Biofeedback Training and Equipment from Stens Biofeedback

An intensive, five-day training workshop, The Professional Biofeedback Certificate Program combines a relaxed seminar learning process with hands-on instruction and clinical practice. The program's flexible structure provides an incomparable learning environment for the beginner and allows experienced practitioners to pursue more advanced applications such as surface EMG in chronic pain and clinical applications in EEG.

Biofeedback is currently used by psychologists and physicians, nurses, physical and occupational therapists, speech pathologists, social workers and marriage/family counselors, dentists, chiropractors and many other allied health professionals. Positive results have been achieved in both inpatient and outpatient programs.

What you will learn and what makes this program different.

The Professional Biofeedback Certificate Program will give you the fundamental skills necessary to use self-regulation techniques that teach your patients to listen to the language of their bodies. Most simply put, you will help them help themselves. Our core curriculum is specifically designed to give you a clear biofeedback model that allows immediate use with stress disorders and explores other new and innovative directions. It is a step-by-step learning process that requires no previous experience with either biofeedback instrumentation or computers. You will learn to conduct clinical biofeedback sessions as well as the basics of clinical hypnosis, autogenic training, guided imagery and other helpful techniques.

Locales, Lodging & Scheduling
Ours is the only national biofeedback training program with more than 25 programs each year across the US and overseas, offering convenience and reduced travel expenses. The workshops are held at comfortable hotels, providing amenities you will find most welcome over the course of the training.

With more than 25 programs per year, you have a variety of training choices that mean greater flexibility and ease of scheduling.

The Latest in Biofeedback Technology
The Stens Corporation is one of the leading distributors of state-of-the- art biofeedback instruments. This distinction allows us to supply the training program with all the equipment needed to give each student extensive experience with the latest technology.

Technical Support
The level of technical support we offer is another unique feature of our organization. On our staff are full-time technical support specialists who have expertise in the capabilities, installation and operation of the leading biofeedback instruments. Before your training you'll receive a questionnaire about your potential uses for biofeedback which you complete and return to us. Well review your questionnaire, talk with you about your needs, and ship appropriate equipment to the training program for you to use. You'll not be restricted to one brand of instrument and you may work with several state-of-the-art systems that are appropriate for your practice.

A Special Approach to Learning
One highly trained instructor will lead you through the program. You will avoid many of the pitfalls inherent in training programs that utilize too many instructors, often resulting in the students inability to understand and integrate a coherent model of biofeedback.

You will learn to operate biofeedback instruments with the aid of well-written labs which are yours to take with you and use as a reference as you practice biofeedback or for your certification exam.

What is the Value of Certification?

Demonstrated Professionalism
When you complete the Stens 5-day training program, you will receive our certificate of completion. If you elect to go on for national certification through the BCIA, you will be required to take a written exam. Passing the national certification examination attests to your competency as a biofeedback practitioner and the completion of prescribed standards of performance and conduct.

Recognition
You will be listed in the Register of the Biofeedback Certification Institute of America, a national directory available to all groups and agencies interested in identifying qualified practitioners.

Credibility
National certification procedures are consistent with the guidelines of the Department of Health and Human Services and give you professional credibility as a qualified health care provider. The Re-certification process ensures that you maintain skills and continue your education.

Primary Instructors for Biofeedback Certificate Workshops

Phillip A. (Tony) Hughes, Ph.D., M.F.C.C.

Training Director, Professional Biofeedback Certificate Program, Stens Corporation. Director of Clinical Services, The Biofeedback Center of Berkeley. Consultant, San Francisco State University. BCIA-Certified.

Dr. Hughes is the Director of the Stens Professional Biofeedback Certificate Program and is in private practice in Berkeley, CA. He is one of the most skilled and interesting lecturers in biofeedback and self-autonomic control today. Nationally known as a professional trainer in applied psychophysiology and biofeedback, he is widely regarded as one of the best teachers in the field.

He is a licensed Marriage and Family Therapist, a certified Biofeedback Therapist, and a BCIA Senior Fellow. His seminars are geared to preparing students and professionals to use biofeedback, autogenic training and other techniques of self control for the treatment of a variety of stress-related and pain disorders. He also serves as a consultant to a number of hospitals and clinics.

