Category: Mental Health

Did you know there are multiple types of depression? There are signs and causes, as well as a variety of treatments. Finding the right treatment and figuring out how to submit claims for insurance reimbursement can be quite complicated as well.

Understanding all the Types of Depression

Depression is a mood disorder characterized by persistent feeling of sadness and a general loss of interest in things that would normally bring you some pleasure. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) gives some insights for understanding depression and according to the criteria, you may be having a depressive episode if you experience these episodes for at least a few weeks.

There are several classifications of depression. There is some distinction based on the cause of the type of depression and the signs and symptoms. Seven of these depression types are as follows

  1. Major Depressive Disorder (MDD)

Also known simply as major depression or clinical depression, this is indeed the classic form and most common type of depression.

To be diagnosed with major depression, you must have 5 or more of the following symptoms

  • Feelings of sadness
  • Feelings of worthlessness
  • Feeling “empty” and hopeless
  • Feelings of guilt
  • Irritability
  • Changes in appetite
  • Loss of energy and fatigue
  • Thoughts of suicide and death

There are two subtypes of major depressive disorder, namely atypical depression and melancholic depression. People with melancholic depression tend to ruminate over some guilt-ridden thoughts and have trouble sleeping. This subtype is common among seniors. On the other hand, atypical depression is more common among young adults. It presents with feelings of anxiety and irritability and people with atypical depression tend to sleep a lot.

  1. Persistent Depressive Disorder (PDD)

Also known as dysthymic disorder or dysthymia, people with this type of depression have depression symptoms lasting for at least 2 years. A child or teen may be diagnosed with PDD if their symptoms last for a year or more.

While the low moods and other symptoms last longer, they are not as severe or as intense as with other types such as major depression. To be diagnosed with PDD, you must have two or more of the following symptoms

  • Sleep problems
  • Low energy and fatigue
  • Low self-esteem
  • Feelings of hopelessness
  • Change in appetite
  • Poor concentration
  • Difficulty making decisions

  1. Major Depressive Disorder with Seasonal Pattern

 Commonly known as seasonal depression, this type of depression was previously defined as seasonal affective disorder (SAD.) This is the recurring kind and common in the winter.

Experts have proposed that seasonal types of depression can be tied to the lack of natural sunlight. Symptoms usually last from early winter through to the spring time. Research has also pointed to an imbalance of serotonin and an overabundance of melatonin, which is the sleep hormone.

There is a less common type of seasonal depression referred to as summer-onset seasonal depression. As the name suggests, it occurs in the summer and spring.

 This type of depression is diagnosed after at least two years of recurring symptoms. Symptoms of major depressive disorder with seasonal pattern are such as are common with other types of depression and include

  • Feelings of anxiety
  • Lack of energy and general fatigue
  • Increase in appetite and weight gain

  1. Bipolar Disorder

This type of depression is also called bipolar depression or manic depression. People with bipolar depressive illness experience extreme mood fluctuations as well as their sleep patterns, energy and general behavior. You may feel hopeless and lethargic one day and bursting with energy and feeling euphoric the next.

You must experience at least one bout of mania to be diagnosed with bipolar disorder. For some, these extreme fluctuations can happen up to several times a week, and for others, it can be quite infrequently, such as once or twice a year.

A difference in severity of the manic symptoms is what distinguishes between bipolar 1 and bipolar 2 disorder. The mania is more severe in bipolar 1.

  1. Psychotic Depression

Psychotic depression is characterized by symptoms of both depression and psychosis. People with this type of depression experience depressive episodes that are so severe that they experience psychotic symptoms.

To be diagnosed with psychotic depression you must have experienced a depressive disorder lasting for at least two weeks accompanied by psychotic symptoms, namely hallucinations and delusions. The content of these hallucinations and delusions are usually consistent with or involve depressive moods such as guilt.

  1. Peripartum/Postpartum Depression

Pregnancy puts many women at an increased risk of depression. Depression during this time is often a combination of several factors.

Baby blues are quite common following birth as you adjust to a new baby. These blues are different from peripartum depression which lasts longer and has a profound impact on the relationship you will have with the new baby, spouse and other family members.

Symptoms of peripartum depression usually appear within a week to a month after delivery. Unlike the baby blues that usually go away without treatment, treatment is necessary for postpartum depression.

Symptoms include

  • Extreme moods ranging from anger and anxiety to hopelessness
  • Irritability
  • Crying
  • Restlessness
  • Fatigue
  • Change in appetite and weight
  • Lack of concentration
  • Rumination
  • Unwanted thoughts, including extremes such as how to self-harm or harm the baby
  • insomnia

Some women will experience depression throughout their pregnancy and not just after delivery. Perinatal depression is the inclusive term doctors use to describe depression that may occur during the pregnancy and after delivery.

