New CPT Codes for Mental Health Services

For those who do their own billing: make sure you've updated your CPT codes to reflect the changes that became effective 1/1/13.

CPT stands for "Current Procedural Terminology." The American Medical Association establishes a code (a number) for each service or procedure a medical provider may perform, including mental health services. From time to time, things are added and removed from the list, and procedures are reorganized based on current practice.

The codes for psychotherapy services have been changed starting this year. The biggest change is that, instead of separate codes for each duration of standard and "interactive" psychotherapy, "interactive complexity" has been added as a separate code to be billed in addition to the standard psychotherapy code when applicable. Therapy is considered "interactive" when it is conducted with non-verbal clients.

Here are the update CPT codes applicable to psychotherapy:

90791     Psychiatric Diagnostic Evaluation (by non-prescribing professionals)
90837     Psychotherapy, 60 minutes (client or family member)
90834     Psychotherapy, 45 minutes (client or family member)
90832     Psychotherapy, 30 minutes (client or family member)
90839     Psychotherapy for Crisis, first 60 minutes
90840     Psychotherapy for Crisis, each additional 30 minutes
90846     Family Psychotherapy (without client)
90847     Family Psychotherapy (with client)
90853     Group Therapy
90785     Interactive Complexity

Private Practice Billing: Anatomy of an Insurance Claim

As I said in an earlier post, billing is a crucial factor in the viability of private practice. In order to be reimbursed by health insurance companies, you have to submit the standardized CMS-1500 form.

To complete the form, you need the following information: The client's name, date of birth, address, phone, marital and employment status, insurance policy number, name and address of the primary insured (if other than the client), as well as the client's relationship to the insured, the employer or school through which the insurance is provided, statement that the client has signed an authorization for the provider to provide medical information to the insurance company and receive payment of medical benefits, a beginning date for the current "illness," ICD-9 diagnosis code(s), prior authorization number (if applicable), date(s) of service (for outpatient therapy, the beginning and end date are the same), place of service code (11 is the designation for an outpatient office), procedure code (see my previous post for common codes), a diagnosis pointer (the number of the line on which the ICD-9 code for which treatment was provided), charges, number of units (a session would be 1), provider's NPI, tax ID, practice and billing address(es), and whether you "accept assignment" (will accept adjustment of the charges without billing the client for the difference - typically, if you have a contract with an insurance company, you have to agree to this provision).

Once you have the information, one option is to submit a hard copy of claims to an address provided by the insurance company, printed on the special paper form with red lines (yes, it has to be on this kind of paper, so you either need a fancy computer program that prints it in red and black following government specifications, and plenty of red ink, or to buy the paper).

Another option is to submit the form electronically. While electronic submission requires more effort to set up initially, it streamlines the process for subsequent submissions. It also has a faster turn-around time, which means you get paid faster. Because of HIPAA requirements for the security of electronic submissions, all claims submitted electronically have to be formatted/encrypted as EDI 837 documents (you may see this number with a letter suffix: 837p is the version for providers, and 837i is the version for institutions). There are several ways to accomplish this:

(1) A few health insurance companies have a system set up via their own website provider portal for claim submission

(2) You can use a billing clearinghouse that takes the non-EDI format claim you submit to the clearinghouse, transfers it to the prope 837 format, and sends it on to the insurance company. Clearinghouses may cost 6%-8% per claim, however.

(3) You may already be using practice management software or an electronic health record platform of some kind. If you are, or plan to use this kind of software, it probably has the capacity to generate claims in the approved format. If the software is web-based, you can probably establish EDI communication with the health insurance companies you work with, through which the claim can be submitted.

Most of these kinds of software platforms have some sort of subscription costs. The more elaborate it is - the more it resembles a medical record rather than a billing program - the higher the cost may be. For the frugal-minded, like myself, there are options, however. For a full electronic medical record, the cheapest option seems to be Care Paths (www.carepaths.com), at about $30 per month. I looked into that option and it seems like a decent system that could be customized to meet the needs of the private practitioner.

However, my practice is small and, as I said, I'm...frugal...so I went with another option: Office Ally (www.officeally.com) offers FREE software, including a bare-bones claim submission platform (Office Ally), but also a more elaborate practice management software platform (Practice Mate), where you can input each of your clients, create visit templates, which automatically fill out all of the key information that stays the same week to week, edit for the given appointment, record copays, issue receipts, and generate claim forms easily and quickly. Office Ally also walks you through the process of setting up EDI communication between Office Ally and each of your payers, allowing you to submit claims and get replies electronically.

Let me know if you are aware of other reasonably priced services, and/or what your billing practices and experiences have been!