Dr. Hughes has been consistently rated as the best by course attendees. In fact, on numerous occasions Dr. Hughes has received a standing ovation at the end of the course for his commitment, breadth of knowledge and his ability to communicate difficult concepts that is understandable to all.

*Instructors vary from program to program. For information on specific instructors and dates, please call us at 1-800-257-8367.

How about the Quality of your products?

Our main product line, the NeXus-10, NeXus-16 and NeXus-32 are all medical products which are manufactured to the highest standards under ISO13485 and FDA QSR. These are medical device class IIa devices (CE 93/42/EEC) and offer extremely high quality, reliability and durability. With lower noise, less artifacts, 24 bit precision and wireless or USB 2.0 technology they are among the most advanced systems currently available on the market. (and may we say; with an excellent price performance ratio)�

What are the advantages of your BioTrace software?

All our products, including the new generation NeXus platforms, run with BioTrace . This means they are all compatible. This software offers a better and easier user interface, smoother and faster graphics and more flexibility than any of our competitors software products. Period! It is not only an ideal tool for researchers, but also a very powerful tool for clinicians, health professionals and trainers. You can configure this open software platform to do almost anything. It features true dual screen support, easy point and click thumbnails, statistical analysis, high sample rates, video capture and more. Convince yourself and request a demonstration. Show us ANY comparable software product from any competitor and we can show you how BioTrace is superior.

Is your software compatible with other products?

Yes. BioTrace can import sessions from our older BioGraph � and MultiTrace software that were formerly used with the ProComp (tm) or Infiniti (tm). Session data can be exported to Microsoft Excel, Word, SPSS, matLab, Statistical, Neuroguide and QEEG database software like the Eureka and SKIL.

What are the advantages of BlueTooth Wireless Technology?

The NeXus-10 is 10 channel system with a built-in wireless BlueTooth connection to your PC. It runs up to 20 hours on just two AA batteries and can send all 10 channels at high speeds (up to 2048 samples per sec.) at full 24 bit resolution. Because it is wireless you are able to use this small portable system almost anywhere. Your patient/client is no longer attached to the computer with a wire and is free to move up to about 10 meters away from the PC. This is not only an advantage for sport physiologists and physiotherapists, but also for those who work with ADHD kids. These kids tend to 'move a lot'. It means there is one less wire to worry about. Several medical BlueTooth enabled products have been approved by the FDA and it is now considered very safe and reliable technology. Because BlueTooth uses very low power (about a 1000 times less than most mobile phones) it is extremely unlikely it will ever interfere with other devices, signals or sensors.

What are the advantages of the new carbon coated electrode cables of the NeXus?

These cables are superior to standard copper wires and more or less make active EEG/EMG/ECG sensors obsolete. Not only do they provide better signals (less artifact, low noise) than most active sensors, because of the active shielding , notch filters (50/60Hz) are NO longer required. So the entire range between 45-65hz is available when you do EEG or EMG. The signals are shielded all the way from the system up to the very end of the snap-on or EEG electrode. Movement artifacts are a thing of the past with our cables, while moving these cables, movement artifact is virtually absent. Then there is the economical advantage: our 2 channel EXG cable costs less than most active EEG sensors for a single channel of EEG or EMG. Yet it offers the same functionality as 6 active sensors for 2 channels of EEG, 2x EMG, 1xECG and 1xEOG. So in terms of price this cable is far better.

What is active shielding?

Active shielding is the better alternative to active sensors. An active sensor is generally a more costly solution and is no guarantee for good signals. The special NeXus active-shielding electronics put a special signal around the electrode shield, starting from the encoder (NeXus) up to the very end of the electrode that's on the body or on the head. This 'field' neutralizes or attenuates interference and noise from the environment. The combination of carbon coating with active shielding is even better, because that also minimizes movement artifact.

What does EXG mean?

EXG stands for any electrophysiological signal starting with an 'E'. Like EEG, EMG, ECG and EOG (electro-oculo-graphy). A single NeXus-10 EXG cable supports all of these modalities.

