteria.  I was able to continue to enter data over time, verify that I met criteria, and then submit to the registry.  Healthmonix staff were helpful in answering specific questions during the process.

A draw back of registry reporting is that it costs $198 per provider per year, at this time.  It is also time-consuming, especially if you wait until the end of the year to submit your data, as I did this year (I was submitting 2014 data via claims for most of the year, but then decided to use the registry).  I had 68 unique FFS Medicare patients encompassing 233 sessions (I entered 100% of my patients, not the 50% that is required by CMS). It took me approximately 11 hours to enter data, but once I was done, I knew that I met CMS criteria and avoided the payment readjustment in 2016 (performance in 2014 impacts payment in 2016).  I chose to enter 100% of my FFS Medicare Patients knowing that I was not 100% compliant on completing measure #130 (verifying medications in the medical record) which requires a review at every session.  Hospitalized patients are easy because the med list is updated daily in the medical record.  Outpatients and home visit patients aren’t as easy.  Patients may not know the names or dosages of medications, but quite frankly, I didn’t feel it was appropriate to discuss medications at every session with every client.

Other benefits of registry reporting include: being prepared when claims reporting is eliminated, provider has complete control over the data reported to CMS, there is no patient identifying data attached to data, increased likelihood of successfully meeting CMS criteria (99%), and participating in the learning curve of quality reporting.

Quality reporting, in one shape or form, is here to stay.  Eventually, all providers will be required to participate whether Medicare providers or not  The data will serve as a way to measure the quality of services relative to similar providers.  Information from quality reporting and other sources will provide a score for each of us.  It is projected that payers and other entities will use the score to make decisions about us, such as what fee to pay us, whether to let us in a provider panel etc.  That’s right, the score we achieve will determine our fee.  Those with higher scores will be paid at higher levels; those with lower scores will be paid less for the same service.  Not participating in quality reporting will lower your score.  CMS and others are looking at ways to measure quality of care with respect to clinical outcomes, financial outcomes, patient satisfaction, population outcomes and many other variables.

Since this is your forum, it is your place to ask questions.  I make every effort to check and double-check what I report to make sure it is accurate, but I am human and there are heaps of documents to sort through.  Please always check with the original sources before implementing specific measures into your practice.  If you see any errors in my posts, please let me know publicly through the blog.  This way we alert others of a potential error and I can correct it quickly.

ADDENDUM.  updated 2/13/15.  Due to the sharp eyes and mind of one of our fellow psychologists Jeremy Katz), it appears that there is another measure that is potentially available to psychologists who report via claims or registry. 

Measure #317:  Preventive care and screening:  screening for high blood pressure and follow-up.   





Federal Register/ Vol.79, No. 219/Thursday, November 13, 2014/Rules and Regulations


Blog author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

Medicare 2014 Physician Fee Rates for Select Codes in Wisconsin

Select 2014 Wisconsin Medicare fee rates as of January, 1, 2014 are as follows:

90791:   $131.28        (In facility: $127.17)  Initial evaluation

90832:   $63.51           (In facility: $62.82)   Psychotherapy 30 minutes

90834:  $84.22            (In facility: $83.88)    Psychotherapy 45 minutes

90837: $126.14           (in facility: $125.45)  Psychotherapy 60 minutes

96101: $79.35              (in facility: $78.67)   Psychological assessment per hour

96118: $96.85              (in facility: $78.32)  Neuropsychological assessment per hour

96150: $21.20              (in facility: $20.86)    H&B initial evaluation per 15 minute unit

96152:  $19.42             (in facility: $19.08)    H&B individual psychotherapy per 15 minute unit

90785: $14.08               interactive complexity add-on

90839: $131.82             (in facility: $130.79)  Psychotherapy for crises, first 60 minutes

These are the most recent published rates which account for the 3 month postponement of the SGR cut with the slight .5% increase in fees.

The Advocacy Cabinet

(Post Author:  Dori Ann Bischmann, PhD)


Hartman-Stein, P. (2014).  Government health care changes have wins, losses for psychology.  The National Psychologist, 23(1), 6-7.

