Author Topic: Biologically based mental health code  (Read 2679 times)

K and K Billing

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Biologically based mental health code
« on: March 22, 2013, 02:42:19 PM »
I have a client who has a patient she is treating for severe general axiety, but it is a biologically based problem due to a severe brain injusry and resultant coma and hospitilization. The insurance comapny will pay if I can find an applicible code, but I can't determine how to find a diagnosis code that will cover the biological problem.

Any suggestions?

PMRNC

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Re: Biologically based mental health code
« Reply #1 on: March 22, 2013, 03:38:10 PM »
No one can or should answer this for you as they are not privy to the medical record.  The provider and any (if any) CPC should be providing the diagnosis.
Linda Walker
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RichardP

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Re: Biologically based mental health code
« Reply #2 on: March 22, 2013, 04:18:41 PM »
To add to what Linda said:

If the patient's insurance company told you this, then you are maybe dealing with a formal definition of "biologically based".  By way of introduction to the subject, look at the top of Page 2 and the bottom of Page 5 at the following link.  In your state, and at your patient's insurance website, you should be able to find something similar - if it was the patient's insurance company that said they would pay for something that was "biologically based".

https://www.oxhp.com/secure/policy/behavioral_health_services.pdf

Biologically based mental illness:  a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness.  This term is often specifically defined by individual state legislation and, in such cases, the state-defined definition applies.

On Page 5 there is a list of conditions, with related codes.  Then this statement:

The State of New Jersey considers all conditions not listed above to be non-biologically based, and as such, may be subject to coverage and cost share structures individually defined by the Member's certificate of coverage.

The Massachusetts Code specifically recognizes biologically-based as a category for mental illness, including anxiety disorders:

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleIV/Chapter32a/Section22

Section 22. (a) The commission shall provide to any active or retired employee of the commonwealth who is insured under the group insurance commission coverage on a nondiscriminatory basis for the diagnosis and treatment of the following biologically-based mental disorders, as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, referred to in this section as the DSM: (1) schizophrenia; (2) schizoaffective disorder; (3) major depressive disorder; (4) bipolar disorder; (5) paranoia and other psychotic disorders; (6) obsessive-compulsive disorder; (7) panic disorder; (8) delirium and dementia; (9) affective disorders; (10) eating disorders; (11) post traumatic stress disorders; (12) substance abuse disorders; and (13) autism.

If you are not in the State of New Jersey, I strongly urge you to find out what your own state rules and codes are, rather than simply using the data at the link I provided.
« Last Edit: March 22, 2013, 04:50:55 PM by RichardP »

K and K Billing

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Re: Biologically based mental health code
« Reply #3 on: March 26, 2013, 07:45:58 AM »
Richard:

Thank you for your information. I'm sure this will resolve the problem when I speak to the provider.

K and K Billing

Karl

RichardP

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Re: Biologically based mental health code
« Reply #4 on: March 26, 2013, 10:29:55 AM »
You are welcome.  When you get a resolution, it will be useful if you come back and tell us what it is.