What does AUX mean?

AUX stands for any auxiliary sensor input. Examples are: respiration, bloodflow, heartrate, oximetry, skin conductance, force and temperature.

How durable is the new NeXus-10?

Very durable and very reliable. These small portable systems are bundled with a protective leather carry case. The brushed metal connectors are medical grade and virtually indestructible. No more cheap plastic connectors that break easily.

How reliable are the signals from the NeXus-10, 16 and 32?

VERY reliable. All the inputs on the NeXus-10 feature full 24 bit resolution at samplerates up to 2048 /sec. Low noise (less than 0.2 microvolt in a typical EEG bandpass range) High frequency range (True DC=0Hz to 1000 Hz) Movement artifacts are a thing of the past. Virtual absence of 50/60Hz interference. And last but not least: online electrode connection quality checks during EEG monitoring . There is no calibration required on our preamplifiers either, they are guaranteed to work within their specified amplitude range according to the specs of the electronics. Simply said: the signal quality is absolutely stunning.

What do you mean by TRUE DC?

The Amplifiers of the NeXus-10, 16 and 32 are built using a TRUE DC design capable of measuring extremely low frequencies, far below 1 Hz. All NeXus Systems can do slow cortical potentials. SCP's reflect general cortical activation. SCP's have been used in research on attention problems and seizure disorders.� The NeXus-32 can even do up to 32 channels of SCP, while recording the EEG as well. TRUE DC means that we can measure the actual DC level of any potential and the signal STAYS there at the actual DC level, there is no time constant.

What is the advantage of the 24 bit resolution?

Around 1985-1990 the industry standard was 8 bit. That provided about 250 steps of digital information for EEG, Respiration, Temperature etc. Soon after that the industry stepped up to 10 and 12 bit. (around 1990-1995) Back then, the best systems had somewhat higher resolution like 13 or 14 bit. That was 10 years ago. Although most people now agree that 16 bit resolution is sufficient for most physiological signals, the NeXus engineers have taken it one step further. With 24 bit you will probably not run out of bandwidth for the next 5-10 years to come. NeXus can detect extremely small physiological changes , such as less than 1/10000th degree of skin temperature or 1/10000th microseconds of skin conductance. This has clinical relevance. Where other systems go flat-line, NeXus still detects real physiological activity. Once you have seen it in action, you probably do never want to go back to 14 bits, 12 bits or less.

How easy is it to get started with your software?

With one key press and 2 mouse clicks you are up and running, recording a new session.� You can assign up to 12 screens to function keys and load and switch between them instantly. Screens are previewed in the screen browser using thumbnail images. The user interface is highly graphical. Over 1 hour of training videos are included when Biotrace is installed. Many of our users who have compared it to other software and say this is the easiest system on the market, while at the same time offering an impressive depth of advanced features.

What sensors and physiological modalities do you currently offer?

We offer sensors and support for: EEG, SCP (slow cortical potentials), EMG, ECG, EOG (DC electro-oscillography), Respiration (abdominal and chest), Bloodflow (PPG), heartrate variability HRV, Skin Conductance, Skin Potentials, Skin Temperature, Oximetry (relative oxygen saturation), Force, HEG and Goniometry.

What is the advantage of using the SCP (slow cortical potentials)?

SCP's are relatively simple to monitor with NeXus. They are easier to interpret than regular EEG and recent research indicates they are applicable not only for epilepsy protocols, but also for attention training. NeXus by the way offers simultaneous monitoring of the SCP and the full EEG (up to 100hz) from the same electrodes. We advise to use high quality sintered Ag/AgCl electrodes for SCP.

Can I combine and monitor several different sensors/modalities?

YES! You can create an almost indefinite amount of flexible sensor configurations. It mostly depends on which sensors you buy and plug into the inputs.

What kind of applications does NeXus/Biotrace support?

Almost too many to sum up. But here are a few: NeXus-10, 16 and 32 support a wide range of Neurofeedback applications including slow cortical potentials. NeXus-32 support real-time QEEG and neuromapping as well. Apart from that Biofeedback protocols and screens for respiration training, heart rate variability and HRV statistical analysis is support. Stress assessment protocols and included. EMG training and Myofeedback is included, also Pelvic Floor Training. General relaxation training is included and stress management. Performance optimization is included as well as many screens and biofeedback games for children.

