Medicare Compliance & Reimbursement

Explore how Medicare is expanding and reimbursing behavioral health services.

On January 1, 2024, Medicare began to accept billing from qualifying marriage and family therapists (MFTs) and mental health counselors (MHC) for the diagnosis and treatment of mental illnesses for Medicare beneficiaries. Following the Consolidation Appropriations Act, 2023, Medicare Part B pays these providers 75 percent of the reimbursement rate of a clinical psychologist under the Medicare Physician Fee Schedule (MPFS).

“Following Congressional action, CMS has finalized procedures to allow Marriage and Family Therapists and Mental Health Counselors (including addiction counselors or alcohol and drug counselors who meet all the requirements to be a Mental Health Counselor) to enroll as Medicare providers. More than 400,000 Marriage and Family Therapists and Mental Health Counselors are now able to independently treat people with Medicare and be paid directly,” said Meena Seshamani, MD, PhD, and Douglas Jacobs, MD, MPH, in a November 2023 Centers for Medicare & Medicaid Services (CMS) press release.

Understand Qualifying Criteria for Providers

Marriage and family therapists are specifically defined. Folks who provide these services and want to bill Medicare need a master’s or doctorate degree, at least two years or 3,000 hours of experience, and to be licensed in their respective state.

“This is huge, because this group of people have never been allowed to bill Medicare before,” explained Susan Roelant, CPC, CPMA, CPCO, CEMC, in her AAPC HEALTHCON Regional 2024 presentation “CMS Guidelines for Mental Health Counselors.”

This helps expand coverage so when people become eligible for Medicare, they can keep seeing their mental health providers. The way this rule is written, mental health counselors like clergy members can bill Medicare for the services they provide, as long as they meet the qualifying criteria and respective state rules.

Document These 9 Elements for Medicare Beneficiaries

If you’re going to bill Medicare for mental health services, you’ll want to make sure your claims are in top shape. Roelant relied on her experience as an auditor and educator to highlight nine elements of care that qualifying MHCs should document in order to receive reimbursement for the mental health care they provide to beneficiaries:

1. Referral: If a beneficiary is in an inpatient setting or a nursing facility, they’ll need a referral. However, if the beneficiary is in an assisted living, outpatient, independent facility, they can self-refer. It’s referral where applicable, according to almost all the guidelines, Roelant said.
2. Chief complaint: Look to signs, symptoms, or diagnosis; why did the beneficiary come in? The exception here is medication management — a patient doesn’t say they’re seeking a visit due to medication management, but, rather, management of their condition. Think of chief complaint as a means of setting up medical necessity, she recommended.
3. History of present illness (HPI): This element of a visit should include the behavioral health, like how long a symptom, such as passive suicide ideation, has been happening, whether it was a sudden onset situation, and if there was a trigger. For behavioral health, the HPI should go beyond the “regular” medical history and illustrate why the patient is seeking mental health care and why the provider is performing a mental health assessment.
4. Complete history: Most local coverage determinations (LCDs) define a complete history as the patient’s psychiatric history, relevant medical history, social history, and family medical and/or psychiatric history.
   Providers should note that aspects of the patient’s record can’t be organized into multiple categories: For example, drug abuse, smoking, and drugs would fall under psychiatric history rather than social history, so providers would need to gather more information to populate a patient’s social history. Roelant says that some relevant CPT^® codes require that providers carve out psychiatric history, but providers can ask patients questions about, say, their marital status or level of education, to gather information that can be considered social history.
   Note: The Medicare Administrative Contractor (MAC) NGS requires both family medical and psychiatric history — they’ll report that information is missing if they don’t have both, Roelant said.

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5. Current medications: Documenting medication can seem tricky to MHCs, as the patient’s medications are often beyond the counselor’s scope, but it’s part of the CPT^® code requirement, Roelant said. For a psychologist or MHC who doesn’t write prescriptions, Roelant recommended just listing the medications. But psychiatrists should list the name, dosage, frequency, etc., because that is within the scope of their practice, she said.
   “I’ve never seen anybody fault a psychiatrist for not listing out their chronic medications, their diabetes meds, their heart meds, and things like that, because they’re not managing them. But they need to be aware of them in case there’s a black box warning,” she explained. Plus, if the patient is taking a drug off-label, the provider needs to be aware, in case there’s interference with a psychiatric drug.
6. Exam: Roelant said that many mental health care providers use the “1997 Documentation Guidelines For Evaluation And Management Services” guidelines for performing a single specialty psychiatric examination. These guidelines “gave us a really great base of all the exam elements for a mental health exam. And we’re still kind of using that framework, if you will, when we audit, to make sure [providers] are collecting enough of that mental status exam,” she explained.
   Although the guidelines come from an evaluation and management (E/M) services document, the E/M-specific guidance is no longer accurate.
   Coding tip: Some MACs, like NGS, require a physical exam for the exam to be considered “complete” and thus to successfully report code 90792, Roelant said.
7. Strengths/liabilities: This category is sometimes called assets/limitations, and one of each must be documented. Roelant provided an example of “independent with activities of daily living (ADLs) but hard of hearing.”
8. Diagnoses: Some MACs, but not all, have specific local coverage articles (LCAs) that detail medical necessity for certain psychotherapy codes. According to ICD-10-CM guidelines, some of the diagnosis codes relevant to psychology have “Code first” requirements. For example, if a patient has vascular dementia, the cause should be coded, too. If you look at the patient’s medical history, you might see that they had a CVA and that the CVA caused the vascular dementia. Without an appropriate “buddy code,” as Roelant nicknamed code first causal conditions, the patient’s medical history won’t be accurate or complete, and a claim submitted for payment might be denied.
9. Evaluation of patient’s ability to respond to treatment: A patient needs to be able to respond to treatment to participate in psychotherapy, Roelant said.
   RCI will continue to cover CMS’ expansion of behavioral health services, detailing information providers need to receive reimbursement for their services.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC