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More insurance billing information and guides visit axisirg.com.

Here’s a cheat sheet for insurance billing related to substance abuse and mental health:

Verify insurance coverage: Before beginning treatment, it’s important to verify the patient’s insurance coverage for substance abuse and mental health services. This includes checking if the insurance plan covers the specific services being provided, such as individual therapy, group therapy, or medication management.
Obtain pre-authorization: For certain types of treatment, such as inpatient hospitalization or intensive outpatient programs, pre-authorization from the insurance company may be required. Make sure to obtain this authorization before beginning treatment to avoid any billing issues.
Check for co-pays and deductibles: Determine the patient’s co-pay and deductible amounts for substance abuse and mental health services. These amounts may be different from those for general medical services, so it’s important to double-check.
Code accurately: Use the correct billing codes for the services provided. This includes the diagnosis codes for the patient’s mental health or substance abuse condition, as well as the procedural codes for the specific services rendered.
Submit claims promptly: Submit claims to the insurance company promptly after the services are provided. This will help ensure timely payment and prevent any delays or denials.
Follow up on unpaid claims: If a claim is not paid within a reasonable amount of time, follow up with the insurance company to determine the reason for the delay. This may require resubmitting the claim or providing additional documentation.
Document thoroughly: Document all services provided and any communication with the insurance company related to billing or reimbursement. This will help ensure accurate billing and prevent any potential audit issues.

By following these guidelines, you can help ensure accurate and timely insurance billing for substance abuse and mental health services.

CPT Cheatsheet

The most common CPT Codes used by professional clinicians and therapists

Diagnostics:

• 90791 – Psychiatric Diagnostic Evaluation (usually just one/client is covered)

• 90792 – Psychiatric Diagnostic Evaluation with medical services (usually just one day per client is covered)

Therapy:

• 90832 – Psychotherapy, 30 minutes (16-37 minutes).

• 90834 – Psychotherapy, 45 minutes (38-52 minutes).

• 90837 – Psychotherapy, 60 minutes (53 minutes and over).

• 90846 – Family or couples psychotherapy, without patient present.

• 90847 – Family or couples psychotherapy, with patient present.

• 90853 – Group Psychotherapy (not family).

Crisis:

• 90839 – Psychotherapy for crisis, 60 minutes (30-74 minutes).

• +90840 – Add-on code for an additional 30 minutes (75 minutes and over). Used in

conjunction with 90839.

Other:

• +90785 – Interactive Complexity add-on code. Covered below.

There are also E/M (evaluation & management) in conjunction with psychotherapy, used by

authorized prescribers. Coding E/M is trickier, harder to document and more vulnerable to

audit but usually results in greater reimbursement. There’s also a series of E/M codes that are

used without the psychotherapy component. For more in-depth coverage on E/M coding for

psychotherapy there are some good free webinars released by AACAP on E/M CPT Codes.

• +90833 – E/M code for 30 minutes of psychiatry (used with 90832).

• +90836 – E/M code for 45 minutes of psychiatry (used with 90834).

• +90838 – E/M code for 60 minutes of psychotherapy (used with 90837).

For Facilities and Offices/Clinics

Residential Treatment:

H0018: Behavioral health; residential, per diem
H0019: Substance abuse treatment; per diem

Partial Hospitalization:

H0035: Mental health; partial hospitalization, treatment, per diem
H0015: Substance abuse treatment; partial hospitalization, per diem

Intensive Outpatient:

H0016: Behavioral health; intensive outpatient program, per session
H0017: Substance abuse treatment; intensive outpatient program, per session

Outpatient:

90832: Psychotherapy, 30 minutes with patient and/or family member
90834: Psychotherapy, 45 minutes with patient and/or family member
90837: Psychotherapy, 60 minutes with patient and/or family member
H0004: Behavioral health; counseling and therapy, per 15 minutes
H2035: Substance abuse treatment; group counseling, per 15 minutes

Other Services:

96150: Health and behavior assessment
96151: Health and behavior reassessment
96152: Health and behavior intervention, individual
96153: Health and behavior intervention, group (2 or more patients)
96154: Health and behavior intervention, family (with patient present)

It’s important to verify the correct codes with the insurance company and ensure accurate billing to prevent any potential issues with reimbursement.

