Medical Billing Forum
Billing => Billing => : Christy January 25, 2016, 12:57:00 PM
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Hi everyone,
I bill for a LMHC. She always bills 90791, 90834, 90853. She is in private practice. She sees people with addiction problems.
She will often ask me to check benefits for a patient's "mental health" as well as "substance abuse" benefits.
This confuses me, as won't billing the above codes means that the benefits would automatically fall into the "mental Health" category of benefits?
What are the codes for office based, private practice "substance abuse" treatment?
This is in New York State, in case that is relevant.
thanks so much!
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The cpt codes are correct. the benefits however go by the diagnosis codes, this is how it is determined.
ex: F43.12 chronic ptsd- (mental health) f12.20 cannabis with intoxication, uncomplicated (mental health still because of the provider- but this dx code is under substance abuse)
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I'm a bit confused by your question:
This confuses me, as won't billing the above codes means that the benefits would automatically fall into the "mental Health" category of benefits?
What are the codes for office based, private practice "substance abuse" treatment?
This is in New York State, in case that is relevant.
You would bill whatever services/dx your given.. I'm not understanding your question really.
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You would bill whatever services/dx your given.. I'm not understanding your question really.
Linda - I think your response to bill whatever services/dx your given.. contradicts both the reality of billing and previous comments you have made.
One of our clients writes down what he did and leaves it to his staff to find the correct code(s). If we think his staff has coded in error, we need to have a solid argument as to why we think this when we return the fee slip to the provider for more proper coding. This requires that we have more than a passing acquaintance with coding - even though we don't offer coding as a service.
Also - in previous discussions, you have presented convincing evidence that billers can be prosecuted for the fraud perpetrated by the provider because "the billers should have known better" or "the billers should have recognized the fraud being perpetrated by the provider". The underlying principle to both of those statements is that billers should be informed enough to recognize when a provider is not providing correct service/dx/cpt information to the biller. Again, billers being informed enough to catch errors (intentional or purposeful) perpetrated by the provider requires that billers have more than a passing acquaintance with coding.
I understand not wanting to do someone's job for them by providing codes to them that they should be getting from their provider. But hopefully my comments here make it clear that we can play a role in educating billers about coding so that they can more successfully catch errors (intentional or purposeful) made in the codes submitted to them with which they are to bill.
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I think the confusion is in calling to check benefits. Wondering why you would check benefits for mental health AND substance abuse. Thinking they are the same?
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thank you, everyone.
rdmoore-I know that this is the case with some insurers, that they apply the benefit in regards to the dx code, but I am not sure that they all do? I am trying to discern this, and in my experience the phone reps at the ins companies are not knowledgeable or helpful in these cases. In my preliminary research, the provider and I found some HCPCS codes for substance abuse tx, but I think those codes cannot be used with POS 11?
linda- the provider and I are working together to correctly bill ins. So yes, I bill as she indicates, but when there is a question, we discuss it and ultimately she chooses the code to bill.
Richard- you have articulated this better than I can. thank you! Yes, I am working with the provider to educate her (and myself!)
Michele- some insurers have a separate benefit for substance abuse with a waived deductible, no coins, etc.
For example, beyond the initial visit, Beacon will not pay a MH claim with a substance abuse dx- they will deny and tell you to send to NYS Medicaid.
So yes, I asked about verifying benefits, but then that would lead to billing correctly.
It's my opinion that even though the patient has a substance abuse problem, the LMHC is providing therapy, or MH and should use the MH codes and benefits. But, she feels that the is providing substance abuse tx and I am trying to research this.
thanks again, all!
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Linda - I think your response to bill whatever services/dx your given.. contradicts both the reality of billing and previous comments you have made.
My response was that I was confused on what question was being asked. I don't think this contractics reality OR previous thoughts/opinions I've had.. in fact it's pretty much in line with my opinions.
One of our clients writes down what he did and leaves it to his staff to find the correct code(s).
What works for one doesn't always work for others. Even in my 20+ years experience I don't CODE.. my clients are responsible for coding. They/we do NOT depend on coders.. as a biller who COULD code if I wanted to accept that responsibility (which i don't). My client is in the room with the patient..they can choose codes and I'll review any questions they may have for that visit.
Also - in previous discussions, you have presented convincing evidence that billers can be prosecuted for the fraud perpetrated by the provider because "the billers should have known better" or "the billers should have recognized the fraud being perpetrated by the provider". The underlying principle to both of those statements is that billers should be informed enough to recognize when a provider is not providing correct service/dx/cpt information to the biller. Again, billers being informed enough to catch errors (intentional or purposeful) perpetrated by the provider requires that billers have more than a passing acquaintance with coding.
Yes, again.. that's what I've said, and stand by. Educating providers doesn't entail doing the actual coding nor accepting the responsibility of such from the medical record. My clients code and if they have a question, they include the question for me to check. The responsibility of a biller is to "RECOGNIZE" coding problems, patterns and errors. Not again sure how this contradicts anything i've said previously. If the biller is a certified coder, they have the proper insurance and want to put their asses on the line.. have at it.
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I think the confusion is in calling to check benefits. Wondering why you would check benefits for mental health AND substance abuse. Thinking they are the same?
There are MANY MH providers who often provide tx for dual diagnosis which includes substance abuse so it DOES make sense to check with carrier when verifying benefits for both mh and substance abuse. SOMETIMES the benefits are separate.
rdmoore-I know that this is the case with some insurers, that they apply the benefit in regards to the dx code, but I am not sure that they all do? I am trying to discern this, and in my experience the phone reps at the ins companies are not knowledgeable or helpful in these cases. In my preliminary research, the provider and I found some HCPCS codes for substance abuse tx, but I think those codes cannot be used with POS 11?
The carrier MIGHT apply the appropriate benefit using the dx code.. but this is easily disputed and appealed if they do. ESPECIALLY if a patient has a combined max benefit for substance abuse and MH treatment.
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When verifying benefits - tell the operator that the provider would like benefits for Mental Health and Substance Abuse. If there are different benefits for each then the operator will tell you. And it may depend on whether the substance abuse treatment is happening in the office as a once a week or every other week patient, or if the provider is seeing the client in group? or seeing the client on an out patient basis.
The more you know about the providers practice the better. You'll be able to answer the operator's questions about treatment and then get the benefits that apply to the providers specific practice.
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