Category: Mental Health

More insurance billing information and guides visit axisirg.com.

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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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
  1. 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.

Before creating your template for referring to PHP or other levels of care for behavioral health, it is good to remember some basic medical necessity criteria from insurance.

Medical necessity criteria for Partial Hospitalization Programs (PHP) in behavioral health may vary depending on the specific treatment facility, insurance provider, and the individual patient’s needs. However, there are some common medical necessity criteria often used to determine if a patient qualifies for PHP care in behavioral health settings. Here are some typical criteria:

  1. Diagnosis: The patient must have a diagnosable mental health condition that requires intensive treatment. This could include conditions such as severe depression, bipolar disorder, schizophrenia, substance use disorders, eating disorders, or other severe mental illnesses.
  2. Risk of Harm: The patient should present a risk of harm to themselves or others. This could manifest as suicidal ideation, self-harm, severe impairment in daily functioning, or violent tendencies.
  3. Symptom Severity: The severity of the patient’s symptoms should be such that they require more than outpatient care but do not require 24-hour inpatient hospitalization. PHP is typically considered when the patient needs structured and intensive treatment during the day but can return home or to a safe living environment in the evenings.
  4. Functional Impairment: The patient’s mental health condition should significantly impair their ability to function in daily life, including but not limited to work, school, relationships, and self-care.
  5. Lack of Progress in Outpatient Care: The patient should have demonstrated a lack of progress or inadequate response to outpatient treatment or less intensive levels of care, such as individual therapy or outpatient group therapy.
  6. Medical Stability: The patient should be medically stable enough to participate in a day program without requiring constant medical supervision. Any medical conditions that need attention should not be so severe that they overshadow the need for mental health treatment.
  7. Support System: Ideally, the patient should have a support system or a safe and stable living environment to return to in the evenings when they are not in the PHP. This helps ensure that they can continue their recovery outside of the program.
  8. Treatment Plan: There should be a clear and comprehensive treatment plan in place that outlines the patient’s specific goals and objectives in the PHP, as well as a plan for transitioning to lower levels of care when appropriate.

It’s important to note that the specific criteria can vary by state, insurance provider, and the policies of the treatment facility.

Sample referral letter to help with authorization approval:

[Your Name]

[Your Title]

[Your Clinic/Hospital Name] 

[Address]

[City, State, ZIP Code] 

[Phone Number] 

[Email Address]

 [Date: MM/DD/YYYY]

To Whom It May Concern,

I am writing this letter to provide a strong recommendation for [Patient’s Full Name], a valued patient under my care, to receive treatment at the Partial Hospitalization Program (PHP) level of care for mental health. I have had the privilege of overseeing [Patient’s Name]’s medical care for [duration of treatment relationship], and I believe that the PHP level of care is an appropriate and necessary step in their journey towards improved mental health and well-being.

[Patient’s Name] is a [age]-year-old [gender] who has been struggling with [brief description of the patient’s mental health condition or concerns, including any relevant diagnoses, such as depression, anxiety, bipolar disorder, etc.]. Despite our best efforts, [he/she/they] have experienced significant challenges in managing their symptoms, which have begun to impact [his/her/their] daily functioning, relationships, and overall quality of life.

After careful consideration and a thorough assessment, I firmly believe that the PHP level of care offers the intensive and comprehensive treatment that [Patient’s Name] requires at this stage. The structured environment, consistent therapeutic support, and access to a multidisciplinary team of mental health professionals provided by the PHP program will be instrumental in addressing [Patient’s Name]’s complex needs.

Specifically, I anticipate that the PHP program will provide the following benefits for 

[Patient’s Name]:

Structured Therapy: [Patient’s Name] will have the opportunity to engage in structured group and individual therapy sessions designed to address [his/her/their] specific mental health challenges.

Medication Management: The PHP program’s medical staff will closely monitor [Patient’s Name]’s medication regimen, ensuring that [he/she/they] receive the appropriate adjustments and support.

Psychoeducation: [Patient’s Name] will gain valuable insights and coping strategies through psychoeducational sessions, empowering [him/her/them] to better manage [his/her/their] symptoms outside of the program.

Peer Support: Interacting with peers who are navigating similar struggles can foster a sense of camaraderie, reducing feelings of isolation and promoting a supportive environment.

Holistic Approach: The PHP program’s holistic approach to treatment will address various aspects of [Patient’s Name]’s well-being, including physical, emotional, and psychological health.

In conclusion, I wholeheartedly recommend [Patient’s Full Name] for admission to Partial Hospitalization for mental health. I am confident that the program’s expert team and comprehensive resources will provide the necessary support to help [him/her/them] achieve meaningful progress in [his/her/their] mental health journey.

