Medical Billing for Behavioral Health Services – Challenges and Solutions

by | Last updated Feb 1, 2023 | Published on Aug 12, 2016 | Medical Billing

Medical Billing
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Recent changes to both diagnostic and procedure codes as well as variability in requirements across private and public insurers pose many challenges for behavioral health medical billing:

  • ICD-10-CM includes combination codes for some conditions and associated symptoms, with details relating to laterality and anatomical site, combination codes for conditions and common symptoms or manifestations, different categories, more complete code titles, extensions to specify encounter, and certain diseases reclassified to reflect current medical knowledge.
  • In 2016, changes have been made to the Behavioral Health E/M (Evaluation & Management) codes with the addition of two new procedure codes and new add-on prolonged service codes.

Under ICD-10-CM, medical coding for mental and behavioral disorders F01-F99 covers disorders of psychological development. Some examples:

  • F01-F09 – Mental disorders due to known physiological conditions
  • F10-F19 – Mental and behavioral disorders due to psychoactive substance use
  • F40-F48 – Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders
  • F90-F98 – Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
  • F-99 – Unspecified mental disorder

Examples of combination codes for mental and behavioral health:

  • F11.23 – Opioid dependence with withdrawal
  • F13.221 – Sedative, hypnotic or anxiolytic dependence with intoxication delirium
  • F16.221 – Hallucinogen dependence with intoxication and delirium

The 2016 CPT code changes for mental / behavioral health include the following:

  • Procedure codes +99354 and +99355 are now “add-on” codes for reporting extended/prolonged services that are applied to face-to-face outpatient psychotherapy services and face-to-face E/M codes. For proper billing, these codes should be used along with the appropriate primary E/M code.
  • +99415 and +99416 are two new “add-on” prolonged procedure codes for mental health and psychiatry. These codes should be used for billing prolonged or extended face-to-face clinical staff service with the physician, NP, or PA supervision in an outpatient setting.

A primary code should be used for reporting all CPT codes with a “+” prefix. As these are add-on codes, they can never be used alone on a claim.

Medicare and Medicaid use HCPCS codes which are monitored by the Centers for Medicare and Medicaid Services (CMS). There are three levels of HCPCS codes, and two of these are relevant to mental health billing. Both Medicaid and Medicare use some of both Level I and Level II, which can be confusing.

In addition to correct coding, proper medical documentation is crucial to successful medical billing. Medical records should be complete and legible. Documentation of each encounter should include: reason for encounter and relevant history, physical exam findings and prior diagnostic test results, assessment, clinical impression, and diagnosis, and plan for care.

With all these challenges, professional behavioral medicine medical billing services can go a long way in helping physicians getting reimbursed appropriately and avoiding insurance audits.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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