by William Van Ornum, Ph.D. on
Consumers of mental-health services may not realize the extensive system of codes that go into insurance billing and medical records, both for mental-health services and other medical services. For mental health, every person who receives insurance reimbursement receives a diagnostic code from the most current Diagnostic and Statistical Manual of the American Psychiatric Association, as well as a code describing the service. The codes are called CPTs (Current Procedural Terminologies).
There are nearly 300 diagnostic codes in the DSM IV TR. These range from well-known and common conditions such as major depression, bipolar disorder, obsessive compulsive disorder, and panic disorder. Lesser known diagnoses such as Munchausen’s syndrome are also included. The clinician is also able to note a secondary code if a learning disorder, developmental disorder, or personality disorder is diagnosed.
The CPT code is a separate entity that indicates the kind of service being provided. For a specialty like dermatology it might include various types of surgery. With the CPT codes for allergies there is a CPT code for allergy testing. Interventional cardiology has codes for various kinds of catheter or stent procedures.
Each insurance company (or Medicare and Medicaid) has a specific amount of money that will be paid for different combinations of DSM IV diagnoses and CPT codes. For example, a diagnosis of major depression occurring with a CPT code for a 50-minute psychotherapy session might pay the provider between 60 and 100 dollars. (This amount is adjusted according to zip code, with areas of higher living expense being associated with higher levels of reimbursement.)
This year (2013) brings a complete new version of the DSM–the Diagnostic and Statistical Manual V. Many major changes are anticipated, and some, like the deletion of Asperger’s syndrome, are controversial. The American Medical Association has also developed new CPT codes for mental health services. These are not as extensive as the diagnostic changes in DSM V.
Many of the CPT codes remain the same for 2013 as they were in 2012: Psychonalysis; Family psychotherapy without the patient present; Family therapy–conjoint psychotherapy with the person present; and group psychotherapy. Three outpatient therapy codes are slightly changing: Outpatient psychotherapy 20-30 minutes becomes Psychotherapy, 30 minutes; Outpatient therapy 45-50 minute becomes Psychotherapy 45 minutes; and Outpatient psychotherapy 75-80 minutes becomes 60 minutes. Looking at these, the major change appears to be the change in outpatient therapy from 75-80 minutes to 60 minutes. If this is reimbursed at the same level 9and it may not be), it would allow practitioners the opportunity to complete more sessions in a day, leading to higher income for the provider.
Two new CPT codes have been devised, Psychotherapy for crisis, first 60 minutes; and Add-on for each additional 30 minutes of psychotherapy for crisis. This will allow more generous reimbursement when a clinician spends extended time with a client who has a genuine psychiatric emergency.
Another new code has been described in this manner by the American Psychological Association: “Of particular interest to prescribing psychologist, a new add-on code will be used for pharmacological management, including prescription and review of medication, when performed with psychotherapy services.A psychologist providing a psychotherapy service with medication management would report the 90863 add-on code along with the applicable new psychotherapy code.
Providers will become adept at using these codes very quickly as the codes are needed for financial reimbursement. It is always good for consumers to know the details behind financial reimbursements for mental heath and medical services they may be receiving.