Introduction Considerable confusion seems to exist among practitioners about how, within an ethical and legal framework, to correctly code and bill for biofeedback and related services to maximize the probability of being reimbursed. This seems to be particularly true in areas like EEG biofeedback, surface EMG (sEMG), and sometimes also with incontinence work. One intent of this series of papers is to help provide some useful information on what is working for at least some practitioners.

Some other related but complex issues follow:

• What can one do about denials?
• When can and can’t you bill the patient when the insurance company will not pay?
• How do you go about getting an authorization for service from an insurance company?
• What is “down coding?”
• How are relative values determined and how can they be changed?
• How does a provider go about dealing with Medicare?
• How can providers avoid engaging in fraudulent behavior?
• What are the rules about using or not using multiple codes within a session?
• Who can use the new Health and Behavior Assessment/Intervention codes, 96150-96155?
• When is it appropriate to use a biofeedback versus a psychotherapy code?
• How can providers go about influencing insurance companies to reimburse for biofeedback and related services?
• How do certification and licensure influence what is happening or not happening?
• What kind of research support is needed currently to enhance the status and recognition of biofeedback and applied psychophysiology?

AAPB is conducting a survey on coding, billing, and reimbursement issues. The survey is available online. If you have not filled out a survey contact the AAPB at aapb@resourcenter.comfor a copy. The survey will help collect the kind of information needed so that AAPB can provide appropriate input to the American Medical Association’s (AMA) coding committee. This is accomplished by sharing information with a representative of the American Psychological Association who represents us on the AMA’s coding committee. At present that person is Antonio Puente, PhD.

Diversity Adds to Confusion The membership of AAPB is very diverse and represents individuals from at least 19 disciplines. This diversity is both a strength and a challenge in dealing with insurance companies and in terms of who can do what. Biofeedback practitioners have an identity or recognition problem that adds to the coding, billing, and reimbursement confusion. Insurance companies often think that everyone who does relaxation training, including biofeedback for that purpose, is or should be a psychologist, and they often do not know who else, when, or if to reimburse. The public often does not know what biofeedback is and often confuses biofeedback with “biorhythms” or meditation, or see it as “just relaxation.”. Others are confused about whether biofeedback is a profession or a modality, and whether it is part of “mainstream health care” or falls under Complimentary and Alternative Medicine (CAM). In any case, they want to see the outcome research data. In addition, there are certain Current Procedure Treatment (CPT) codes that are very useful and appropriate when used by members of some disciplines, but which are inappropriate for use by other disciplines. In part, the appropriateness of using particular CPT codes is governed by the rules and tions of specific third-party payers, and in part, it is governed by the licensing laws of individual states. For example, some states have licensing laws that define the practice of specific disciplines to include procedures and interventions like biofeedback and psychotherapy, and include all assessments of and treatment of mental and emotional problems. In such states the specified interventions are the domain of practitioners licensed in those specific disciplines, those exempted by the law (e.g., clergy), or those supervised by such licensed professionals. Utah’s psychology licensing law has such provisions and makes exceptions for other licensed professionals whose own licensing law allows them to provide such services as psychotherapy or biofeedback. Other individuals are prohibited from providing such interventions. Texas law goes so far as to prohibit licensed professionals from even supervising unlicensed practitioners in the provision of certain services, with of course some exceptions. For more information on this topic see Striefel (2003, 2001). The bottom line is that it is very important to establish and maintain a good working relationship with third-party payers so that one can learn what and how to work effectively and efficiently with each provider within their coding, billing, and reimbursement structure.

CPT Codes The CPT codes were originally developed for obtaining reimbursement from Medicaid and Medicare. Later, other insurance companies started to use the codes, but they do not have to, and they do not all use them in the same way so this also adds to practitioner confusion. The AMA’s coding committee may have added to the confusion with codes 90875/90876 and 90901 because they seem to create a mind-body split. The 90875/90876 codes include biofeedback and psychotherapy and are appropriately used by those who can legally provide psychological or mental health services within the state in which they practice. Using these codes when not legally allowed to do psychotherapy or when psychotherapy is not an appropriate part of a client’s treatment is illegal and unethical. Of course these codes also imply that biofeedback is also a part of the client’s treatment. Generally, 90901 was created for all those others who can legally provide biofeedback, but where psychotherapy is not provided (a mind-body split).

