Application of Billing Practices
States, settings, and insurance companies will have different rules around how often a certain code can be billed. Below are some logistics to take into consideration.
Proper documentation is key.
Providers-across specialties-must meet certain documentation criteria to use ANY CPT code. Usually a quick internet search of ‘documentation requirements’ for each code is sufficient. Otherwise, contact your organization’s billing and coding department so they can find the information for you.
Know how frequently the insurance company will cover the therapy visits.
Some will not allow same CPT code within the same calendar week.
Some will not allow billing for the same condition by two different providers on the same day (e.g., medical provider addresses depression and MedFT addresses depression).
Many insurance companies will max out at covering 26 therapy visits annually, some cover less.
Some insurance plans, especially state insurance (e.g., Medicaid) will expect a treatment plan.
Usually on the 2nd visit following the diagnostic assessment and quarterly updates thereafter.
Treatment plan is signed by the provider and patient and kept as part of the chart.
If the treatment plan is unchanged at the time of update, it may be sufficient to include a special note in the documentation stating the treatment plan dated (##/##/##) was reviewed and continues to be appropriate. Otherwise, organizations may have treatment plan forms that are filled out for every update.
Please check with state insurance or coding and billing to determine how often a treatment plan is needed.
A diagnostic assessment can be billed annually.
For example, if a MedFT does an assessment in October 2018, they can bill for another re-assessment in October 2019
If the diagnosis changes or clarifies during the that year, but before the next assessment is due, the diagnosis and justification for the change should be added to the patient’s chart. Billing cannot occur for this change until the next assessment.
The annual update should include updates in patient’s circumstances, functioning, and mental well-being in addition to the diagnosis, presenting concerns, symptoms, etc.
The first appointment does not have to be a diagnostic assessment.
If the provider has insufficient information to diagnose and bill 90791, a follow-up psychotherapy code may be used instead.
For example, the patient is in crisis or significant emotional distress and it is inappropriate or challenging to obtain diagnostic information.
The second appointment should complete the diagnostic assessment.