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.