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When it comes to billing, couples therapy can be more challenging than individual therapy sessions. Unlike individual therapy, insurance companies hardly cover couples therapy unless it is considered “medically necessary”. As a result, therapists often face difficulties with insurance policies. This includes using the right CPT codes, and understanding the necessary billing requirements.
This article will guide you on how to bill insurance for couples therapy. It provides solutions to the common challenges therapists face with insurance billing in private practice.
What is Couples Therapy?
Couples therapy is an aspect of therapy that aims to help couples strengthen their relationships and marriage. It is frequently used to settle disagreements, improve communication, and address concerns about intimacy and sexual satisfaction. Couples therapy seeks to assist couples in identifying and resolving issues relating to the dynamics of their relationship. However, couples therapy is covered by insurance only if it is strictly necessary for treating one partner’s mental health condition.
Billing Insurance For Couples Therapy
Here are some things to consider when billing insurance for couples therapy:
1. Verify The Couple’s Insurance Coverage Before The First Session
Before having the first session, it is important to verify the couple’s insurance coverage. Insurance companies have varied plans that have different coverages. While some plans may cover the full session, others might have underlying criteria that influence coverage. Verifying coverage ahead of the session helps you avoid surprises later.
Such verifications also help you to understand the insurance company’s policies. Failure to know these policies ahead of time could cause you to take actions that lead to denied claims. This would impact your income and affect the couple’s ability to continue repeated sessions.
Aside from the aforementioned reasons, coverage verification saves you from administrative stress after the session. During the verification, you can correct wrong policy details that could lead to claim rejections. Hence reducing the paperwork and administrative tasks you need to do after the session.
2. Choose The Correct Current Procedural Terminology(CPT) Code
CPT codes are a numerical coding system standardized by the American Medical Association (AMA). Medical practitioners use them to report medical, surgical, and psychological services while mental health practitioners use them to differentiate between different therapy types. When billing for couples therapy, the most relevant psychotherapy codes for psychologists are:
- 90847 – Family Therapy With Client Present
90847 is used when one of the partners is identified as the client, but both partners participate in the session. This is referred to as conjoint psychotherapy. The session would focus on the mental needs of the partner identified as the client. However, the session will consider the dynamics of the relationship between both partners. The time range spans a minimum of 26 minutes but typically, the duration of this session is 50 minutes.
- 90846 – Family Therapy Without Client Present
90846 is used when the session is held only with the client’s partner or other family members concerning the mental health of the client. In this case, the client does not attend the session. Usually, the session needs to be at least 26 minutes long. The duration for family therapy without the client involved is 50 minutes.
Some therapists tend to find the following codes confusing and use them in billing for Couple’s Therapy
- 90837 – Individual Therapy
Several therapists tend to inaccurately bill 90837 which is for Individual Therapy when billing for couples therapy. This is an improper billing code for couples therapy, especially when the session addresses the dynamics of the relationship of the couples. This session can take 53 minutes or longer although it is a 60-minute therapy session.
- 99050 – After-Hours Service Code
99050 is used when a therapy session is conducted outside official work hours. Whenever it is used, it attracts additional reimbursement and charges. However, this code is not primarily for couples therapy, so it may not be covered by the insurance company.
Using incorrect CPT codes has several consequences. These mistakes delay claim processing. It could also lead to outright claims denial, which would lead to financial loss. When your practice has repeated track records of such billing mistakes, it can lead to reputational damage.
3. Establish Medical Necessity
Couple therapy is often accompanied by unique challenges therapists do not encounter when handling individual therapy sessions. Most insurers focus on individual mental health challenges. As such, they do not recognize relational issues as medical conditions that need therapy sessions.
When billing for couples therapy, ensure the session is on the basis of the mental health condition of one of the couples. Your diagnosis of the primary client with a diagnosable disorder should align with the specifications of DSM-5 so that it can be valid. Also, a plan should be documented to prove how the couples therapy session will improve the health of the diagnosed partner.
Establishing medical necessity is a guaranteed way to ensure you get insurance reimbursement. Without proper documentation that backs up the need for the sessions, the claims have a high chance of being denied.
4. Document Sessions Properly
Without proper documentation of your sessions, reimbursement is not guaranteed. Your progress notes should be extensive and robust so that the importance of the sessions can be established. It should also show a clear connection that proves how the sessions are improving the health of the client.
The documentation should contain the following details:
- The primary client’s diagnosis (using DSM-5 codes).
- A detailed treatment plan linking therapy goals to the diagnosis.
- Specific interventions used in the session, for example, cognitive-behavioral strategies or communication training
- Progress notes that outline the importance of subsequent sessions.
- Therapist’s credential and licensure details.
- Date and duration of the sessions
5. Submit The Insurance Claim
The final phase of your billing is the insurance claim submissions. Before submitting a claim for your Couples Therapy clients, ensure to get the client’s insurance policy number, full contact information, and date of birth from both partners involved in the therapy session. You will need this information to process the insurance claim.
