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CPT, ICD-10, and DSM-5.
CPT Codes. You are already aware of these. AMA publishes them and you/we use it all the time for tests, evaluations, treatments, and any other medical procedure done by our providers.
ICD-10 Codes – WHO publishes IDC-10 and the US modified it to ICD-10-CM (clinical modification). You know these – we use these for diagnoses.
DSM Codes – therapists know these very well (because of the Diagnostic and Statistical Manual of Mental Disorders – the authoritative guide to the diagnosis of mental disorders). Try NOT to use these codes for mental health billing purposes.
Mainly because all payers use ICD in their claims. Each time you submit charges, you are going to have to add the DX code (ICD) + CPT. While DSM is truly a great tool for identification and diagnosis of mental disorders, stick to ICD-10 as your “true north”. As a note, the latest DSM version (DSM-5) does have pointers to ICD-10.
For mental health, most of the time, you are going to deal with the F codes.
F00–F09 — organic, including symptomatic, mental disorders
F10–F19 — mental and behavioral disorders due to psychoactive substance abuse
F20–F29 — schizophrenia, schizotypal, and delusional disorders
F30–F39 — mood disorders, depression, and bipolar disorders
F40–F49 — neurotic, anxiety, stress-related, and somatoform disorders
F50–F59 — behavioral syndromes associated with physiological disturbances and physical factors
F60–F69 — disorders of adult personality and behaviors
F70–F79 — intellectual disabilities
F80–F89 — pervasive and specific developmental disorders
F90–F98 — behavioral and emotional disorders with onset usually occurring in childhood and adolescence
F99 — unspecified mental disorder
CPT codes for mental health fall between codes 90785-90899.
These are in the Psychiatry section of the CPT code set.
Some of these codes can only be used for psychiatrists billing.
The rest of the codes can be used for billing for clinical psychologists, licensed professional counselors, licensed marriage and family therapists, and licensed clinical social workers.
90791 – Psychological Diagnostic Evaluation, 60 minutes (initial evaluation done by a non-physician)
90792 – Psychological Diagnostic Evaluation with Medication Management, 60 minutes (initial evaluation done by a physician)
90837 – Psychotherapy, 60 minutes
90834 – Psychotherapy, 45 minutes
90791 – Psychiatric diagnostic evaluation without medical services
90847 – Family psychotherapy (with client present), 50 minutes
90853 – Group psychotherapy (other than of a multiple-family group)
90846 – Family psychotherapy (without the client present), 50 minutes
90875 – Under other psychiatric services or procedures
90832 – Psychotherapy, 30 minutes
90838 – Psychotherapy, 60 minutes, with E/M service
99404 – Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure)
These are to be used by psychiatrists when the psychotherapy is provided in the same encounter as medical E/M or evaluation and management.
90833 – 30 minutes
90836 – 45 minutes
90838 – 60 minutes
These add-on codes are ones that you can only use in conjunction with another CPT code. Hence, you will find these with the + sign.
CPT 90785 – this may be used with any code in the Psychiatry section (has to be appropriate, of course).
Typically you use CPT code 90839 for the first 60 minutes of a patient’s crisis management. When this crisis encounter goes beyond 60 minutes use 90840 as the add-on code for each additional 30 minutes
Use the E/M CPT Codes when your provider does pharmacologic management for a patient. However, if your provider is in New Mexico or Louisiana, use the add-on code 90863. Keep in mind that this code is not to be used by psychiatrists or other medical mental health providers.
Many of you will not be using these as the interactive complexity CPT code 90785 is used when the encounter is more complex than usual. Billing for this typically requires your provider’s encounter to involve people other than the patient alone (e.g. during treatment of children). If you are billing for this, your documentation has to be air-tight, explaining what exactly the interactive complexity was.
There are 2 of these codes to keep in mind – 90791 and 90792. Your psychiatrists will most probably not be using the 90791.
This is to be used for a Psychiatric Diagnostic Evaluation – aka an initial diagnostic interview exam that does not include any medical services.
