Clinician’s Guide to Medical Insurance Billing

Introduction:

While many MCO clients pay for therapy out of pocket and do not involve insurance, others elect to attempt to gain reimbursement via their health care plan.  Fees for therapy are due at the time of billing, however, these charges can be submitted to insurance.  MCO utilizes a contractor to handle the details of medical billing and there is a nominal charge to clients for this service.  Therapists have an important part in the process, providing a diagnosis code and defining what CPT code is appropriate.  Insurance requires both.  Think of it as the insurance wanting to know what service you provided and why you provided it.

Using ICD-10 Codes:

ICD-10 is an acronym used in the medical field that stands for International Classification of Diseases, tenth revision.  The ICD is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics.  Therapists must be sure to use ICD-10 codes, as ICD-9 (ninth revision) is no longer accepted.

Therapists should consider which diagnosis to utilize, fitting their client’s presenting symptoms and can provide this upon request.  Therapists can consult with supervisors and colleagues as needed.

Examples of Common Diagnosis Codes:

• F43.21 Adjustment Disorder, with depressed mood
• F43.22 Adjustment Disorder, with anxiety
• F43.23 Adjustment Disorder, with anxiety and depressed mood
• F33.0 Major Depressive Disorder, recurrent episode, mild
• F33.1 Major Depressive Disorder, recurrent episode, moderate
• F33.2 Major Depressive Disorder, recurrent episode severe
• F41.1 Generalized Anxiety Disorder

V Codes & Z Codes

V Codes (in the Diagnostic and Statistical Manual of Mental Disorders [DSM-5] and International Classification of Diseases [ICD-9]) and Z Codes (in the ICD-10), also known as Other Conditions That May Be a Focus of Clinical Attention, address issues that are a focus of clinical attention or affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder. However, these codes are not mental disorders.

As such, clinicians should be aware that V and Z Codes are not typically accepted by insurance companies for any sort of reimbursement and should not be used as the primary diagnosis.  

Current Procedural Terminology (CPT) Codes

CPT is a uniform coding system developed by the American Medical Association (AMA). The AMA first established this system in 1966 to standardize terminology and simplify record-keeping for physicians and staff. Since its development, CPT has undergone several changes. The most recent edition focuses on using CPT codes to report physician services.

CPT codes describe medical procedures — such as tests, evaluations, surgeries, and other practices — performed by a physician on a patient. For example, behavioral health CPT codes describe the length of a psychotherapy session with a client or a diagnostic interview. CPT codes are necessary to receive reimbursement from health insurance companies.

CPT codes are essential parts of practice management for clinicians and health care staff because they determine compensation and the practice’s overall success. To receive the correct reimbursement rates, clinicians must ensure the codes on insurance claim forms accurately reflect the services they provided before submitting the claims to insurance companies.

The codes most typically used by MCO are as follows:

Questions:

If you have any questions or concerns, please reach out to your supervisor.