Please feel free to contact me at [phone number] or [email address] should you require any additional information or insights regarding [Patient’s Name]’s medical history and current condition. I am dedicated to collaborating closely with the PHP program to ensure the best possible outcomes for [Patient’s Name].

Thank you for your attention to this matter and for the invaluable service you provide to individuals seeking to improve their mental health and well-being.

Sincerely,

[Your Signature]

[Your Printed Name] 

[Your Title] 

[Your License Number] 

[Your Clinic/Hospital Name]

Getting clients for an Partial Hospitalization Program/Intensive Outpatient Program (PHP/IOP) treatment facility in any location, involves a combination of marketing, networking, and providing high-quality services. Here are some steps to help you attract clients to your PHP/IOP treatment facility:

1. **Understand the Market**:

   – Research the local market to understand the demand for PHP/IOP treatment services, including addiction or mental health treatment.

   – Identify your target audience, such as individuals struggling with substance abuse, mental health issues, or other behavioral health concerns.

2. **Regulatory Compliance**:

   – Ensure your facility complies with all relevant state and federal regulations, including licensing requirements.

3. **Develop a Strong Program**:

   – Create a comprehensive and effective PHP/IOP treatment program that addresses the needs of your target population.

   – Hire experienced and qualified staff, including therapists, counselors, and medical professionals.

4. **Build an Online Presence**:

   – Create a professional website with information about your facility, treatment programs, staff credentials, and contact details.

   – Optimize your website for search engines (SEO) to improve its visibility in local search results.

5. **Social Media Marketing**:

   – Use social media platforms to share educational content, success stories, and updates about your facility.

   – Engage with the online community by responding to comments and messages promptly.

6. **Content Marketing**:

   – Develop and share informative and engaging content related to addiction treatment, mental health, and recovery on your website and social media.

   – Consider starting a blog or producing videos that provide valuable information to potential clients.

7. **Local SEO**:

   – Claim and optimize your Google My Business listing to ensure your facility appears in local searches.

   – Encourage satisfied clients to leave reviews on Google and other review platforms.

8. **Networking**:

   – Establish relationships with local healthcare professionals, therapists, psychiatrists, and other professionals who may refer clients to your facility.

   – Attend industry events, conferences, and meetings to network and build partnerships.

9. **Community Outreach**:

   – Engage with the local community by participating in health fairs, workshops, and events.

   – Offer free or low-cost educational sessions on addiction, mental health, or related topics.

10. **Advertising**:

    – Consider running targeted online ads on platforms like Google Ads and Facebook to reach potential clients.

    – Use online advertising to promote specific treatment programs or special offers.

11. **Insurance and Payment Options**:

    – Accept a variety of insurance plans to make your services more accessible.

    – Clearly communicate your payment options and any financial assistance programs you offer.

12. **Track and Analyze**:

    – Use tools like Google Analytics and social media insights to track the effectiveness of your marketing efforts.

    – Adjust your strategies based on what works best for your facility.

13. **Client Testimonials**:

    – Encourage satisfied clients to share their success stories and testimonials on your website and social media.

14. **Continuous Improvement**:

    – Continuously evaluate and improve your treatment programs based on client feedback and outcomes.

Truth be Told

The number one way to increase your inquiries to your program is to get credentialed as in-network for most major insurance carriers. This is not always a simple process, but works out in the long run.

Remember that building a strong reputation for your PHP/IOP treatment facility may take time. Focus on delivering high-quality care, maintaining ethical standards, and demonstrating empathy and compassion to help clients on their journey to recovery. Over time, positive word-of-mouth referrals and reviews can be one of your most valuable assets in attracting clients.

Tech developers are foaming at the mouth trying to address the shortage of psychiatrists and other mental health professionals with something called telepsychiatry!

In a day in age where mental health care is at its highest it has ever been, hospitals, clinics, and treatment facilities are unable to keep up with the demand due to the shortage of mental health professionals, specifically psychiatrists. If that doesn’t grab your attention, experts say that it’s only going to get worse within the next decade.

In California, as of 2013, there was a shortage of 336 psychiatrists and forecasted to reach between 729 and 1,848 by 2025, reported by the national projections from the Health Resources and Services Administration, cited by the state Governor’s Office.

In the Chicago, the St. Bernard Hospital, CEO Charles Holland said its extremely hard to recruit psychiatrists as it expands its mental health services. Three years ago, due to the growing demand, they opened an outpatient mental health clinic and next month will expand its inpatient mental health unit from 40 beds to 60 beds.

