Which of the following documents must a medical assistant provide for a patient to submit for reimbursement?

• By Ritu Bhatnagar

During these difficult and uncertain times, psychotherapy and mental health services are more important and more in-demand than ever.

As such, psychotherapy medical billing guidelines are also more important than ever.

Whether you’re a psychiatrist (MD), licensed clinical social worker (LCSW), clinical psychologist (PsyD or PhD), or licensed professional counselor (LPC), CPT codes are how mental health professionals across the country get paid for their essential work.

Is your practice considering adding an additional office location or providing teletherapy services?

Will your EMR allow you to stay HIPPA compliant while incorporating Centers for Medicare and Medicaid Services changes in behavioral health guidelines?

If so, it is crucial that your practice stay up to date on current changes in psychotherapy medical billing and coding.

Psychotherapy Medical Billing & Coding Guide for 2022

Neolytix has compiled this psychotherapy medical billing 101-guide to help mental health practices everywhere get up to speed with the new rules.

This guide was written by our expert team of medical billers and coders. It examines core topics of psychotherapy medical billing and coding such as:

• The different types of CPT codes used in psychotherapy medical billing
• The definitions and requirements for each code
• Which healthcare providers bill for which codes
• Applicable modifiers for codes
• Rules of proper documentation

Psychotherapy notes are kept confidential and excluded from an individual’s right under HIPAA to access protected health information. However, the healthcare professional is still required to maintain adequate documentation for each encounter.

As a growing mental health practice, your success hinges on understanding the ins and outs of psychotherapy medical billing.

This guide will show you how to do just that. It is based on ICD-10-CM, which took effect in October of 2021 and will apply for calendar year 2022.

Short Handed? Try Hourly Services

Complex reimbursement rules and not enough time chasing claims.
We can help.

Table of Contents

Commonly Used CPT Codes in Psychotherapy Medical Billing

There are many CPT codes currently used by mental health professional that can be reported under the following categories:

1. Health Behavior Assessment and Intervention (CPT codes 96156-96171)
2. Psychotherapy Codes (CPT codes 90832-90863)
3. Psychological and Neuropsychological Testing Codes (CPT codes 96105-96146)

Listed below are the most common psychotherapy CPT codes, as well as which healthcare professionals can report which codes.

This is not a comprehensive list of CPT codes. It is simply a general description of commonly performed mental health services.

Small Practice Solutions

Solopreneur practices benefit most from using hourly services for billing.
No long term commitments.

When to Use Psychotherapy CPT Codes

The treatment of mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, revere or change maladaptive patterns of behavior, and encourage personality growth and development.

As such, individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy.

Psychotherapy CPT codes should not be used when other CPT codes are more appropriate. For example, for some services an evaluation and management (E/M) or pharmacological code may be more fitting.

Important! All psychotherapy CPT codes are time-based. The time for a psychotherapy code is defined as the time spent with the patient and/or patient’s family.

While time for each code is specified in increments of 30, 45, or 60 minutes, the coding manual actually allows for some flexibility. Luckily, the American Academy of Child & Adolescent Psychiatry (AACAP) has developed a rule for recording time accurately when it does not match the exact time increments specified in the CPT code. The rule is:

All mental health professionals who deliver psychotherapy services, including psychologists, psychiatrists, nurses, and social workers, use the same applicable CPT codes.

They use them when billing clients and when filing CMS-1500 claim forms with third-party payers such as Medicare, Medicaid, and private health insurance carriers.

Finally, what’s the difference between report E/M CPT codes and psychotherapy CPT codes? The following table explains the key distinctions:

Are you worried about receiving and validating all the necessary info for your psychotherapy services on time? Consider these custom online fillable forms from Practice Tech Solutions.

Different CPT Codes for Psychotherapy Services Rendered

Each CPT code describes a specific medical, diagnostic, or surgical procedure or service. These codes were created by the AMA to reflect the service rendered by the provider. In choosing a CPT code, the medical coder must select the code that best reflects the service rendered by the healthcare professional.

