For behavioral health providers, denials can drain resources and delay care. Here’s how to fix the top 5 culprits of mental health billing denials, with examples and compliance tips:
Step 1: Nail CPT Code Accuracy
Why it matters: 30%+ denials stem from mismatched CPT codes for therapy types or session lengths.
Fix:
- 90837 vs. 90834:
o 90837 = 60+ minutes of psychotherapy (document start/end times and complexity).
o 90834 = 45 minutes (commonly denied if notes lack medical necessity). - Group Therapy (90853): Ensure notes list participant count and treatment focus (e.g., “6 patients, CBT for anxiety”).
- Crisis Code 90840: Use only for immediate risk (e.g., suicidal ideation R45.851) with detailed crisis intervention notes.
Pro Tip: Add a time-stamp template to EHR notes: “10:00-11:00 AM: 60-min session for PTSD (F43.10) due to elevated SI risk. Safety plan reviewed
Step 2: Master Telehealth Compliance
Why it matters: 25% of telehealth claims are denied for missing modifiers or consent.
Fix:
- Modifiers & POS Codes:
o Use -95 modifier + POS 02 for telehealth.
o For audio-only, add modifier -FQ (e.g., rural patients).
Consent Forms: Document verbal/written consent in EHR (required by Medicare and many payers).
- State-Specific Rules: Check Medicaid parity laws (e.g., Texas requires video for initial visits).
Red Flag: Denial code CO-252 = “Telehealth service not covered.” Fix by verifying payer-specific rules.
Step 3: Justify Medical Necessity
Why it matters: Denials spike when notes lack evidence linking diagnosis to treatment intensity.
Fix:
- ICD-10 Linking:
o Example: 90837 + F33.1 (major depressive disorder, recurrent, severe).
o Avoid: Vague codes like R45.9 (unspecified emotional distress). - Progress Notes: Include:
o Treatment Goals: “Reduce panic attacks from 5x/week to 2x/week.”
o Risk Factors: “Patient’s PHQ-9 score increased to 18 (moderate-severe depression).”
Denial Prevention: Use AI tools to flag notes missing ICD-10 links.
Step 4: Automate Prior Authorization (PA) Workflows
Why it matters: 40% of denials for services like TMS (90867) or ketamine therapy (J3490) stem from missed PAs.
Fix:
- PA Checklist for High-Risk Services:
Automate Alerts: Use EHR tools to flag services needing PAs at scheduling
Example: Resubmit denied TMS claims with retroactive PA forms and clinical notes proving severity (e.g., TRD diagnosis F33.2).
Step 5: Verify Eligibility & Educate Patients
Why it matters: Surprise out-of-network denials and patient payment delays hurt cash flow.
Fix:
- Real-Time Eligibility Checks:
o Flag plans with limited mental health coverage (e.g., HMOs requiring referrals).
o Confirm session limits (e.g., 20 therapy visits/year). - Patient Cost Estimates:
o Provide upfront quotes for cash rates (e.g., $150/session) and deductible status.
o Use scripts: “Your plan covers 70% after deductible – you’ll owe $45 today.”
Result: Reduce A/R days by 30% and patient disputes.
Bonus: Denial Prevention Checklist
✅ Weekly Audit: Top 5 denial codes (e.g., CO-16, CO-22).
✅ Staff Training: Quarterly updates on CPT 2024 changes (e.g., new codes for ASD screening).
✅ Appeal Playbook: Template letters for common denials (e.g., “lack of medical necessity”).
Results You Can Expect:
- 40-60% Fewer Denials in 90 days.
- 20% Faster Reimbursements with clean claims.
- Higher Patient Satisfaction via transparent billing.
“These steps helped us recover $58K in 6 months – and our therapists finally have time to focus on patients.”
— Dr. Sarah Kim, Clinical Director, Hope Behavioral Health
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