It is important for practitioners to remember that the CPT codes do not make any distinction about whether the provider of services must be licensed or not. The decision about who can legally provide service is decided initially by individual state licensing laws. Further restrictions depend on the policies of third-party payers. For example, a state may allow an unlicensed provider to provide biofeedback services, but Medicare rules in that state may restrict such treatment payments to licensed personnel. For a licensed or unlicensed provider to bill Medicare for services provided by an unlicensed provider in such a state would be fraud. Likewise, when a state restricts the provision of biofeedback services to someone licensed in specific health care disciplines; as such it would be illegal for someone to provide such services if not licensed appropriately even though a thirdparty payer might pay for services provided by unlicensed personnel.

Practitioners should know the laws of their individual state in reference to who is and who is not legally allowed to provide biofeedback, psychotherapy, and other health care related services. Laws in some states restrict the provision of some health care services such as biofeedback and psychotherapy to members of specific disciplines and some do, and some do not, allow licensed practitioners to supervise unlicensed personnel in the provision of these restricted services. What do the relevant laws in your state say governing the provision of biofeedback, psychotherapy, and related services? It is critical that you know what the provisions of your state laws are. Colorado has licensing laws governing the practice of specific disciplines like psychology, social work, nursing, and physical therapy, but it allows unlicensed practitioners to register themselves as unlicensed psychotherapists and to provide such services as biofeedback.

AAPB has had some successes or victories in the CPT code arena. John Perry, PhD working with AAPB’s legislative and insurance committees helped in getting Medicare to pay for incontinence biofeedback. In addition, Antonio Puente, PhD, was instrumental in helping to create the new CPT Health and Behavior codes (96150-96155). It does take advocacy on the part of practitioners in order to change CPT codes and get reimbursement for biofeedback and related services. Are you doing your share of advocacy work? Bob Whitehouse is the current chair of the insurance committee and can be reached in the following ways: Bob Whitehouse, EdD 1526 Spruce, Suite 302 Boulder, CO 80302 Telephone: 303-417-0293 Fax: 303-666-7160 Email: BobWhiteho@aol.com Note: telephone and fax preferred.)

The co-chair of the insurance committee is Ronald Rosenthal, Ph..D., of Florida, and he can be reached best via e-mail at: RRosent710@aol.com

The AMA’s coding committee gives this definition of biofeedback:

BIOFEEDBACK is the process of detecting information about a patient’s biological functions, e.g., heart rate, breathing rate, skin temperature, and amount of muscle tension, picked up by surface electrodes (sensors) and electronically amplified to provide feedback, usually in the form of an audio-tone and/or visual read-out to the patient. Biofeedback training uses the information that has been monitored from the sensors attached to a muscle on the skin’s surface, or to the skin only for thermal or other readings. With the help of a trained clinician, the patient can learn how to make voluntary changes in those biological functions and bring them under control.

The definition includes all kinds of biological functions and the feeding back or training of individuals using monitors, i.e., doing biofeedback the way it would be done in a clinical setting.

CPT Codes The CPT codes concerning biofeedback and their codes in the CPT Manual are:

Biofeedback 90901 This code applies to biofeedback training using any modality.

90911 This code applies to biofeedback training of the perineal muscles and/or the anorectal or urethral sphincter. It includes EMG biofeedback, and/or manometry.

Other Psychiatric Services or Procedures 90875 This code applies to individualpsychophysiological therapy that incorporates biofeedback training by any modality with psychotherapy (e.g., insight oriented, behavior modifying or supportive psychotherapy). It must be face-to-face with the patient and session length is approximately 20-30 minutes.

90876 The definition for this code is the same as for 90875, but the session length is approximately 45-50 minutes in duration.

The only difference between the 90875 and 90876 is the length of the treatment session, i.e., 20-30 minutes versus 45-50 minutes. Anyone who can legally provide psychological/mental health services within their state can use the 90875 or 90876 codes. Of course not every insurance company pays for this service or they may pay for it within one client coverage policy contract and not within another, adding to the coding, billing, and reimbursement confusion. The code for psychotherapy without biofeedback is discussed later under the section on Other Codes.