Below we look at three CPT codes in detail to better understand the requirements of performing and documenting certain psychotherapy services.

CPT Code 90791: Psychiatric diagnostic evaluation

This CPT code is used to describe an initial visit with a new patient. This visit may include diagnostic assessment or reassessment but not psychotherapy services.

During the visit, the provider performs a psychiatric diagnostic evaluation. This involves the assessment of the patient’s psychosocial history and current mental status. It also involves reviewing and ordering diagnostic studies and making appropriate treatment recommendations.

The provider interacts face-to-face with the patient, makes a mental health diagnosis, and develops a treatment plan suitable for that diagnosis.

As such, medical documentation must show that this is a new patient and document the interactions with the patient.

CPT Code 90832: Psychotherapy; 30 minutes with patient

Psychotherapy includes a wide variety of treatment techniques. A mental health professional helps a patient with a mental illness or behavioral disturbance. They work to identify and alleviate emotional disruptions, maladaptive behavioral patterns, and contributing or exacerbating factors.

Psychotherapy treatment also involves encouraging personality growth and development through coping techniques and problem-solving skills.

Here, the provider will record the face-to-face time with a patient as 30 minutes (family or other informers may also be present). This is because certain insurance payers will not reimburse if the time of service is less than 30 minutes.

The provider will document pharmacologic management in time allocated to psychotherapy service codes. Basic pharmacologic management is included when reporting psychotherapy and E/M code together.

CPT Code 90839: Psychotherapy for crisis; first 60 minutes

This CPT code is used for emergency sessions. The patient may be in high distress or under complex or life-threatening circumstances that demand immediate attention.

For this code to apply, the presenting problem must typically be highly complex or life-threatening. During the encounter, the provider must document:

• A 60-minute session with start and stop time (30–74 minutes).
• A preliminary assessment of risk, mental status, and medical stability.
• The need for further evaluation or referral to other mental health services, if applicable.
• Communication with contacts who may have pertinent information for the assessment of the patient, such as provision of psychotherapeutic intervention to minimize emotional trauma.
• Substance use, if applicable.
• Outcome of the session.

Rejected Claims?

Not sure why Insurance is rejecting your simple claims?
Ask us for Help!

Incident-To Guidelines in Psychotherapy Medical Billing

It is common for multiple healthcare professionals to work together in providing care for patients. When a non-physician provider furnishes services to a physician professional, incident-to guidelines are used for billing under the provider’s NPI.

According to the Medicare Benefit Policy Manual, incident-to is defined as:

Services that are furnished incident to a physician’s professional services when the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness and services are performed in the physician’s office.

The physician professional in the medical documentation must clearly note the incident-to guidelines when work is performed by a non-physician provider. The following information must be included:

• Documentation entries must have co-signature or legible identity and credentials(i.e., MD, DO, NP, PA, etc.) of both the practitioner who provided the service and the supervising physician.
• Some indication of the supervising physician’s involvement with the patient’s care. This indication could be satisfied by:
  • Notation of supervising physician’s involvementwithin the text of the associated medical record entry. The degree of involvement must be consistent with clinical circumstances of the care.
  • Documentation from other dates of servicethan those requested (the initial visit, for example). This establishes the link between the two providers.

Modifiers Used in Psychotherapy Medical Billing

Modifiers are used to show that a medical service or procedure has been altered by some specific circumstance but has not been changed in its definition or code.

Psychotherapy medical billing does not have any modifiers associated with it. However, you should review your insurance carriers to see if they require any local modifiers. For example, if psychotherapy is conducted via teletherapy, an applicable telemedicine modifier may be required.

Proper Documentation for Psychotherapy Medical Billing

Documentation plays the essential role of explaining the medical necessity of procedures rendered by the provider. All documentation must comply with legal/regulatory requirements of the state in which the provider practices.

Psychotherapy notes should not be included in the medical records. This is because they are excluded from the rights of access to protected health information.

