New Guidelines for Third Party Reimbursement for Biofeedback
Ronald Rosenthal, PhD
In an ideal world, we would be able to generate a long list of insurance companies and managed care organizations that have consistently paid for biofeedback services.However, the world we live in is far from ideal and insurance reimbursement for biofeedback continues to be inconsistent and unpredictable.
In order to try to bring some order to this topic, it is important to remember how third party reimbursement works. When billing to third party payers, we need to complete (accurately) a claim form that provides specific information about what we did. In addition to the basic demographic information identifying your client, the claim form will include a diagnosis code and a procedure code. All of the decisions regarding payment will be based upon the combination of codes you provide.
The first step in the process is to contact the insurance company and verify coverage. The basic details of coverage may be available on-line, but it you want to determine if you will be paid for biofeedback services, you will need to call the insurance company. Payment may be restricted to participating providers or there may be higher deductibles and increased copays if you are not a network provider. Some services may also require preauthorization
Many insurance companies have (long) lists of excluded services, and the biofeedback codes are often on these lists. In other cases, the procedure codes will only be paid if the diagnosis code is from a list of covered conditions. As an example, the basic mental health procedural codes, like 90806, used by psychologists and counselors are only covered when the diagnosis is for a psychiatric or developmental disorder.
There is a relatively small set of procedural codes for biofeedback. There are two pure biofeedback codes, 90901 and 90911. The 90901 code is for any modality of biofeedback and the 90911 code is pelvic floor training for the treatment of incontinence. There are also two codes for mental health providers, 90875 and 90876. These refer to sessions that combine biofeedback with some kind of talk therapy or counseling—90875 for a 25 minute session and 90876 for a 50 minute session In addition to the codes listed above, some practitioners have been billing using codes from the physical medicine section of the code book or with the new health and behavior intervention/assessment codes. The use of these other codes reflects the complex and diverse ways that biofeedback training can be used. Most biofeedback practitioners believe in an integrated treatment approach in which biofeedback training is just one part of a package. Other modalities could include counseling, breathing training, relaxation and meditation techniques, Feldenkrais exercises, Tai-Chi, yoga, and so on. The basic biofeedback codes may not reflect accurately all of what is done within a session.
The set of alternative codes that have been used with biofeedback include 96150 and 96152, 97532, 97112. 96002 and 90806. The 90806 code is for psychotherapy, not biofeedback, and providers combining biofeedback and psychotherapy are advised to use 90876 or 90875,. Some providers may be tempted to use 90806 when 90876 is not covered, but this can be considered to be a misrepresentation and leaves one open to charges of insurance fraud. Many clinicians have reported that insurance company representative have told them to use the 90806 when 90876 is not covered, but unless these instructions are obtained in writing, a significant risk remains. The health and behavior codes, 9615x, were released in 2002. They are used for the assessment or treatment by a psychologist of patients with primarily a physical complaint diagnosed by a physician. These codes recognize the mind/body connection and the interplay of biopsychosocial factors in the expression of health and disease. In many cases, a legitimate case for the use of these codes can be made for treatment that includes biofeedback for patients with chronic medical conditions such as headache, hypertension or fibromyalgia.
The health and behavior codes are time based codes. They are billed in 15 minute units and permit billing for extended sessions, e.g., 6 units for a 90 minute evaluation. They must be linked to a medical diagnosis given by a physician. It was intended that payment for these codes would come from the general medical pool of funds, not from mental health funds. In practice, the use of the medical diagnosis has caused problems at times because some insurance companies require the use of only mental health codes by psychologists.
The 97532 code refers to cognitive retraining; it has typically been used by speech and language pathologists working to improve cognitive function of patients with cognitive deficits. Many neurofeedback providers have started to use this code when working with clients with ADHD or TBI. The 97112 code refers to neuromuscular retraining of movement, balance or coordination. Surface EMG training (as well as some less common techniques) in rehabilitation settings can be coded with 97112. I have also come across a relatively new code, 96002, that is used for dynamic surface EMG recording for gait training and other functional activities. We may be able to use this code when providing EMG biofeedback to improve motor control.
Medicare will pay for CPT codes 90901 and 90911 when specific criteria are met. Medicare does not reimburse for 90876. Under Medicare guidelines, biofeedback training for muscular pain or weakness may be eligible for payment. Each carrier will have a list of eligible diagnoses and you would have to check to see what conditions are eligible for your local carrier and whether you can be reimbursed as a provider.
The main concern when billing Medicare with 90901 is that reimbursement is quite low. The allowance is between $40-50 per session, regardless of the length of the session. The reimbursement for 90911 is typically higher. Billing Medicare for 90901 also requires the use of a modifier (GP or GN) to indicate whether the services are coordinated with physical therapy or occupational therapy.
All of the Medicare carriers are now paying for the health and behavior intervention codes. In Florida, the allowance is $97 for the evaluation (96150—1 hour or 4 units) and $89 for individual treatment (96152—1 hour or 4 units).
I don't have information on Medicare coverage of 97532. Since the vast majority of clients getting neurofeedback for attention deficit disorder are children, it is highly unlikely that they will have Medicare for insurance.
The federal workers' compensation program (http://owcp.dol.acs-inc.com/portal/main.do) will pay for biofeedback training. The enrollment process can be tedious, but once you are enrolled as a participating provider, you can bill for biofeedback services provided to federal employees who are injured on the job.
With regards to the major insurance carriers, it is impossible to give any universal advice. Many providers have reported success in getting reimbursement for biofeedback services, but it often requires getting authorization on a case-by-case basis. Certification by BCIA has been helpful as well as documentation from AAPB's Evidence-Based Practice in Biofeedback and Neurofeedback . Neurofeedback providers have reported that having a QEEG brain map has been helpful in getting authorization or reimbursement. Blue Cross/Blue Shield has long been considered to be quite negative in its views about biofeedback, but several providers have reported success in getting paid by Blue Cross for biofeedback. In addition, we have reports of biofeedback reimbursement from Aetna, United and Delta on the West coast.
The best advice is to be persistent and prepared. Have your office verify coverage for all possible biofeedback codes for all of your patients. Coverage often varies widely based upon the specifics of a given contract and may include restriction based upon type of licensure. If you get a rejection initially, contact a supervisor, case manager or provider relations. If you have success, let us know at AAPB or BCIA.