Billing for mental health and behavioral health services can be tricky, especially with the constantly evolving rules, codes, and insurance requirements. Whether you’re a provider dealing with claims denials or trying to stay compliant with mental health parity laws, getting it right is essential for smooth operations and faster payments.
In this article, we’ll break down the key differences between mental health (MH) and behavioral health (BH) billing, share crucial CPT and ICD-10 codes, and give you practical tips to overcome common billing challenges.
Mental Health vs. Behavioral Health
While mental health (MH) and behavioral health (BH) are terms often used interchangeably, they represent distinct concepts, especially when it comes to billing and coding. Understanding these differences is critical for providers who need to navigate the complexities of insurance claims, reimbursements, and compliance.
| Aspect | Mental Health (MH) | Behavioral Health (BH) |
| Focus | Diagnoses such as depression, anxiety, PTSD, etc. | Actions, habits, and behaviors such as addiction, ADHD, etc. |
| Common Treatments | Psychotherapy, medication management | Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), addiction counseling |
| Billing Complexity | Requires psychiatric CPT codes (e.g., 90837) | Often needs extended session codes (e.g., 90853) |
| Key Takeaway | BH often includes substance abuse treatment, requiring additional documentation for insurers. | Behavioral health may require more documentation for complex issues like addiction and substance abuse. |
Key Insight: While MH focuses on internal conditions like mood and cognition, BH deals with external behaviors that affect mental and emotional well-being. The distinction is essential for accurate billing, as different insurance carriers and payer systems may treat these conditions differently, requiring different coding protocols.
Types of Mental & Behavioral Health Services
A. Mental Health Services
Mental health services typically deal with psychological disorders that affect mood, cognition, and emotional well-being. These services often require regular monitoring and specialized treatments. Common mental health services include:
- Psychotherapy (Individual, Group, Family): These sessions aim to treat mood disorders, anxiety, and other emotional struggles through talk therapy and interventions.
- Psychiatric Evaluations & Medication Management: Often provided by psychiatrists or advanced practice nurses, these services involve assessing patients’ mental health and prescribing medications when needed.
- Crisis Intervention: Involves rapid response to acute mental health crises, such as suicidal ideation, severe anxiety, or psychotic episodes
B. Behavioral Health Services
Behavioral health services focus on the treatment of behaviors that impact mental well-being, including substance use disorders, compulsive behaviors, and other forms of maladaptive behavior. Some of the common services offered include:
- Substance Use Disorder (SUD) Treatment: Treatment for individuals struggling with addiction, ranging from inpatient rehab to outpatient counseling.
- Applied Behavior Analysis (ABA) for Autism: A therapy focused on improving specific behaviors associated with autism spectrum disorders.
- Anger Management & Behavioral Therapy: Aimed at modifying problematic behaviors such as excessive anger, impulsivity, or aggression through various therapeutic techniques.
The distinction between these services plays a significant role in billing, as different CPT codes and insurance requirements apply.
For example, while psychotherapy may be covered under mental health services, substance abuse treatment may require more detailed documentation to meet insurer guidelines.
CPT & ICD Codes for Mental & Behavioral Health Billing
Common CPT Codes
Proper CPT and ICD coding is essential for submitting claims, avoiding denials, and ensuring accurate reimbursements. Below are some of the most commonly used CPT codes in mental and behavioral health billing.
| Service | CPT Code | Description |
| Psychotherapy (60 min) | 90837 | Individual therapy session for mental and behavioral health |
| Group Therapy | 90853 | Group therapy with a behavioral health focus (e.g., addiction) |
| Psychiatric Evaluation | 90791 | Initial diagnostic assessment for mental health |
| Applied Behavior Analysis (ABA) | 0362T | Autism behavior treatment under applied behavior analysis |
Essential ICD-10 Codes
To ensure proper billing, it’s important to match the correct ICD-10 codes to the corresponding CPT codes. Some of the essential ICD-10 codes include:
- Depression: F32.9 (Major depressive disorder, single episode, unspecified)
- Anxiety: F41.1 (Generalized anxiety disorder)
- Opioid Dependence: F11.20 (Opioid dependence, uncomplicated)
- ADHD: F90.9 (Attention-deficit hyperactivity disorder, unspecified)
Always pair the appropriate CPT and ICD-10 codes to avoid claim rejections. For example, use 90837 for an individual therapy session combined with F32.9 for a major depressive disorder diagnosis.