National Government Service:  http://www.ngsmedicare.com/ngs/portal/ngs medicare/fee schedules downloads part b.


PQRS Requirements for 2014

Despite recommendations to the contrary by many provider associations, CMS (12/13/13) made major changes to PQRS reporting starting in 2014.   Most PQRS eligible providers (EPs) will be required to report 9 PQRS measures covering at least 3 National Quality Strategy Domains (NQS).  There are a variety of ways to report measures, but I will only address claims based reporting because this is the only mechanism currently available to psychologists.  Note that CMS would like to move all EPs in the direction of registry reporting, but according to APA, there are currently no registries available to psychologists.  NQS domains are categories that CMS determined to be important in meeting the overall goal of improved medical services and outcomes.  The NQS domains are:  patient safety, person and caregiver centered experience and outcome, communication and care coordination, effective clinical care, community/population health, efficiency and cost reduction.

To avoid a 2% penalty in 2016 AND achieve a .5% incentive payment in 2015

  • In 2014, report 9 measures covering at least 3 NQS domains on 50% of eligible fee for service (FFS) Medicare recipients (Medicare advantage plans are excluded).

To avoid a 2% penalty in 2016

  •  In 2014, report at least 3 measures covering at least 1 NQS domain.

Medicare does provide a provision for those providers who have fewer than 9 available measures.  It is my opinion, that Medicare does not adequately spell out how they will distinguish EPs who are reporting less than 9 measures because of lack of availability versus those EPs who just don’t submit enough measures for one reason or another.

I have reviewed the measures list for 2014 and have found the following measures to be appropriate for psychologists.  My criteria included:  clinical procedures that we are trained to provide and claims based reporting.   I have grouped these measures by the NQS domain:

Effective Clinical Care

#106 Adult Major Depressive Disorder (MDD): comprehensive Depression Evaluation:  Diagnosis and Severity.

#107 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

#247 Substance Use Disorders:  Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence

#248   Substance Use Disorders:  Screening for Depression Among Patients with Substance Abuse or Dependence

Patient Safety

#130 Documentation of Current Medications in the Medical Record

#181 Elder Maltreatment Screen and Follow-Up Plan

Community/Population Health

#131 Pain Assessment and Follow-Up

#134 Preventive Care and Screening:  Screening for Clinical Depression and Follow-Up Plan

#226 Preventive Care and Screening:  Tobacco Use:  Screening and Cessation Intervention

In summary, we have 9 measures appropriate for our discipline that cover 3 NQS domains.  There were a couple other measures that might be appropriate for specialized practices with Asthma and weight control.
Additional information to be aware of:

1.  If you don’t report on a particular measure during the year because you didn’t have an appropriate patient to report on, this measure will not be counted toward your goal of reporting 9 measures over 3 NQS domains.  For example, if none of your Medicare patients are over the age of 65, you are not eligible to screen for Elder Maltreatment and thus can not report this measure.  Likewise if you have no Medicare patients who have alcohol dependence, you would not be able to use the Substance Use disorders measures.

2.  Psychologists are currently not eligible to report measures via registry (we have no registry), Electronic Health Record (EHR: we are not eligible for EHR meaningful use at this time) or measures groups (changes were made in how measures groups are reported this year).

3.Please make sure your biller uses a charge of “$.01” rather than “$.00” when listing the PQRS measure.  As of 4/14, Medicare will treat these differently and they are encouraging all EPs to use “$.01” charge.

I will continue to research this information and bring you updates as I become aware of them.

Advocacy Cabinet

(Post Author:  Dori Ann Bischmann, PhD)


CMS (12/13/13).  2014 physician quality reporting system (PQRS) implementation guide.

CMS (12/13/13). 2014 Physician quality reporting system (PQRS) measures list.

Rosett, Amy (1/3/14).  2014 PQRS Reporting Summary.  Personal communication.

