Maximizing Reimbursement: Navigating Insurance Billing For Telehealth Psychotherapy

Billing insurance for telehealth psychotherapy can be a complex process, requiring correct medical claims coding, modifiers, and place of service codes. The process varies depending on the insurance company and the patient's specific plan. It is important to verify coverage and understand the requirements and restrictions of the insurance provider before billing. Some insurance companies may require prior authorization or have specific codes and modifiers that need to be used for telehealth services. Additionally, it is crucial to gather necessary patient information, including demographic and insurance details, to submit accurate claims.

Confirm patient's insurance coverage before appointments

Confirming a patient's insurance coverage before their appointment is crucial to ensure smooth billing and reimbursement processes. Here are some detailed steps to verify insurance coverage for telehealth psychotherapy:

• Gather Patient Information: Obtain the patient's demographic and insurance details, including their full name, date of birth, address, gender, phone number, email address, and insurance subscriber ID. Having a copy of the front and back of their insurance card is also helpful.
• Contact the Insurance Provider: Using the customer service phone number on the insurance card, call to verify coverage for mental health services. Ask about eligibility and benefits for outpatient mental health benefits.
• Provide Necessary Details: During the call, provide the insurance company with your National Provider Identifier (NPI) and Tax ID. Also, give them the patient's name, date of birth, and subscriber ID.
• Inquire about In-Network Status: Ask if you are considered an in-network or out-of-network provider for the patient's plan. This will impact billing and reimbursement rates.
• Check Telehealth Coverage: Specifically, ask if the patient's insurance plan covers telehealth psychotherapy sessions. If so, inquire about any specific modifiers (e.g., 95 or GT) or place of service codes (e.g., POS Code 02) they require for billing.
• Obtain Reimbursement Information: Confirm the claims submission process, including the claims address and payer ID. Additionally, ask about the patient's deductible, copay, and coinsurance to understand their financial responsibility.
• Document the Conversation: Take detailed notes during the call, including the date, time, representative's name, and any reference or confirmation numbers provided. This documentation will be essential for future reference and billing purposes.
• Follow up with the Patient: After confirming coverage details, communicate the relevant information to the patient. Let them know about any out-of-pocket expenses they may incur and address any questions or concerns they may have.

By following these steps, you can ensure that you have the necessary information to bill the patient's insurance correctly and avoid surprises for both you and the patient regarding coverage and reimbursement.

Learn the CPT codes for mental health 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 performed on a patient, including tests, evaluations, surgeries, and other practices. CPT codes are necessary to receive reimbursement from health insurance companies.

The CPT codes related to mental health services 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 counsellors, licensed marriage and family therapists, and licensed clinical social workers.

The mental health CPT codes used by therapists are organized into four distinct categories: Psychiatric Diagnostic Interview, Psychiatric Therapeutic Services, Family Medical Psychotherapy, and Common Mental Health CPT Codes.

• 90832 - Psychotherapy, 30 minutes
• 90834 - Psychotherapy, 45 minutes
• 90837 - Psychotherapy, 60 minutes
• 90846 - Family psychotherapy (without the patient present), 50 minutes
• 90847 - Family psychotherapy (with the patient present), 50 minutes
• 90853 - Group psychotherapy (not family)
• 90839 - Psychotherapy for crisis, 60 minutes
• 90840 - Add-on code for an additional 30 minutes of psychotherapy for crisis
• 90785 - Interactive complexity add-on code
• 90863 - Pharmacologic management after therapy
• 99050 - Services provided outside regular office hours
• 99051 - Services provided during evenings, weekends, or holidays
• 99354 - Additional time after 74 minutes of psychotherapy
• 99355 - Additional time after the first 60 minutes of psychotherapy

It is important to note that CPT codes are updated annually and may change, so it is essential to refer to the most recent CPT manual to ensure accurate coding.

Verify eligibility and benefits for behavioural health services

Before billing for telehealth psychotherapy, it is important to verify eligibility and benefits for behavioural health services. This process can be complex and time-consuming, but it is crucial to ensure that you will be reimbursed for your services. Here is a detailed guide on how to verify eligibility and benefits:

• Gather necessary information: Collect the client's demographic and insurance information, including their full legal name, date of birth, address, gender, phone number, email address, and insurance subscriber ID. You may also need your National Provider Identifier (NPI) and Tax ID.
• Review the client's insurance card: Call the customer support number or mental health number on the back of the client's insurance card. This number may also be listed as pre-certification or the number for eligibility and benefits.
• Verify eligibility and benefits: When you call the insurance company, ask to check "eligibility and benefits for outpatient mental health benefits". Provide them with your NPI, tax ID, and office location. Give them the client's name, date of birth, and subscriber ID.
• Confirm in-network status: Ask the insurance company if you are in-network or out-of-network with the client's plan. This will impact reimbursement rates and coverage limits.
• Obtain approval for telehealth sessions: Ask if they have approval for telehealth sessions and, if so, write down the modifier that the insurance company requires you to use (usually 95 or GT). If they do not have approval, inquire about how to obtain it.
• Confirm claims submission information: Get the claims submission address and payer ID from the insurance company. This information is necessary for submitting your claims.
• Get a reference number: Ask for a reference number, date, time, and the representative's name for your call. This information can be useful if you need to reference the call in the future or if there are any discrepancies.
• Verify coverage for private insurance: If the client has private insurance, it is important to verify coverage by checking the insurance provider's policy or requesting the client to confirm coverage before each appointment.
• Check state-specific Medicaid coverage: If the client has Medicaid, check your state's current laws and reimbursement policies to see what telebehavioural and telemental health services are covered.
• Review Medicare billing guidelines: If the client has Medicare, familiarise yourself with their telehealth billing guidelines, such as the required CPT codes, Place of Service code (02), and telehealth modifiers.
• Consider using a billing service: The process of verifying eligibility and benefits can be tedious and time-consuming. Consider outsourcing this task to a specialised billing service, which can handle insurance billing on your behalf.