Billing for Therapy Sessions: Step-by-Step Guide
Properly billing for therapy sessions involves more than just selecting the right codes. Providers must follow a systematic approach to ensure that claims are processed efficiently and correctly.
Step 1: Verify Insurance & Benefits
Before providing any services, verify the patient’s mental health benefits with their insurance carrier. Some plans may limit the number of therapy sessions covered per year, and others may require pre-authorization for certain services. Always confirm the patient’s coverage level to avoid surprises later on.
Step 2: Document Accurately
Accurate and detailed documentation is crucial in therapy billing. It’s important to record:
- Start and End Times: Be precise about the duration of each therapy session.
- Modality: Specify whether the session was in-person or via telehealth.
- Treatment Plan: Include a clear and concise treatment plan that outlines the goals, methods, and interventions.
Proper documentation helps to prove medical necessity and supports the service provided.
Step 3: Submit Claims with Correct Codes
Once you’ve completed the session, it’s time to submit the claim. For example:
- CPT Code: 90834 (45-minute therapy session)
- ICD-10 Code: F41.1 (Generalized anxiety)
- Modifier: 95 (Telehealth, if applicable)
Ensure you’re using the appropriate codes and modifiers to match the session type and treatment. Modifiers are especially important for telehealth services (e.g., Modifier 95) to ensure that insurers know the session was conducted remotely.
Step 4: Track & Appeal Denials
It’s not uncommon for claims to be denied, especially if coding errors are present or modifiers are missing. Common reasons for denial include:
- Missing modifiers (for telehealth)
- Incorrect time documentation (e.g., billing for a 45-minute session as an hour)
- Invalid or mismatched CPT and ICD-10 codes
If a claim is denied, promptly appeal the decision. Review the claim, correct any errors, and resubmit it as soon as possible.
Billing for Psychological Evaluations & Assessments
Psychological evaluations often require additional documentation and may involve more complex billing. The most commonly used CPT codes for psychological testing are:
- CPT 96130: Psychological testing, first hour
- CPT 96131: Psychological testing, each additional hour
These codes cover the administration and interpretation of psychological tests, including cognitive, emotional, and personality assessments.
Required Documentation: For psychological evaluations, insurers typically require the following:
- Test Results: A detailed summary of the results from the psychological tests.
- Clinical Summary: A written summary of the findings, including diagnosis and treatment recommendations.
- Medical Necessity: Proof that the testing was necessary for the patient’s treatment plan and diagnosis.
Many insurers also require prior authorization before approving psychological testing, so it’s important to check their specific guidelines before proceeding.
Top Billing Challenges & How to Solve Them
Billing for mental health and behavioral health services isn’t always straightforward. Providers often encounter challenges that can result in delays, denials, or even underpayments. Below are some of the most common issues along with solutions to resolve them:
Challenge 1: High Denial Rates
Denial rates for mental and behavioral health claims are often high, especially when billing for therapy services or psychological evaluations. Some of the common reasons for denials include:
- Incorrect CPT/ICD-10 pairings
- Missing or incorrect modifiers (e.g., for telehealth sessions)
- Lack of proper documentation supporting medical necessity
Solution:
To reduce denial rates, consider using AI-powered claim scrubbers or automated billing software that can detect errors before claims are submitted. Additionally, make sure your staff is trained in accurate documentation, ensuring all necessary details are included, such as session length and treatment goals.
Regular audits of your billing process can help identify common mistakes and provide opportunities for improvement.
Challenge 2: Varying Payer Rules
Different insurance companies may have different billing rules, even for the same services. Some might require specific modifiers, while others may restrict coverage for certain diagnoses.
Solution:
The best way to handle varying payer rules is to maintain an insurer-specific billing guide. This guide should include details on specific payer requirements, such as documentation standards, CPT/ICD code guidelines, and pre-authorization protocols. Consistently update the guide to reflect changes in payer policies.
Challenge 3: Telehealth Billing Errors
Telehealth has become a cornerstone of mental and behavioral health services, but it presents its own set of challenges when it comes to billing. Errors such as missing modifiers or incorrect service codes are common when billing for remote sessions.
Solution:
For telehealth, always use Modifier 95 or GT, which indicates that the session was conducted remotely. Familiarize your team with the latest telehealth billing standards, as many insurance companies have specific guidelines that may differ from in-person sessions.