You need to note the patient’s chief complaint, history of present illness, family and psychosocial history, and complete mental status examination.
Keep in mind that Medicare will pay for only one 90791 per year for institutionalized patients – that is, of course, unless your provider has established medical necessity for more work.
Unlike the previous one, use this for Psychiatric Diagnostic Evaluation with Medical Services.
You need to include a patient’s chief complaint, history of present illness, review of pertinent systems, family and psychosocial history, and complete mental status examination.
You also have to include any medical work done. This could include ordering labs, reviewing/interpreting lab results, prescribing medications etc.
Keep in mind that Medicare will pay for only one 90792 per year for institutionalized patients – that is, of course, unless your provider has established medical necessity for more work
There are now three basic timed individual psychotherapy codes.
You use them in all settings.
On top of that, you use add-on codes when psychotherapy is done along with medical E/M.
You can also use add-on codes when psychotherapy is provided along with interactive complexity.
The great thing is that now the CPT codes include time spent in the descriptors themselves (makes it a lot easier to handle). These are not face-face time limited. Rather, these are the time spent with a patient and/or their family member.
Keep the following in mind.
You can account for time spent with the patient (not reviewing documentation, labs, scheduling etc).
Select the CPT code closest to the time your provider spent with the patient. So, this typically means the midpoint rule. If you spend 16 mins with the patient, bill for 30 minutes. If you spent 31 minutes with the patient, bill for 30 minutes.
You would use a modifier when you have to pass on additional information to the payer about your claim. There are many different modifiers, but only a few that we use commonly.
What happens when the same E/M service is done by the same provider, on the same day? It doesn’t happen often. When you encounter this situation, use modifier 59 to describe this to the payer (you better have documentation to back this up).
You can only attach modifier 25 to codes 99201-99215, 99341-99350. Occasionally, the same provider might have to do 2 (or more) full separate E/M services on the same date of service. Use modifier 25 for these claims. Mod 25 states that the 2nd service is separate and reimbursable.
You might have a lot of these based on your patient population. This is used to bill for patients that were treated in crisis (aka not all the time, CPT 90839).
This has primarily been used for telehealth sessions (audio/video modality). However, do note COVID related changes.
Use the following CPTs to handle billing for time spent with a group / family of patient members.
CPT code 90846
This can be used if your provider is performing Family Psychotherapy without the patient being present. However, your documentation has to really be able to support the fact that this family therapy session was not to treat issues the family might be facing due to the patient’s issues. This is to be used specifically (and documented) when your patient will clearly benefit from their family undergoing this session.
CPT code 90847
Unlike 90846, use this when the patient is present. You won’t get as many push backs or denials as the patient is present (e.g. couples therapy)
CPT code 90849
Use this only if your therapist is using this strategy to modify the family behaviors in relation to the patient. Again, the documentation/treatment plan has to support the fact that this is medically necessary for the patient.
This Multiple-Family Group Psychotherapy code is covered by most insurance plans but has to be abetted by good documentation.
CPT code 90853
This CPT code is to be used for Group Psychotherapy. Note that this is not the same as a Multiple-Family Group (90849). When your provider is holding a session with a group (whatever the size might be, reasonably so) and is in the process of examining the issue(s) of each individual in the group, this code can be used. However, the code cannot be used for general therapy sessions. The group has to be put together for the treatment plan of the patient members. If you ever were to bill for this, you can use 90853 to report per-session services. This is applicable for each group member.
Your therapists / providers can use EM codes in both inpatient and outpatient settings like provider office, hospital, nursing home, emergency department, etc
Do keep in mind that you need to read the EM code descriptions and really understand the situations / scenarios under which E/ M billing works.