Does Biotrace support ERP (event related potentials)?

Yes. BioTrace can acquire multiple EEG trials and do averaged response analysis on automatic tasks or stimuli. Through this analysis the P300 and other event related potentials can be displayed.

Do you offer QEEG functions in the BioTrace software?

YES. The NeXus-32 is a combined QEEG and neurofeedback/Biofeedback platform. With BioTrace it can do real time recording of up to 24 or 32 EEG channels. It does real time re-montaging, spectral analysis, Neuromapping (Brainmapping) and offline artifact rejection and export to QEEG software. The NeXus-32 also incorporates all the functions of the NeXus-10 and therefore is also fully capable of Biofeedback and Neurofeedback.

I need to monitor/train a group of 'X' people, can I do that?

Yes. for instance NeXus-10 can already monitor 4 people at once, if you want. With NeXus-32 you could monitor a group of 32 people. When combining two NeXus-32 you could even make that 64. The possibilities almost endless. If you have any special project, just ask us. We also support training with multiple systems ( group training ) over a computer network.

I want to use my own sensors, is that possible?

Usually the answer is YES. For special research purposes we can make almost any existing sensor work on our NeXus-10, NeXus-16 and NeXus-32. Just ask us.

How about software upgrades?

The BioTrace software updates are free to download as they become available.�

Can I configure the software and build my own screens?

YES. You can build screens in the integrated screen editor. (WYSIWYG) With our editor, you do not need to go through complicated steps in order to change screens and stop a session first. You can edit screens on the fly and create as many as you wish. You can also add your own images, videos, sounds, music and other multimedia contents to the software. Feedback functions like CD and DVD are also supported.

What are the recommended computer requirements necessary for running the BioTrace software with the NeXus-4, NeXus-10, or NeXus-32 platforms?

You can download the requirements here.

How do I join the Users Forum on Yahoo?

Please click here: http://health.groups.yahoo.com/group/Nexus10/.� You must be a registered owner of a Nexus System to join the group.

We also recommend that you join the Biofeedback group, http://health.groups.yahoo.com/group/biofeedback/ and the ISNR member forum group, http://tech.groups.yahoo.com/group/SNR_Members_Forum/.

BCIA General Biofeedback Certification Information

Certification in General Biofeedback is open to professionals from clinical health care areas including, but not limited to, psychology, nursing, counseling, and therapy who hold a degree from a regionally accredited academic institution. A complete list of accepted degree fields is found in this brochure.

Candidates must file an application and demonstrate completion of:

A human anatomy, human physiology, or human biology course from a regionally accredited academic institution covering the organization of the human body and all 11 systems.
A 48 hour didactic education program specifically covering all topics as listed in the BCIA Blueprint of Knowledge taken from either a regionally accredited academic institution or a BCIA accredited training program.
20 contact hours spent with a BCIA approved mentor to learn to apply the clinical biofeedback skills through learning self-regulation, 50 patient/client sessions, and case conference presentations. Please see the Mentoring Guidelines.
When working with a medical or psychological disorder, candidates must show proof of license/credential to practice independently or agree to work under the licensure of another professional.
The written certification exam which may be taken either at one of the scheduled exam sites or through the special exam option which allows a pre-approved candidate to schedule their exam through a university testing center with a proctor. A Suggested Reading List is provided to aid in preparation for the exam and to reinforce the learning of the science, history, and theory of biofeedback.
Payment of certification fees: $25 application purchase, $100 filing fee, $275 certification fee.

The first step to certification is filing an application. Once your application has been approved and fees received, you may schedule a time for your exam. A completed application must include a signed, sealed, original transcript and payment of filing fees. You may complete your requirements in any order. You may order your application packet from BCIA for $25. If you download the application packet from the website, your filing fee will be $125. The documents included are: Application, Application Instructions, Blueprint, Mentoring Guidelines, Suggested Reading List, Ethical Principles, and Exam Registration Form.

