Clinical social workers are required to follow specific guidelines when billing Medicare.
A clinical social worker (CSW) helps people in several different ways: developing skills in solving problems and coping with stressful situations; providing input into community mental health services; and acting as liaison between patients and the mental health community. According to the Medicare Benefit Policy Manual, the definition of a clinical social worker is a person who has earned a master's or doctorate in social work, has performed at least two years of clinical social work and is licensed or certified as a clinical social worker in the state of practice. Clinical social workers who practice in a state that has no licensing must complete at least two years or 3,000 hours of supervised clinical social work under master level supervision in a hospital or clinic.
CSW Services
CSW Medicare services are billed in an identical manner to those services performed by a physician or a physician's service. The CSW must be legally authorized to perform services in the state where services are rendered. Services provided to an inpatient or outpatient that a hospital is required to provide may not be covered for a CSW; however, services in a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) may be billed, as long as they are the same type of service a physician would perform. The social worker must meet the Medicare definition of a CSW and not be otherwise unable to participate in Medicare coverage. Each practice should develop a list of covered practices.
Limitations
Medicare enforces a limitation on expenses for outpatient mental health treatment provided by CSWs. This limitation is referred to as the the outpatient mental health treatment limitation. Outpatient services are reimbursable at 62.5 percent of the usual Medicare approved amount. The limitation is not in effect for some diagnostic services. Also, office visits for prescription maintenance are not included in the limitation. (For a full rendering of this limitation, please see the Medicare Claims Processing Manual, Chapter 9.)
Location of Services
Services that are performed by clinical social workers in a clinic are considered services of the clinic and are billed by the clinic only. As well, services performed by employees or agents of the clinic in an off-site location are also billed by the clinic. For example, a clinical social worker might see patients who are home bound. In this case, the social worker may not bill the Medicare participant (beneficiary) but must bill Medicare directly. Services performed that are outside the scope of Medicare coverage will not be reimbursed by Medicare. Services outside the scope of Medicare include those that are not considered "reasonable and necessary" in the diagnosis and treatment of a mental illness.
Recent Changes
In January 2010, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) went into effect. This act includes changes that will affect Medicare billing for clinical social workers as discussed in the following sections.
Outpatient Services
MIPPA updates the existing statute to gradually eliminate co-payments for psychiatric services. Co-payments, which had previously been 50 percent of the cost as opposed to 20 percent for other health services, will be phased out over years 2010 to 2014. In 2010, Medicare will begin the process by paying 55 percent of the cost of outpatient services.
Bonus Payments
MIPPA awards a 2-percent bonus payment for CSWs who use the Medicare Physician Quality Reporting Initiative program. For more information on this program, including submit reports and receive the bonus, visit the Centers for Medicare & Medicaid Services (see Resources).
Behavior Assessment
The current procedural terminology (CPT) code 96152 has expanded to include telehealth services for health and behavior assessment performed at a distance.
Medicare Enrollment
Medicare enrollment by an Internet-based enrollment program is now required. This system is known as the Provider Enrollment Chain and Ownership System. Social workers who have previously enrolled using paper applications will now be required to re-enroll using the online system.
Fee Changes
Between the years 2010 and 2014, social workers will receive a 7-percent reduction in Medicare expenses. This reduction begins in 2010 with a 1-percent reduction in Medicare-identified labor, supplies and equipment.
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