“We feel it is an emergency. We feel it’s getting worse.”— Marvin Lindsey, CEO of the Community Behavioral Healthcare Association of Illinois

 

In 2005, Minnesota depression rates in women living in rural counties were as high as 40 percent, compared to only 13 to 20 percent in urban counties reported by the Department of Health. In more recent years, a report produced by the Minnesota Hospital Association indicated that from 2007 to 2014, there was a 40 percent increase in emergency department use for mental illness encounters in Greater Minnesota, compared to only a 34 percent increase in the Twin Cities.

We can see the demand is here and not stopping from rising higher and higher. So why isn’t there any young, eager students seeking a career in this much-needed industry?

Let’s just be honest, being a procedure-oriented doctor will get a straightforward payoff for fixing a broken arm or leg, rather than a broken heart where psychiatrists know their treatment is more of a lifetime plan.

“There’s no victory lap (in psychiatry) where you can say you fixed that patient, on to the next one,”- Travis Singleton, Senior Vice President of Physician Staffing Firm Merritt Hawkins.

 

Greater awareness, diminishing stigma and a worsening opioid crisis in America,  are making more individuals seek mental and behavioral health care. Meanwhile, nearly 60 percent of psychiatrists are over age 55, fueling a retirement wave that experts say exceeds the pipeline of the new doctors who are expected to fill the limited psychiatric residency slots.

What if I told you, one strategy that has shown effective promise for addressing this shortage is telepsychiatry? What is that exactly? Well, it allows patients to obtain psychiatric services from a provider at a distant location through technology such as video consultations. Brilliant!

In Ector County, Texas, Independent School District Head Nurse Laura Mathew, has utilized this technological advancement to help with students at her school when two years ago, Texas Tech’s Chair of Psychiatry, Dr. Bobby Jain, started a program where students could book telepsychiatry appointments through the school nurse. School nurse Laura Mathew says 70 kids have used the program so far.

“We should never discount the power in our pocket,” -Dr. Thomas Kim, the Austin, Texas-based Internist and Telepsychiatrist

 

Dr. Kim, also in Texas,  has adapted to the new wave of virtual healthcare providers, exchanging the doctor’s office, medical clinic or hospital, for a mobile-based health platform that connects with people wherever they are that need immediate help. This platform has taken high praise in the behavioral health industry, as a fast-growing field in which discreet access to health care has become monumental for improved care, and addressing the shortage of psychiatrists.

“Nowadays we can easily, across a screen, look face-to-face with somebody, and we can do what we normally would do in an office … but then we can also see how that person lives.”-  John Sharp, Chief Behavioral Health Officer for MDLive

 

“As telemental health care gains in popularity, it gives rise to a number of significant legal and regulatory issues, including privacy and security, follow-up care, emergency care, treatment of minors, and reimbursement, among other things,” says Rene Y. Quashie of Cozen O’Connor’s healthcare practice.

“While some federal laws and regulations (such as HIPAA) apply, most of the issues involve state law, which has resulted in an inconsistent patchwork of laws and regulations that vary widely by state. And there are a number of states that don’t address telemental health specifically in their laws.”

In a recent interview, he said, “The nation is starting to turn a corner in understanding the value of telemental health. The technology has improved dramatically. Healthcare providers are starting to realize the value of technology … in deploying the healthcare experience when and where it’s needed.”

With this new technology taking off and only getting better, it’s a great reassurance and significant step towards addressing the shortages we are experiencing in the mental health care industry.

How does Insurance determine Medical Necessity?

Many insurance carriers determine RTC/PHP/IOP authorization for care by utilizing medical necessity criteria to make determinations. The medical necessity criteria applied varies according to the behavioral health service being requested. To determine which criteria set will be used, general examples use the list below:

  • Level of Care Utilization System (LOCUS) will be used to evaluate behavioral health treatment requests for adults age 19+ years.
  • Child and Adolescent Level of Care Utilization System (CALOCUS) will be used to evaluate mental health treatment requests for children and adolescents ages 6-18 years.
  • Early Childhood Service Intensity Instrument (ECSII) will be used to evaluate mental health treatment requests for infants, toddlers and children ages birth through 5 years.
  • ASAM Criteria will be used to evaluate substance use disorder service and treatment requests
  • New Directions medical policies apply to the following treatments and services, as applicable:
    • Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder (ABA for ASD)
    • Applied Behavior Analysis for the Treatment of Down Syndrome (ABA for DS)
    • Transcranial Magnetic Stimulation (TMS)
    • Electroconvulsive Therapy (ECT)
    • Psychological/Neuropsychological Testing (PNT)
    • 23-Hour Observation

LOCUS was developed by the American Association of Community Psychiatrists (AACP). CALOCUS was developed by AACP in collaboration with the American Academy of Child and Adolescent Psychiatry (AACAP). Both are maintained by Deerfield Solutions, LLC. ECSII was developed by AACAP. The ASAM Criteria was developed by the American Society of Addiction Medicine. New Directions administers each benefit as designed by the health plan and set out in the member’s benefit agreement. The presence of a specific level of care criteria within a criteria set does not constitute the existence of a specific benefit. Providers and facilities should verify the member’s available benefits online when available, or by contacting the applicable Customer Service department.

Access to LOCUS can be found by clicking here.

Access to CALOCUS can be found by clicking here.

Access to ECSII can be found by clicking on the following links:
ECSII Domains (Handout)
ECSII SI Definitions (Handout)
ESCII Manual 1.1 (Rev 4.2019) – QUICK REFERENCE ANCHOR POINT SHEETS INCLUDED

Access to the ASAM Criteria can be found by clicking here.

Specific policies or criteria set by insurance carriers in 2023. Insurance coverage and criteria can vary significantly depending on the insurance company, the specific plan, and the jurisdiction in which you reside. Insurance carriers often update their policies and criteria regularly.

However, we look can at some general information about the levels of care commonly seen in mental health treatment. These RTC/PHP/IOP levels of care may require varying criteria for insurance coverage:

  1. Outpatient Care: This typically includes individual therapy, group therapy, counseling, and medication management provided on an outpatient basis. Patients may need a mental health diagnosis and recommendation from a healthcare professional to access this level of care.
  2. Intensive Outpatient Program (IOP): IOP offers more structured and intensive treatment than traditional outpatient care. It may involve several hours of therapy and support services each day, usually for several days a week. Insurance carriers may require a mental health diagnosis and a treatment plan from a healthcare professional for coverage.
  3. Partial Hospitalization Program (PHP): PHP provides a higher level of care than IOP. It involves full-day or nearly full-day treatment programs, usually provided in a hospital or specialized facility. PHP may be recommended for individuals who need more support but do not require 24-hour inpatient care. Insurance coverage may require medical necessity criteria and a treatment plan.
  4. Inpatient Hospitalization: This level of care involves round-the-clock treatment in a hospital setting. It is typically reserved for individuals who are in crisis or at risk of harm to themselves or others. Insurance carriers often require a medical necessity determination and authorization for coverage.

The specific criteria for insurance coverage may include other factors for medical necessity, including severity of symptoms, risk of harm, and the recommendations of healthcare professionals.

What is the criteria for medical necessity using LOCUS assessment for RTC/PHP/IOP mental health?

The Level of Care Utilization System (LOCUS) is a tool used to assess the level of care needed for individuals with mental health and substance use disorders. It provides a framework for evaluating the severity of a person’s condition and determining the appropriate level of care, including Residential Treatment Centers (RTC), Partial Hospitalization Programs (PHP), and Intensive Outpatient Programs (IOP). While I can provide a general overview of the LOCUS assessment criteria, please note that the specific criteria and scoring may vary depending on the version and guidelines implemented by different organizations or jurisdictions. It’s always best to refer to the official documentation or guidelines provided by your healthcare provider or insurance carrier.

A look in detail of the LOCUS assessment of six different dimensions

Certainly! The Level of Care Utilization System (LOCUS) assessment evaluates individuals with mental health and substance use disorders across six different dimensions to determine the appropriate level of care. Here’s a detailed explanation of each dimension:

  1. Risk of Harm: This dimension assesses the individual’s risk of harm to themselves or others due to their mental health condition. It considers factors such as the severity of suicidal ideation, presence of self-harm behaviors, risk of aggression, or violence. The assessment may include evaluating the frequency, intensity, and duration of these behaviors. A higher score in this dimension indicates a greater risk of harm and may indicate a need for a more intensive level of care.
  2. Functional Status: This dimension focuses on the individual’s functional abilities and limitations. It evaluates their ability to perform activities of daily living, including self-care, work or school functioning, social functioning, and relationships. Impairments in these areas may indicate the need for a higher level of care. The assessment may consider factors such as the individual’s ability to maintain personal hygiene, manage finances, sustain employment or education, and engage in social interactions.
  3. Medical, Addictive, and Psychiatric Co-Morbidity: This dimension assesses the presence of additional medical conditions, substance use disorders, or co-occurring psychiatric disorders that may impact the individual’s overall functioning and treatment needs. The assessment considers the severity and complexity of these co-morbid conditions, including their impact on physical health, mental health, and substance use. A higher score in this dimension indicates a greater need for comprehensive care that addresses these co-occurring conditions.
  4. Recovery Environment: This dimension evaluates the individual’s living situation, support system, and access to resources that promote recovery. It considers factors such as stable housing, family support, availability of outpatient services, and involvement in the criminal justice system. The assessment examines the quality and stability of the individual’s recovery environment, including the level of support and resources available to them. A higher score in this dimension indicates a more supportive recovery environment and may influence the level of care recommended.
  5. Treatment and Support History: This dimension examines the individual’s history of mental health and substance use treatment. It considers the effectiveness of past interventions, engagement in treatment, and adherence to medication regimens. The assessment may also evaluate the individual’s experience with different treatment modalities, such as therapy, medication management, or residential programs. A comprehensive understanding of the individual’s treatment history helps determine the most appropriate level of care and treatment interventions.
  6. Engagement/Relapse Potential: This dimension assesses the individual’s motivation and ability to engage in treatment and their potential for relapse or non-compliance with recommended treatment. It considers factors such as the individual’s readiness for change, level of motivation, willingness to participate in treatment, and history of relapse or treatment non-compliance. A higher score in this dimension may indicate a need for a more structured and intensive level of care to support engagement and prevent relapse.

Each dimension is scored on a scale ranging from 0 to 4 or 0 to 5, with higher scores indicating a greater level of severity or need for care. The total scores across these dimensions are used to determine the appropriate level of care, such as Residential Treatment Centers (RTC), Partial Hospitalization Programs (PHP), or Intensive Outpatient Programs (IOP).

Specific guidelines and scoring criteria may vary depending on the version and guidelines implemented by different organizations or payers. There are other official LOCUS guidelines available online, or seeking guidance from a healthcare professional familiar with the assessment can help provide the most accurate and up-to-date information regarding the six dimensions of the LOCUS assessment.

A more specific model of what questions the LOCUS assessment requires to complete criteria

While I can provide a general overview of the dimensions assessed in the Level of Care Utilization System (LOCUS) assessment, I don’t have access to the exact questions or specific questionnaires used in the assessment. The LOCUS assessment is typically administered by trained professionals, such as mental health clinicians or care managers, who follow specific guidelines provided by the organization or jurisdiction implementing the assessment.

However, I can outline the general areas of inquiry that are typically covered in each dimension of the LOCUS assessment:

  1. Risk of Harm:
  • Inquire about suicidal ideation, intent, and plans.
  • Assess for self-harm behaviors or risk of harm to others.
  • Explore recent history of aggression or violence.
  1. Functional Status:
  • Evaluate the individual’s ability to perform activities of daily living, such as personal hygiene, dressing, and eating.
  • Assess their work or school functioning, including attendance, productivity, and ability to carry out tasks.
  • Examine social functioning, including relationships, social support, and engagement in social activities.
  1. Medical, Addictive, and Psychiatric Co-Morbidity:
  • Gather information about any medical conditions or physical health concerns.
  • Assess the severity and impact of substance use disorders, including patterns of use, dependence, or withdrawal symptoms.
  • Evaluate the presence and impact of co-occurring psychiatric disorders, such as anxiety, depression, or personality disorders.
  1. Recovery Environment:
  • Inquire about the individual’s living situation, stability of housing, and availability of a safe and supportive environment.
  • Assess the presence and quality of social supports, including family, friends, or support groups.
  • Evaluate the availability of outpatient services and resources that promote recovery, such as transportation or financial assistance.
  1. Treatment and Support History:
  • Gather information about previous mental health and substance use treatment experiences.
  • Assess the effectiveness of past interventions and treatments.
  • Evaluate the individual’s level of engagement and adherence to treatment plans, including medication management.
  1. Engagement/Relapse Potential:
  • Assess the individual’s motivation and readiness for change.
  • Evaluate their willingness to participate in treatment and engage in therapeutic activities.
  • Inquire about the individual’s history of relapse, treatment non-compliance, or difficulty sustaining recovery.

The questions and scoring criteria may vary based on the version and guidelines implemented by different insurance carriers.

Just because a person is fully covered with a great health insurance plan does not mean they “medically” qualify for the proper addiction treatment or mental health care.

Problem: not all benefits, levels of care, or the interpretation of “medical necessity” are created equal.

In our experience, we have seen most approvals or denials of treatment based on the principal of medical necessity. Half of the information needed by insurance companies to make an educated decision comes from the patient themselves.

Because of this, you can understand the importance for the patient to tell the truth about their actual level of current and past drug use – as well as other concerning behavioral or mental health issues.

Most families are unaware of how addiction works and aren’t able to fully advocate the right way for their loved one. Remember, addiction is a chronic illness – and though the exact definition of a chronic disease varies, but these ailments are usually identified as long lasting, noncontagious, and resistant to cure.

This brings up another extremely valid point when dealing with addiction and substance abuse and how the insurance system is set up: these conditions that work in so many ways against the patient. Quality care is very expensive and a long term solution is generally not covered out-of-the box by insurance companies. You have to fight for coverage – that is why getting every level of care deemed necessary is so important.

Every patient must show that they have medical need for substance abuse treatment on any level – detox, residential coverage, partial hospitalization, or intensive/general outpatient care.

David Goldhill of The Atlantic has a great take to create a logical foundation for medical necessity:

We have a vague definition of medical necessity in the back of our minds: if the mastectomy was necessary, doesn’t that mean the reconstruction is, too? Should we pay for prosthetic limbs only if they are functional, or are cosmetic attributes alone worthy of reimbursement? If cosmetic surgery helps a woman develop greater self-esteem or avoid postpartum blues, wouldn’t it serve the same purpose as an antidepressant? And following that logic, shouldn’t it be reimbursed just like a prescription?

Lets start with who defines medical necessity by most insurance companies?

This is a great question that has many, many players involved. This can only be defined by a personal therapist, the medical history of the patient, and the customer service rep at any given insurance company. The “who” is an ongoing, evolving, not-always-straight-forward enigma.

The same problem happens with what defines medical necessity by most insurance companies.

Here is one of many definitions given by payors:

Definition and Application of Medical Necessity. Medical necessity is defined as accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care.

What all this should really come down to for us as a nation and for insurance law is not, Is it worth the money? But, Is it good for us?

Ok, you have a potential patient with health coverage – what now?

All health coverage plans vary by company and by benefit package. Now its time to determine what is covered and what isn’t. They very well could have the medical portion of care covered, but housing and other ancillary aspects are not.

A patient’s need for the different levels and settings of care is not per-determined, it is established upon arrival at a drug treatment facility through discussions with professionals and the insurance company. A few things that go into this decision include:

  1. Acute Intoxication and/or Withdrawal Potential
  2. Biomedical Conditions/Complications
  3. Emotional, Behavioral, or Cognitive Conditions/Complications
  4. Readiness to Change
  5. Relapse, Continued Use or Continued Problem Potential
  6. Recovery/Living Environment

Do they qualify for all levels of care?

Residential (RTC)

the effects of addition on the individual’s life are so significant and the level of addition-related impairment is so great that outpatient strategies alone would not be feasible or effective.  Programming and staffing address more severe medical, emotional, cognitive, and behavioral problems. Case management provides a “wrap-around” service.

Partial Hospitalization (PHP)

Ready access to psychiatric, medical, and lab services make this level of service a step up from the previous. The effects of addition on the individual’s life are so significant and the level of addition-related impairment is so great that outpatient strategies alone would not be feasible or effective.  . Typically this level of service is the situation warrants daily monitoring or management but can be appropriately addressed in structured outpatient setting

Intensive Outpatient (IOP)

Psychiatric and medical services are addressed through consultation and referral arrangements. This service is provided in 9 or more hours of structured counseling and education services per week.

General Outpatient (GOP)

Designed to treat the assessed level of illness severity and to achieve permanent changes in substance using behavior. This service is provided in fewer than 9 contact hours per week.

It is Complicated

With all these coverage types, you can see some of the generic language in them and how it can be difficult to determine which is absolutely necessary. There are times when insurance companies require an individual to “fail” out of a lower level of care in order to get approved for the structure actually needed. it can be a very backwards system sometimes.

And of course you will need all the appropriate licensing in order to bill for each level of care. Whether a facility qualifies for each license is determined by the State it is in.

What are the Alcohol and Drug Abuse Treatment HCPCS Code range H0001-H0043

The HCPCS (Healthcare Common Procedure Coding System) code range for Alcohol and Drug Abuse Treatment is as follows:

H0001 – Alcohol and/or drug assessment

H0002 – Behavioral health counseling and therapy, per 15 minutes

H0003 – Alcohol and/or drug screening

H0004 – Behavioral health counseling and therapy, per hour

H0005 – Alcohol and/or drug education

H0006 – Alcohol and/or drug prevention, per 15 minutes

H0007 – Individual counseling and therapy, per 15 minutes

H0008 – Group counseling and therapy, per 15 minutes

H0009 – Alcohol and/or drug services; not otherwise specified

H0010 – Alcohol and/or drug screening, brief intervention, and referral to treatment (SBIRT)

