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Everything a Mental Health Provider Needs to Know about Billing

Few things fluster a mental health therapist more than the billing and filing claims for their patients. Fortunately, we hope to make navigating the complex medical billing landscape a little easier for you. We’ll start with breaking down the process of the Revenue Cycle.

Intake Information

Efficient billing practices begin the moment you initiate a new patient record. The reason being is that most bills are rejected by the insurance company are felled by simple mistakes: a misspelled name, a typo in the patient’s insurance ID number, a blank field, etc. To create a mistake-free claim, you’ll need meticulous accuracy on all personal information, such as:

  • Patient’s full legal name
  • Date of birth
  • Current address
  • Insurance member ID number

When typos or incorrect information sneaks into the initial patient records, those “pre-fill” mistakes appear on every claim until you realize there was an error. Months of billing may be lost. Most behavioral & mental health providers see patients on a regular basis. You may have multiple, time-consuming medical insurance claims to correct simply due to oversight in the beginning.

Special note: Double check their insurance coverage for mental health services right away and make sure they are covered for the services you provide.

Patient Copay

Collect the patient’s copay at the time of the visit or on a bi-weekly or monthly basis. Once the patient leaves your office or clinic, the odds of collecting payment diminish greatly. In addition, trying to collect multiple copays at a later date may surprise your patient with an unexpectedly large price tag that they are prepared to cover. Therefore, collecting the copay immediately needs to be a priority.

Create & Submit your HCFA 1500 (CMS 1500) claim form

The HCFA 1500 (CMS-1500) medical insurance claim form is the industry-standard form for filing claims for mental health professionals. In addition to the patient’s identifying information and insurance, the form will ask for data on your treatments and your practice, such as when and where the service took place, what diagnostic or service codes apply, your tax ID, etc. A clean claim is formatted correctly, contains accurate information, and is free of mistakes or typos. You can simply download the HCFA-1500 claim form here or use a software to help you prepare it. We advise to consider our HCFA-1500 software for this purpose.

What is included in an HCFA form?

The HCFA form is made up of 33 boxes. If that seems like an overwhelming number, fret not – each box requires little information, most of which is rudimentary. Plus, we’ve prepared the following billing guide to HCFA so you can breeze through the process. Each numbered entry in this guide corresponds to the same box number on the HCFA form.

  1. Insurance information: Indicate Medicaid, Medicare or the patient’s private insurer alongside their insurance ID, which goes in box 1a.
  2. Patient’s name: Write the patient’s full legal name.
  3. Patient’s sex and date of birth: Write the month, date and year as two digits each. Check the appropriate box for the patient’s sex assigned at birth.
  4. Insured’s name: If the patient is using their own insurance plan, you can leave this box blank. If their plan is in someone else’s name, write that name here.
  5. Patient’s address and phone number: Fill out each box in this section with the appropriate information.
  6. Patient’s relationship to insured: Check the appropriate box. You should only check one of the four boxes present.
  7. Insured’s address: Again, leave this box blank if the patient is self-insured. Otherwise, add this information for the person whose name is on the insurance plan.
  8. Patient status: Check one box in the first row (marital status) and one box in the second row (employment status).
  9. Other insurance information: Leave this section blank if the patient has only the primary insurance indicated earlier on the form. If the patient has secondary insurance, include all requested information here.
  10. Patient condition and Medicaid information: Here, indicate whether the services you provided were in response to injuries or illnesses sustained on the job, in a car accident or in another kind of accident. In the “reserved for local use” box, add the patient’s Medicaid number if they have one.
  11. Insured’s policy or group number: Here, write down the patient’s policy, group or FECA number. You should also include the identifying information requested. If you’ve added information to box 9, check “yes” in box 11d.
  12. Patient’s signature: All HCFA forms require a patient’s signature to submit. This box is where you’ll record that signature.
  13. Insured’s signature: You only need to complete this section if the patient has secondary insurance, as indicated in box 9.
  14. Date of condition being treated: Write the date when the patient first began experiencing symptoms.
  15. Previous reports of condition being treated: If the date of the patient encounter you’re billing for isn’t the patient’s first instance of this condition, record the first date here instead. You should write the date of the encounter you’re billing for if this is indeed the patient’s first time with symptoms.
  16. Dates out of work: If the patient’s condition has put them out of work, include the dates the patient has been sidelined.
  17. Referring provider: If another practitioner referred the patient to you, list that practitioner’s name, ID number and National Provider Identifier (NPI).
  18. Hospitalization dates: If the patient’s condition has led to their hospitalization, list the hospitalization dates here.
  19. Reserved for local use: Leave this section blank for the recipient of the form should they need it.
  20. Outside lab charges: If you’re filing a claim for third-party lab tests, check the “yes” box and write down the charge amount.
  21. CPT codes: List the CPT codes corresponding to the services provided. You can use the page-width lines under “Diagnosis Pointer” to provide additional codes.
  22. Medicaid resubmission code: If you’re resubmitting a rejected claim to Medicaid, write the original claim’s reference number here.
  23. Prior authorization number: If your patient brought prior authorization from the payer to their appointment, add the authorization number here. You’ll also need a seven-digit IDE number for investigational devices and a ZIP code for ambulance services.
  24. Service details: Here, you’ll list the dates and location of service, the services provided, and the corresponding charge amounts. You’ll also complete the diagnosis pointer section you first encountered in box 21. Note that you can leave this box blank for influenza or pneumococcal vaccines.
  25. Tax identifier: Provide your employer identification number (EIN) or, if you’re a sole practitioner with no EIN, your Social Security number.
  26. Patient account number: Though completing this box is optional, writing your patient’s account number within your practice can help you link the claim with the patient and track progress accordingly.
  27. Accept assignment: Check the “yes” box for physician, laboratory, surgical, supplier or ambulance services.
  28. Total charges: Write the total amount of reimbursement you’re seeking.
  29. Amount paid: If part of the claim has already been paid, indicate that amount here.
  30. Balance due: Subtract the value in box 29 from box 28, then write that amount here.
  31. Provider signature: Sign your HCFA form here.
  32. Service facility location information: Write the full address of the location where services were provided.
  33. Service provider information: Here, list your address again alongside your NPI and phone number.