Mental Health Parity Laws & Compliance
The Mental Health Parity and Addiction Equity Act (MHPAEA) ensures that insurers cannot impose more restrictive conditions on mental health and behavioral health services compared to medical and surgical benefits. This includes equal coverage for treatment and equal access to care, as well as restrictions on prior authorization requirements for MH/BH services.
Key Features of the MHPAEA:
Equal coverage: Insurers must provide equal coverage for mental and behavioral health services as they do for medical and surgical care. This includes hospital stays, outpatient visits, and medication coverage.
No stricter prior authorization: Insurance companies cannot impose more stringent pre-authorization rules for therapy sessions or mental health treatment than they would for physical health care.
Transparency: Insurers must make it clear to consumers how much their mental health and addiction treatment will cost.
How to Ensure Compliance?
To stay compliant with mental health parity laws, take the following steps:
1. Audit Your Claims: Regularly check for discrepancies between claims for MH/BH services and medical services. Are the denial rates for MH/BH services higher? If so, this could indicate potential parity violations.
2. Thoroughly Document Medical Necessity: Insurers often request documentation that proves medical necessity, and MHPAEA mandates that this be consistent with medical care documentation. Ensure that every therapy session, evaluation, or treatment plan has clear documentation that explains why the service is required for the patient’s health and well-being.
3. Educate Staff: Keep your team updated on changes to mental health parity laws, and provide training on how to properly document claims in line with these laws.
Failure to comply with the MHPAEA could lead to costly legal issues, so understanding these regulations is essential for smooth billing practices.
Best Practices for Fewer Denials & Faster Payments
For providers in the mental and behavioral health fields, ensuring accurate and timely payments is crucial. To minimize denials and speed up your reimbursement process, here are some best practices:
1. Use EHRs with Built-in Coding Alerts
Electronic Health Records (EHR) systems like Epic or TherapyNotes are powerful tools that can help streamline the billing process. Many of these systems feature built-in alerts for coding errors, helping prevent mistakes before claims are submitted.
These systems can also provide reminders for updated CPT codes, ensuring you always use the most current codes.
2. Train Staff Annually on CPT & ICD Updates
CPT and ICD coding changes happen regularly, and keeping your billing staff updated is key to maintaining accuracy. Schedule regular training sessions to ensure your team is aware of new codes, especially if there are significant changes in the codes for psychotherapy, substance use disorder treatments, or psychological evaluations.
3. Outsource Complex Billing
Billing for complex services such as Applied Behavior Analysis (ABA) or Substance Use Disorder (SUD) treatment can be highly complicated due to the specific documentation and billing requirements.
If your practice handles a significant amount of these cases, consider outsourcing your billing to a specialized third-party provider. They’ll have the expertise to manage complex claims, which can reduce errors and ensure compliance with insurance policies.
4. Submit Clean Claims
It’s vital that claims are submitted cleanly and completely the first time. Double-check that all necessary information is included—such as patient details, CPT/ICD codes, modifiers, and the correct documentation for medical necessity. The cleaner your claims, the faster they’ll be processed.
5. Appeal Denied Claims Promptly
Even with the best practices in place, some claims will inevitably be denied. Ensure that your team is prepared to promptly address denials by reviewing the reasons for the rejection and providing additional documentation or corrections. The quicker you can appeal a denial, the faster you’ll get paid.
Bottom Line
Mastering mental health and behavioral health billing is crucial for providers who want to minimize denials and optimize their reimbursement processes. By understanding the distinctions between MH and BH, staying updated on coding requirements, ensuring compliance with mental health parity laws, and using best practices to streamline your billing process, you can avoid common pitfalls and improve your cash flow.
For providers looking to streamline their billing process and overcome common billing challenges, services like those offered by MedXpert Services can help. Their specialized behavioral and mental health billing services are designed to ensure accurate claims, faster payments, and reduced administrative burdens—allowing you to focus more on patient care.
FAQs
Q: Can I bill for no-shows in therapy?
A: Some insurance plans, like Medicare, allow billing for no-shows under modifier CR2. Check with each insurer to see if this is a covered service under their policy.
Q: Does Medicaid cover behavioral health services?
A: Yes, Medicaid covers behavioral health services, but coverage varies significantly by state. Be sure to review your state’s Medicaid manual for specific guidelines on coverage.
Q: How do I bill for family therapy?
A: Family therapy sessions should be billed under CPT code 90847 (Family psychotherapy with patient present). Make sure to include the appropriate ICD code based on the diagnosis being treated.
