Mental health has been center stage in recent years thanks to the COVID-19 pandemic. And while there’s increased awareness, mental health practitioners remain overwhelmed and under-supported.
Part of the frustration faced by providers stems from complex mental health billing. The complicated coding rules are ever-changing, making the claims process slow and frustrating.
Reimbursement for mental health is also often lower for mental health providers. A Milliman study showed that primary care reimbursements were more than 23% higher than behavioral health reimbursements. Combined with tedious billing rules, it’s no wonder many therapists are out-of-network or don’t accept insurance.
How Is Mental Health Billing Different From Medical Billing?
The primary difference between mental health billing and medical billing are the limits and restrictions insurance companies have for behavioral health claims.
Behavioral health care also involves more nuanced treatment plans. Billing for a 45-minute therapy session may not be as straightforward as billing for a yearly wellness check or lab test.
Below are some of the main differences between mental health billing and medical billing.
For most medical care, you bill a current procedural terminology (CPT) code based on the service. For example, you would use CPT code 36415 for a blood draw or code 99385 for a well-woman visit for a new patient ages 18-39.
But mental health visits can vary in the amount of time they take, which means the mental health billing codes vary, too. After a visit, you’ll bill the code that’s closest with the amount of time you spent with the patient. For example:
- 90832: 30 minutes of individual psychotherapy (fits for sessions 16-37 minutes)
- 90834: 45 minutes of individual psychotherapy (fits for sessions 38-52 minutes)
- 90837: 60 minutes of individual psychotherapy (fits for sessions 53+ minutes)
- 90846: 50 minutes of family psychotherapy without the patient/client (fits for sessions 26+ minutes)
- 90847: 50 minutes of family psychotherapy with the patient/client (fits for sessions 26+ minutes)
For most insurers, there are limits on how many mental health sessions or services you can provide in a certain period. For example, insurers may only allow one session per day or week.
It’s important to understand the limits set by your insurer. Otherwise, you may face claim denials or reimbursement problems for the mental health care you provide.
Customized Treatment Plans
Mental health care plans vary from patient to patient — there isn’t a one-size-fits-all treatment or diagnostic process. These customized care plans can result in more intricate and complicated billing.
Insurers sometimes need prior authorization (pre-authorization) before approving a patient for mental health care. This varies across insurers and may depend on the service. An initial office visit may not need pre-authorization but psychological testing may require it. An insurer may also need prior authorization for additional care after a certain number of visits.
Service Location (Telehealth)
Since the COVID-19 pandemic, more clinicians are providing mental health care via telehealth. In some cases, you may be able to bill the same CPT codes for telehealth as you would for in-person visits. But, you must add a modifier to the code.
- 95 modifier: Add this to a code if the interaction is real-time (not recorded) but done virtually via telecommunciations system (such as a video chat).
- 02 modifier: This code shows that the point-of-service (POS) for the interaction was a telecommunications system. By contrast, you would use the 11 POS code for an in-office visit.
There is also a separate set of behavioral health telemedicine billing codes under the Healthcare Common Procedural Coding System (HCPCS). These codes sometimes start with the letter “G” rather than a number. For example:
- G2010: Remote evaluation of an established patient’s recorded video
- G2012: Virtual check-in or short, patient-initiated visit
Other HCPCS telehealth codes can include:
- 99421: Online evaluation and management with an established patient; five to 10 cumulative minutes over seven days
- 99422: Online evaluation and management with an established patient; 11-20 cumulative minutes over seven days
- 99423: Online evaluation and management with an established patient; 21+ cumulative minutes over seven days
Because many mental health providers are out-of-network, they often use superbills to collect payments. Submitting a superbill can sometimes speed up the reimbursement process. Superbills can be an alternative to joining an insurance panel and becoming in-network.
With mental health becoming a bigger part of the healthcare landscape, billing rules and regulations are always changing. Many of the telehealth codes, for example, were added during the COVID-19 pandemic. The Centers for Medicare and Medicaid Services (CMS) continues to update its telehealth fee schedules.
Staying on top of these changes can be challenging, especially if you run a small practice with limited staff. But if you’re not aware of these changes, you could be submitting incorrect claims that hamper your revenue cycle and slow down reimbursement.
Schedule a Risk-Free Medical Billing & Revenue Cycle Analysis Today!
Mental Health Billing Tips
There’s no denying the fact that behavioral health billing is complex. What’s more, mental health practices are often small — in most cases, there may not be a billing team to help with claim submission and coding.
But that doesn’t mean that your practice should go underpaid or worse — unpaid. Following these tips can help make sure you’re optimizing billing for mental health services and maximizing reimbursements.
Use a Reliable Insurance Eligibility Tool
Verifying benefits is the most important part of the revenue cycle management (RCM) process. If you don’t understand the patient’s coverage before their appointment, you could lose the claim from the get-go.
Having a reliable and instant eligibility tool is a great start. It’s also helpful if your eligibility tool can automate some of the processes for you (this is especially helpful for those small practices). Ideally, the tool can automatically check patient benefits for the week’s schedule and notify you if there are any issues or expired plans.
Maintain Detailed Documentation
Detailed patient documentation will help you with both prior authorizations and claim appeals. Aside from accurate demographic information, make sure you have specifics on diagnosis, medications and treatments. It’s also helpful to document all steps in the prior authorization process if it’s needed.
Understand Nuances for Each Payer
Every payer is different, which means each one will have different forms and criteria you need to file claims. Even if you’re only working with one or two payers, it’s important to understand the nuances of each to avoid claim rejections or denials.
Start the Billing Process ASAP
Don’t wait to file your claims. Since the process is often drawn out and complicated, starting as soon as possible will help make sure you’re getting paid in a timely manner.
Partner With an RCM Expert
If you find your practice is struggling to manage a healthy reimbursement process, it might be time to partner with an RCM expert. You could add a smart software solution to augment your existing team. The software can provide automated claim workflows that save time and reduce errors.
Or, you may want to consider a fully-managed RCM solution. This option comes with a team of revenue cycle experts who know how to maximize your reimbursements.
Whether you’re looking for that software solution or the full support of an RCM team, Gentem has you covered. We provide physician-designed technology that increases reimbursements and reduces administrative costs for behavioral health practices.
Book a risk-free demo today and see for yourself.