You’re now done with your HCFA form.


Monitor your claims progress

Once your claim has been properly filled out and submitted, it’s imperative that you monitor its progress through the system. Payers and clearinghouses will allow you to track electronically-submitted claims on a user dashboard. Pay special attention to aging claims, those that aren’t being processed within the typical timeframe. You may need to prompt a clearinghouse or payer to identify why it’s stalled and how soon it can be resolved.

UB04 Software uses two clearinghouses, Ability Network & PhiCare, to check the medical claims for errors, ensuring the claims can get correctly processed by the payer.

Here’s the nuts and bolts of how it works.

The medical billing software on your desktop creates an electronic file (the claim) also known as the ANSI-X12 - 837 file, which is then uploaded (sent) to your medical billing clearinghouse account. The clearinghouse then scrubs the claim checking it for errors (arguably the most important thing a clearinghouse does); and then once the claim passes inspection, the clearinghouse securely transmits the electronic claim to the specified payer with which it has already established a secure connection that meets the strict standards laid down by a HIPAA. (Medical claims are also known technically as ‘HIPAA Transactions’ and it is because of HIPAA that we cannot send claims for patient billing to insurance payers simply by email.)

At this stage, the claim is either accepted or rejected by the payer, but either way, a status message is usually sent back to the clearing house who then updates that particular claim’s status in your control panel. Now you have an accepted or rejected claim. If rejected, you have a chance to make any needed corrections and then re-submit the claim. Ultimately, assuming there are no other corrections required, and the patient’s insurance was verified beforehand, you’ll receive a reimbursement check or Electronic Funds Transfer (EFT) along with an explanation of benefits (EOB).

Special Note: The average error rate for paper claims is 28%. But using the right clearinghouse can reduce that to 2-3%.

Managing Denials and Appeals

Insurance companies reject claims for any number of reasons. Some involve coverage issues, others are easy fixes, like outdated or missing information.

Clearinghouses screen for incorrect content and discrepancies before a claim ever reaches the insurance company, so your claim may be rejected by the clearinghouse first. Usually, you can fix it and resubmit. To check whether the claim is hung up at the clearinghouse or with the payer, check your clearinghouse software for a claim rejection. If the claim has passed the clearinghouse checkpoint, you will need to call the payer to determine why there is a delay in payment.

After the clearinghouse, your request for coverage must be accepted by the payer. Denials and rejections at this stage should be thoroughly investigated to determine the root cause and potential solutions. Speak with an insurance representative directly for ideas on how to fix and resubmit denied requests. The representative may be able to assist you with the solution that will result in a payment. Sometimes the patient’s plan simply doesn’t cover a particular treatment and there’s little you can do.

Get Paid

You’ll receive a check or EFT along with an explanation of benefits to explain the payment amount. If insurance refused to cover the entire cost of services, you’ll have to bill your patient for the difference. This is one reason why checking benefits eligibility for all services up front is critical. If you don’t do it, you could surprise your patient later with an unexpected bill.


Bonus: Commonly Used CPT Codes in Psychotherapy Medical Billing

There are many CPT codes currently used by mental health professional that can be reported under the following categories:

  • Health Behavior Assessment and Intervention (CPT codes 96156-96171)
  • Psychotherapy Codes (CPT codes 90832-90863)
  • Psychological and Neuropsychological Testing Codes (CPT codes 96105-96146)

Listed below are the most common psychotherapy CPT codes, as well as which healthcare professionals can report which codes. This is not a comprehensive list of CPT codes. It is simply a general description of commonly performed mental health services.

Psychiatric Diagnostic Procedures

CPT Code Descriptor Healthcare Professionals Documentation Requirements
90791 Psychiatric diagnostic evaluation MD, NPP, LMSW, LCSW, Licensed Psychologist, RN, LMHC, LMFT, LCAT
  • Assessment
  • Patient’s psychosocial history
  • Current mental status, review, and ordering of diagnostic studies followed by appropriate treatment recommendations
90792 Psychiatric diagnostic evaluation with medical services MD, NPP
  • Assessment
  • Patient’s psychosocial history
  • Current mental status, review, and ordering of diagnostic studies followed by appropriate treatment recommendations

Psychotherapy

CPT Code Descriptor Healthcare Professionals Documentation Requirements
90832 Psychotherapy, 30 minutes with patient MD, PA, RN, LCSW/LMSW Therapeutic communication to:
  • Ameliorate patient’s mental and behavioral symptoms
  • Modify behavior 
  • Support and encourage personality growth and development
Treatment for: 
  • Behavior disturbances
  • Mental illness
+90833 Psychotherapy, 30 minutes with patient with E/M MD Therapeutic communication to:
  • Ameliorate patient’s mental and behavioral symptoms
  • Modify behavior 
  • Support and encourage personality growth and development
Treatment for: 
  • Behavior disturbances
  • Mental illness
90834 Psychotherapy, 45 minutes with patient MD, PA, RN, LCSW/LMSW Helps a patient with a mental illness or behavioral disturbance identify and alleviate any emotional disruptions, maladaptive behavioral patterns, and contributing/exacerbating factors.
+90836 Psychotherapy, 45 minutes with patient with E/M MD, PA, RN, LCSW/LMSW Helps a patient with a mental illness or behavioral disturbance identify and alleviate any emotional disruptions, maladaptive behavioral patterns, and contributing/exacerbating factors.
90837 Psychotherapy, 60 minutes with patient MD, PA, RN, LCSW/LMSW Helps a patient with a mental illness or behavioral disturbance identify and alleviate any emotional disruptions, maladaptive behavioral patterns, and contributing/exacerbating factors.
+90838 Psychotherapy, 60 minutes with patient with E/M MD, PA, RN, LCSW/LMSW Helps a patient with a mental illness or behavioral disturbance identify and alleviate any emotional disruptions, maladaptive behavioral patterns, and contributing/exacerbating factors.
90845 Psychoanalysis MD
90846 Family psychotherapy (without the patient present), 50 minutes MD, PA, RN, LCSW/LMSW
90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes MD, PA, RN, LCSW/LMSW
90849 Multiple-family group psychotherapy MD, PA, RN, LCSW/LMSW
90853 Group psychotherapy (other than of a multiple-family group) MD, PA, RN, LCSW/LMSW

Psychotherapy for Crisis

CPT Code Descriptor Healthcare Professionals Documentation Requirements
90839 Psychotherapy for crisis; first 60 minutes 
*Billed for the first 60 mins of psychotherapy for a patient in crisis, and add-on code 90840 billed for each additional 30 mins.
MD, PA, RN, LCSW/LMSW Report these codes when the psychotherapy is for a patient with a life-threatening or highly complex psychiatric crisis.
90840 Psychotherapy for crisis; each additional 30 minutes (list separately in addition to code for primary service). MD, PA, RN, LCSW/LMSW Report these codes when the psychotherapy is for a patient with a life-threatening or highly complex psychiatric crisis.

For more information, please consider reading the following article: Tips for Completing The HCFA-1500 (CMS 1500)Form