- Financially Better for Clients. This maybe counterintuitive, but paying out of pocket for many healthcare services has been shown to actually be the same or less expensive. The average number of sessions I see clients in a year is 21. Here’s the math: 21 Sessions x $159/session = $3339. That’s a big chunk of money. But…whatever is not reimbursable to you by insurance is often tax deductible. Most healthcare expenses can also be paid directly with an HSA or FSA. Additionally, more and more families are choosing high deductible, lower fee plans. Pay $5000 deductible and then insurance kicks in. That’s after you’ve paid your $833/month.
- Less Complication. It takes longer to verify insurance, verify their plan covers my services and ensure they can be seen It is a fact that every document or form that needs to be sent to insurance is an opportunity for them to avoid financial responsibility. I’ve had dozens of situations where my office manager would send in a form and the insurance company would first claim they never got it. We’d resend it. Then they claimed it was not completed correctly. Resend after corrections. Then they would claim it was incomplete. This game can last up to a year (I’m still getting payments from insurance claims filed over a year ago).
- Clinical Decisions are Not Driven By Insurance. I’ve had way too many instances where an insurance company told me or the family that the client ‘no longer met criteria for services.’ What? How the heck would they know that? It’s based on the number of sessions they allot, the diagnosis I gave and how much money has been spent. At no time does insurance actually review my notes, talk to the client or family or inquire about the clinical status. No thanks – I don’t want insurance professionals making decisions for my clients. And just in case you were thinking it, I’m not a right-wing, libertarian nut job. This is actually my progressive, liberal side coming out advocating for my clients against huge companies whose sole business model is to take in as much money as possible and avoid contractual obligations.
- Flexibity. No insurance company has ever liked hearing that I’m on-call for clients and use texting, video chat, etc. to continue treatment and support between sessions. They also are not fans of me working with parents in a consulting manner. They don’t want to hear that I provide insider knowledge of treatment programs. None of this fits within their narrow definition of what a counselor should do. I do what is necessary to create stability and promote a healthier life.
- Protection. Until there are safeguards that protect clients from being blacklisted for a preexisting condition (ACA is currently under attack from the Trump administration for this) I’d prefer not be forced by insurance companies to diagnose a client. For me to get payment, I have to provide client’s name, diagnosis code, CPT code (what service I provided), my license information, and my NPI (national identifier for healthcare professionals). If I fail to provide any of that, the claim with be denied. In my opinion, there is no reason why a company needs evidence that a client has a diagnosible condition. I totally understand requiring all the other information but diagnosis is unnecessary. At times, a diagnosis is important for the client or family to hear and understand.
Most lingo of mental health and substance abuse is unintentionally seemingly undecipherable psycho-babble which actually turns out to be pretty important. There are diagnostic codes (eg. Bipolar Disorder II), NPI numbers, license numbers, and CPT codes. Today, we’ll be examining the role of the often quiet but super important CPT code.
Let’s start with the basics like what CPT stands for. It’s an acronym for the Current Procedural Terminology.
What is it Code for?
CPT is the coding set maintained by the American Medical Association (AMA) through the CPT Editorial Panel. The CPT code defines all AMA-approved medical, surgical, mental health, substance abuse and diagnostic services. It’s designed to provide consistent and uniform information about medical and mental health services and procedures among physicians, coders, patients, accreditation organizations, insurance companies and payers for administrative, financial, and analytical purposes.
For example, let’s say you are working with a therapist at Fonthill Counseling for individual outpatient therapy each week and using your insurance to cover the cost. Fonthill creates an invoice (aka ‘Superbill’) after each session and sends it to the insurer. In that invoice, Fonthill puts in the CPT code ‘90837’ which is numeric language for ’50 Minute Outpatient Therapy Session.’ The invoice also includes several other pieces of info but we’ll cover that another time. Let’s say that one week, you want to bring your family in for a session since there seems to be some unresolved issues with your recent move to a new home in a new community. The family comes in and has a great, productive session. Following the session, Fonthill creates another invoice but this time uses the CPT code ‘90847’ which is for ’50 Minute Outpatient Family Therapy with Client.’
If Fonthill did not put in any CPT code, the insurer would not pay for the service and Fonthill would send you a bill for the session. Sometimes, there are services (CPT Codes) insurance does not pay for.
Some insurance companies, for instance, do not cover for clients to have a phone session with their psychiatrist to discuss medication changes. The service has a CPT code (99443) but if the insurance company does not consider it a good return on investment, they will not cover it.
How Do I know Which CPT Codes are Covered by Insurance?
Bottom line – most ‘typical’ procedures or services for mental health counseling like individual outpatient therapy are covered. If you need or are recommended by a professional for an ‘atypical’ service, first – find out what the service is called and, if possible, what the CPT code is. Next, contact your insurer with the info and ask how much they cover for that. If they say they do not cover it, ask how to receive an exception for your situation. You have a much better chance of getting an exception if the service was recommended in a psychological evaluation or discharge summary from inpatient at a hospital.
Are CPT Codes Updated?
New editions or updates are released each October. The current version is the CPT 2014. It is available in both a standard edition and a professional edition. Not every CPT code changes every year. Mental health CPT codes do not change very often.