All candidates must agree to abide by the BCIA Ethical Principles and follow the appropriate rules and regulations of their profession and their state.

Certification is valid for four years. To recertify, the candidate must demonstrate completion of 80 hours of continuing education and must attest that their license/credential has not been suspended, investigated or revoked.

Clinical Biofeedback Supervision For Certification

(30 Hours over a minimum of 10 weeks)

Individual arrangements can be made through Phillip Hughes, Training Director, Stens Corporation, to provide up to 30 hours of BCIA Clinical Biofeedback Supervision. Of these hours, three must be in the form of direct observation (audio tape, video tape or in person). Small group conferencing is available at a reduced fee.

Members of the Stens Corporation Board of Advisors who are located around the US may also act as clinical supervisors. Stens will be happy to help you contact our Advisors to make your supervision arrangements.

Direct Clinical Biofeedback Treatment

(90 Hours over a minimum of 10 weeks)

Trainees will acquire 90 hours of Direct Clinical Treatment with patients over a minimum of 10 weeks. It is the responsibility of the trainee to arrange for a field placement. Stens Corporation learns of a limited number of field placements around the US. When they are available, Stens is happy to share them with our students.

Software for Review of Biofeedback Concepts and On-site and International Training Opportunities

Flash for Biofeedback is a computer-based review of pertinent biofeedback concepts and vocabulary. Self-Assessment in Biofeedback, based on the BCIA test blueprint, provides a multiple choice exam with answer key to help identify your strengths and weaknesses as you prepare for the exam. They can be ordered from the Stens Corporation at 1-800-257-8367.

In certain circumstances, it may be practical to bring our training program to your site, especially if you are located outside of the US and have a group of 15 students or more. Contact Stephen Stern at 1-800-257-8367 for fees and further information.

What CPT codes should I use for biofeedback?

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 . 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.

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

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Guidelines for Third Party Reimbursement for Biofeedback

Ronald Rosenthal, PhD

In an ideal world, we would be able to generate a long list of insurance companies and managed care organizations that have consistently paid for biofeedback services. However, the world we live in is far from ideal and insurance reimbursement for biofeedback continues to be inconsistent and unpredictable.

In order to try to bring some order to this topic, it is important to remember how third party reimbursement works. When billing to third party payers, we need to complete (accurately) a claim form that provides specific information about what we did. In addition to the basic demographic information identifying your client, the claim form will include a diagnosis code and a procedure code. All of the decisions regarding payment will be based upon the combination of codes you provide.

The first step in the process is to contact the insurance company and verify coverage. The basic details of coverage may be available on-line, but it you want to determine if you will be paid for biofeedback services, you will need to call the insurance company. Payment may be restricted to participating providers or there may be higher deductibles and increased copays if you are not a network provider. Some services may also require preauthorization

Many insurance companies have (long) lists of excluded services, and the biofeedback codes are often on these lists. In other cases, the procedure codes will only be paid if the diagnosis code is from a list of covered conditions. As an example, the basic mental health procedural codes, like 90806, used by psychologists and counselors are only covered when the diagnosis is for a psychiatric or developmental disorder.

There is a relatively small set of procedural codes for biofeedback. There are two pure biofeedback codes, 90901 and 90911. The 90901 code is for any modality of biofeedback and the 90911 code is pelvic floor training for the treatment of incontinence. There are also two codes for mental health providers, 90875 and 90876. These refer to sessions that combine biofeedback with some kind of talk therapy or counseling�90875 for a 25 minute session and 90876 for a 50 minute session In addition to the codes listed above, some practitioners have been billing using codes from the physical medicine section of the code book or with the new health and behavior intervention/assessment codes. The use of these other codes reflects the complex and diverse ways that biofeedback training can be used. Most biofeedback practitioners believe in an integrated treatment approach in which biofeedback training is just one part of a package. Other modalities could include counseling, breathing training, relaxation and meditation techniques, Feldenkrais exercises, Tai-Chi, yoga, and so on. The basic biofeedback codes may not reflect accurately all of what is done within a session.

