Psychiatry Practice Management: Navigating Insurance Coding And Reimbursement

Billing insurance is a complex and challenging process for psychiatrists, psychologists and therapists. The byzantine rules and regulations of the insurance industry make successfully submitting claims difficult and frustrating. Mental health professionals often face an uphill battle when seeking reimbursement for the services they provide and often only collect 85% of the money owed to them.

The process is made even more complicated by the fact that there are thousands of different billing codes to choose from, and many different guidelines to follow. Current Procedural Terminology (CPT) codes are essential to the health insurance billing process. CPT is a uniform coding system developed by the American Medical Association in 1966 to standardize terminology and simplify record-keeping for physicians and staff. CPT codes describe medical procedures performed on a patient, including tests, evaluations, surgeries and other practices. For example, behavioural health CPT codes describe the length of a psychotherapy session with a client or a diagnostic interview.

In addition to CPT codes, there are also International Classification of Diseases (ICD) codes, which describe a patient's diagnosis and why treatment was necessary. For example, F41.9 is the ICD code for anxiety disorder, while F33 is the code for major depressive disorder, recurrent. Both CPT and ICD codes are necessary for reimbursement from health insurance companies.

The reimbursement rates for psychiatrists vary by insurance type (commercial, Medicare, or Medicaid), psychiatric CPT code rendered, and by each insurance company’s rate. Psychiatrists with a physician's license will receive the highest level of reimbursement for Medicaid programs. Medicare pays psychiatrists surprisingly well, but now requires electronic billing. Medicaid pays providers low amounts but sustains a high volume of new and established clients. Commercial insurance rates vary dramatically across companies, with some rates lower than Medicaid.

Understanding Current Procedural Terminology (CPT) Codes

The Current Procedural Terminology (CPT) system, developed by the American Medical Association (AMA) in 1966, is a uniform coding system that standardises terminology and simplifies record-keeping for physicians and staff. CPT codes are integral to billing medical services and procedures for reimbursement and are used by physicians, allied health professionals, non-physician practitioners, hospitals, outpatient facilities, and laboratories. Each CPT code represents a written description of a procedure or service, removing subjective interpretations of what was provided to the patient. CPT codes are updated annually by the AMA, with new, revised, and deleted codes released, along with changes to CPT coding guidelines.

There are three categories of CPT codes:

• Category I CPT Codes: These are the most commonly used codes, consisting of five-digit numeric codes that describe existing services or procedures widely used and approved by the U.S. Food and Drug Administration (FDA). They are accepted by third-party payers and are considered the "usual" CPT codes.
• Category II CPT Codes: These are supplemental tracking codes used for performance management and data collection on positive health outcomes and quality patient care. They consist of five-digit codes with four numbers and end with the letter "F". Category II codes are not linked to reimbursement and are optional.
• Category III CPT Codes: These are temporary codes used to report emerging and experimental services, procedures, and technologies. They consist of five-digit codes with four numbers and end with the letter "T". Category III codes are used to facilitate data collection and assessment of new services and procedures and are typically valid for up to five years.

CPT codes are essential for clinicians and healthcare staff as they determine compensation and the practice's overall success. Clinicians must ensure that the CPT codes on insurance claim forms accurately reflect the services provided before submitting claims to insurance companies. CPT codes, along with International Classification of Diseases (ICD) codes, paint a complete picture for health insurance companies to process reimbursement.

CPT codes cover a wide range of medical procedures, including tests, evaluations, surgeries, and other practices. They are used to describe the length of psychotherapy sessions, diagnostic interviews, and various medical services. CPT codes are necessary to receive reimbursement from health insurance companies.

When using CPT codes, it is important to select the most specific code that accurately reflects the service provided. Modifiers can be added to CPT codes to provide additional information and further describe the service or procedure. These modifiers consist of two numbers, two letters, or a combination of both.

The CPT coding system plays a crucial role in billing and reimbursement processes, ensuring accurate and efficient communication between providers and payers.

CPT Codes for Psychiatric Services

CPT (Current Procedural Terminology) codes are essential to the health insurance billing process. CPT is a uniform coding system developed by the American Medical Association in 1966 to standardize terminology and simplify record-keeping for physicians and staff. CPT codes describe medical procedures a physician performs on a patient, including tests, evaluations, surgeries, and other practices. CPT codes are necessary to receive reimbursement from health insurance companies.

The CPT code set contains over 8,000 codes and is published and updated annually by the American Medical Association. The codes related to mental health (codes 90785-90899) are found in the Psychiatry section of the CPT code set and cover services provided by medical professionals such as psychiatrists, as well as services that can be delivered by non-medical professionals such as licensed clinical psychologists, licensed professional counselors, and licensed clinical social workers.

There are four distinct categories of CPT codes for mental health:

• Psychiatric Diagnostic Interview
• Psychiatric Therapeutic Services
• Family Medical Psychotherapy
• Common Mental Health CPT Codes

• 90791: Psychiatric diagnostic evaluation without medical services
• 90792: Psychiatric diagnostic evaluation with medical services
• 90832: Psychotherapy, 30 minutes
• 90834: Psychotherapy, 45 minutes
• 90837: Psychotherapy, 60 minutes
• 90846: Family or couples psychotherapy, without the patient present
• 90847: Family or couples psychotherapy, with the patient present
• 90839: Psychotherapy for crisis, 60 minutes
• 90840: Add-on code for an additional 30 minutes, used in conjunction with 90839
• 90833: Evaluation and management with 30 minutes of psychotherapy
• 90836: Evaluation and management with 45 minutes of psychotherapy
• 90838: Evaluation and management with 60 minutes of psychotherapy

It is important to use the correct CPT codes for mental health services to ensure timely acceptance of claims and to avoid audits and potential fines.