  1. Premenstrual Dysphoric Disorder (PMDD)

This disorder is the more severe form of premenstrual syndrome (PMS) and affects up to 10% of women who are of childbearing age. Symptoms of PMDD include irritability, anxiety and general sadness.

These symptoms may start to show after ovulation and throughout that window of time before menstruation starts.

Scientist believe that PMDD is as a result of abnormal sensitivity to the hormonal changes that occur during the menstrual cycle.  

billing codes for depression

Depression Causes and Risk Factors

There are several causes and risk factors for depression including the following

  1. Brain Chemistry Imbalances

Neurotransmitters such as dopamine , norepinephrine and serotonin play a big role in mood regulation experts believe that imbalances in these brain chemicals can cause depression. Its therefore no surprise that some of the medications used to treat depression target restoring the balance in these levels of brain chemicals.

  1. Physical Health and Medical Conditions

People suffering from a chronic illness are at a higher risk of experiencing symptoms. Conditions such as sleep disorders, cancer, multiple sclerosis are top among the list of medical conditions that are a risk factor for depression.

The toll of a physical health condition can also impact your mental health. Again, some illnesses such as thyroid disorders cause symptoms that are similar to those of depression.

  1. Genetics and Family History

You are at a greater risk of developing depression if there is a history of depression and other mood disorders in your family. Family studies have shown the strong connection between depression and genetics. That being said, researches are yet to pinpoint the exact genes that affect and increase the risk of depression.

  1. Risk Factors Related to Lifestyle

From poor nutrition to stress and substance use, there are several lifestyle choices that can put you at a greater risk of suffering from depression. While you may not be able to change other risk factors such as genetics and you have little control over brain chemistry, you have full control over these lifestyle choices that are a risk factor.

Are Depressed Brains Different?

The thalamus, amygdala and hippocampus are the main areas of the brain affected by depression.

Research has shown that a depressed brain has a smaller hippocampus. It gets smaller with every bout of depression. Experts believe that stress, which plays a huge role in depression causes this shrinkage by suppressing the production of new nerve cells in this part of the brain.

A depressed brain also has more activity in the amygdala. This is the part of the brain associated with emotions including pleasure and anger. It gets activated when someone has or recalls an emotional experience, such as the loss of a loved one.

Experts believe that people with depression have some of the functionality of the thalamus impaired. This is on account of impaired nerve cell growth in this brain region.

Which Type?

A diagnosis by a doctor is the sure way to tell which type of depression you have. Diagnosis may involve

  • A psychiatric evaluation done against the DSM-V criteria.
  • Physical examination and blood tests to rule out other medical conditions

Get in Touch

Treatment plans for depression involve psychotherapy and medication. Noticed the signs and symptoms of depression?  contact us for a clinical diagnosis and effective treatment plan.

How to Bill Insurance with for Depression and Other Mental Health Diagnosis

Below are some of the more common F codes you would need to submit claims to insurance.

F41.1 – Generalized anxiety disorder
F43.23 – Adjustment disorder with mixed anxiety and depressed mood
F41.9 – Anxiety disorder, unspecified
F43.22 – Adjustment disorder with anxiety
F43.10 – Post-traumatic stress disorder, unspecified
F33.1 – Major depressive disorder, recurrent, moderate
F43.20 – Adjustment disorder, unspecified
Z63.0 – Problems in relationship with spouse or partner
F43.21 – Adjustment disorder with depressed mood
F34.1 – Dysthymic disorder
F32.9 – Major depressive disorder, single episode, unspecified
F90.9 – Attention-deficit hyperactivity disorder, unspecified type
F32.1 – Major depressive disorder, single episode, moderate
F90.0 – Attention-deficit hyperactivity disorder, predominantly inattentive type
F41.0 – Panic disorder [episodic paroxysmal anxiety] without agoraphobia
F33.0 – Major depressive disorder, recurrent, mild
F33.2 – Major depressive disorder, recurrent severe without psychotic features
F43.25 – Adjustment disorder with mixed disturbance of emotions and conduct
F40.10 – Social phobia, unspecified
F42 – Obsessive-compulsive disorder

There are essentially four separate levels of care that a patient could be getting treated with any of these diagnosis. Residential/inpatient (RTC), Partial Hospitalization (PHP), Intensive Outpatient (IOP), and Routine Outpatient (ROP).

There are specific tasks to all of these in reference to getting insurance reimbursement through the entire authorization and claims submission process. Please reach out to 541-ASK-AXIS for questions on this.

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”). 

