Psychiatry Coding & Reimbursement Alert

Question:  I am new to psychiatry coding, and I am now coding for a group practice. I recently sent out a claim for a psychotherapy session (90834) conducted by our CSW, but it was rejected. The payer’s reason for rejection stated that a modifier was missing for the claim. I thought it was a straight forward claim, and I am not too sure about the need for any modifier. Can you tell me where I have gone wrong, so I will be able to correct the claim and receive reimbursement for it?

Texas Subscriber

Answer: Some payers may require the use of Healthcare Common Procedure Coding System (HCPCS) modifiers like “AJ” or “AH” when filing claims for services performed by a clinical social worker or a clinical psychologist respectively. These HCPCS modifiers let the payer know that the work was performed by a clinical social worker (CSW) or a clinical psychologist who is qualified, as per Medicare guidelines, to handle the services performed.

These modifiers should be mentioned in the field 24d of the Centers for Medicare & Medicaid Services (CMS) 1500 form. The modifier should be placed after the CPT® code that is used to describe the services performed. In your instance, since you are claiming for psychotherapy session that was performed by your clinical social worker, you will need to report 90834 (Psychotherapy, 45 minutes with patient and/or family member) with the modifier AJ appended to the code.

But, according to guidelines issued in Transmittal 2656, CMS mentions that “Contractors shall not require the submission of modifier AJ for clinical social workers (CSWs) or modifier AH for clinical psychologists (CPs).” The transmittal also clarifies that the modifiers “AJ” and “AH” are not eliminated, but they no longer need to be submitted with the claims.

Best bet: Check payer policies and rules to see if modifiers “AJ” and “AH” need to be submitted when you are submitting claims for services provided by your clinical social worker or your clinical psychologist, so you do not run the risk of denial for your claims.