The set of alternative codes that have been used with biofeedback include 96150 and 96152, 97532, 97112. 96002 and 90806. The 90806 code is for psychotherapy, not biofeedback, and providers combining biofeedback and psychotherapy are advised to use 90876 or 90875,. Some providers may be tempted to use 90806 when 90876 is not covered, but this can be considered to be a misrepresentation and leaves one open to charges of insurance fraud. Many clinicians have reported that insurance company representative have told them to use the 90806 when 90876 is not covered, but unless these instructions are obtained in writing, a significant risk remains. The health and behavior codes, 9615x, were released in 2002. They are used for the assessment or treatment by a psychologist of patients with primarily a physical complaint diagnosed by a physician. These codes recognize the mind/body connection and the interplay of biopsychosocial factors in the expression of health and disease. In many cases, a legitimate case for the use of these codes can be made for treatment that includes biofeedback for patients with chronic medical conditions such as headache, hypertension or fibromyalgia.

The health and behavior codes are time based codes. They are billed in 15 minute units and permit billing for extended sessions, e.g., 6 units for a 90 minute evaluation. They must be linked to a medical diagnosis given by a physician. It was intended that payment for these codes would come from the general medical pool of funds, not from mental health funds. In practice, the use of the medical diagnosis has caused problems at times because some insurance companies require the use of only mental health codes by psychologists.

The 97532 code refers to cognitive retraining; it has typically been used by speech and language pathologists working to improve cognitive function of patients with cognitive deficits. Many neurofeedback providers have started to use this code when working with clients with ADHD or TBI. The 97112 code refers to neuromuscular retraining of movement, balance or coordination. Surface EMG training (as well as some less common techniques) in rehabilitation settings can be coded with 97112. I have also come across a relatively new code, 96002, that is used for dynamic surface EMG recording for gait training and other functional activities. We may be able to use this code when providing EMG biofeedback to improve motor control

Medicare

Medicare will pay for CPT codes 90901 and 90911 when specific criteria are met. Medicare does not reimburse for 90876. Under Medicare guidelines, biofeedback training for muscular pain or weakness may be eligible for payment. Each carrier will have a list of eligible diagnoses and you would have to check to see what conditions are eligible for your local carrier and whether you can be reimbursed as a provider.

The main concern when billing Medicare with 90901 is that reimbursement is quite low. The allowance is between $40-50 per session, regardless of the length of the session. The reimbursement for 90911 is typically higher. Billing Medicare for 90901 also requires the use of a modifier (GP or GN) to indicate whether the services are coordinated with physical therapy or occupational therapy.

All of the Medicare carriers are now paying for the health and behavior intervention codes. In Florida, the allowance is $97 for the evaluation (96150�1 hour or 4 units) and $89 for individual treatment (96152�1 hour or 4 units).

I don�t have information on Medicare coverage of 97532. Since the vast majority of clients getting neurofeedback for attention deficit disorder are children, it is highly unlikely that they will have Medicare for insurance.

The federal workers� compensation program (http://owcp.dol.acs-inc.com/portal/main.do) will pay for biofeedback training. The enrollment process can be tedious, but once you are enrolled as a participating provider, you can bill for biofeedback services provided to federal employees who are injured on the job.

With regards to the major insurance carriers, it is impossible to give any universal advice. Many providers have reported success in getting reimbursement for biofeedback services, but it often requires getting authorization on a case-by-case basis. Certification by BCIA has been helpful as well as documentation from AAPB�s Evidence-Based Practice in Biofeedback and Neurofeedback. Neurofeedback providers have reported that having a QEEG brain map has been helpful in getting authorization or reimbursement. Blue Cross/Blue Shield has long been considered to be quite negative in its views about biofeedback, but several providers have reported success in getting paid by Blue Cross for biofeedback. In addition, we have reports of biofeedback reimbursement from Aetna, United and Delta on the West coast.

The best advice is to be persistent and prepared. Have your office verify coverage for all possible biofeedback codes for all of your patients. Coverage often varies widely based upon the specifics of a given contract and may include restriction based upon type of licensure. If you get a rejection initially, contact a supervisor, case manager or provider relations. If you have success, let us know at AAPB or BCIA.

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