Comprehensive and accurate mental health coding is vital as behavioral and mental health claims are on the rise.

We frequently find ourselves progressively adapting to learn nuances with each insurer differently to avoid claim delays or denials. Making improvements accordingly helps make the overall patient experience a lot smoother for the facility’s care team, the engagement with the insurer, and of course the patient’s family.

Nowadays, entities like behavioral health facilities are far more prone to denials and payer audits more than any other medical coverage a patient may have. This puts mental health services at risk as the insurers concentrate on the coding accuracy and things like the duration of services rendered.

The insurance carriers are all about its utilization. They perform plenty of data mining, so all mental health providers regardless what profession they are like psychotherapist, licensed clinical social worker, physician, licensed mental health counselor, or non-physician practitioner, all require that documentation be accurate to avoid delay or denial of claims.

What are CPT codes?

For those who are reading this and not familiar with how claims are paid, they all start with a medical code that can be billable to the insurance carriers.

CPT (Current Procedural Terminology) codes are extremely important and are used for payment for services, especially when it is to be reimbursed by the insurance companies. The American Medical Association developed the CPT codes and assigned from surgical to diagnostic codes for medical providers to use for their patients.

What type of documentation do insurance carriers want to see from providers to avoid any scrutiny?

  • Patient’s diagnosis. This is critical as the insurance carriers use this information to determine if therapy is medically necessary and if the specific therapy type is warranted. For instance, insurers may question the validity of therapy sessions provided to a patient with a neurological or cognitive deficit or a chronic brain injury when a drug intervention may be more appropriate.
  • Therapy type. Physicians likely provide supportive therapy while other mental health providers may provide an array of options, for example, cognitive behavioral therapy, psychoanalysis, or insight-oriented therapy. This is important when initially verifying coverage and benefits, and specifying therapy type, facility, etc… to ensure it will be a billable service provided.
  • Therapy goals: What treatment plans are set in place for the patient, short and long term?
  • Progress reports: Is the therapy being provided benefiting the patient?
  • Duration of sessions: What is the therapy start and stop times, to the exact minute.

How to know what psychotherapy codes to use?

As of 2013, CPT codes distinguishes between physician and non-physician providers performing psychotherapy services. Physician and Non-physician providers doing psychotherapy services use CPT codes such as 90832, 90836, or 90837, but all are based on the duration of the session. Aside from coding these services accurately, they should always be accompanied with documentation supporting the time spent providing the psychotherapy service.

help with insurance billing for drug rehab

Coding tips when billing for mental health services.

  • Clearly document the time spent and benefits of the psychotherapy. The carriers want to see that a physician billing for psychotherapy is actually doing a therapeutic intervention. Spending extra time talking with the patient does not translate to a billable psychotherapy service. Generally, insurance carriers are worried about over-use of psychotherapy services, particularly if it appears the patient gets no benefit or shows no progress. If in some cases the patient is resistant to psychotherapy interventions or is not taking sessions to heart, it’s not going to benefit them.
  • Documentation justifies any sessions extending beyond 45 minutes. The carriers want to see and know why time extension was necessary. Without proper supporting documents, claims may receive lower reimbursement or even denial.
  • Use group therapy (CPT code 90853), when appropriate. Group therapy is great for patients because they can meet and talk with others with similar problems and usually looked at as very beneficial. Carriers may also consider patients who go through bereavement counseling during a public tragedy or for a court-ordered group setting counseling session for whatever reason valid to use this code.

Documents that are compliant and accurate coding helps providers in avoiding delays and denials. Staying up to date with best practices seems to be a never-ending task, however,  we are glad we could share some insight with you about the significance of correctly utilizing CPT codes when billing for mental health services.

Here’s what the Supreme Court’s ACA Ruling Means for Addiction Treatment Centers

information on insurance billing for mental health and addiction

On 17th June 2021, the Supreme Court ruled in favor of the Affordable Care Act (ACA), dismissing the challenge that the ACA is unconstitutional.

Since it was signed into law, the ACA, widely known as the health reform law or Obamacare, has allowed nearly 31 million Americans to access healthcare coverage.

Besides banning insurers from basing health coverage on people’s pre-existing conditions, the law prohibited insurance providers from imposing lifetime or annual caps on benefits while also placing limits on yearly out-of-pocket spending.

One of the greatly felt impacts brought about by Obamacare is the comprehensive healthcare plans, which allows people with mental health conditions and substance abuse disorders to access healthcare coverage just like other people.

Over the last four years, some changes have been made to the health care reform law, but the new administration is now reversing some of them.

To help you understand the impact that the Supreme Court ruling has on addiction treatment centers, I’ve covered everything from ACA’s impact on substance abuse to billing and reimbursement requirements for addiction treatment centers.