All medical records should include:

• Date of service and provider information
• History
• Observations and type of therapy
• Diagnoses
• Medications
• Progress and follow-up
• E/M documentation if applicable

If you’re a little uncertain about documentation, or just don’t have the time, consider hiring a virtual medical assistant. VAs can handle all sorts of administrative and clerical tasks with expertise and efficiency.

Most Common Reasons for Psychotherapy Claim Denials

1. Incorrect patient insurance and coverage: Always verify patient information and coverage. Many times, mental health services are offered by a third-party insurance. Thus, it is critical to conduct a verification of benefits yourself.
2. Incorrect CPT codes: CPT codes change rapidly. Your practice should keep their superbills updated to the most accurate CPT codes set by AMA.
3. Inaccurate time-based codes: This is another frequent error. If a CPT code is time-based, ensure that the units of service are accurate.
4. Timely filing: Make sure all claims are submitted on time. Missing even one deadline can cause major delays in filing and reimbursement.

Bundle & Save!

We provide volume discounts to solo practices.
Learn how!

Conclusion

In conclusion, we hope this guide has helped you and your practice understand the basics of psychotherapy medical billing and coding. No matter your field, all providers must complete the proper medical documentation, explain the medical need for services rendered, and submit clean claims to insurance companies.

If the documentation is clear and well written, billing is easy. Make a habit of keeping up to date on the latest changes in psychotherapy medical billing, and you’ll save yourself a lot of trouble down the road.

Looking for some quick assistance with your psychotherapy medical billing?

Neolytix offers a full selection of medical billing services. We work with therapists and mental health professionals across the country to optimize their billing processes and boost their cash flow.

Reach out to us anytime, or complete the from below for a free consultation.

Get Help with Billing, Credentialing, & Virtual Assistants - Work With A Team of Experts

Contact Us

During these difficult and uncertain times, psychotherapy and mental health services are more important and more in-demand than ever.

As such, psychotherapy medical billing guidelines are also more important than ever.

Whether you’re a psychiatrist (MD), licensed clinical social worker (LCSW), clinical psychologist (PsyD or PhD), or licensed professional counselor (LPC), CPT codes are how mental health professionals across the country get paid for their essential work.

Is your practice considering adding an additional office location or providing teletherapy services?

Will your EMR allow you to stay HIPPA compliant while incorporating Centers for Medicare and Medicaid Services changes in behavioral health guidelines?

If so, it is crucial that your practice stay up to date on current changes in psychotherapy medical billing and coding.

Psychotherapy Medical Billing & Coding Guide for 2022

Neolytix has compiled this psychotherapy medical billing 101-guide to help mental health practices everywhere get up to speed with the new rules.

This guide was written by our expert team of medical billers and coders. It examines core topics of psychotherapy medical billing and coding such as:

• The different types of CPT codes used in psychotherapy medical billing
• The definitions and requirements for each code
• Which healthcare providers bill for which codes
• Applicable modifiers for codes
• Rules of proper documentation

Psychotherapy notes are kept confidential and excluded from an individual’s right under HIPAA to access protected health information. However, the healthcare professional is still required to maintain adequate documentation for each encounter.

As a growing mental health practice, your success hinges on understanding the ins and outs of psychotherapy medical billing.

This guide will show you how to do just that. It is based on ICD-10-CM, which took effect in October of 2021 and will apply for calendar year 2022.

Short Handed? Try Hourly Services

Complex reimbursement rules and not enough time chasing claims.
We can help.

Table of Contents

Commonly Used CPT Codes in Psychotherapy Medical Billing

There are many CPT codes currently used by mental health professional that can be reported under the following categories:

1. Health Behavior Assessment and Intervention (CPT codes 96156-96171)
2. Psychotherapy Codes (CPT codes 90832-90863)
3. Psychological and Neuropsychological Testing Codes (CPT codes 96105-96146)

Listed below are the most common psychotherapy CPT codes, as well as which healthcare professionals can report which codes.

