Benefit carve-outs
A patient can hold a commercial medical card while psychiatric visits adjudicate through Optum, Carelon, Magellan, or Evernorth Behavioral Health. Separate contracts, portals, fee schedules, and authorization rules.
What psychiatry billing has to handle
Key point
High claim volume at low dollar value means a denial rate other specialties can absorb will drain a psychiatric practice.
A full-time psychiatrist may close 20 to 30 encounters a day. A therapist on the same panel may close 6 to 8. Each encounter produces a claim worth somewhere between $60 and $250, and there is no high-dollar procedure at the end of the month to cover what went unpaid.
Mental Health Billing works only in behavioral health. We bill for psychiatrists, psychiatric nurse practitioners, psychologists, clinical social workers, counselors, group practices, IOP and PHP programs, and hospital-affiliated behavioral health departments. Our coders know why a 90837 sits in review longer than a 90834, and how to document a 99214 paired with 90833 so it survives a post-payment audit.
Why billing is different in psychiatry
Most specialties bill for what was done to the patient. Psychiatry bills for minutes spent with the patient, and that one difference changes everything downstream.
Key point
Two minutes either side of a time threshold changes the code, even when the clinical work was identical.
90832 covers 16 to 37 minutes. 90834 covers 38 to 52. 90837 covers 53 or more. Payers know exactly where those lines fall, and several run utilization edits on practices with heavy 90837 volume.
The 190-day limit
Medicare caps inpatient care in freestanding psychiatric hospitals at 190 days per lifetime. No equivalent lifetime limit applies to general hospital admissions.
42 CFR Part 2
Substance use records carry disclosure restrictions beyond HIPAA, which changes how appeals and payer records requests get handled.
Parity rules
MHPAEA gives practices a real basis to challenge a payer applying limits to psychiatry that it does not apply to comparable medical care.
Credentialing sits on top of all of it. Behavioral health panels close and reopen without notice, and a psychiatrist waiting 120 days for an effective date accumulates unbillable encounters the entire time.
Where psychiatric claims actually fail
These are the patterns we find in almost every practice audit, roughly in order of how much they cost.
Time documentation that does not support the code
A note reading "50-minute session" without start and stop times will not hold up when a payer pulls records for 90837. Auditors want recorded face-to-face time, not the length of the appointment slot.
E/M paired with psychotherapy, coded wrong
Two errors repeat constantly. Practices select the E/M level by total time, which is not allowed here because that time already belongs to the psychotherapy add-on. And practices append modifier 25 out of habit, when the add-on structure does not require it and some payers reject the combination when it appears.
Interactive complexity misuse
90785 is an add-on, never a standalone service. It requires a documented complicating factor such as high-conflict family communication, mandated reporting during a session, or use of an interpreter or play equipment because the patient cannot communicate adequately. It cannot be reported with crisis codes 90839 and 90840, or with an E/M when no psychotherapy occurred.
Prior authorization on the highest-value services
Testing, TMS, ECT, and esketamine administration commonly require authorization. TMS reviews are the strictest: most payers want documented failure or intolerance of multiple antidepressant trials from more than one drug class at adequate dose and duration, often alongside a psychotherapy trial, plus baseline symptom scale scores.
Diagnosis specificity
Unspecified F codes get rejected on recurring claims. F32.9 and F33.9 pass a first visit and start producing medical necessity denials by the sixth. Severity, episode, remission status, and psychotic features all matter across F30 to F39, and substance use codes in F10 to F19 need the correct fifth and sixth characters.
Duplicates and patient balances
When a prescriber and a therapist under one tax ID see a patient the same day, payers routinely deny the second claim as duplicate. Those are winnable with the right modifiers and distinct-service documentation. Separately, high-deductible plans push a large share of psychiatric revenue onto the patient, and practices that skip benefit verification end up chasing $175 balances one statement at a time.
How our service works
Take the whole cycle or only the parts you need. A typical engagement moves through these stages in order.
Onboarding audit
We review 60 to 90 days of your encounters against your payer contracts before submitting anything. This surfaces undercoded 99213s that should have been 99214s, missing add-ons, expired authorizations, and timely filing losses.
Eligibility and benefits
Every new patient, and every established patient at plan renewal. Carve-out status, service-level copay or coinsurance, deductible, session limits, and authorization requirements for the planned modality.