Afterward, fill out the CMS-1500 claims forms. Some of the fields you will encounter are:
- Box 21: This field captures the ICD-10 diagnosis code related to the couple’s presenting issues, like “relationship distress” or “marital discord.”
- Box 24: You are required to enter the CPT code for the service you rendered in this section for the couple’s therapy session, i.e., 90847 or 90846. You can also include the number of therapy sessions you provided.
- Box 33: This segment captures your name as the therapist or your practice name, address and full contact information when you are submitting the claim for payment.
Once all fields have been filled correctly, you can submit your claims through an EHR software or clearinghouse. Even though some insurers accept paper claim submissions, it is usually faster to submit claims electronically.
Common Challenges Therapists Face When Billing Insurance For Couple Therapy and How To Solve Them
1. Lack of Coverage For Couples Therapy
Most insurance companies do not cover couples therapy. These companies do not consider it a necessity, so they do not see a need to create a plan that caters to it. While this could look like a setback, there are ways to navigate it.
One of the major ways to navigate this challenge is to use alternative terminology to “couples therapy.” Several insurance companies that do not cover “couple therapy” cover “family therapy (CPT code 90847).” Ensure to use terminologies recognized by an insurance company when submitting claims. To avoid challenges, always verify the insurance coverage and policies of the company ahead of sessions.
2. Diagnostic Requirements
Couples therapy primarily focuses more on the dynamics of the relationship between the partners rather than each individual’s mental health condition. This might make it difficult to fit it into a billable diagnostic category that qualifies for reimbursement. The best way to navigate this is to identify whether one of the partners has a diagnosable mental health condition. As a therapist, this will allow you to bill for couples therapy.
3. Billing Code Restrictions
Couples therapy does not have a universal CPT code assigned to it. This could make it difficult for therapists to generate claims for it. The closest CPT code to couples therapy is 90847, which signifies family psychotherapy with the client present. Although, this may not be reimbursed by all insurance companies because most of them prefer billing for individual therapy codes.
Confirm the CPT codes that are accepted by the company before submitting insurance claims. Also consider issuing superbills if the client has out-of-network benefits. As a rule of thumb, ensure confirmations are done before sessions so you do not run at a financial loss.
4. Preauthorization Requirements
Some insurance companies require therapists to get preauthorization before sessions. By implication, any session conducted without approval is not recognized by the company. Ensure you research the unique needs of insurance providers before therapy. If necessary, you can have personal contact with the company to confirm if preauthorization is necessary.
If the company requires preauthorization, confirm the documentation required and begin the process early. Late submissions could lead to delays that would hinder you from having the sessions on time. Also, encourage your client to follow up with the insurance company to confirm the approval status of the application.
5. Session Limits and Reimbursement Caps
Insurance companies that cater to couples therapy place a limit on the number of sessions therapists can have with clients. Most times, they place a cap on the reimbursement amounts. Consequently, this restricts the scope of care therapists can provide to their clients.
While this might be uncomfortable, it is best to work with the insurance limits set by the company. Although, you could negotiate for more sessions with the insurance provider so that the clients can get extensive care.
Conclusion
Insurance billing for couples therapy is quite different from individual therapy sessions. It has several challenges therapists must be willing to surmount. One of the most common challenges you might face is the absence of a universal CPT code for therapy sessions. Using the correct billing code is essential so, we have provided the step-by-step process for therapists to bill insurance for couples therapy. We also outlined common challenges you might face and how to navigate them.
As a mental health therapist, your documentation also plays a key role in ensuring you get the appropriate insurance reimbursement. With Mentalyc automated HIPAA-compliant note templates, your documentation process will be smoother and more organized. Mentalyc can help to speed up your therapy notes so you can get reimbursed faster.
Frequently Asked Questions
Can Both Partners in Couples Therapy Be Listed As Clients For Insurance Billing?
It is not possible to list both partners as clients for the insurance billing. The insurance company needs one of the partners to have a diagnosable mental health condition like anxiety, depression, or PTSD. The therapy sessions will focus on improving this underlying mental health condition. Hence, one of the partners is seen as a part of the therapeutic process, not as a client.
Are There Alternatives If The Insurance Company Does Not Cover Couples Therapy?
If the insurance company does not cover couples therapy, you can consider alternative payment methods like – Medicare, sliding case fees, employee assistance programs, out-of-pocket payments, health savings accounts and superbills for reimbursement.
Can Therapists Use Telehealth For Couples Therapy And Bills Insurance?
Yes, therapists can use telehealth therapy sessions. Before proceeding, you should confirm that the insurance company covers virtual couples therapy. Also, ensure to use the appropriate telehealth CPT codes.
How Can Clients Check Their Insurance Coverage For Couples Therapy?
Clients can confirm their insurance coverage for couples therapy by contacting their insurance provider. They should ask questions about what is covered by their policy, reimbursable CPT codes, and session limits. They should also confirm if they need preauthorization for therapy sessions.