Teaser for New Information to Come Soon

There are so many changes in Healthcare that it has been difficult to keep up!   Starting in January, I will to go through the changes in more depth, but for now here is a summary:

1.  Wisconsin is expected to delay the cancellation of Badger care and HRSP (the WI high risk insurance sharing plan) to March so people can avoid coverage gaps while ACA (Affordable Care Act, e.g. Obamacare) website is fixed.

2.  As of January 1, 2014, Medicare payments for mental health services are on full parity with Medical services.  Medicare pays 80% for all services. Thus there is a 20% copay for all services.

3.  Most psychotherapy codes will have a small increase in Medicare reimbursement due to changes in the work value formula.  90832 does not increase and 90791 is expected to decrease by 15% (national average).

4.  SGR cut is delayed for three months to allow congress more time to figure out an alternative.

5.  No news yet on whether recent budget will impact the expected 2% sequestration cut to physician fees.

6.  The healthcare exchange website, Healthcare.gov, is working better and more people have been able to sign up for insurance policies through the website (including me, yippie!), but there are still technical problems to be worked out.

7.  Dean care insurance will be/is expanding its coverage area east into Waukesha County.  Dean does offer insurance plans on the Healthcare exchange for Waukesha Co residents, but in my opinion they don’t yet have enough providers east of Oconomowoc.

8.  Medicare is changing the rules regarding PQRS.  It is expected that completing 9 PQRS measures on 80% of your Medicare patients will be required for 2014 to avoid penalty in 2016.  Some PQRS claims based measures (what psychologists use) may be retired.  New ways to measure services, such as “value” are being proposed for the next couple of years.

9.  It appears that reporting PQRS measures via a registry is valued above reporting via claims based reporting.  APA is discussing the feasibility of developing a registry for psychologists.  It is my read that in the next couple of years psychologists will not be able to participate in PQRS (but will be able to incur penalties) if we are unable to report via Registry.

10.  The “Physician Compare” website is up and running.  This website will provide data on all physicians (including psychologists) and is available to the public (and insurance companies).  The website is put together by Medicare, but it is a requirement of the ACA.  The only interesting data I see on my listing so far is that I participate in PQRS.  Eventually, the ACA’s goal is to include ratings and other information that will allow the public to determine how an individual physician compares to others in his/her discipline.  Imagine what an insurance company might use this information for…..just saying.

11.  Healthcare changes are occurring rapidly.  These are changes you must know or you will potentially suffer penalties, be left out of insurance panels or other undesired things.  Please, please, please be a member of  your respective provider associations.  It is their job to sort through the volumes of government information and bring the must know info to you. It is impossible to keep up with the changes independently and you can’t afford to wait for pertinent info to trickle down through the grapevine. The changes are occurring too rapidly and they are often quite complex.

12.  While most of these changes start within the Medicare program, they will be applied to all programs in one way or another.  With the ACA, what was once restricted to Medicare, will eventually apply to all insurance plans.

13.  Details to come in January when written policies are available for review.

The WPA Advocacy Cabinet

(post author:  Dori Ann Bischmann, PhD)

Another Medicare Payment Cut?

You may have noticed a small cut to your Medicare reimbursement starting this past August.  According to Paula Hartman-Stein (2013), Medicare payments to psychologists were cut, on average, by 2 percent.

James Georgoulakis, PhD, the psychology representative to the Relative Update Committee (RUC) of the American Medical Association (AMA) told Dr. Hartmann-Stein via telephone interview that the practice expenses for psychologists were calculated incorrectly.  As of January, 2013, psychologists should have been paid, on average, 2% less than the actual fees paid.  The mistake was identified and the reduction started in August.   Medicare reportedly has a number of options to address the over payments made to psychologists between January and August, but no specific plan has been identified.  It is possible that psychologists will be asked to pay the over payments back to Medicare.

Dr. Hartmann-Stein (pg 1, 2013) quoted Dr. Georgoulakis, “the correction shows psychology has an increase of work values of plus 1 percent but a decrease of minus 3 percent in our practice expense, resulting in the combined impact of minus 2 percent.  What is interesting is that psychiatry got a decrease in their overall work values (minus 1 percent) but an increase in practice expense (plus 3 percent), making their impact a plus 2 percent increase in payment for psychiatric services overall.”

Note that “work values” include effort in completing the work.  Effort includes technical skill, physical and mental effort, judgement and stress associated with risk to patient’s involved in performing psychological services.  “Practice expense” includes the costs of performing the service such as cost of office space, secretarial services and tools used such as computers, medical equipment etc.   It has been suggested that psychiatry’s practice expense is higher because they employ nurses, secretaries and others to perform various services whereas psychologist’s work very frugally.  I’d like to point out, that since psychologist’s “work values” were increased, it is clearly acknowledged that psychologist’s technical skill, mental effort, judgement etc. are an important and valued aspect of our work.

The 2 percent reduction is an average.  Psychological services that have a higher practice expense (neuropsychology) may experience more reduction than psychological services that have lower practice expense, but higher work values (psychotherapy).

In November 2014, CMS will publish the final rule for reimbursements in 2014.  We will keep you posted.


Hartman-Stein, P.E. (2013) Medicare payments to psychologists  suddenly reduced.  The National Psychologist, 22(5), pgs 1, 3.

The WPA Advocacy Cabinet

(blog author:  Dori Ann Bischmann, PhD)

Establishing PQRS in Large Medical Systems that Have Electronic Health Records.

I’ve recently taken a journey trying to implement PQRS for psychologists in a large medical system that has electronic health care records.  Here are some interesting things that I have learned:

1.  It is a very complex endeavor.

2.  It is important to find out which people in the system actually “build” topics such as PQRS into the electronic health care record.

3.  The most important contact person may very well be an IT (information technologist) who “builds” the structure into the electronic record to measure and report data such as PQRS.

4.  How the system is set up for one discipline (i.e. MD) may not be the same way it is built for other disciplines.

5.  It is important to thoroughly understand CMS requirements for PQRS and help others in the system separate this from what might be required by the electronic health care record system.

6.  Requirements related to HITECH (the financial incentive from Medicare that encourages physicians and hospitals to establish electronic health care records) are frequently confused with PQRS requirements.  Note:  psychologists are eligible for PQRS, but they are not eligible for the HITECH incentives.  Thus, if someone tells you that psychologists are not eligible for “meaningful use” codes, remind them that they are likely referring to HITECH and that psychologists are certainly eligible for PQRS.

7.  The measures used for the Hitech incentive may be the same as the measures used for PQRS.  Medicare has a variety of incentive programs that various providers can be involved in.  They may overlap.  As a psychologist, be very clear about what Medicare incentive programs psychologists are eligible for.

8.  It is important to persevere.  PQRS can be accomplished even in big systems, it just might take a while to find the people in the system who know how to “build” it.

9.  When educating administrators or others about the importance of PQRS, be sure to highlight the financial benefits.  Health care margins are slim and seem to be getting slimmer.  Everyone is interested in bringing in a little more revenue for services already being done and/or avoiding penalties for completed services.

10.  Once the PQRS appears built into the system, be sure to follow the PQRS code from its origin to the final bill sent into CMS.  It is important to make sure that the code is “sticking” in the system all the way to billing.

11.  Electronic health care record systems are quite complex and require teams of people working on different parts of the system.  The person/team who “builds” the clinical parts of the system are usually different from the person/team who sets up the billing aspect of the system.

12.  Because of requirements related to the electronic health care record system, you might have to complete extra steps to accomplish PQRS.  CMS has certain requirements, but depending on how the electronic health care record system is set up, you may have to do something over and above what CMS requires just to get the PQRS code to stick all the way to billing.

13.  I suspect that the steps to completing PQRS are going to be different at different hospitals (different hospital networks) even when the same electronic health care system is utilized.

14.  Keep going and don’t give up.  You can get PQRS accomplished at your facility.


The WPA Advocacy Cabinet

(post author:  Dori Ann Bischmann, PhD; WPA Medicare Liaison and Federal Advocacy Coordinator)