Medical Coding for Mental Health – Challenges Involved

Mental health issues are widespread and patients need access to proper care. According to the National Alliance on Mental Illness (NAMI), one-in-four individuals experiences a mental illness each year, which points to a critical need for mental and behavioral health services to meet the needs of all patient populations. As psychiatrists strive to provide the right interventions, medical billing outsourcing to an expert is a practical option to get properly paid for services.

Why Mental Health Billing and Coding is Complex

Mental health coding and billing is challenging as it requires knowledge about reimbursement guidelines, terminology, and payer contract rules and conditions. Mental healthcare is highly regulated and governed by federal laws, Medicare and Medicaid policies which may differ by state, practising regulations, and commercial payer billing guidelines. Accurate coding and billing that complies with these regulations is crucial to report services correctly, avoid auditor scrutiny and get reimbursed.

Documentation Requirements

Providers need to document each patient encounter completely, accurately, and in a timely manner to meet ongoing patient needs, fully describe the extent of services rendered, and support coding and billing. In behavioral health, identifying an accurate diagnosis depends heavily on the patient’s conversation with the psychiatrist, psychologist, or therapist. Proper documentation is also essential to support each level of care and continuity of care, reimbursement, and meet state and payer guidelines. Documented services must:

• Reflect medical necessity and justify the treatment and clinical rationale
• Be complete, concise, and accurate, including the face-to-face time spent with the patient
• Be legible, signed, and dated;
• Be maintained and available for review
• Be coded correctly for billing purposes

Psychiatry documentation should typically include the following details:

• Date of the initial visit and start and stop times
• Type of service (individual, group, family, psychotherapy)
• Names of individuals present during the session and duration of each separate individual interviewed
• Referral source

Comprehensive mental status examination

• Results of the relevant diagnostic tests, with interpretation and screening tools when available
• Past psychiatric and substance use disorder history, including inpatient or outpatient treatment
• Current therapies including medications and ongoing therapies
• Medical history and current medications
• Evidence of coordination of care
• Person-centered detail such as behavior, description, or quotes
• Documentation of progress (or lack of progress) toward identified goals
• Treatment plan or change in plan

Telepsychiatry gained significant traction in recent times. In addition to most of the above components, clinical documentation in telepsychiatry should include:

• The time, date, remote site location
• The duration of the encounter and time spent face-to-face with the patient in interview and examination
• The originating site location and personnel

Codes for Mental and Behavioral Health Services

• Psychiatry Diagnostic Evaluation

90791 Psychiatric diagnostic evaluation: CPT describes 90791 as an “integrated biopsychosocial assessment, including history, mental status, and recommendations.” CPT also states that this evaluation may include ” communication with family or other sources and review and ordering of diagnostic studies”

CPT 90792 Psychiatric diagnostic evaluation with medical services involves diagnostic assessment with medical services and includes an E/M component.

Subject to payer guidelines, 90791 and 90792 can be billed once per six to 12 months or any time there is a significant change in patient status, diagnosis, or treatment plan, it’s important to check payer guide.

Both these psychiatric diagnostic evaluation codes cannot be billed the same day as psychotherapy or E/M (evaluation and management) service performed by the same individual for the same patient.

• Psychotherapy
• Individual and Family Psychotherapy codes

The time for each psychotherapy code is described as time spent with the patient and/or family.

The individual psychotherapy codes are: 90832, 90834, 90837 – Psychotherapy 30 minutes, 42 minutes, and 60 minutes with patient, respectively.

Family and group psychotherapy (90846-90849, 90853) and individual therapy can be billed on the same date of service, though it’s important to check your payer guidelines.

• Evaluation Management (E/M) and Psychotherapy

Codes 90833, 90836, and 90838 can be used for psychotherapy when performed with E/M service, according to an American Medical Association (AMA) webinar titled “Sustaining Behavioral Health Care in your Practice”. One of the speakers, Leslie Prellwitz (CPT Content Management & Development, AMA) explains that these codes are applicable for behavioral health focus, not requiring for larger collaboration.

Psychotherapy codes cannot be reported on the same day as the assessment codes (90791, 90792). Any service that is less than 16 minutes is not billable.

Psychoanalysis and Other Psychiatric Services

Procedure code 90845 includes psychoanalytic services and does not have a time limit. An AAPC article explains, that psychoanalysis (90845) is performed “using methods of intense observation and analytical skill to investigate the patient’s past experiences, unconscious motivations, and internal conflicts, as well as contributing mental conditions”.

90845 can be widely used by therapists who are trained and credentialed to provide psychoanalytic services. However, keep in mind that specific private insurances may have restrictions on the use of this code.

Other psychiatric services or procedures that behavioral health specialists may provide include:

90870 Electroconvulsive therapy (ECT), Single Seizure; or 90871, Multiple Seizures, per day

90880 – Hypnotherapy

90901 or 90912 or 90913 – biofeedback training

Integrating Mental and Behavioral Health Services in Primary Care

The AMA webinar lists several codes to help primary care practices integrate patient access to mental and behavioral health services into their workflow. These include:

• Preventive medicine codes:

Preventive medicine and behavior change interventions can bring about a positive change in harmful behavior before it becomes a medical concern.

Preventive services for mental health include counseling risk-factor reduction and behavior change interventions that promote health and can prevent illness or injury. The CPT codes in this category are 99401, 99402, 99403, 99404, 99411, and 99412.

CPT 99401-99404 – Preventive medicine counseling, individual)

CPT codes 99411 and 99412 – Preventive counseling group visit

• Behavior change intervention codes

99406-99407 – Smoking and tobacco use cessation counselling visit

99408-99409 – Alcohol and/or substance (other than tobacco) abuse structured screening, brief intervention services

These services are preventative and help connect with patient before a behavioral health problem occurs. They are provided before a patient has an illness or a set diagnosis. The time spent with the patient is taken into account in individual and group settings.

Other behavioral health services that can be integrated into primary care include:

• Developmental/behavioral screening
• Adaptive behavior services
• Health behavior assessment and intervention
• Psychiatric collaborative care management
• Cognitive assessment and care plan services
• thorough eval of medical and psychosocial factors, potentially contributing
• Telemedicine services

As the provision of these services involves valuable use of the physician’s time and effort, knowing how to code them is paramount. Tacking the coding complexities for mental health is much easier when you have the support of an experienced medical billing company. Such companies have an expert team of certified medical coders and billing professionals and can provide timely and accurate medical billing and coding services for successful claim submission.