This is not a comprehensive list of CPT codes. It is simply a general description of commonly performed mental health services.

Small Practice Solutions

Solopreneur practices benefit most from using hourly services for billing.
No long term commitments.

When to Use Psychotherapy CPT Codes

The treatment of mental illness and behavioral disturbances in which the physician or other qualified health care professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, revere or change maladaptive patterns of behavior, and encourage personality growth and development.

As such, individual psychotherapy CPT codes should be used only when the focus of treatment involves individual psychotherapy.

Psychotherapy CPT codes should not be used when other CPT codes are more appropriate. For example, for some services an evaluation and management (E/M) or pharmacological code may be more fitting.

Important! All psychotherapy CPT codes are time-based. The time for a psychotherapy code is defined as the time spent with the patient and/or patient’s family.

While time for each code is specified in increments of 30, 45, or 60 minutes, the coding manual actually allows for some flexibility. Luckily, the American Academy of Child & Adolescent Psychiatry (AACAP) has developed a rule for recording time accurately when it does not match the exact time increments specified in the CPT code. The rule is:

All mental health professionals who deliver psychotherapy services, including psychologists, psychiatrists, nurses, and social workers, use the same applicable CPT codes.

They use them when billing clients and when filing CMS-1500 claim forms with third-party payers such as Medicare, Medicaid, and private health insurance carriers.

Finally, what’s the difference between report E/M CPT codes and psychotherapy CPT codes? The following table explains the key distinctions:

Are you worried about receiving and validating all the necessary info for your psychotherapy services on time? Consider these custom online fillable forms from Practice Tech Solutions.

Different CPT Codes for Psychotherapy Services Rendered

Each CPT code describes a specific medical, diagnostic, or surgical procedure or service. These codes were created by the AMA to reflect the service rendered by the provider. In choosing a CPT code, the medical coder must select the code that best reflects the service rendered by the healthcare professional.

Below we look at three CPT codes in detail to better understand the requirements of performing and documenting certain psychotherapy services.

CPT Code 90791: Psychiatric diagnostic evaluation

This CPT code is used to describe an initial visit with a new patient. This visit may include diagnostic assessment or reassessment but not psychotherapy services.

During the visit, the provider performs a psychiatric diagnostic evaluation. This involves the assessment of the patient’s psychosocial history and current mental status. It also involves reviewing and ordering diagnostic studies and making appropriate treatment recommendations.

The provider interacts face-to-face with the patient, makes a mental health diagnosis, and develops a treatment plan suitable for that diagnosis.

As such, medical documentation must show that this is a new patient and document the interactions with the patient.

CPT Code 90832: Psychotherapy; 30 minutes with patient

Psychotherapy includes a wide variety of treatment techniques. A mental health professional helps a patient with a mental illness or behavioral disturbance. They work to identify and alleviate emotional disruptions, maladaptive behavioral patterns, and contributing or exacerbating factors.

Psychotherapy treatment also involves encouraging personality growth and development through coping techniques and problem-solving skills.

Here, the provider will record the face-to-face time with a patient as 30 minutes (family or other informers may also be present). This is because certain insurance payers will not reimburse if the time of service is less than 30 minutes.

The provider will document pharmacologic management in time allocated to psychotherapy service codes. Basic pharmacologic management is included when reporting psychotherapy and E/M code together.

CPT Code 90839: Psychotherapy for crisis; first 60 minutes

This CPT code is used for emergency sessions. The patient may be in high distress or under complex or life-threatening circumstances that demand immediate attention.

For this code to apply, the presenting problem must typically be highly complex or life-threatening. During the encounter, the provider must document:

• A 60-minute session with start and stop time (30–74 minutes).
• A preliminary assessment of risk, mental status, and medical stability.
• The need for further evaluation or referral to other mental health services, if applicable.
• Communication with contacts who may have pertinent information for the assessment of the patient, such as provision of psychotherapeutic intervention to minimize emotional trauma.
• Substance use, if applicable.
• Outcome of the session.