Private Practice: Billing Terminology

You've set up your office, finalized insurance contracts, and marketed your practice. You've scheduled appointments, and seen your first clients. The hard part is done, right? Smooth sailing?

Not quite. Now you have to actually get paid for the services you are providing. That's pretty easy if your clients are self-pay...but many (perhaps most) people want to use insurance if at all possible.

I thought billing an insurance company would be relatively straight-forward: enter some information on the insurer's secure website, or perhaps fill out and send in a form I could download. Nope. It turns out to be quite a bit more complicated than that.

In order to understand billing, you first have to familiarize yourself with key terms and abbreviations. You have to know these terms to even begin to sort out the billing process (which I'll write about it a future post).

1) Information about the Provider
To begin with, you need to know your NPI number (might as well memorize it, really, you'll be using it so often!), and your tax ID number - that is either your personal social security number, or a special tax ID provided if you registered yourself as a company or business (in which case it would be called an EIN - Employer Identification Number). If you are asked to select between S or E, it's asking whether your tax ID number is a "social" or "employer" number.

2) Information about the Client
You will need to know the client's insurance policy member identification number and date of birth. For medicaid products, you may hear the member number referred to as the RID - short for medicaid recipient identification number. You may also need their social security number, address, phone number, and employer. If the insurance policy is in someone else's name (e.g., a parent or spouse) - referred to as the policy holder, or perhaps the guarantor - you will need that person's name, date of birth, and possibly social security number.

3) Information about the Service Provided
You will need to provide the client's diagnosis, with associated ICD code (International Classification of Disease). Yes, just when you thought you had the DSM down, they want you to use a different system. Thankfully, many of the codes in ICD-9 are very similar to their DSM-IV-TR counterparts. I don't know, however, how things will change with ICD-10, which will be required within the next 2 years, and expands the possible length of each code to a maximum of 7 digits. Bear in mind that the diagnosis code determines whether the client is eligible for parity.

You also have to provide a code indicating what procedure (service) you provided. These are called CPT (Current Procedural Terminology) codes, established by the American Medical Association. The insurance company likely provided a list of relevant CPT codes in your contract, specifying the reimbursement rate for each. Ones you should know include:

90801 - Diagnostic Interview Evaluation (i.e., assessment)
90804 - Individual Therapy, 20-30 minutes
90806 - Individual Therapy, 45-50 minutes
90853 - Group Therapy
90847 - Family Therapy, with Patient Present

Note that there are separate codes (not listed here) for therapy including medication management (for prescribing professionals), and codes designated "interactive therapy" - the latter refers only to therapy that is non-verbal, and relies on assistive additions, such as an interpreter or technology for non-verbal communication. Play therapy does not qualify (it is partially verbal).

4) Standardized Billing Formats
All of this information must be encapsulated into a standardized form, to comply with Federal regulations (HIPAA). It seems that specific standards were developed for Medicaid and Medicare, and private insurance companies have decided to apply these standards across the board (I suppose it simplifies things somewhat to use one standard, rather than trying to keep track of different rules for each insurance company).

Paper billing must be done on specific forms called CMS-1500 forms. CMS stands for Centers for Medicare and Medicaid Services. This government agency was previously known as the Health Care Financing Administration (HCFA), and thus the forms were HCFA-1500 forms. The version of the form does change over time, and the current version is 5010. Be sure you are using the right form. Furthermore, the grid lines on the form are red - and must be red for it to be submissible. That means you either need to purchase official forms, or use a computer program and printer that will print it with red lines. Also keep track of your insurance company contracts for any other requirements; for example, one company with whom I contract requires the form be typed (either via a computer program designed for the form, or via typewriter!), in all capitals.

If you want to submit claims electronically, you will need to set up EDI - Electronic Data Interchange - with the insurance companies, to ensure that protected health information is being submitted securely. You will either need access to a secure FTP program (File Transfer Protocol), or use a service of some kind (a topic for the next post on the subject). The CMS-1500 form is still used, but this time an electronic version that has been encrypted in a standard way (referred to as EDI 837, with suffix p for individual providers and i for institutions). If you want electronic notification of the insurance company's response to the claim, you want electronic remittance advice (ERA), which has a formatting designation EDI 835.

That sounds complicated - but it isn't as hard as it sounds, and you don't have to pay for a billing service. More to come on that. Why would you want to learn it? Insurance companies say that it is faster (2 weeks versus 45 days), and has a higher approval rate due to fewer user errors (since omissions and typos may be caught by whatever program you are using).

Please leave comments with any billing tips you have, and any terms I've missed!