May 10, 2024 | By: LaDonna D. Brown CPC, CPMA, CEMA
When I was asked if I would like to be a contributor to NAMAS May articles, my first thought was absolutely. This is particularly timely as May is Mental Health Awareness Month, a crucial period for coders and auditors to reflect on the importance of accurate billing and documentation for behavioral health services. Our focus and education have been primarily on Evaluation and Management services’ CPT codes. However, let’s challenge ourselves and shift our focus to other services that can be billed as a time-based service. So, let’s delve into the complexities of behavioral health.
Psychotherapy is the treatment of mental illness and behavioral disturbances in which the physician or other qualified healthcare professional, through therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.
When billing out for psychotherapy CPT codes 90832 (16-37 minutes), 90834 (38-52 minutes), and 90837 (53 minutes or greater), the visits are face-to-face with the patient. These visits may also include crucial informants, such as family members, friends, or colleagues, who provide valuable information about the patient beyond what they think about themselves.
When documenting the initial assessment, it’s essential to be comprehensive. This includes noting the chief complaint, history of present illness, past, family and social history, mental status exam, diagnosis/diagnostic impression, and summary/plan. Each element contributes to understanding the patient’s condition, which is vital for accurate billing.
A treatment plan should include a behavioral definition of the problem identified, specific goals with a timeframe for the goal, and interventions to be utilized. The plan should also include the frequency of the treatment and whether anyone other than the patient should be involved in it.
We should remember that the time spent should be specific, “time in/time out.” This is a critical aspect of accurate billing for behavioral health services. It is also important to note the location of the visit, whether it was in the office or virtual. The CPT code selected must correspond with the “time in/time out” statement. The documentation should always include the focus of the therapy and issues addressed during the visit.
Through my research, I discovered a staggering statistic: in 2022, approximately 55.8 million adults in the United States sought treatment or counseling for their mental health.
Remember, you are not alone in this. If you or someone you know is experiencing a mental health crisis or other kind of emotional distress, there is help available. Call, chat, or text 988, and speak to trained crisis counselors. The national hotline is available 24 hours a day, seven days a week.
LaDonna D. Brown CPC, CPMA, CEMA
CPT Current Procedural Terminology 2024 page 758-759