Supreme Court Ruling on ACA.

Knowing that their policies will cover the need for this higher level of care and future care is critical for all who need mental health services. Taking away any stigma with any mental health disease is important knowing that some if not all of the cost can be shared by the insurance policy they pay for monthly.

As well as knowing the fact the SCOTUS has upheld Obamacare time and time again shows how important the issue is and will be going into the future for more families and individuals who suffer from the mental health dilema day in and day out

Additionally, we shall see the potential impact this ruling has on the demand for treatment of behavioral health conditions and whether or not it will influence reimbursement rates for behavioral health.

This is the 3rd and 4th attempt to strike down the law which provides coverage for this dire need of insurance coverage for many of the millions of Americans who are stricken with mental health issues.

As time goes on the insurance industry will adapt and find a usual and customary reimbursement rate for providers and insurance policy holders alike but know that this mandated coverage has been deemed worthy and constitutional by the supreme court of law.

Earlier Changes Made to ACA

Since its implementation in March 2010, The Affordable Care Act had survived two earlier Supreme Court challenges. However, the law has also seen several changes during the last administration. Below is an overview of some of the biggest amendments made.

Elimination of the Individual Mandate

When ACA was passed into law, all US residents were required to have health insurance or pay a given penalty. This mandate was designed to have everyone, including the more healthy people to enter the health insurance market. Similarly, it helped keep the ACA premium policies low. A 2017 tax overhaul legislation reduced the penalty for not having a health plan to $0. In December 2018, following the tax overhaul, a Texas federal judge ruled that the $ 0 penalty, by law, is no longer a tax, but a command, hence declaring the whole ACA unconstitutional. The case then moved to Supreme Court, and a ruling was made in favor of the ACA on 17th June 2021.

Work Requirements Added to Medicaid

After the ACA Medicaid expansion was adopted, the federal government required states to have Medicaid beneficiaries prove that they either go to school or work. This change was highly politicized, and hundreds of thousands of Americans, including those with substance abuse disorders, were expected to lose their healthcare coverage.

The Ending of Cost-Sharing Reduction Subsidies to Insurance Providers

In 2017, the federal government stopped paying subsidies to insurers, which was seen as a critical element in motivating these companies to keep premiums down. This change disproportionately affected individuals and families who are not eligible for subsidies.

Expansion of Short-Term Plans

Under the initial ACA, short-term insurance that didn’t provide essential benefits was limited to not more than three months. However, in 2019, the federal government extended this duration to 364 days with the option to renew for three years. Since these health care plans are non-comprehensive, they do not fully protect individuals in severe health conditions.

Slashed Budgets for HealthCare.gov Sign-Ups

Initially, the ACA had navigator programs with allocated budgets to help drive the healthcare sign-up campaigns. In 2017, these budgets were slashed, and the net impact was slowed and depressed enrollment. In the following year, the uninsured rates for US residents rose to 8.5% or 27.5 million people (the highest since the ACA went into effect) not having any healthcare plan at any point in 2018. This translated to more people, including those with pre-existing conditions not accessing medical care.

The Impact That ACA Has on Substance Abuse Treatment

The Affordable Care Act made it possible for people with pre-existing conditions such as drug and alcohol addiction to be accepted by insurance providers. At the same time, the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) mandated all insurers to offer the same level of coverage for substance abuse and mental health treatment as for regular medical care.

Now that the Supreme Court has spared ACA, patients receiving alcohol and drug recovery treatments have been relieved of the stress of covering all the rehab costs. Moving forward, rehab patients will continue to benefit from the covered rehab expenses. That said, here are the four ways ACA will continue to keep inpatient and outpatient rehab treatment costs affordable.

  • Drug and Alcohol Addiction Treatment Remains a Priority: The ACA considers substance abuse disorders as one of the ten elements of essential health benefits. That means Medicaid and other forms of healthcare coverage sold via Health insurance Exchanges should cover services for substance abuse. 
  • Greater Access to Healthcare: More people will continue to sign up and access medical coverage through the expansion of Medicaid and other low-cost insurance plans. Similarly, states accepting federal aid allocated by the ACA will expand Medicaid coverage to individuals and families living below and slightly above the pre-determined federal poverty line.
  • Young Adults Will Remain on Parent’s Health Plan: Individuals up to the age of 26 will continue to receive coverage under their parent’s health insurance coverage. According to a SAMHSA survey, nearly 7% of young adults in the US between 18 and 25 have a substance disorder. By extrapolation, more young adults will continue to benefit from covered rehab expenses under the ACA.
  • Free Screenings and Referrals: If the ACA were ruled unconstitutional, patients with Medicare, Medicaid, or plans under the Health Insurance Marketplaces would have been charged for mental health and alcohol screenings. Now that the law is intact, these services come with no cost for insured individuals.