Health and Behavior Assessment/Intervention Codes The new CPT Health and Behavior Assessment/Intervention codes were basically developed to recognize the work of professionals, like psychologists, with physical health problems. Their use does not require that there be a psychological diagnosis. Prior to their creation, psychological interventions could not be provided to those with medical or physical problems unless there was a psychological diagnosis to help verify “medical necessity.”

These new codes, 96150-96155, are used for health and behavior assessments and interventions where it is not necessary to make a psychological diagnosis (e.g., DSM IV). Of course one must engage in the activities that fit the definition for these specific codes. The health and behavior codes follow.

96150 This code applies to health and behavior assessment (e.g., healthfocused clinical interviews, behavioral observations, psychophysiological monitoring, health-oriented questionnaires). A practitioner can bill for each 15 minutes of face-to-face assessment with the patient. This code is used for the initial assessment.

96151 This code is used for re-assessment(s).

96152 This code applies to health and behavior interventions. Each 15 minutes of face-to-face intervention with an individual client is billable.

96153 This code applies to group treatment/intervention (2 or more patients).

96154 This code applies to family treatment/intervention (with the patient present).

96155 This code applies to family treatment/intervention (without the patient present).

Other Codes That Are Potentially Useable Some other codes that might be used if approved by the third-party payer follow:

94010 This code applies to spirometry and includes a graphic record, total timed vital capacity, and expiratory flow rate measurement(s), with or without maximal voluntary ventilation.

94400 This code applies to the breathing response to CO2 (includes the CO2 response curve).

96002 This code applies to dynamic surface electromyography during walking or other functional activities for 1-12 muscles.

95957 This code applies to digital analysis of the electroencephalogram (EEG) (e.g., for epileptic spike analysis). (Some practitioners are using this code for QEEGs because it consists of a digital analysis of the EEG).

90806 This is the code for individual psychotherapy, insight oriented, behavior modifying and/or supportive psychotherapy in an office or outpatient facility for sessions lasting approximately 45-50 minutes, face-to-face with the patient. (Note: some insurance companies will allow biofeedback to be used as a psychological modality if part of a psychotherapy treatment and provided by a licensed mental health provider, but not if provided by an unlicensed provider. Do not try to deceive the insurance company about what you are doing by using this code when only biofeedback services are provided. Doing so would be fraud).

Other Codes There are some new Complimentary and Alternative Medicine (CAM) codes that use five letters of the alphabet instead of numbers. The code CDAAP applies to biofeedback, counseling, mental health services and practice specialties, e.g., assisting the client to modify body functions using feedback from biofeedback instruments. The codes were developed by Alternative Link for over 4000 procedures that describe the patient encounter with nursing, CAM, and indigenous medical services. Laws governing providers of such services differ by state and are available at 877-621-LINK or www.alternativelink.com. At present it is not clear what role these codes will play in the coding, billing, and reimbursement of services to clients.

An IDC-9-CM code was developed by the World Health Organization (WHO) for treating the psychogenic aspects of a medical disorder using biofeedback. It is 94.39 - other individual psychotherapy (biofeedback). It should be remembered that managed care considers insurees to be customers and it uses a business code of ethics that emphasizes making money. This focus often appears to be totally opposite that of health care practitioners, such as those providing biofeedback, where the focus is on meeting the specific current needs of the client/patient.

Billing Choices Remaining current on coding, billing, and reimbursement is an ongoing learning process that requires practitioners to make many choices as previously discussed. It is important to know what the correct CPT code is for the services that are provided, but it is just as important, if not more important to know what the third-party payer’s rules and regulations are that govern coding, billing, and reimbursement based on the specific insurance coverage of a client. Failure to know and abide by the rules can have dire consequences. It is easier to call for the third party information.