Hospitals and nursing facilities are used to frequently using the E/M codes. Before you start using E/M codes for your office visits, read the guidelines thoroughly
This CPT code is for Psychoanalysis and is not time based. Use this on a per session basis. However, do note that medical necessity will be challenged by your payers. Be prepared with documentation to support medical necessity
There are 7 components that are used to define E/M levels of service:
– Patient history
– Examination
– MDM/ medical decision making
– Counseling
– Coordination of care
– Nature of presenting problem
– Time
Which level of service you or your provider is going to code, depends on 3 main things
– How extensive is the history documented
– The extent of the examination during the patient’s visit
– Medical decision making complexity
By patients
– “new patients” has 5 levels (99201-99205)
– “Existing patients” has 5 levels (99211-99215)
By place of service
– “Office consults” have 5 levels (99241-99245)
– Similarly, “initial inpatient consults“ have 5 levels (99251-99255)
The more detailed the history, the more you get paid. Your most expensive resource (aka the psychiatrist) doesn’t have to do the history themselves. This can be delegated to MAs and NPs working under their supervision.
There are four levels of history you get paid for, progressively higher
– problem focused history
– expanded problem focused history
– detailed history
– comprehensive history
The more detailed the examination, the more you get paid. Your most expensive resource (aka the psychiatrist) doesn’t have to do the examination themselves. This can be delegated to MAs and NPs working under their supervision.
There are four levels of history you get paid for, progressively higher
– problem focused examination
– expanded problem focused examination
– detailed examination
– comprehensive examination
There are four levels of medical decision making you get paid for, progressively higher
– Straightforward
– Low complexity
– Moderate complexity
– High complexity
If you’re going to code for high complexity, make sure your documentation fully supports
– the number of diagnoses or management options
– the complexity of data reviewed
– risk of complications and/or morbidity or mortality.
You cannot really nail down the actual mental health reimbursement rates for various CPTs that easily. It’s more of a “matrix” across various payers, plans. But, at the same time it also changes all the time. So, by the time you google the info, you are probably looking at outdated data.
A better way to approach this is to look at which payers pay more for mental health and be credentialed with those payers + plans.
Medicare and Medicaid reimbursement rates for mental health
As usual, the exception is Medicare and Medicaid. The CMS tells you what Medicare/ Medicaid will pay you for your location, license, education level and specialization. This would be an average amount but you will have a good idea, nevertheless.
– Therapist / provider office location
– Provider license
– Provider education level
– Provider specialization
Do keep in mind that after enrollment and credentialing, when you’re accepted into a payer’s network (aka at par), you’ll be negotiating your reimbursement rates.
Keep in mind that you can renegotiate your rates every year. However, to successfully negotiate higher rates each year, you need a very specific strategy (that’s a subject for another post).
You have to understand this very clearly. There’s a difference between inpatient and outpatient services, and how time is counted.
For inpatient services, you cannot count non face to face time. That means any time spent before and after the patient encounter (note, not visit) does not count as reimbursable. This is because CMS has already accounted for those times (average) in reimbursement.
When you’re billing for inpatient hospital care, hospital consults, and nursing facility care you use something called “unit floor time”. This is basically the time that your provider(s) spend with the patient. This, unlike outpatient services, can include chart reviews, test results review, charting, preparation of care plan, team meetings pertaining to that specific patient’s care, counseling, meetings with the patient’s family etc. Note that the time spent in reviewing patient’s charts while your provider is not in front of the patient is already included in CMS calculation for reimbursement, so you cannot add up those times.
When your provider is spending more than 50% of their time with a patient (or family) doing counseling or care coordination, bill by time spent. For this, the history taking, MDM, examination become less relevant.
If your provider/ therapist is spending time in any of the following, you can consider it as counseling
– Discussing diagnosis or prognosis
– Explaining treatment benefits and risks
– Discussing management of patient’s condition
– Explaining how to reduce risks
– Educating the patient and/or the patient’s family
During some of your patient encounters, your therapist will be consulting with other providers included in your patient’s care. Your therapist might have to coordinate with other agencies as part of the patient’s treatment plan. This constitutes Coordination of care for mental health billing purposes.