SAMSHA White Paper on MH Billing Codes in the Public Sector

This white paper written by SAMSHA's Center for Mental Health Services is an overview of the states' mental health billing codes. See this link: http://www.hipaa.samhsa.gov/pdf/Ex_States_Billing_Codes_public_MH_Services.pdf

What Services and Codes are not reimbused?

V codes are rarely covered by insurers. We have also seen instances of claims denials when a V code was used as a secondary diagnosis. Best not to use V codes for billing purposes.

Telephone therapy is typically not reimbursed by payers.

Telepsychiatry is reimbursed by many private insurers, but not by all. Telepsychiatry services in nursing homes and community mental health centers are reimbused by Medicare. Medicaid also reimburses for telepsychiatric services in 24 states.

Certain diagnoses are also not covered, depending on the payer. Commonly excluded diagnoses include:
-Mental Retardation
-Learning Disabilities
-ADHD Adult
-ADHD Child
-Substance abuse
-Self inflicted injuries

Also, intensive outpatient services such as partial hospital or intensive outpatient (IOP) services are often excluded.

Insurers publish a certificate of coverage which describes what mental health services are covered and what are excluded.

All About Clearinghouses

Most claims are routed to payers via clearinghouses. There are hundreds of clearinghouses. Clearinghouses are depots where the electronic claims are dropped off. The clearinghouse checks the dropped off claims, makes sure they are configured correctly and then sends them on to the payer for processing.

Clearinghouses got started before HIPAA, in the days when there was little in the way of standardization and when different payers had different requirements for payment. The first clearinghouses took the paper HCFAs (as well as electronic formatted claims) submitted by the doctor’s office, formatted the claims to meet the specific requirements of the payer, and then sent them to the payer in the digital format the payer accepted. Thus clearinghouses were switchboard operations that could translate incoming claims into the format used by specific payers.

HIPAA was designed to create one standard language for claims. That language is called x12. Some thought that this would eliminate the need to have clearinghouses: out of the Babel of competing languages the universal language of X12. Even though all payers are now required to accept and use X12 exclusively, this has not eliminated clearinghouses. As it happens payers can configure their claims requirements in a limitless number of idiosyncratic ways. Clearinghouses are expert at dealing with this complexity and so they live on.

Clearinghouses are the depots where electronic claims are routed. If the claim sent in has missing data, is not configured correctly, etc most clearinghouses will send back feedback indicating as much. There are some pieces of information clearinghouses do not have, e.g. subscriber ID, eligibility, etc. So even if a claim is passed by the clearinghouse to the payer, it may get rejected at the payer level because the client is no longer covered or the subscriber # is incorrect and so on.

Some clearinghouses are free, e.g. Availity; most you have to pay for. One of the great privileges of being a behavioral health clinician is that in most instances you must pay to get paid. Free clearinghouses like Availity are paid by the payers for routing clean electronic claims to them. Insurers save money when they don’t have to deal with paper claims (you need staff to open them, scan them, correct the illegible input, etc), so paying a clearinghouse a small amount per claim to route claims to them is a net savings.

However, not all payers deal with Availity or other free clearinghouses. The Anthem for profit Blue Cross Plans only connect with clearinghouses that charge, for instance. Most non-profit Blue Cross Plans use Availity.


Let’s take a look at the price for some clearinghouses.

Availity--free for unlimited claims they connect to electronically. (Availity connects electronically to over 1500 payers) They offer to send claims in paper HCFA format onto those who they don’t connect to for $.38 per claim.

ENS--up to 100 claims $49.95/month setup $200

Gateway EDI--unlimited claims $85 /$114/mo per clinician

I-Plexus--$.15 per claim

Clearinghouses offer additional services, e.g. real time eligibility look-up, electronic remittance advice, etc.

Are Billing Services Worth it?

Most billing services charge a percent of claims paid, often 5 to 9%. For this they provide one or more of the following services:
· Electronic filing of insurance claims
· Patient billing (self-pay, co-pays)
· Authorizations (initial and tracking)
· Payment posting (including electronic payment advise)
· Follow up on unpaid or improperly processed claims
· Reports, e.g. aging, etc
· Benefit verification
The trade off for the peace of mind that the billing and patient accounting will be done promptly and well is cost. Billing services can easily run even part-time therapists hundreds of dollars per month.
The argument against billing services is that billing is not that complicated: a clinician with a good system after working out the kinks will spend less than an hour a month to get the same results as a billing service. So the question: is an hour of time worth the hundreds of dollars a month paid to a billing service? To some the answer may be yes. To most, the answer is no.
For those opting to do billing themselves, the biggest hurdle is getting set up. The first question is which claims system to use. Prices vary.
Therapist Helper, the most widely used behavioral health billing system, charges a sign up fee of $75 and a yearly support fee of $329 per year for one provider ($45 for each additional clinician). Ongoing fees are: monthly fee of $10.00 per provider, plus $.27 per claim. Thus for a solo practitioner sending in 100 claims per month, the monthly fee be over $60 per month. A larger practice would achieve some efficiencies but the price for claims would still likely exceed $50 per month per clinician. Therapist Helper charges part-time clinicians the same amount as full time clinicians. Other healthcare billing systems, such as NueMD, are terribly expensive, starting at well over $200 per clinician.
A cheaper alternative is CarePaths e-Record. The e-billing module costs $20 per month per clinician. For the eRecord (includes EMR) the price is just $35.

Reimbursement of Telepsychiatric Services

Telepsychiatry services are two-way, interactive video (or store-and-forward technology consultations) between a clinician and a patient. Psychiatry and behavioral health are particularly suitable applications for this technology. As more and more laptop computers come with built-in, high resolution cameras, telepsychiatric consultation has become increasingly feasible.

Medicare
As of Jan 1, 2009, Medicare will cover telepsychiatric services in nursing homes and community mental health centers.

Medicaid
State Medicaid programs may choose to include telemedicine as an optional benefit; currently, 24 states allow reimbursement of services provided via telemedicine for reasons that include improved access to specialists for rural communities and reduced transportation costs (http://www.cms.hhs.gov/home/medicaid.asp).

In the 24 states, the most common reimbursable services are behavioral/mental health diagnostic consultations or treatment. When billing for telemedicine, states generally use a modifier to existing CPT codes to identify a telemedicine claim. However, practitioners in some states that reimburse for telemedicine state that billing rules are complicated and repeated claims denials had discouraged some providers from seeking reimbursement.

Private Payers
Many private payers, including most Blue Cross plans, cover telepsychiatric behavioral services. However, there is no federal mandate to cover these services and not all payers will reimburse for them.

Behavioral health CPT codes for patients with a physical diagnosis

There are six reimbursement codes for health and behavior assessment and intervention. These codes apply to behavioral, social, and psychophysiological procedures for the prevention, treatment or management of physical health problems.

The health and behavior assessment and intervention codes

96150 – the initial assessment of the patient to determine the biological, psychological, and social factors affecting the patient’s physical health and any treatment problems.

96151 – a re-assessment of the patient to evaluate the patient’s condition and determine the need for further treatment. A re-assessment may be performed by a clinician other than the one who conducted the patient’s initial assessment.

96152 – the intervention service provided to an individual to modify the psychological, behavioral, cognitive, and social factors affecting the patient’s physical health and well being. Examples include increasing the patient’s awareness about his or her disease and using cognitive and behavioral approaches to initiate physician prescribed diet and exercise regimens.

96153 – the intervention service provided to a group. An example is a smoking cessation program that includes educational information, cognitive-behavioral treatment and social support. Group sessions typically last for 90 minutes and involve 8 to 10 patients.

96154 – the intervention service provided to a family with the patient present. For example, a psychologist could use relaxation techniques with both a diabetic child and his or her parents to reduce the child’s fear of receiving injections and the parents’ tension when administering the injections.

96155 – the intervention service provided to a family without the patient present. An example would be working with parents and siblings to shape the diabetic child’s behavior, such as praising successful diabetes management behaviors and ignoring disruptive tactics.

