A Simple Coding Guide for Standardized Assessment, Screening, and Testing for Behavioral Health

Mental health services are crucial today as they support our well-being. Considering the progress in handling mental health conditions. It is wonderful to see how far we have come now that the subject is being talked about and managed in a promising way!

For Mental Health Awareness, we discuss efficient mental health billing to prevent denials.

With increasing related cases, treatment methods are advancing. We will try to go through them step-by-step and break them down for you, starting from some basic ones.

Let’s start with Initial Evaluations

For the very first interaction with the patient, we have some options to go through. Your choice of service depends on various factors, including:

  • Provider’s specialty and credentials (M.D, P.A., NP) OR (a psychologist or psychiatrist)
  • Patient’s age (many services are age-dependent)
  • Any pre-existing diagnosis or treatment
  • Number of screening tests performed before? (Limited units)
  • Referrals

Option 1 – E/Ms

Internal medicine M.D.s or nurse practitioners assessing patients for behavioral health. They may evaluate the patient or refer to a specialist for billing purposes:

Office Visit: 99202-99215

Inpatient Visit: 99221-99233

(*Or any other related POS- E/M like Home, domiciliary Assisted Living, etc.)

So, these E/M would be somewhere to start.

Remember, E/Ms include the history, exam, and MDM. Only CMS-approved practitioners like Psychologists & Social Workers can bill standard E/M codes. The rule of thumb is if you can manage medication or prescriptions, you can bill E/M services.

Option 2 – Standardized Test with Preventive Visits

Annual Depression Screening: G0444

This one is billed once annually with AWVs only as a preventive measure. This is your typical Depression Inventory using a standard test for scoring.

Option 3 – Standardized Screening Tests (Substitute codes)

Brief emotional and behavioral assessments performed with standardized instruments: 96127 (GAD-7 or PHQ-9)

This next step initiates treatment and defines the patient's diagnosis. Two ‘Units’ might be billed on the same day with or without the visit for each screening. Codes Z13.31 and Z13.39 are used for depression and mental health screenings. A total of 4 units of the services might be billable per year to most payers. For AWVs, diagnosis codes Z00.00 or Z00.01 for normal or abnormal findings are more suitable

Option 4 – Standardized Tests (Substitute codes)

Other similar codes that include assessment and intervention for a health risk analysis:

96156 is for health behavior assessment or re-assessment.

96158 Health behavior intervention, individual, face-to-face; initial 30 minutes

Intervention improves the patient's psychological and psychosocial well-being. The CPT codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168 may be used only by a Clinical Psychologist (CP). The primary diagnosis must include ICD-10 CM code(s) for the treated physical condition(s).

96160 is for administering and scoring a standardized patient health risk assessment.

The provider administers a health risk questionnaire and analyzes, scores, and documents the results. Use this code for each standardized survey questionnaire.

Examples of Standardized Screening Tests?

Option 5 – Psychiatric Diagnostic Evaluation

This is where things start to get interesting. As, at this point, we are beyond the standardized tests and tools now. The provider interviews the patient to diagnose through biopsychosocial assessment.

Psychiatric Diagnostic Evaluation – without any medical services: 90791

Psychiatric Diagnostic Evaluation – with medical services: 90792

Medical Services for 90792 might include

Prescription of medication or coordination of medications as part of medical care. Order/review of medical diagnostic studies – Lab, imaging, and other diagnostic studies. Psy.D and LCSWs bill 90791 based on the general rule.

Guidelines on how to bill these codes and avoid denials

  • 90792 applies to new patients or patients undergoing re-evaluation. Use 90791 only once per day, regardless of sessions or time spent with the patient.
  • When a patient undergoes a psychiatric diagnostic evaluation, report either 90791 or 90792.
  • Payers previously allowed one unit of psychiatric diagnostic evaluation code per patient. Guidelines permit billing multiple 90791/90792 units for evaluations across different dates.
  • Example: psychiatrist evaluates child with parents, then independently, across sessions. Bill multiple 90791/90792 units across sessions on different days if medically necessary.
  • When billing for Medicare, CMS will allow only one claim of 90791 or 90792 in a year. Medicare may reimburse for multiple 90791/90792 units based on medical necessity. You can also report these codes when the psychiatrist is seeing the patient after a span of three years. 90792 conflicts with 90791 and other codes. A modifier is not allowed to override this relationship.

90785 is an add-on code for communication difficulties during psychiatric procedures. Add-on codes may only be reported in conjunction with other codes and never alone. Specific communication difficulties are present with patients who typically:

  • Include legally responsible individuals like minors or adults with guardians.
  • Request others involved in care, like family, interpreter, or translator.
  • Involves third parties like child welfare, parole, probation, or schools.

Report interactive complexity with psychiatric procedures for certain communication difficulties.

  • Uncooperative participants impair care delivery.
  • Emotions or actions of the carer that prevent the treatment plan from being carried out.
  • Report sentinel incidents like abuse to state agencies and discuss with patients.
  • Use toys, aids, interpreters, or translators for language barriers.

Don't report 90785 with crisis codes or E/M if there is no psychotherapy.

Treatment Options – Psychotherapy

All roads (might) lead here! Accurate assessments lead to psychotherapy sessions with a licensed professional.

Let’s have a look at standard Psychotherapy codes here

Psychotherapy codes are time-based codes that may be billed with or without the E/M codes

Psychotherapy billed without E/Ms

Psychotherapy billed with E/Ms

Concluding it up….

Managing behavioral health patients can be streamlined for improved efficiency. Use evaluation tools that adhere to payer requirements and billing guidelines. Following the step-by-step process is key for unique patient diagnosis. Detailed documentation helps payers understand patient progress and aids claim reimbursement.

AltuMED Medical Billing Solution is one of the five star rated Medical Billing Companies in Michigan, USA. Contact us for a detailed demo of our Medical Billing Services.

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