These codes are just a starting point, and the specific codes used may vary depending on the patient’s insurance plan and the services provided. It’s important to verify the correct codes with the insurance company and ensure accurate billing to prevent any potential issues with reimbursement.

To obtain accurate and up-to-date information regarding ChampVA billing codes, condition codes, occurrence codes, and value codes for behavioral health RTC, PHP, and IOP claims. It can be best to consult the official resources provided by ChampVA.

Every plan is different, and they can provide you with the most current and accurate information related to their billing and coding requirements.

What are the ChampVA Billing Codes for Behavioral Health

ChampVA follows the standard coding systems for billing behavioral health services. The most commonly used coding systems for behavioral health services are the Current Procedural Terminology (CPT) codes and the Healthcare Common Procedure Coding System (HCPCS) codes. Here are some common CPT and HCPCS codes that may be used for billing behavioral health services with ChampVA:

CPT Codes:

90791: Psychiatric diagnostic evaluation
90832: Individual psychotherapy, 30 minutes
90834: Individual psychotherapy, 45 minutes
90837: Individual psychotherapy, 60 minutes
90846: Family psychotherapy without the patient present
90847: Family psychotherapy with the patient present
90853: Group psychotherapy
96101: Psychological testing evaluation services
96118: Neuropsychological testing
99213: Evaluation and management (E/M) service for an established patient, 15 minutes

HCPCS Codes:

H0031: Mental health assessment, by a non-physician
H0035: Partial hospitalization (PHP) services, per diem
H0036: Community-based psychiatric rehabilitation and support, per 15 minutes
H2011: Crisis intervention, per hour
H2035: Alcohol and/or drug services, group counseling
H0004: Behavioral health counseling and therapy, per 15 minutes
S9484: Behavioral health, counseling and/or therapy provided via synchronous telecommunication
T1015: Mental health case management

The specific codes used for billing behavioral health services may vary depending on the nature of the service provided, the duration, the level of care, and other factors. Consult the most recent version of the ChampVA provider manual or contact ChampVA directly for the most accurate and up-to-date information on billing codes specific to their program.

How to become credentialed with ChampVA as a healthcare provider?

Providers need to go through a credentialing process. Here are the general steps involved:

Determine eligibility: First, ensure that you meet the eligibility criteria to participate as a provider in the ChampVA program. This typically involves having the necessary licenses, certifications, and qualifications to provide the specific healthcare services covered by ChampVA.
Complete the application: Obtain the provider application form from ChampVA. You can typically find the application form on their official website or by contacting their provider enrollment department. Fill out the application form accurately and completely, providing all the required information.
Gather required documentation: Along with the application form, you will need to submit various supporting documents. These may include proof of your professional qualifications, such as copies of licenses, certifications, and educational degrees. You may also need to provide documentation related to your professional liability insurance, practice locations, and other relevant details.
Submit the application: Once you have completed the application and gathered the necessary documentation, submit the application and supporting documents to ChampVA according to their specified instructions. This is typically done either electronically or by mail, depending on their preferred method.
Follow up and respond to inquiries: After submitting your application, be prepared to respond to any additional requests for information or clarifications from ChampVA. They may contact you if they require any further documentation or have questions regarding your application.
Await review and decision: The ChampVA provider enrollment department will review your application, verifying your credentials and evaluating your eligibility to participate in the program. The review process can take some time, so it’s important to be patient.
Notification of credentialing decision: Once the review process is complete, you will receive a notification from ChampVA regarding the status of your credentialing application. If approved, you will be provided with further instructions on the next steps to become an enrolled provider with ChampVA.

Specific requirements and processes for credentialing with ChampVA can be dependent on each provider. Providers can also contact the enrollment department directly to obtain the most accurate and up-to-date information on their credentialing process and any specific requirements they may have.

The specific number of patients allowed in either a Partial Hospitalization (PHP) or Intensive Outpatient Program (IOP) for behavioral health can vary depending on the state, program, facility, and the resources available.

However, there is no universally fixed limit on the number of patients that can participate in an IOP. Generally, state insurance agencies nor insurance carriers do not have a requirement.

Here is what we will try to answer:

1. How many patients are allowed to be in PHP/IOP together?

2. Is reimbursement higher for per diem or per session?

2. Can S9480 ever be billed on a CMS 1500 without the revenue code or must it always be on UB04?

3. A little clarity on how to bill using the S9480 code…for example if a program had 3 patients in treatment and they met for 3 hours a day 3 days a week. What would that look like in terms of insurance billing?

There are a lot of variables to insurance billing, each policy of a plan needs to be vetted and checked for limitations and criteria

The capacity and census of a PHP/IOP can depend on factors such as the size of the facility, the staffing levels, the treatment philosophy, and the specific needs of the patients. Some PHPs/IOPs may have smaller groups with fewer patients to allow for more individualized attention and a more intimate therapeutic environment. In contrast, others may accommodate larger groups if they have the resources to support it.

Although the reimbursement rate for IOP (S9480) should not be the same as individual, family, group therapy (90837/90847/90853) because it’s per diem and these codes add up to the same clinical hours to be about 3 hours a day, reimbursement is sometimes equal. Many insurance carriers do not allow for multiple services for therapy to be billed on the same day regardless of modifiers that can be used to specify this. Providers must bill for the actual services provided essentially.

S9480 will generally be billed on UB04 since it is a per diem fee although some insurance carriers that carve out with UHC will require HCFA/CMS 1500. It is unlikely, but there could be a published list of those requiring S9480 be billed HCFA/CMS 1500.

Insurance carriers often are not allowed to inform providers how to bill or which codes to use, unfortunately.

Carriers change billing requirements often, and finding up-to-date information on specific insurance carriers and their billing requirements can be challenging. Each insurance carrier may have their own policies and guidelines regarding billing procedures, including which forms should be used for specific services.

To obtain accurate and current information on insurance carriers that require S9480 (which appears to be a Healthcare Common Procedure Coding System code for PHP/IOP Psychiatric Services) to be billed on the HCFA and CMS 1500 forms, we can help, and recommend reaching out to the specific insurance companies or consulting the provider manuals and billing guidelines provided by those carriers.

One common code for non-intensive outpatient groups for Mental Health or insurance billing for Substance Abuse diagnoses is CPT code 90853.

This code is used to bill for group psychotherapy services, which involve treating two or more patients in a group setting.

To use this code for insurance billing for substance abuse, the mental health provider must conduct a group therapy session that is typically around 60 minutes in length. During the session, the provider works with the group members to address mental health concerns, such as depression, anxiety, or substance use disorders.

It’s important to note that the use of this code is typically limited to certain mental health diagnoses, such as those listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Additionally, insurance companies may have specific requirements or limitations on the use of this code, so it’s always best to check with the patient’s insurance provider before submitting a claim.

Here is the common mistake, not adding the correct modifier. Often times it could possibly be done to use modifier 59 to do 2 groups on the same day, however most carriers don’t allow for the same code on the same day.

Again, The billing code for non-intensive outpatient group therapy for mental health diagnoses is known as CPT code 90853. This code is used to bill for group therapy sessions that are conducted in an outpatient setting, and the therapy is provided by a licensed mental health professional, such as a psychologist, social worker, or counselor.

CPT code 90853 is used for group therapy sessions that typically last for about an hour and are attended by several patients with similar mental health issues. These therapy sessions may focus on a specific mental health diagnosis or issue, such as depression, anxiety, or addiction.

