Many therapists find themselves in a challenging situation when providing couples counseling: how to reconcile the relational nature of couples therapy with the individual-focused diagnostic requirements of insurance billing. It’s a common question: How do you write a treatment plan and session notes, or bill insurance, when the couple’s issues don’t neatly fit into a single, billable diagnostic category? This dilemma frequently arises because couples seek therapy to address relationship problems, not necessarily individual mental health disorders. However, the reality of using insurance often necessitates a mental health diagnosis for reimbursement. This creates unique hurdles in diagnosing for couples counseling.
The core of the issue stems from the question, “If ‘the couple is the client,’ whose diagnosis do you use for billing?” Furthermore, what happens when no individual diagnosis seems to apply? While the therapeutic focus is on the dyad, billing structures often require identifying an “identified client” with a mental health diagnosis. Upon assessment, it may become apparent that one partner does indeed meet the criteria for an ICD-10 diagnosis. In such cases, billing under that individual’s diagnosis becomes a viable path.
However, what if neither partner presents with a clear-cut mental health disorder? In these instances, transparency is key. Explain to the couple that the positive news is they don’t meet the criteria for a mental health diagnosis. Conversely, the challenging news is that ethically, insurance cannot be billed for relationship issues devoid of an underlying mental health condition. This straightforward answer, while ethically sound, poses financial difficulties for couples reliant on insurance and income challenges for therapists.
For situations where a potential, but not yet confirmed, mental health concern exists, or when further evaluation is needed, utilizing “Adjustment Disorder Unspecified” can be a strategic initial step. It allows you to acknowledge the distress related to the marital issues. When completing authorization forms, it’s crucial to include a concise narrative detailing the couple’s challenges and their impact on the relationship. Employ behavioral language to illustrate the problems and their severity. For example, instead of saying “They argue a lot,” specify “Couple engages in verbal fights multiple times per week.” Furthermore, incorporate relevant bio-psycho-social stressors that contribute to the relational difficulties. Examples include:
- “Their children are distressed by the frequent arguments, leading to behavioral issues at home and school, which intensifies parental conflict.”
- “Client is facing potential job loss, exacerbating tension and disagreements within the couple.”
- “Client’s wife is the primary caregiver for an aging parent requiring constant care, contributing to increased irritability and marital friction.”
Often, couples seeking therapy are navigating multiple life stressors. These stressors, many of which can be coded using T and Z codes in the DSM-5, are valuable to document in authorization requests. While T and Z codes are not primary, reimbursable diagnoses, they provide crucial context and support the medical necessity for continued treatment.
It’s important to note the limitations of the Adjustment Disorder approach. Typically, Adjustment Disorders have a six-month timeframe. Prolonged use beyond this period may raise flags with insurance companies, potentially leading to claim denials or reviews. Similarly, “Unspecified Disorders” can trigger scrutiny due to their non-specific nature. However, “Adjustment Disorder Unspecified” serves as a valuable starting point, providing a window of approximately six months to gather comprehensive information, refine diagnostic impressions, and concurrently support the couple therapeutically. Significant progress can be made within six months, potentially uncovering avenues to further substantiate medical necessity and secure continued sessions to assist the couple effectively.
Resources like workshops on documenting medical necessity for psychotherapy delve deeper into these complexities and offer expanded guidance.
