Accurate medical billing is crucial for the financial health of any healthcare practice, and mental health services are no exception. However, navigating the intricate world of medical codes, especially for psychotherapy, can be daunting for small practices and solo practitioners. The complexity of evolving terminologies and acronyms associated with mental and behavioral health services can easily lead to errors. Incorrect coding or missing information can result in significant revenue delays, claim rejections, and denials, impacting your practice’s bottom line.
Physicians and their administrative teams must constantly manage various code sets, including CPT, ICD-10, and DSM-5. The subjective nature of mental and behavioral health disciplines makes selecting the correct code particularly challenging. This article aims to clarify some of the most frequently used mental and behavioral health codes, providing a clearer understanding of their application in psychotherapy and mental health billing.
Understanding CPT Codes in Psychotherapy Billing
Current Procedural Terminology (CPT) codes are a standardized coding system developed and maintained by the American Medical Association (AMA). These five-digit codes are essential for reporting medical procedures and services, including psychotherapy, to insurance payers. While CPT codes are widely used in medical billing, mental healthcare professionals, including ABA therapists, also utilize other specific codes.
A significant revision of CPT codes for psychiatry, psychology, and behavioral health services occurred in 2013, and no further updates are anticipated in the near future. CPT codes primarily describe the services, treatments, or actions provided to patients. Additional “add-on” codes can be used to provide more detailed information about the services rendered.
For efficient medical billing, CPT codes are fundamental for ensuring accurate claims and timely reimbursement from insurance companies and other payers. Using incorrect CPT codes can severely disrupt your revenue cycle management, leading to claim rejections, denials, and payment delays. This is particularly true when it comes to undercoding or upcoding.
Undercoding and Upcoding: Avoiding Billing Errors in Mental Health
Undercoding Explained
Undercoding occurs when a CPT code is used that represents a less expensive treatment or a less severe diagnosis than what was actually provided. While sometimes unintentional, undercoding can also be a deliberate attempt to lower patient costs or avoid audits. Regardless of intent, undercoding is considered illegal and can have negative consequences, even if done inadvertently.
Upcoding Explained
Upcoding, conversely, involves using a CPT code that corresponds to a more expensive treatment or a more serious diagnosis. Often, upcoding is intentionally done to obtain higher reimbursement rates from payers. While unethical and potentially illegal, upcoding isn’t always malicious. It can sometimes stem from untrained staff applying incorrect codes. However, the physician remains responsible for any audits or penalties resulting from upcoding, regardless of the cause.
Common CPT Codes for Mental Healthcare Professionals
While the CPT codebook contains over 800 codes, mental health professionals primarily use a select few for psychotherapy and related services. These frequently used codes include:
- 90791 – Psychiatric Diagnostic Evaluation: Used for initial psychiatric assessments to diagnose a patient’s mental health condition.
- 90792 – Psychiatric Diagnostic Evaluation with Medical Services: Applies when the diagnostic evaluation includes medical services, such as medication management or physical examinations.
- 90832 – Psychotherapy, 30 minutes (16-37 minutes): For individual psychotherapy sessions lasting approximately 30 minutes.
- 90834 – Psychotherapy, 45 minutes (38-52 minutes): For individual psychotherapy sessions lasting approximately 45 minutes.
- 90837 – Psychotherapy, 60 minutes (53 minutes and over): For individual psychotherapy sessions lasting approximately 60 minutes or longer.
- 90846 – Family or Couples Psychotherapy, without Patient Present: Used when providing therapy to families or couples without the identified patient being present.
- 90847 – Family or Couples Psychotherapy, with Patient Present: Used when providing therapy to families or couples with the identified patient present.
- 90853 – Group Psychotherapy (not Family): For group psychotherapy sessions (excluding family therapy).
- 90839 – Psychotherapy for Crisis, 60 minutes (30-74 minutes): For psychotherapy sessions addressing acute crisis situations, lasting approximately 60 minutes.
Understanding these core CPT codes is essential for accurate billing of psychotherapy services. However, it’s equally important to recognize their relationship with ICD-10 and DSM codes.
The Interplay of CPT, ICD-10, and DSM Codes in Mental Health Diagnosis
While the limited number of frequently used CPT codes in mental health might seem manageable, their connection to ICD-10 and DSM codes adds another layer of complexity. Mental health professionals and their staff must be familiar with all three coding systems and stay updated on any revisions.
To grasp the relationship between these codes, we must first understand the link between ICD-10 and DSM-5. Both ICD-10 and DSM-5 codes are used for diagnosis, but with slight differences in their purpose and application.
ICD codes, maintained by the World Health Organization (WHO) as part of the International Classification of Diseases & Related Health Problems, are used globally for various health conditions. In the context of billing, ICD-10 codes are used alongside CPT codes for claims submitted to private insurance companies and public payers.
DSM-5 codes are found in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, published by the American Psychiatric Association. This manual serves as a taxonomic and diagnostic tool specifically for mental disorders.
