Practicum Journal: Reimbursement Rates Assignment

The Current Procedural Terminology (CPT) system is used by third payers to analyze the provided healthcare services to process payment/reimbursement for these healthcare services from Medicaid and other medical insurance companies (Colquhoun et al., 2020). Similarly, mental health practitioners use the CPT codes to bill for the provided services (Chang, 2016). However, the reimbursement rates for physicians are higher when compared to the rate for PMHNPs. Evidence shows that advanced practice nurses (APNs) improve access to healthcare and hence the lower reimbursement rates for APNs hinder access to healthcare services and as a result hinder access to mental health services (Ortiz et al., 2018). Lower reimbursement rates for the PHMNPs may lower their willingness to work, especially in remote areas. Therefore, the purpose of this paper is to compare the reimbursement rates for physicians and PMHNPs for the same mental health care services in order to illustrate the discrepancy.

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Reimbursement Rate Template

Type of Service CPT code Private insurer reimbursement rate for PMHNP Private insurer reimbursement rate for physicians Medicare

the reimbursement rate for PMHNP

Medicare

the reimbursement rate for physician

Psychiatric diagnostic evaluation

Depression

90791 $ 157.194 $ 142.15 $ 101.847

 
$119.82
Individual psychotherapy (45 min)-Outpatient

Bipolar disorder

90834 $72.6 $95.8 $ 58.2165 $ 68.49

 

Family Psychotherapy in presence of the patient

Schizophrenia

90847 $68.93 $81.09 $ 68.2 $ 72.97
Psychotherapy, 30 minutes with patient and/or family member

Anxiety disorders

90833 $63.78 $78.8 $108.34 $108.34
Individual psychotherapy for 45 minutes

Substance abuse and related disorders

 

90836 $70.703 $83.18 $34.85 $ 40.01

 

According to the above reimbursement template, the reimbursement rates for mental health practitioners are low, while the rates for physicians are comparatively higher for equivalent services. The insurance companies, including Medicaid, have lower reimbursement rates for PMHNPs when compared to the rate of the physicians. For example, for the psychiatric evaluation for depression, the reimbursement rate for PMHNPs from Medicaid is $ 101.847, while physicians are reimbursed by Medicaid $119.82 for the same services. Likewise, PMHNPs are reimbursed $142.15 by the private insurance companies for diagnostic evaluation for depression, while physicians are reimbursed $ 157.194 by the private insurance companies for diagnostic evaluation for depression. This is supported by Phoenix & Chapman (2020) who explain that reimbursement rate for advanced practice nurses like PMHNPs is 85 percent for similar healthcare services of the reimbursement rates for physicians. The reimbursement rates are however different, depending on the state.

Conclusion

It is important to have the issue of lower payment for APNs such as PMHNPs addressed to facilitate equal reimbursement rates for the same services. APNs need to rally policies that support better pay for them. Moreover, insurance companies, including Medicaid need to come up with equivalent reimbursement rates for healthcare providers providing the same services. This will motivate APNs such as PMHNPs to continue practicing in order to improve access to mental healthcare services. This is because APNs are greatly involved in improving access to health care services.

References

Colquhoun, D. A., Shah, N., Kheterpal, S., & Saager, L. (2020). Classification of Current Procedural Terminology Codes from Electronic Health Record Data Using Machine Learning. Anesthesiology, 132(4), 738–749. https://doi.org/10.1097/ALN.0000000000003150

Chang J. (2016). CPT 101: An Introduction to Coding and Reimbursement. Journal of the American Academy of Child & Adolescent Psychiatry, 55(10), S34.

Ortiz, J., Hofler, R., Bushy, A., Lin, Y. L., Khanijahani, A., & Bitney, A. (2018). Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes. Healthcare (Basel, Switzerland), 6(2), 65. https://doi.org/10.3390/healthcare6020065

Phoenix, B. J., & Chapman, S. A. (2020). Effect of state regulatory environments on advanced psychiatric nursing practice. Archives of psychiatric nursing, 34(5), 370–376. https://doi.org/10.1016/j.apnu.2020.07.001

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Research reimbursement rates for various treatment modalities.
Compare NP rates to other provider rates. Then, complete the attached reimbursement rate template for the 5 different psychiatric disorders listed in the template.

Complete the reimbursement rate template for the 5 different psychiatric disorders listed below

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