When billing for non-intensive outpatient group therapy using CPT code 90853, the mental health professional must provide documentation that includes the date and duration of the session, the number of patients in attendance, the diagnosis or issue addressed during the session, and a description of the therapy provided.

It’s important to note that insurance coverage for mental health services varies by plan, so it’s important to verify coverage and reimbursement rates before billing for services. Additionally, mental health professionals should be familiar with the specific requirements and guidelines for billing and documentation set forth by insurance companies and regulatory agencies.

UBH/Optum discontinuing Out of Network Benefits …and it doesn’t stop at behavioral health services…medical services might be equally affected.

As of July 1, 2021 UBH/Optum has notified some providers about changes to UBH/Optum plans that apparently include, among other changes, the decision to exclude members’ out-of-network benefits for services located outside of the member’s plan’s service area. Notably, a “Fully Insured” plan according to Optum is a plan wherein the insurer pays for the services and the member is not covered by a self-funded employer plan.. The change will apply to medical and behavioral health services. Keep in mind, services are already subject to prior authorization, and this will add one more barrier to a growing number of barriers to care.

The Notice specifically calls out behavioral health exclusions for non-emergent, sub-acute inpatient or outpatient services received at any of the following facilities:

• Alternate Care Facility – PHP or IOP

• Freestanding Facility – Psychiatric or Substance Use

• Residential Treatment Facility – Psychiatric or Substance Use

• Inpatient Rehabilitation Facility – Psychiatric or Substance Use

While the Notice appears to have been directed to in-network (“INN”) providers, the changes we shared above would not affect services provided by INN providers who evidently can continue to admit and treat members of Fully Insured plans regardless of geography. Indeed, the Notice specifically advises INN providers that they may be asked to accept Optum members who are currently at out-of-netowork (“OON”) facilities that will no longer be covered at those facilities once this change in coverage goes into effect.

optum out of network benefits — This Optum decision could lead the way for other carriers to force providers to go in-network

Despite Optum’s couching this change in policy as a “quality and cost-share” issue, it seems more likely to be strictly a cost-cutting measure, particularly given that the change applies only to Fully Insured plans where Optum is “on the hook” for the cost of care, but not to self-funded employer-plans where Optum’s role is only to serve as an administrator of claims that ultimately are paid by the self-funded plans themselves.

Sounds convenient, doesn’t it? It also sounds like a barrier to much needed care.

As for providers, especially in the behavioral health space, they typically are either unable to secure contracts with payors like Optum despite efforts to do so, or they opt to stay out-of network because they do not want to accept the lower reimbursement rates demanded by the major payors when contracting to be an INN provider.

We fear that Optum’s new policy is a violation of Mental Health Parity laws. While on its face the Notice appears to apply to both medical and behavioral care, in practice, there likely will be a disproportionate impact against behavioral health providers, especially residential treatment centers (“RTC’s”).

Axis Comprehensive recently visited NATSAP and had the honor of participating in and supporting the Saving Teens annual Charity Golf Scramble.

Axis Supports Saving Teens

We enjoyed a perfect day of sun, fun, and golf why also supporting a great organization – SavingTeens. SavingTeens is a philanthropic organization dedicated to assisting troubled teens and their families struggling with significant emotional and behavioral challenges including anxiety, depressions, addictions and other risky behaviors.

Working in close collaboration with the therapeutic community, SavingTeens provides financial and other support to families of teens in crisis.

For more on information on the program visit them here.

Raising Money to Help Families

It was a nice trip for us – we were the only substance abuse insurance billing company at the event. The charity golf tournament was put on by some tremendously generous and heart felt folks, who did a phenomenal job raising more than $40,000 to support their programming. This means that Saving Teens will be able to help dozens of more families find the resources they need to fight addiction and other emotional issues.

We were happy to join a variety of adolescent treatment programs, educational consultants, and other substance abuse and mental health professionals to help make the even a success!

We hope to see all our new friends again next year! Count us in:)