Rejected Claims?

Not sure why Insurance is rejecting your simple claims?
Ask us for Help!

Incident-To Guidelines in Psychotherapy Medical Billing

It is common for multiple healthcare professionals to work together in providing care for patients. When a non-physician provider furnishes services to a physician professional, incident-to guidelines are used for billing under the provider’s NPI.

According to the Medicare Benefit Policy Manual, incident-to is defined as:

Services that are furnished incident to a physician’s professional services when the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness and services are performed in the physician’s office.

The physician professional in the medical documentation must clearly note the incident-to guidelines when work is performed by a non-physician provider. The following information must be included:

• Documentation entries must have co-signature or legible identity and credentials(i.e., MD, DO, NP, PA, etc.) of both the practitioner who provided the service and the supervising physician.
• Some indication of the supervising physician’s involvement with the patient’s care. This indication could be satisfied by:
  • Notation of supervising physician’s involvementwithin the text of the associated medical record entry. The degree of involvement must be consistent with clinical circumstances of the care.
  • Documentation from other dates of servicethan those requested (the initial visit, for example). This establishes the link between the two providers.

Modifiers Used in Psychotherapy Medical Billing

Modifiers are used to show that a medical service or procedure has been altered by some specific circumstance but has not been changed in its definition or code.

Psychotherapy medical billing does not have any modifiers associated with it. However, you should review your insurance carriers to see if they require any local modifiers. For example, if psychotherapy is conducted via teletherapy, an applicable telemedicine modifier may be required.

Proper Documentation for Psychotherapy Medical Billing

Documentation plays the essential role of explaining the medical necessity of procedures rendered by the provider. All documentation must comply with legal/regulatory requirements of the state in which the provider practices.

Psychotherapy notes should not be included in the medical records. This is because they are excluded from the rights of access to protected health information.

All medical records should include:

• Date of service and provider information
• History
• Observations and type of therapy
• Diagnoses
• Medications
• Progress and follow-up
• E/M documentation if applicable

If you’re a little uncertain about documentation, or just don’t have the time, consider hiring a virtual medical assistant. VAs can handle all sorts of administrative and clerical tasks with expertise and efficiency.

Most Common Reasons for Psychotherapy Claim Denials

1. Incorrect patient insurance and coverage: Always verify patient information and coverage. Many times, mental health services are offered by a third-party insurance. Thus, it is critical to conduct a verification of benefits yourself.
2. Incorrect CPT codes: CPT codes change rapidly. Your practice should keep their superbills updated to the most accurate CPT codes set by AMA.
3. Inaccurate time-based codes: This is another frequent error. If a CPT code is time-based, ensure that the units of service are accurate.
4. Timely filing: Make sure all claims are submitted on time. Missing even one deadline can cause major delays in filing and reimbursement.

Bundle & Save!

We provide volume discounts to solo practices.
Learn how!

Conclusion

In conclusion, we hope this guide has helped you and your practice understand the basics of psychotherapy medical billing and coding. No matter your field, all providers must complete the proper medical documentation, explain the medical need for services rendered, and submit clean claims to insurance companies.

If the documentation is clear and well written, billing is easy. Make a habit of keeping up to date on the latest changes in psychotherapy medical billing, and you’ll save yourself a lot of trouble down the road.

Looking for some quick assistance with your psychotherapy medical billing?

Neolytix offers a full selection of medical billing services. We work with therapists and mental health professionals across the country to optimize their billing processes and boost their cash flow.

Reach out to us anytime, or complete the from below for a free consultation.

Get Help with Billing, Credentialing, & Virtual Assistants - Work With A Team of Experts

Which of the following actions should a medical administrative assistant take when collecting monies owed?

Which of the following types of files should a medical administrative assistant maintain to remind patients of future appointments or procedures?

Which of the following information is included on a patient encounter form?

Which of the following actions is appropriate for a administrative medical assistant to take when providing preoperative instructions to a patient who is anxious?