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NCPA recently worked with Blue Cross Blue Shield of North Carolina (BCBSNC) to address concerns raised by a member whose Spravato treatment claims were automatically downcoded to a lower-level E/M service. NCPA advocated that psychiatric claims should be evaluated based on the services actually provided and supporting clinical documentation, particularly for specialized treatments such as Spravato that require physician oversight, clinical assessment, and at least two hours of post-administration monitoring.

As a result of those discussions, BCBSNC has implemented system changes intended to carve out qualifying Spravato administration claims from its high E/M leveling algorithm. BCBSNC reports that the update is designed to prevent eligible Spravato claims from being inappropriately affected by E/M leveling edits and that the plan will identify previously impacted claims and take appropriate remediation steps.

This outcome highlights the importance of members bringing reimbursement concerns to NCPA. If you are experiencing claim downcoding or reimbursement concerns related to psychiatric services, please let NCPA know so we can continue advocating on behalf of North Carolina psychiatrists.