Crucially, ICD-10 and DSM-5 codes are essentially aligned for mental health diagnoses. The DSM-5 acts as a guide to assist providers in selecting the most appropriate ICD-10 code for a given mental health condition. The DSM-5 was published in May 2013 and implemented in January 2014, preceding the broader healthcare transition from ICD-9 to ICD-10 in October 2015.
The DSM-5 is particularly relevant for mental health professionals as it specifically endorses and lists the majority of mental and behavioral health ICD-10 codes. This close alignment can sometimes lead to the misconception that there are separate “DSM codes” distinct from ICD codes. In reality, the DSM-5 provides guidance for using ICD-10 codes within the context of mental health.
Ultimately, the connection between an ICD-10 code and a CPT code lies in the principle of medical necessity. The diagnosis (ICD-10 code) must justify the medical necessity of the treatment or service provided (CPT code).
Furthermore, HIPAA regulations since 2003 mandate the inclusion of an ICD code in any electronic healthcare transaction for billing, reimbursement, or reporting. This means that submitting claims to insurance providers or payers requires both a CPT code detailing the service provided and an ICD-10 code clearly outlining the patient’s diagnosis that necessitates the treatment.
Common ICD-10 Codes in Mental and Behavioral Health Practice
Mental and behavioral health practitioners frequently use a specific set of ICD-10 codes. Some of the more common examples include:
- F32.9 Major depressive disorder, single episode, unspecified
- F32.0 Major depressive disorder, single episode, mild
- F32.1 Major depressive disorder, single episode, moderate
- F32.2 Major depressive disorder, single episode, severe without psychotic features
- F32.3 Major depressive disorder, single episode, severe with psychotic features
- F32.4 Major depressive disorder, single episode, in partial remission
- F32.5 Major depressive disorder, single episode, in full remission
- F32.8 Other depressive episodes
- F33.1 Major depressive disorder, recurrent, moderate
- F33.2 Major depressive disorder, recurrent severe without psychotic features
- F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
- F39 Unspecified mood [affective] disorder
- F25.9 Schizoaffective disorder, unspecified
- F25.0 Schizoaffective disorder, bipolar type
- F25.1 Schizoaffective disorder, depressive type
- F25.8 Other schizoaffective disorders
- F29 Unspecified psychosis not due to a substance or known physiological condition
- F41.9 Anxiety disorder, unspecified
- F41.1 Generalized anxiety disorder
- F41.8 Other specified anxiety disorders
- F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia
- F41.1 Generalized anxiety disorder
- F42 Obsessive-compulsive disorder
- F42.1 Agoraphobia with panic disorder
- F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type
- F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type
- F90.2 Attention-deficit hyperactivity disorder, combined type
- F90.8 Attention-deficit hyperactivity disorder, another type
- F90.9 Attention-deficit hyperactivity disorder, unspecified type
- G30.0 Alzheimer’s disease with early-onset
- G30.1 Alzheimer’s disease with late-onset
- G30.8 Other Alzheimer’s disease
- G30.9 Alzheimer’s disease, unspecified
- F31.9 Bipolar disorder, unspecified
- F31.0 Bipolar disorder, current episode hypomanic
- F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified
- F31.11 Bipolar disorder, current episode manic without psychotic features, mild
- F31.12 Bipolar disorder, current episode manic without psychotic features, moderate
- F31.13 Bipolar disorder, current episode manic without psychotic features, severe
- F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified
- F31.31 Bipolar disorder, current episode depressed, mild
- F11.20 Opioid dependence, uncomplicated
- F11.21 Opioid type dependence in remission
- F11.220 Opioid dependence with intoxication, uncomplicated
- F11.221 Opioid dependence with intoxication delirium
- F11.22 Opioid dependence with intoxication with perceptual disturbance
- F43.10 Posttraumatic stress disorder, unspecified
- F43.11 Posttraumatic stress disorder, acute
- F43.12 Posttraumatic stress disorder, chronic
- F43.23 Adjustment disorder with mixed anxiety and depressed mood
- Z79.891 Long term (current) use of opiate analgesic
- Z79.899 Other long terms (current) drug therapy
- Z03.89 Encounter for observation for other suspected diseases and conditions ruled out
This list represents some of the more frequently encountered ICD-10 codes in mental health. It’s crucial to remember that this is not exhaustive, and other conditions may require different codes. Staying informed about updates to both ICD-10 and related CPT codes for mental health is an ongoing necessity for accurate billing.
The Advantages of Outsourcing Medical Billing and Coding
For solo practitioners and small mental health practices, outsourcing medical billing and coding to a specialized third-party service like Operant Billing Solutions can be a strategic decision. Experienced professionals possess the specialized skills, meticulous attention to detail, and extensive training required to ensure claims are accurately coded before submission to payers.
Outsourcing significantly reduces the risk of claim delays, denials, and rejections, leading to a more consistent and reliable revenue stream. Furthermore, it frees up valuable time for practitioners and their staff to focus on patient care and practice growth. By entrusting billing complexities to experts, you can dedicate more energy to expanding the reach and impact of your mental health services.