Charge entry and coding review
Coded from your documentation, with queries back to the clinician when a note does not support the level billed. We do not upcode, and we do not let undercoding pass either.
Claim submission
Clean claims go out daily, scrubbed against payer-specific edits before transmission rather than after a rejection returns.
Denial and rejection work
Every rejection worked within 48 hours. Appeals carry clinical rationale and supporting records instead of a form letter.
Payment posting
ERAs and manual EOBs posted with contractual adjustments checked against your contracted rates, so underpayments surface instead of settling in.
A/R follow-up
Worked in aging buckets with documented payer contact and escalation paths. We also tell you when a balance is not worth pursuing rather than letting it inflate your A/R report.
Monthly reporting
Performance by provider, payer, and CPT code, so you can see where revenue comes from and where it is stuck.
Specialty coding expertise
Psychiatric coding turns on two questions: how many minutes were face to face, and whether a prescriber was involved.
| Session length | 16–37 min | 38–52 min | 53+ min |
|---|---|---|---|
| Psychotherapy alone | 90832 | 90834 | 90837 |
| With E/M billed as an add-on | 90833 | 90836 | 90838 |
Key point
On the bottom row, the E/M level must come from medical decision making. The clock is already committed to the psychotherapy add-on.
Diagnostic evaluation
90791 90792
90792 covers evaluations including medical services. Payers differ sharply on how often a repeat evaluation is allowed for the same patient and provider.
Crisis services
90839 90840
90839 covers the first 60 minutes, 90840 each additional 30. The note has to establish urgency and mobilization of resources, not just a long session.
Family and group
90846 90847 90849 90853
90846 is family therapy without the patient present, 90847 with the patient. Whether the identified patient was in the room decides the code, and payers audit the pairing.
Add-on services
90785 90863
90785 needs a documented complicating factor and cannot ride along with crisis codes. 90863 applies only where the rendering provider type permits it.
Procedures
90867 90868 90869 90870
TMS separates initial mapping, subsequent delivery, and motor threshold re-determination. The authorization file carries more weight here than the coding.
Testing
96127 96130–96139
Evaluation services and test administration bill separately, each with base and add-on units tied to time. Miscounted units are the leading cause of partial payment on testing claims.
Collaborative care
99492 99493 99494 99484
Billed monthly by the primary care practice against documented care manager minutes and patient consent. The psychiatric consultant is paid by contract rather than by claim.
Evaluation and management
99202–99215
Used alone for medication management, or as the primary code beneath a psychotherapy add-on. Prolonged service codes apply once the visit clears the time threshold.
State Medicaid HCPCS
H0031 H0035 H2012 H2019
The H-code series used by IOP, PHP, and community programs varies considerably between states. We bill against your state's fee schedule and unit definitions.
Modifiers cause as many denials as codes do
These produce rejections that look like coverage problems but are really formatting problems. The right combination depends on payer, provider credential, and state.
95Synchronous telehealth by real-time audio and video.
93Audio-only telehealth. Coverage varies more than any other modifier here.
GTStill expected on institutional claims by some payers.
FQ / FRMedicare behavioral telehealth indicators for audio-only service and supervising practitioner presence.
HO / HN / HPCredential-level modifiers required by many state Medicaid programs.
AH / AJMedicare identifiers for clinical psychologists and clinical social workers.
Denial management and A/R follow-up
Key point
Fixing one claim recovers one payment. Fixing the cause stops the next forty from failing the same way.
Our scrubbing catches the errors behind the most common psychiatric denials before submission: missing or expired authorization, place of service conflicts on telehealth claims, add-on codes without a valid primary, diagnosis codes outside a payer's covered list, and units that conflict with documented time.
CO-97 · bundledPsychotherapy add-on absorbed into the E/M. Usually a payer edit to challenge with contract language, not a coding change.
CO-50 · not medically necessaryRecurring psychotherapy without measurable progress or updated goals. Fixed at the documentation level.
CO-197 · no authorizationAlmost always a unit count that ran out three visits earlier. We track units against the schedule, not the claim.
CO-18 · duplicatePrescriber and therapist seen the same date under one tax ID. Appealable with distinct-service documentation.
Compliance and documentation support
We give clinicians direct, practical notes: start and stop times on timed services, the medical decision making elements that support the E/M level chosen, treatment plan updates with measurable goals, risk assessment documentation, and the specific elements payers look for during TMS and testing reviews.