Billing and Reimbursement for Behavioral Health Service Providers

Now that you know everything about the Affordable Care Act, from the changes made to what to expect moving forward, let’s look at the other side of the ACA – i.e., what it takes for behavioral health service providers to be reimbursed by insurance companies.

Typically, there are four service categories that insurers may consider for reimbursements. These include:

Hospital-Based and Residential Inpatient Care

Hospital-based care and residential programs, widely known as RTC, are acute and sub-acute recovery centers offering nursing care, medical monitoring, and behavioral-health services 24/7. Services provided by these programs are reimbursed on a standardized per-diem basis. Here, the per-diem rate includes all services offered in the program from the accommodation, lab fee, therapies, services of licensed professionals and counselors, dietitians, psychiatric nurses, etc.

Partial Hospital Programs (PHP)

Here, services are offered in an ambulatory setting and require a minimum of 20 hours per week. Billing is done per diem basis, and reimbursement is made on the lesser charges, including services from social workers, addiction counselors, occupational therapists, addiction counselors, etc.

Intensive Outpatient Programs (IOP)

These programs provide patients with behavioral health services for 9 to 19 hours per week for adults and at least 6 hours for children and adolescents. Billing for IOP is cumbersome compared to hospital-based and inpatient programs; hence, it’s challenging to get reimbursement.

Services offered by IOP include family, group, and individual psychotherapy, medical monitoring, and psycho-education. To be eligible for reimbursement, IOP providers must:

  • Supervise the patient at all times.
  • Adhere and be consistent with the initial treatment plan
  • Address the diagnosis that required admission.
  • Provide enough IOP care to patients for about 12 to 16 weeks.
  • Be consistent with clinical best practices.

Other Key Takeaways

Due to the Supreme Court ruling, enrollment for healthcare plans will probably rise, and more people with substance abuse disorders will be seeking specialized treatments. It’s therefore fair to conclude that to a given extent, the demand for treatment services for behavioral health conditions will increase.

As far as reimbursement is concerned, the current rates are significantly lower than those for other medical and surgical treatments, and this has led to a lower network of behavioral health providers participating in healthcare plans. If this were to be resolved, health plans would need to raise reimbursement rates. But even then, it would be very costly to try and level up with what behavioral health providers charge patients who pay out-of-pocket. And while there are no official plans to raise reimbursements yet, efforts to boost these rates will be highly beneficial.

Last but not least, addiction treatment centers that accept Obamacare, Medicare, and Medicaid plans should prepare to help more patients access quality care. They should also keep up with the CMS billing requirements to ensure compliance and minimize delays of reimbursements which could otherwise hurt service delivery.

What You Need to Know for PHP Insurance Billing in 2021

A partial Hospitalization Program (day hospitalization) is a structured day program providing several hours of therapy and necessary skill-building groups daily. Participants in a daily PHP routine go back home each night. The program can last for a week or up to six months.

PHP treatment programs closely resemble a highly structured but short-term hospital inpatient program. It’s more intense than psychosocial rehabilitation or outpatient day treatment. We have prepared this article to provide general guidelines for insurance billing for PHP.

Behavioral Health Levels of Care

Behavioral health facilities provide four types of services needed by patients that insurance companies may reimburse. These include:

  1. Hospital-based inpatient programs where patients need medical monitoring, nursing care, or other behavioral health services requiring 24/7 treatment.
  2. Residential treatment programs (RTC) are a form of sub-acute facility-based monitoring that offers other behavioral health services.
  3. Partial hospital programs (PHP) provide services in an ambulatory setting and often require 20 hours per week.
  4. Intensive outpatient programs (IOP) where patients get behavioral health services for nine to 19 hours per week (adults) and at least six hours for children and adolescents.

Insurance Billing for PHP in a Nutshell

PHP services receive insurance reimbursement for an all-inclusive per diem payment, including services used in the program or the lesser charges. It includes all disciplines and services such as therapies, social workers, psychiatric nurses, dieticians, occupational therapists, and licensed addiction counsellors.

Psychologists, psychiatrists, psychiatrist physician assistants, and psychiatric nurse practitioners may bill separately on a CMS-1500 Claim Form if they provide services outside of a treatment program, for example, individual therapy, E&M services, or psychological testing. Additionally, appropriately licensed providers can bill separately for labs or psychiatric diagnostic evaluations.

Providers cannot bill Family or group counseling in addition to PHP.