How these services differ from psychotherapy

Until now, almost all intervention codes used by psychologists involved psychotherapy and required a mental health diagnosis, such as under the DSM-IV. In contrast, health and behavior assessment and intervention services focus on patients whose primary diagnosis is physical in nature.

The codes capture services addressing a wide range of physical health issues, such as patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness. In almost all of these cases a physician will already have diagnosed the patient’s physical health problem.

If a mental health clinician is treating a patient with both a physical and mental illness he or she must pay careful attention to how each service is billed. The health and behavior codes cannot be used for psychotherapy services addressing the patient’s mental health diagnosis nor can they be billed on the same day as a psychiatric CPT code. The clinician must report the predominant service performed.

Use of the codes will enable reimbursement for the delivery of psychological services for an individual whose problem is a physical illness and does not have a mental health diagnosis. Since these codes are new, reimbursement rates from the private sector have not been determined. However, it is important that psychologists begin to use these codes now to accurately capture the services provided.

New codes to be paid with physical health dollars in Medicare

When providing outpatient care to Medicare beneficiaries, services for these patients will be reimbursed at a higher rate than psychotherapy because under current Federal regulations, the outpatient mental health treatment limitation does not apply to these new services (it only applies to services provided to patients with a mental, psychoneurotic, or personality disorder identified by an ICD-9 CM diagnosis code between 290 and 319). For example, Medicare would reduce the approved amount of a 45-minute outpatient psychotherapy session by 62.5% and then reimburse 80% of the remainder, resulting in a payment of approximately $48. In contrast, Medicare would reimburse a 45-minute outpatient health and behavior intervention for an individual at 80% of the approved amount, or approximately $59.

Federal reimbursement for the health and behavior assessment and intervention codes will come out of funding for medical rather than psychiatric services and will not draw from limited mental health dollars. For private third party insurance we expect these services to be treated under the physical illness benefits of a plan and thus not be subjected to the higher outpatient consumer co-payment found in Medicare or relegated to behavioral health “carve out” provisions.

What non-physician practitioners are eligible for Medicare Part B for reimbursement?

Non-physician practitioners who are authorized under Medicare Part B programs to furnish mental health services include clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants. Medicare does not pay marriage and family therapists or licensed professional counselors for their mental health services.

Most Common CPT Codes used by Non-MD Behavioral Clinicians

Current Procedural Terminology or CPT codes are used by psychologists and other mental health professionals in order to bill their services to an insurance company or Medicaid. The following is a list of some of the most commonly used CPT codes in mental health and psychology services.

90801
Psychological Diagnostic Interview Examination (Includes report prep time 90885)

90802
Interactive Diagnostic Interview (with language interpreter or other mechanisms

90816
Individual medical psychotherapy, 20 - 30 minutes for Inpatient (Outpatient = 90804)

90818
Individual medical psychotherapy, 45 - 50 minutes for Inpatient (Outpatient = 90806)

90821
Individual medical psychotherapy, 75 - 80 minutes for Inpatient (Outpatient = 90808)

90847
Family Psychotherapy with patient Present (90846 without patient present; 90849 Multiple-family group psychotherapy)

90853
Group psychotherapy

96101
Psychological testing, interpretation and reporting per hour by a psychologist (Per Hour)

96102
Psychological testing per hour by a technician (Per Hour)

96103
Psychological testing by a computer, including time for the psychologist’s interpretation and reporting (Per Hour)

96105
Assessment of Aphasia

96111
Developmental Testing, Extended

96115
Neurobehavioral Status Exam (Per Hour)

96116
Chart Review, Scoring and Interpretation of Instruments, Note-Writing

96118
Neuropsychological testing, interpretation and reporting per hour by a psychologist

96119
Neuropsychological testing per hour by a technician

96120
Neuropsychological testing by a computer, including time for the psychologist’s interpretation and reporting

96150
Health & Behavioral Assessment – Initial

96151
Reassessment

96152
Health & Behavior Intervention - Individual

96153
Health & Behavior Intervention - Group

96154
Health & Behavior Intervention – Family with Patient

96155
Health & Behavior Intervention – Family without Patient

97770
Cognitive Rehabilitation