Understand telehealth billing requirements for Medicare

Billing for telehealth psychotherapy services under Medicare is a complex process that requires knowledge of the correct medical claims coding, CPT codes, modifiers, and place of service code. Here is a detailed guide to help you understand the telehealth billing requirements for Medicare:

CPT Codes and Modifiers:

• Current Procedural Terminology (CPT) codes are used to bill for telehealth psychotherapy services. Examples of CPT codes for psychotherapy include 90832, 90834, and 90837.
• Modifiers are appended to CPT codes to indicate that the service was provided via telehealth. Common modifiers for Medicare include "GT" and "95", with "GT" being a legacy code. Since 2017, Medicare has only required the Place of Service code without the GT modifier.

Place of Service Code:

The Place of Service code for telehealth services is typically "02", indicating that the service was provided remotely and not in the patient's home. However, during the COVID-19 public health emergency, Medicare also allowed the use of the Place of Service code "10" for services provided in the patient's home.

Telehealth Service Requirements:

• Medicare has specific requirements for telehealth services to be reimbursable. Services must be provided using interactive telecommunications systems, such as video teleconferencing, with two-way, real-time interactive audio and video capabilities. Telephones, fax machines, and email systems do not meet these requirements.
• Medicare reimburses for both audio-only and audio-visual telehealth services. However, reimbursement for audio-only services is currently only covered through December 31, 2024.
• Medicare Advantage plans may offer more telehealth benefits than Medicare Part B. For example, they can provide services to patients in their homes and outside of rural areas.

Eligible Providers and Licenses:

• Medicare has a list of eligible providers who can bill for telehealth services, including nurse practitioners, physician assistants, clinical nurse specialists, clinical psychologists, and clinical social workers.
• It's important to note that some providers, such as clinical psychologists and social workers, cannot bill Medicare for certain services, such as psychiatric diagnostic interview examinations.

Reimbursement and Cost-Sharing:

• Medicare Part B covers certain telehealth services, and beneficiaries pay the same amount as they would for in-person services after meeting the Part B deductible.
• During the COVID-19 public health emergency, Medicare paid for telehealth services as if they were administered in person, with payment rates varying based on the provider's location.
• Medicare Advantage plans have the flexibility to waive or reduce cost-sharing requirements for telehealth services during emergencies.

Billing Process:

• To bill Medicare for telehealth psychotherapy services, providers must submit claims using the appropriate CPT codes and the correct Place of Service code.
• It is recommended to verify eligibility and benefits, gather patient demographic and insurance information, and understand the specific requirements of Medicare before submitting claims.

Submit claims with the correct information

Submitting claims with the correct information is a crucial step in the telehealth billing process for psychotherapy services. Here are the key points to keep in mind:

• Use the appropriate CPT codes: CPT (Current Procedural Terminology) codes are standardised codes used to describe medical services provided by healthcare professionals. For telehealth psychotherapy, the CPT codes you should use include 99201-99215 for evaluation and management services, 90832-90838 for individual psychotherapy, 90846 for family psychotherapy without the patient present, and 90847 for family psychotherapy with the patient present. These codes ensure that your services are accurately represented and billed accordingly.
• Select the correct Place of Service code: The Place of Service code indicates the location where the healthcare service is provided. For telehealth services, the Place of Service code is typically 02, which signifies that the service is provided remotely and not in the patient's home. However, starting in 2022, some insurance companies have implemented the new Place of Service code 10 for telehealth services provided in the patient's home.
• Determine the required telehealth modifier: A telehealth modifier is added to the CPT code to indicate that the service was provided via telehealth. While Medicare no longer requires a telehealth modifier as of 2017, other insurance companies may still require it. The most commonly used telehealth modifiers are "GT" and "95". It is important to verify with each insurance company what modifier they require for telehealth billing.
• Verify patient information: Before submitting a claim, ensure that you have accurate and up-to-date patient information, including their full legal name, date of birth, address, gender, phone number, email address, and insurance details. This information is necessary for claim processing and reimbursement.
• Include diagnosis codes: It is essential to include specific diagnosis codes on your claims. Avoid using unspecified diagnoses, as they may be rejected by Medicare and other insurers. Use the ICD10 Mental Health Diagnosis Code Search Tool to select the most accurate diagnosis for each session.
• Follow up on pending claims: After submitting your claims, keep track of their status. If you have mailed your claims, wait for about four weeks before calling to verify if they have been received. If they have not been received, double-check the claims address and resubmit. Stay within the timely filing window specified by the insurance company, which is typically 90 days.
• Handle denials and rejections: If your claims are denied or rejected, don't hesitate to reach out to the insurance company to understand the reason. Denials and rejections can occur at the Clearinghouse level or the insurance company level. Work closely with the insurance provider to correct any issues and resubmit the claims as necessary.
• Utilise billing software or services: To streamline the claim submission process, you can use billing software such as "PracticeMate" by OfficeAlly or consider engaging professional billing services that specialise in mental health billing. They can help take care of the administrative burden and ensure accurate and timely claim submissions.

Frequently asked questions