Instructions for Insurance Billing for PHP

Facilities provide different substance use and psychiatric service levels with various licensure types. Each care level requires specific coding and billing information to determine appropriate reimbursement. Below is the insurance billing for PHP guide on the UB-04 Claim Form.

Psychiatric Services

Facility or Service Type

Bill Type

Revenue Code

Level

HCPCS

PHP

131

0912

Full day

H0035

PHP

131

0912

Eating Disorder Program

S9485

 

Substance Use Services

Facility or Service Type

Bill Type

Revenue Code

HCPCS

PHP

131

0912

S9475

 

Billing Limitations and Exclusions

When insurers consider reimbursement, payment determination is subject to the following:

  • Individual or group benefit
  • Provider Participation Agreement
  • Mandated or legislative-required criteria always supersede
  • Routine claim editing logic that includes but not limited to mutually exclusive or incidental logic and medical necessity

If the insurance provider participates based on member benefits, then coinsurance, co-payment and deductible apply.

Does Medicare Cover PHP?

Medicare could cover PHP programs if a Medicare-certified CMHC or a hospital outpatient department provides them. Medicare does not cover psychosocial programs that provide only socialization, vocational rehabilitation, or a structured environment. A program comprised primarily of social, recreational, or diversionary activity does not constitute a PHP.

Patients that meet benefit category requirements for PHP Medicare coverage comprise of two groups:

  • Those discharged from inpatient hospital treatment programs where PHP is in place of a continued inpatient treatment
  • Those who would be at risk of needing inpatient hospitalization in the absence of PHP

Over to You

Reimbursement policies for insurance billing for PHP are intended to establish general guidelines under the specific insurance providers’ plans. Therefore, providers retain the right to review and update reimbursement policy guidelines at their discretion.

We hope this short but informative article was helpful. If you have any queries about insurance billing for PHP and how to maximize your reimbursement, please contact us via email or our contact us website page.

Understanding Insurance Issues For Eating Disorders

Navigating an insurance billing for eating disorders can be a nuisance if you do not know what to do or where to “touch.”  One of the main obstacles to treatment for individuals with eating abnormalities is the cost of the treatment.  Some residential treatment centers can cost up to $30,000 a month! This makes getting insurance reimbursement for people needing help with eating disorders very critical.

Now, while studies show that early diagnosis and evidence-based medical care approach are both critical for recovery, insurance regulations and guidelines in most cases make it almost impossible to receive the appropriate care needed. The treating clinical professionals 

So, if you or your loved one is faced with this type of condition, where do you start? Sadly, these challenges sometimes include determining how to analyze your insurance plans to understand the treatment coverage that is ideal for you. Here are some aspects that you should know about insurance billing for disorders:

What type of eating disorders are covered by your insurance?

Many insurances have eating disorders cover benefits that technically cover these eating disorder diagnoses:

  • Binge eating disorder
  • Anorexia nervosa
  • Bulimia Nervosa
  • Avoidant/ restrictive intake disorder
  • Any other specified eating or feeding disorder.

What will be deducted, and how much is it?

In most cases, once you make a phone call to the company, the admission department or the respective department will check your benefits. After the confirmation, you will be informed of any deductible that you are supposed to pay out of your pocket. This is usually the amount you are supposed to pay before an insurance company covers a claim. The specific amount sometimes varies depending on the insurance company as well as the plan.

For instance, if your deductible is $ 500 and treatment is billed at $ 250 daily, you would be responsible for covering the initial two days on your own. After you make the payments or meet the deductible, the insurance firm will cover the expenses 100 %. Some firms require policyholders to pay co-insurance. This is where you are responsible for paying a certain percentage of the entire insurance billing for eating disorders. This can range from 10 to 50 %.

What level of care is paid for?

In most cases, the level of care that insurance companies approve for is individual outpatient therapy. The best level, however, of behavioral healthcare is inpatient, then residential care, PHP (Partial Hospital program (PHP), and finally the IOP (intensive outpatient program).  Note that, for you to access any of the above treatments, you must

  • Have benefits under your plan for these levels of healthcare
  • Meet the necessity, which is evaluated by the severity of symptoms, current weight, vital signs, and blood work results.

How long will the cover last?

This will depend on various factors. Has your condition improved? Is it deteriorating? Most insurances state in their “insurance billing for eating disorders” policy that you have unlimited days depending on medical necessity. Once you stop meeting the level of care required for a certain program, you will have to step down for a less intensive level of care.

For instance, you can be admitted into a residential program once you stabilize and no longer need critical care or you do not meet the clinical or medical criteria. Similarly, if you do not improve in that care, and your condition is worsening, you will be admitted to a better level of care, such as inpatient.

What if my insurance does not cover eating disorders?

There are a few things you can do depending on your personal and financial circumstances:

  • Switch plans; This should be pretty straightforward for anybody whose current plan does not cover eating disorders. Not all insurance companies offer this, but some reliable ones do it as a reprieve for members from a high-cost treatment.
  • Some non-profit organizations now partner with various treatment centers to provide financial help to those who cannot afford life-saving treatments. Look for one and ask for help.

It is important to understand these factors so that you can advocate to receive the right treatment. You are capable and strong enough to mastermind your future.

 

Having an effective revenue cycle management in place for your center is essential in optimizing performance and margins. From the first contact with patients, such as verification of benefits and authorization preparation, to efficient service coding and billing, to finalizing and collecting on all claims. 

Throughout the whole process, there are key elements in ensuring success with revenue collections that we will cover in this article. Finding the right people to facilitate and function technology, getting real-time eligibility and service authorizations, using data to build a successful game plan for claims denials. 

Finding the right people to facilitate and function technology: Billers are in high demand now days and technology tools continually advance in ways of making jobs and tasks streamlined and accommodating for centers and their treatment teams, however, you still need people with the ability to use the tools available to them. They have to be able to use those tools effectively while understanding the billing and collection process behind them. Payers advise that we use their online tools to obtain the information we need, so it is very important to utilize those tools available to prevent delays or denials. A solid process and accountability of each person involved, maintenance training, and incentives are all factors in maximizing your revenue cycle management.

Getting real-time eligibility and service authorizations: More than 20% of denied claims are usually caused from an authorization issue. Prioritizing real-time verification of benefits and authorizations has to be the main ingredients to ensure success from beginning to end. Many payers allow the ability to get this information online also, making it even more convenient when you don’t have to call someone and wait on hold forever. Create structured processes, that is frequently updated, for prior authorizations for each payer including any benefit coverages or medically necessity requirements. 

Using data to build a successful game plan for claims denials: The only way to prevent claim denials is to use data from denied claims to improve the process. Understanding the how, why, and what caused claims to be denied, you can adjust accordingly to prevent it from happening again with future claims, resulting in an improved revenue cycle management process. There are cases where it may seem impossible to overturn a denied claim, but if you do your due diligence, respond in a fast and timely manner, there’s a good chance you may surprise yourself. Exhaust all options before archiving denied claims. 

These are just a few ways to possibly help increase your insurance reimbursements for your patients and decrease claim denials. This is so beneficial to everyone involved, from the insurance companies to the staff and treatment team at the center, and most importantly, the patient and their family. 

I would like the opportunity to hear what has worked for your center in the past or present? What obstacles do you frequently run into when dealing with your insurance claims? I look forward to discussing more ways to improve. 

Billing for IOP in a nutshell

Are you seeing changes in IOP billing for mental health in 2021? We certainly are. There are new requirements coming from UHC, BCBS, Cigna, Aetna and all the rest for all levels of care including RTC and PHP billing all the way through outpatient services.

When dealing with IOP billing specifically, there are generally a few more requirements and consistent attention needed to make sure everyone involved is happy. From the patient being able to continue their treatment, to the doctors treating the patient, and of course, making sure the insurance companies are on board with allowing the overall treatment to happen.

Behavioral health levels of care

Behavioral health facilities essentially provide four types of services that insurance companies may consider reimbursement when treating a patient.

  1. Hospital-based inpatient programs, that require medical monitoring, nursing care, and other behavioral health services treated 24/7.
  2. Residential treatment programs, also known as RTC, which is more of a sub-acute facility based monitoring, offering other behavioral health services.
  3. Partial hospital programs, better known as PHP, providing services in an ambulatory setting, and generally requires 20 hours per week.
  4. Intensive outpatient programs, known as IOP, where the patient is provided with behavioral health services for at least 9 to 19 hours a week for adults, and for children and adolescents at least six hours is generally acceptable.

There are so many different modalities and service types when billing for IOP, compared to inpatient and hospital-based programs, which in turn makes it more challenging when trying to get reimbursement.

Similar Article: The Secret To Getting Reimbursed Quicker- Claims Follow Up

Typical services covered in IOPs

If a facility is offering IOP services, they must be licensed at the state level and usually will treat substance abuse and most mental health disorders. Most facilities will set up a weekly schedule for IOP patients, consisting of meeting at least two hours per day, and from three to five days a week.

Typical services generally covered are:

  • Individual psychotherapy
  • Family psychotherapy
  • Group psychotherapy
  • Psycho-educational services
  • Medical monitoring

CMS guidelines required in order for the facility to be eligible for reimbursement for IOP services are:

HCPCS and revenue codes for IOPs

IOP billing codes may differ depending on what the patient’s diagnosis is, and what services are provided primarily either for substance abuse or for mental health issues. Also, another thing to remember when billing for IOP services, if the patient has a dual-diagnosis for both substance abuse and mental health, you can generally only bill for one IOP session per day, even if both were being addressed in therapy. It is always good to document that information for the insurance company, but beware to not submit duplicate claims, as they’ll inevitably get denied and or delay payment.

  • S9480/0905: The per diem outpatient IOP code for psychiatric issues which may include eating disorders, is S9480, and most times is always paired with revenue code 0905. This is generally used for private payers, as Medicare does not recognize these codes.
  • H0015/0906: The per diem outpatient IOP code for all chemical dependency is H0015, and is always paired with revenue code 0906.

Similar Article: 5 Insurance Billing Errors Drug Treatment Centers Can Avoid

Pre-authorization, clinical and IOP all go hand in hand

Just like with all inpatient level care services, most insurance companies require all IOP services obtain a pre-authorization before reimbursement is complete. Although IOP, technically provides only two to three hours per day, most payers require at least 180 minutes of active therapy per day in order to reimburse the per diem rates.

This is why I stated earlier, that clinical documentation is a key element in supporting the full 180 minutes per day, otherwise you’ll end up with a denied claim. A concurrent authorization is generally required to continue to treat the patient and sometimes referred to as short-term interventions, where all clinical and progress of the patient is considered and decided for continued authorization.

We hope this was a helpful and informative article about IOP in particular. If you have any questions about IOP billing and how to maximize your reimbursement for behavioral health services or any other billing concern, please feel free to contact us via email, or check out a ton of extra billing resources here.

The UTAH State Board of Education has put an entity to provide oversight for those Utah mental health adolescent programs that are approved NPS providers for California!

Since it will take them some time to get up and running, the Board will provide a temporary certification to RTCs that apply for certification by August 30, 2019, until their application can be reviewed and a site visit conducted, at which time each RTC will either be approved for a 2-year term or denied certification. Both California and Illinois will accept Utah’s temporary certification.

August 30th is the deadline so if you have not filled out the attached application, you are running out of time.

RTC Special Education Program Certification Application

On June 6th, 2019, Anthem, Inc. announced that they are in the definitive stages to acquire Beacon Health Options, Beacon currently serves more than 36 million individuals across all 50 states, and 3 million of those under comprehensive risk-based behavioral programs.

“Our member-focused, integrated clinical care model helps individuals and their families cope with their physical and behavioral health challenges. Together, we will expand access and enhance the quality of care for our mutual members. I am proud of the talented and committed team at Beacon, and we look forward to our future with Anthem.”Russell C.Petrella, Ph.D., Beacon Health Options President and CEO

Anthem didn’t disclose a price it is paying Bain Capital Private Equity and Diamond Castle Holdings for Beacon Health, which is privately held. The acquisition is expected to close in the fourth quarter of 2019. However, this is a great opportunity for Anthem to utilizing Beacon Health Options, already stellar business model, not to forget they are the country’s largest independently held behavioral health provider.

“As Anthem works to improve lives, simplify healthcare and serve as an innovative and valuable partner, we’re focused on providing solutions that address the needs of the whole person,” -Gail K. Boudreaux, President and CEO, Anthem

The acquisition will offer the opportunity to combine both successful business models to diversify the health services and deliver market-leading integrated solutions. Progressing towards a stronger portfolio of specialized services, improved clinical expertise, and ability to offer broader provider networks and establishing positive relationships.

“We are excited to partner with Anthem to serve the behavioral health needs of more than 60 million Americans,” –Russell C. Petrella, Ph.D., Beacon Health Options President and CEO

Once the acquisition is complete Beacon, combined with Anthem’s behavioral health business, will operate as an integrated team within Anthem’s Diversified Business Group. Russell C. Petrella, Ph.D., Beacon Health Options President and CEO, as well as other key members of Beacon’s senior team, will join Anthem’s Diversified Business Group to lead the efforts to offer innovative behavioral health solutions and further expand this business.

“With an extensive track record in behavioral health, Beacon fits well with our strategy to better manage the needs of populations with chronic and complex conditions, and deliver integrated whole health solutions. Together with Beacon, we will enhance our capabilities to serve state partners, health plans and employer groups as they seek to address consumer behavioral health needs.” -Gail K. Boudreaux, President and CEO, Anthem

We are excited and believe this is very significant as more insurers are working on addressing the determinants of care for mental illness that fall outside of the traditional medical care. One out of every five adults suffers from mental illness, and is only increasing, according to the National Institute of Mental Health.

What are your thoughts on this acquisition? Is this good or bad, why so?