In Utah, a psychologist was working with both the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS, the insurance coverage for military personnel and their families) and Medicaid. He hired several unlicensed individuals with degrees in social work and psychology to provide clients with treatment/therapy. He was charged with 66 counts of mail fraud and related offenses, in what was described in the newspaper, as an alleged billing scheme to defraud government subsidized health-care programs. In at least Utah, CHAMPUS and Medicaid will reimburse only for therapy provided by a licensed mental health professional. To not follow the government’s rules was considered to be fraud. Such fraud is punishable by large fines and even jail time. In Houston, Texas, a physician was actually sentenced to a prison term for violating Medicare’s billing and reimbursement rules. Think about the damage to the practitioner’s reputation, the emotional turmoil, and the damage to the trust with referral sources and clients.

Practitioners should take coding issues very seriously and know the rules of thirdparty payers. Third-party payers are placing greater emphasis on detecting and punishing those who engage in fraud and the penalties can be severe. Seek the assistance you need to ensure that all of your coding, billing, and reimbursement activities are legal and ethical.

Whitehouse’s Seven Rules of Thumb for Billing And Coding Bob Whitehouse’s seven rules of thumb for billing and coding follow:

1. Decide who is responsible for obtaining the information about the client’s insurance coverage. Practitioners often assume that the client is responsible for obtaining the insurance information and for dealing with the third-party payer. In recent years there have been successful lawsuits against practitioners that have made clear that during the informed consent process the practitioner should clarify for the client what the limitations are that are imposed by his or her insurance coverage, e.g., what services are or are not covered, number of sessions, etc. It is important for practitioners to reconsider what they do or don’t do during the informed consent process about insurance imposed limitations.
2. Decide who is responsible for the bill at the onset of services. Have an agreement with the client about this issue.
3. Determine what the appropriate CPT code is for use in billing based on the client’s diagnosis and the services provided. Determine the appropriate rate of reimbursement, co-pay, and provider requirements. Do not make uninformed assumptions. Instead, form a working relationship with the appropriate third-party payer personnel to be sure you have the information needed to comply with their rules and regulations.
4. Be sure that your clients are informed about your “no show and late cancellation policies.” Do not violate any contract you have with a third-party payer that prohibits you from billing for “no shows” or other violations of your policies. Know what is in any agreement that you sign with a third-party payer before you sign to be sure you can and are willing to abide by the agreement. The courts have repeatedly ruled that you are responsible for abiding by the contracts that you sign, but you are also responsible for meeting your professional responsibilities to clients.
5. Keep both your clients and the thirdparty payer informed concerning your legal and ethical obligations, your fee structure, and your responsibilities, including your ethical responsibility to advocate for your clients if you disagree with a third-party payer decision concerning number of sessions, etc. Carefully document all of your advocacy efforts on behalf of a client in their file and be sure to keep them informed about your efforts.
6. Do your best to make sure that the diagnosis you assign to a client’s problem is accurate, that the billing code used is accurate and appropriate, and do include the amount of time spent and the fee charged for services in your billing statement. Be sure you are in compliance with the Health Insurance Portability and Accountability Act requirements.
7. Avoid engaging in any fraudulent behavior such as over or under diagnosing, providing one service but using a different code because the insurance company will pay for that code, inappropriately using dual billing codes, etc.

References Striefel, S. (2001). The role of aspirational ethics and licensing laws in the practice of neurofeedback. Journal of Neurotherapy, 4(1), 43-55.

Striefel, S. (2003). The application of ethics and law in daily practice. In M. S. Schwartz and F. Andrasik (Eds.), Biofeedback: A practitioner’s guide (3rd Ed.) (pp. 813-834). New York: Guilford Press.

Striefel, S., Whitehouse, R., & Schwartz, M. S. (2003). Other professional topics and issues. In M. S. Schwartz and F. Andrasik (Eds.), Biofeedback: A practitioner’s guide (3rd Ed.) (pp. 835-866). New York: Guilford Press.

Whitehouse, R. (1997). Suggested coding guidelines based on CPT code answers from the AMA. Biofeedback, 25(2), A-13A.

Whitehouse, R. (1998). CPT coding issues: 1998 update. Biofeedback, 26(2), 14A-17A.

Article by: Sebastian “Seb” Striefel, PhD, and Bob Whitehouse, EdD as published in AAPB BIOFEEDBACK, Winter 2003 Volume 31, Number 4