CPT Codes for Mental Health Tests and Assessments

CPT codes are essential to the health insurance billing process. CPT stands for Current Procedural Terminology and it is a uniform coding system developed by the American Medical Association in 1966. CPT codes are five-digit numeric codes that describe medical procedures performed on a patient, including tests, evaluations, surgeries and other practices. CPT codes are necessary to receive reimbursement from health insurance companies.

• 96105: Aphasia assessment
• 96110: Developmental screening
• 96112: Developmental test administration with interpretation
• 96113: Each additional 30 minutes of developmental test administration with interpretation
• 96116: Neurobehavioral status exam, 60 minutes
• 96121: Each additional hour of neurobehavioral status examination
• 96125: Standardized cognitive performance testing, 60 minutes
• 96127: Brief emotional or behavioral assessment
• 96130: Psychological testing evaluation services provided by a physician or qualified health professional, 60 minutes
• 96131: Each additional hour of psychological testing evaluation services performed
• 96132: Neuropsychological testing services, 60 minutes
• 96133: Each additional hour of neuropsychological testing services performed
• 96136: Psychological or neuropsychological test administration and scoring by a physician or qualified health professional, 30 minutes
• 96137: Each additional 30 minutes of neuropsychological test administration and scoring by a physician or qualified health professional
• 96138: Psychological or neuropsychological test administration and scoring by a technician, 30 minutes
• 96139: Each additional 30 minutes of neuropsychological test administration and scoring by a technician
• 96146: Psychological or neuropsychological test administration via an electronic platform with automated results
• 96156: Health assessment or reassessment
• 96160: Patient-focused health risk assessment
• 96161: Caregiver-focused health risk assessment

Psychological testing CPT codes are five-digit codes that psychologists and therapists use to bill insurance providers for specific psychological and neuropsychological tests. These tests help clinicians assess patients' symptoms to determine a diagnosis, which ultimately dictates the treatment plan.

CPT Codes for Telehealth

CPT codes are used to bill for telebehavioural and telemental health services and have been codified into the current Medicare Physician Fee Schedule (PFS). CPT codes are also used for billing Medicare Fee-for-Service (FFS) telehealth claims.

Medicare has expanded access to telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. This is especially important during the COVID-19 public health emergency, to help people who need routine care and to keep vulnerable beneficiaries and those with mild symptoms in their homes.

There are three main types of virtual services that physicians and other professionals can provide to Medicare beneficiaries: Medicare telehealth visits, virtual check-ins, and e-visits.

Medicare telehealth visits require the use of an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home. Medicare telehealth visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.

Virtual check-ins are brief communication services with practitioners via a number of communication technology modalities, including synchronous discussion over a telephone or exchange of information through video or image. Medicare pays for these "virtual check-ins" for patients to communicate with their doctors and avoid unnecessary trips to the doctor's office.

E-visits are non-face-to-face, patient-initiated communications with physicians through an online patient portal. These services can be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal.

99091, 98970, 98971, 98872, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99421, 99422, 99423, 99441, 99442, 99443, 99453, 99454, 99457, 99458, 99473, and 99474.

It is important to note that incorrect billing codes can delay reimbursement. It is recommended to stay up to date on the latest Medicare billing codes for telehealth to keep practices running smoothly.

How to Maximize Reimbursement and Avoid Insurance Claim Denials

Understanding the System

The first step to maximizing reimbursement and avoiding insurance claim denials is to understand the system. Current Procedural Terminology (CPT) codes are essential to the health insurance billing process and are used to describe medical procedures performed on a patient, including tests, evaluations, surgeries, and other practices. Using the correct CPT codes is critical to receiving reimbursement for your services and avoiding audits. The CPT code set is complex, and using medical codes properly requires understanding various guidelines.

Choosing the Right CPT Codes

When selecting CPT codes, it is important to consider the three distinct categories: Category I, Category II, and Category III. Category I codes are the most frequently used and have different sections based on various health care fields. Category II codes are optional and provide additional information, while Category III codes are temporary and represent new or experimental procedures.

Psychiatrists typically use CPT codes for psychiatric diagnostic evaluations, psychotherapy, and other psychiatric services. It is important to choose the correct CPT code to reflect the service provided and the patient's status as a new or established patient. For example, CPT codes 90832, 90834, and 90837 correspond to 30, 45, and 60 minutes of individual psychotherapy, respectively.

Maximizing Reimbursement

To maximize reimbursement, it is crucial to ensure correct coding, claim only what is medically necessary, and file claims on time. Inaccurate coding can lead to payment delays or rejected claims, so it is important to strive for the highest accuracy and refer to the American Medical Association's CPT manual. Additionally, claiming services that are not medically necessary will likely result in claim denials. It is important to link the appropriate International Classification of Diseases (ICD) code with the associated CPT codes to demonstrate medical necessity.

Another way to maximize reimbursement is to emphasize quality documentation. Incomplete or inadequate documentation can affect the reimbursement process, so it is important to ensure that patient information, such as name, Social Security number, date of birth, insurance payer, and policy number, is correct. Encouraging staff members to double-check documentation can help reduce errors.

Avoiding Insurance Claim Denials

To avoid insurance claim denials, it is crucial to verify insurance and eligibility before providing services. Checking that the patient's plan covers your services and that their information is up to date can help prevent denials. Additionally, automating processes, such as using electronic health record (EHR) software, can help streamline the billing process and reduce rejected claims. EHR software can also help with automatic coding, ensuring that you have the proper documentation for your billing claims.

Staying up to date with CPT code changes and insurance policies is also essential to avoiding denials. Understanding the requirements and any recent revisions can help ensure that your claims meet the necessary standards and are less likely to be rejected. Regular training and education for staff can help keep everyone informed and reduce errors.

Frequently asked questions