How to Bill Insurance for Couples Therapy

Billing insurance for couples therapy presents unique challenges. While often assumed not covered, it can be when specific medical necessity criteria are met. This article clarifies the process for navigating insurance billing.

Establishing Medical Necessity for Couples Therapy

Establishing medical necessity is required for insurance coverage. For couples therapy, this means identifying one individual as the “identified patient” (IP). This person must have a diagnosable mental health condition as the primary treatment focus, with symptoms impacted by relationship dynamics. Relationship problems alone are not typically a medical diagnosis. Therapy must address the IP’s condition, with the partner’s presence supporting treatment goals.

Diagnostic criteria for medical necessity come from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) or the International Classification of Diseases (ICD-10). Conditions warranting couples therapy include Adjustment Disorders, Major Depressive Disorder, Generalized Anxiety Disorder, or Post-Traumatic Stress Disorder (PTSD). Therapy must focus on how relationship dynamics influence the IP’s symptoms and recovery.

Thorough initial assessment and ongoing documentation support medical necessity for the identified patient. This documentation demonstrates how the IP’s symptoms are addressed through couples therapy. The treatment plan should clearly link couple interactions and interventions to the IP’s diagnosis and treatment goals. Without this connection, insurance companies may deny coverage.

Understanding Service Codes and Documentation

CPT (Current Procedural Terminology) codes are used for billing couples or family therapy. The two primary codes are 90847 and 90846. Code 90847 is for family psychotherapy with the patient present, including couples therapy where the identified patient participates. This code applies when the therapist provides therapy to a couple, with at least one member being the identified client.

CPT code 90846 is for family psychotherapy without the patient present. This code applies when the therapist meets with family members or a partner without the identified patient, such as to support the IP’s treatment. Modifiers, like GT for telehealth services, may be used depending on the service delivery method and payer requirements.

Session-by-session documentation supports the CPT code billed and demonstrates ongoing medical necessity for the identified patient. Progress notes should include date, start and stop times, and the session’s focus, detailing how couple interactions relate to the IP’s treatment goals. Documentation must align with the chosen diagnostic and CPT code for each session, showing the IP’s progress and how symptoms are addressed. This record-keeping justifies services to the insurance payer.

The Insurance Claim Submission Process

Once medical necessity and service codes are determined, the next step is submitting an insurance claim. An initial step is verifying the client’s insurance benefits for couples therapy. This involves contacting the insurer to inquire about coverage for family or couples therapy, understanding their medical necessity criteria, and checking for pre-authorization. Ask specific questions about coverage for CPT codes 90847 and 90846, and any exclusions for marriage counseling.

Completing a CMS-1500 claim form, or its electronic equivalent, is required. This form submits claims for professional services. Key fields must be accurately populated with the identified patient’s details, diagnostic code, CPT code for the service rendered, and dates of service. The identified patient’s name and diagnosis should be listed on the claim, with the primary insurance holder in the designated field if different.

Claim submission methods include electronic submission via a clearinghouse, direct online portal, or mail. Electronic submissions are often preferred due to improved accuracy, faster processing, and reduced administrative burden. A clearinghouse acts as an intermediary, reviewing claims for accuracy and compliance before transmitting them to the insurer, which can reduce rejection rates. After a claim is submitted, obtain a confirmation or claim number for tracking.

Managing Reimbursement and Denials

After a claim is submitted, understanding the Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) is important. An EOB is a document sent to the provider and patient from the insurer, detailing how the claim was processed, including amounts paid, patient responsibility, and reasons for denials. An ERA is an electronic version sent directly to the provider, allowing for faster processing and reconciliation. Both documents explain what insurance covered and what remains the patient’s financial responsibility, such as co-payments, co-insurance, or deductibles.

Common reasons for couples therapy claim denials include insufficient medical necessity documentation, incorrect coding, identified patient issues, or policy exclusions for relationship counseling. If documentation does not clearly demonstrate how couples therapy treats the identified patient’s diagnosable mental health condition, the claim may be denied. Denials can also occur due to technical errors like missing information, incorrect CPT or diagnostic codes, or late submission.

If a claim is denied, a process exists for appealing the decision. This involves an internal appeal to the insurer, followed by an external review if the internal appeal is unsuccessful. The appeal process requires gathering supporting documentation, such as detailed progress notes and a letter explaining why the service was medically necessary for the identified patient. Adhere to appeal deadlines, which can range from 60 to 180 days from the denial date. For out-of-network services, clients may submit claims for reimbursement using a superbill provided by the therapist, containing all necessary information for the insurer to process the claim.