We also track regulatory changes that move psychiatric reimbursement, including annual Medicare Physician Fee Schedule updates and the addition of marriage and family therapists and mental health counselors as billable Medicare providers effective January 2024.
Note
The in-person visit requirement attached to Medicare behavioral telehealth has been delayed repeatedly by Congress. We confirm where it stands before advising, rather than working from last year's guidance.
Technology and software experience
Migration is disruptive and rarely necessary. We work inside the platforms behavioral health practices already run, plus the major clearinghouses.
- SimplePractice
- TherapyNotes
- Valant
- ICANotes
- Kareo / Tebra
- AdvancedMD
- eClinicalWorks
- athenahealth
- NextGen
- Netsmart
- Qualifacts CareLogic
- Epic behavioral health
- Availity
- Office Ally
- Waystar
- Optum
What outsourcing changes
- Coverage does not vanish when a biller takes leave or resigns mid-quarter.
- Claims go out daily instead of in weekly batches that push payment dates back.
- Denials get worked by people who have appealed the same payer edit fifty times.
- Credentialing runs on expiration dates rather than being discovered when a claim denies.
- Fixed cost becomes variable cost. No salary, benefits, software licenses, or training for a function that scales unevenly with patient volume.
- Solo practices get time back. Billing work that eats eight to ten hours a week is eight to ten hours not spent seeing patients.
Why providers choose Mental Health Billing
Behavioral health is the whole business, so our coders are not learning psychiatric rules on your claims.
Payer-level knowledge
Which regional Blues plans require authorization for 90837, which Medicaid managed care plans need credential modifiers, which carve-out vendors still take appeals by fax, and how long each actually pays in.
A named account manager
One person who knows your practice, plus direct access to the people working your claims. No shared ticket queue.
Reporting with context
Broken out by provider, payer, and CPT code, rather than a single collection percentage with nothing behind it.
Who we work with
- Solo psychiatric practices
- Group practices with prescriber and therapist panels
- Psychiatric nurse practitioners
- Psychologists and neuropsychology testing
- LCSWs, LPCs, and LMFTs
- Counseling centers
- TMS and esketamine clinics
- Substance use programs, IOP and PHP
- Hospital-affiliated outpatient behavioral health
- Multi-state telepsychiatry groups
Frequently asked questions
Our psychiatrist does medication management and therapy in one visit. One code or two?
Two. Bill the appropriate E/M level for the medication management and the matching psychotherapy add-on (90833, 90836, or 90838) for the therapy time. Select the E/M level using medical decision making, and document psychotherapy time separately. This pays better than either service alone and is entirely legitimate when the documentation separates the two.
Payers keep pulling records on our 90837 claims. Should we just bill 90834?
Not if the sessions genuinely run 53 minutes or more. Downcoding to avoid review costs real revenue and creates its own compliance problem. The fix is documentation: recorded start and stop times, clinical rationale for extended sessions, and a treatment plan that supports the intensity.
Our patients' mental health benefits run through a separate company. Can you handle that?
Yes. Carve-out billing is routine here. We verify at intake which entity holds the behavioral health benefit, submit to the correct payer ID, and maintain portal access with the major managed behavioral health organizations.
Do you handle credentialing and payer enrollment?
Yes, including CAQH maintenance, initial applications, revalidations, and re-credentialing deadlines. We also track when panels reopen for behavioral health providers in your area, since closed panels are a common obstacle for new practices.
We are starting collaborative care with a primary care group. How does that get billed?
Codes 99492, 99493, and 99494 are billed monthly by the treating primary care practice, not by the consulting psychiatrist, and they depend on documented care manager time and patient consent. We help both sides set up time tracking and consent before the first claim goes out, because reconstructing care manager minutes after the fact rarely survives an audit.
How do you handle telehealth and audio-only sessions?
Correct modifier and place of service assignment by payer, since commercial plans, Medicare, and state Medicaid programs do not agree on these. Audio-only coverage varies the most, and billing an audio-only session as audio-video is a compliance risk rather than a shortcut.
Will you work in our current EHR, or do we have to switch?
We work in your system. If your platform is creating avoidable billing errors we will say so, but the decision stays with you.
What about self-pay patients and superbills?
We manage self-pay rates, out-of-network superbills for patients seeking reimbursement, and good faith estimates required under the No Surprises Act for uninsured and self-pay patients. For mixed insurance and cash panels we keep the workflows separate, so cash rates never reach a contracted payer.