H0011 – Alcohol and/or drug program administration and coordination

H0012 – Alcohol and/or drug prevention, per hour

H0013 – Alcohol and/or drug services; group counseling by a clinician

H0014 – Alcohol and/or drug services; group counseling by a peer

H0015 – Alcohol and/or drug services; group counseling by a non-physician

H0016 – Alcohol and/or drug services; group counseling by a physician

H0017 – Alcohol and/or drug services; individual counseling by a clinician

H0018 – Alcohol and/or drug services; individual counseling by a peer

H0019 – Alcohol and/or drug services; individual counseling by a non-physician

H0020 – Alcohol and/or drug services; individual counseling by a physician

H0021 – Alcohol and/or drug services; ambulatory detoxification

H0022 – Alcohol and/or drug services; partial hospitalization (6 or more hours)

H0023 – Alcohol and/or drug services; partial hospitalization (less than 6 hours)

H0024 – Alcohol and/or drug services; detoxification

H0025 – Alcohol and/or drug services; day treatment/partial hospitalization

H0026 – Alcohol and/or drug services; short-term residential

H0027 – Alcohol and/or drug services; intermediate residential

H0028 – Alcohol and/or drug services; long-term residential

H0029 – Alcohol and/or drug services; crisis intervention

H0030 – Alcohol and/or drug services; environmental intervention

H0031 – Alcohol and/or drug services; peer support services

H0032 – Alcohol and/or drug services; acupuncture

H0033 – Alcohol and/or drug services; residential (non-hospital)

H0034 – Alcohol and/or drug services; day treatment

H0035 – Alcohol and/or drug services; partial hospitalization (treatment program of at least 20 hours per week)

H0036 – Alcohol and/or drug services; halfway house

H0037 – Alcohol and/or drug services; family/couples counseling

H0038 – Alcohol and/or drug services; intensive outpatient (treatment program of at least 9 hours per week)

H0039 – Alcohol and/or drug services; medicated assisted treatment (MAT) with extended-release injectable naltrexone (XR-NTX)

H0040 – Alcohol and/or drug services; medicated assisted treatment (MAT) with buprenorphine

H0041 – Alcohol and/or drug services; medicated assisted treatment (MAT) with methadone

H0042 – Alcohol and/or drug services; therapeutic leave

H0043 – Alcohol and/or drug services; not otherwise classified

The most recent version of the HCPCS codebook can change and sometimes getting denials and resubmitting claims is the only way to find the right code for each service, or check with your biller for appropriate coding for the most accurate and up to date information.

So, what else is needed besides the right codes to bill insurance for Alcohol and Drug Abuse Treatment HCPCS Code range H0001-H2043?

Billing insurance requires more than just the correct HCPCS codes. Here are some additional elements that may be needed:

  1. Accurate and complete documentation: Proper documentation is essential for billing insurance. It should include relevant patient information, assessment results, treatment plans, progress notes, and any other supporting documentation required by the insurance company.
  2. Verification of insurance coverage: Before providing services, it’s important to verify the patient’s insurance coverage and benefits. This helps determine if the services are covered, any limitations or pre-authorization requirements, and the patient’s financial responsibility.
  3. Prior authorization: Some insurance plans may require prior authorization for certain services. The provider must submit a request to the insurance company, providing clinical documentation to support the need for treatment. The insurance company will review the request and either approve or deny the authorization.
  4. Credentialing: Providers must be properly credentialed and contracted with the insurance company to bill for services. This involves submitting necessary paperwork and meeting the insurance company’s requirements for network participation.
  5. Correct coding and modifiers: Ensure that the appropriate HCPCS codes from the designated range (H0001-H2043) are used for the specific services provided. Additionally, if any specific modifiers are required by the insurance company, they should be applied correctly to indicate additional information about the services rendered.
  6. Timely submission of claims: Claims should be submitted to the insurance company in a timely manner, following their specific guidelines and deadlines. Late submission may result in claim denials or delays in reimbursement.
  7. Compliance with insurance policies and guidelines: Familiarize yourself with the insurance company’s policies, guidelines, and reimbursement rules for Alcohol and Drug Abuse Treatment services. This helps ensure that services are provided in accordance with their requirements and that claims are submitted correctly.

HCPCS codes in the range H0001-H2043, modifier codes may be required in certain situations: 

  • U1 – Modifier U1 is used to indicate that services are provided by a licensed clinical psychologist.
  • U2 – Modifier U2 is used to indicate that services are provided by a licensed master’s level clinician.
  • U3 – Modifier U3 is used to indicate that services are provided by a licensed bachelor’s level clinician.
  • U4 – Modifier U4 is used to indicate that services are provided by a peer specialist.
  • U5 – Modifier U5 is used to indicate that services are provided by a non-physician.
  • U6 – Modifier U6 is used to indicate that services are provided by a physician.
  • U7 – Modifier U7 is used to indicate that services are provided by a certified physician assistant.
  • U8 – Modifier U8 is used to indicate that services are provided by a certified nurse practitioner.
  • U9 – Modifier U9 is used to indicate that services are provided by a certified clinical nurse specialist.
  • U1U9 – Modifier U1U9 is used to indicate services provided by a licensed clinical social worker or a licensed marriage and family therapist.

Modifiers vary depending on the requirements of each insurance company, if any are necessary, they will be needed for accurate billing.

Tips to get care authorized treatment HCPCS Code range H0001-H2043

What else is needed besides the right codes to bill insurance for Alcohol and Drug Abuse Treatment HCPCS Code range H0001-H0043?

The medical necessity guidelines for Alcohol and Drug Abuse Treatment can vary depending on the insurance company and plan:

  1. Diagnosis of Substance Use Disorder (SUD): Generally, a patient must have a documented diagnosis of Substance Use Disorder, which may include alcohol or drug dependence or abuse. The diagnosis should be based on established diagnostic criteria such as those outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
  2. Functional Impairment: The patient’s substance abuse or addiction should be causing significant functional impairment in their daily life. This can include impairments in occupational functioning, social relationships, physical health, psychological well-being, or other areas of life functioning.
  3. Severity of the Condition: The severity of the patient’s Substance Use Disorder is often considered. This may include the frequency and intensity of substance use, presence of withdrawal symptoms, risk of harm to self or others, or the level of impairment caused by the substance use.
  4. Failed Attempts at Less Intensive Treatment: In some cases, insurance companies may require documentation of failed attempts at less intensive levels of treatment, such as outpatient counseling or support groups, before authorizing more intensive levels of care, such as residential treatment or partial hospitalization.
  5. Treatment Goals: The requested services should align with specific treatment goals and objectives. The treatment plan should be designed to address the patient’s substance abuse or addiction, promote recovery, and improve overall functioning and well-being.
  6. Evidence-Based Practices: Insurance companies often look for evidence that the requested services align with established evidence-based practices for Alcohol and Drug Abuse Treatment. These may include recognized treatment modalities, therapies, or approaches that have been shown to be effective in addressing Substance Use Disorders.

Medical necessity for behavioral health insurance authorization refers to the criteria that must be met in order for insurance companies to approve coverage for behavioral health services. It involves demonstrating that the requested treatment is medically necessary and appropriate for the patient’s condition.

To summarize medical necessity for behavioral health as far as most insurance is concerned:

To establish medical necessity, certain factors are typically considered. These include the presence of a diagnosable mental health or substance use disorder, functional impairment caused by the condition, the severity and impact of symptoms on daily life, failed attempts at less intensive treatments, and the alignment of the treatment plan with evidence-based practices. Documentation should clearly articulate the treatment goals, the expected outcomes, and how the proposed services will address the patient’s specific needs. Collaborating with other healthcare professionals and following the insurance company’s guidelines and documentation requirements can improve the chances of obtaining authorization for behavioral health services.

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.

Is it possible to submit claims for 90837, 90847, or 90853 along with IOP services?

Normally 90853 is not separated out from IOP per diem claims. Some of the below codes are what Medicare has suggested previously for IOP.

$20 per claim is the Medicare average on occasion because there are normally multiple patients being able to receive benefits in the group for that same service. So theoretically, as medicare and other carriers see this, the provider is being reimbursed for 8-20 patients for the same group 90853 service.

The Centers for Medicare & Medicaid Services (CMS) publish the Medicare Physician Fee Schedule (MPFS) every year, which includes the current procedural terminology (CPT) codes and reimbursement rates for various medical services, including intensive outpatient programs (IOP) for substance abuse.

However, the reimbursement rates may vary based on factors such as geographic location, individual patient characteristics, and other circumstances. It is recommended that you contact Medicare or consult with a healthcare billing professional for more specific information.

That being said, here are some CPT codes commonly used for IOP for substance abuse treatment that Medicare may accept:

H0015: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education

H0016: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 6 hours/day and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education

H0017: Alcohol and/or drug services; intensive outpatient (treatment program that operates less than 3 hours/day and less than 5 days/week), including assessment, counseling; crisis intervention, and activity therapies or education

Please let us know any questions!