As is the case in many countries across the world, the prevalence of mental health disorders in the U.S. has been rising over the years. According to Mental Health America, in 2017-2018, 19% of adults experienced a mental illness, an increase of 1.5 million people over last year’s dataset. COVID-19 has reportedly exacerbated mental stress and psychosocial well-being among all sections of society. Psychiatrists use a variety of methods to diagnose, treat and prevent mental, emotional and behavioral disorders. Treatments include various forms of psychotherapy, medications, psychosocial interventions and other modalities such as electroconvulsive therapy or ECT, based on each patient’s needs. However, while they strive to provide quality mental health services, submitting claims for reimbursement is a major challenge due to the variety in the types of services and numerous coding and billing rules and payer regulations. Partnering with a psychiatry/mental health billing company can help practitioners file accurate claims and get paid appropriately and faster.
Challenges of Billing Mental Health Services
Psychiatrists treat diverse conditions such as anxiety, depression, schizophrenia, bipolar disorder, anorexia, substance abuse, ADHD, OCD, and PTSD. Billing mental health services is different from billing medical conditions.
- In a medical setting, patients are billed for standard services such as laboratory tests, x-rays etc., which are almost similar for all patients and vary only slightly in terms of time taken. Mental health services vary in type and scope and may include therapy, psychological testing and also medical treatments. Insurers have specific rules on how they pay for mental health services, which makes billing for them a challenge.
- Pre-authorization are required for inpatient psychiatric care, adding to the complexity of mental health billing.
- Mental healthcare practices are usually do not have a dedicated staff member to manage coding and billing
- It is difficult to convince payers that the treatment prescribed was appropriate for the patient. Insurers usually have restrictions about the number of sessions that can be billed per day.
Submitting Accurate Claims for Mental Health Services
Payment rates for common behavioral health services tend to be lower than for other specialties and understanding how to bill for mental health services is essential for obtaining proper reimbursement.
- Know the codes and how to use them: Proper reimbursement depends on accurate procedure coding. Coding errors can lead to late payments or claim rejections. Frequent errors can attract audits, or even charges of fraud and abuse, resulting in elimination from managed care networks. Physician coding service providers always verify CPT codes with the AMA’s latest CPT manual to ensure correct and up-to-date procedure codes. The most common CPT codes used by therapists are:
90832: 30 minutes of individual psychotherapy
90834: 45 minutes of individual psychotherapy
90837: 60 minutes of individual psychotherapy
90846: 50 minutes of family psychotherapy without the client present
90847: 50 minutes of family psychotherapy with the client present
90849: Multiple-family group psychotherapy
90853: Group psychotherapy
When reporting a psychotherapy CPT code, care should be taken to select the one closest to the time spent in the session. The APA’s recommendations on this are:
- Use 90832 for sessions that run between 16 and 37 minutes
- Use 90834 for sessions lasting from 38 to 52 minutes
- Use 90837 for sessions of duration 53 minutes or longer
- Use 90846 or 90847 for 26 minutes or more of family psychotherapy
A thorough understanding of the most common mental health CPT codes is essential to report the most appropriate code for the services provided.
- Ensure accurate office/outpatient E/M billing and documentation: Mental health specialists should be aware about E/M Office/Outpatient Services coding. For 2021, CMS made changes to the way office/outpatient E/M codes (99202-99215) are chosen and documented. As of January 1, 2021:
- Codes for office/outpatient medical (E/M) care are selected on the basis of the complexity of the medical decision making (MDM) or on the basis of the total time on the date of the encounter.
- When providing E/M services along with psychotherapy, psychiatrists must determine the appropriate E/M code by the level of the medical decision making, based on the new definition.
- Time cannot be used to determine E/M when adding on psychotherapy.
- When billing outpatient E/M on the basis of time, the total time on the date of the service related to the patient encounter can be used, not just the face-to-face time. This, as stated by the APA, includes:
- Preparing to see the patient (e.g., review of test, records)
- Obtaining and/or reviewing separately obtained history
- Performing a medically necessary exam and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other healthcare professionals (when not reported separately)
- Documenting clinical information in the electronic or paper health record
- Independently interpreting results of tests/labs and communication of results to the family or caregiver
- Care coordination (when not reported separately)
Other changes include the creation of two new prolonged service codes to report outpatient E/M services that exceed each 15 minutes beyond the highest level E/M code (99205, 99215) and simplification of documentation.
- Use Mental Health CT Code Modifiers correctly: Mental health therapists should utilize the CPT code modifiers to report their license level and those that best describe the services they provide. Examples:
95 Modifier – Synchronous Telehealth Services
GT Modifier – Synchronous Telehealth Services [Medicare]
Modifier 25 – Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service
Modifier 59 – Distinct Procedural Service
Modifier UT – Used when the provider sees a patient in crisis
AJ Modifier – Licensed Clinical Social Worker (LCSW)
HJ Modifier – EAP or Employee Assistance Program Visits (EAP)
HE Modifier – Mental Health Program (MHP)
AH Modifier – Doctorate Level or Clinical Psychologist (PhD or PsyD)
AF Modifier – Psychiatrist (MD)
For insurance reimbursement, the billing process also involves completing an intake assessment that covers all the information needed to manage the patient’s billing during the care process. Documentation must also provide evidence that the care is medically reasonable and necessary. Insurance benefits verification must be performed before services are provided to check the patient’s active coverage with the insurance company. This can be complex as covered benefits vary between companies and with each individual insurance plan.
With all the complexities involved, it’s clear that mental health billing and coding would be much easier with expert support. As you focus on providing the care your patients need, hiring a medical billing outsourcing company with experience in coding, pre-authorization and insurance eligibility verification, and third party billing for mental health services is a practical option to reduce risk of denials and optimize reimbursement.