Psychiatry Services
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Psychiatric services for both children and adults are essential components of behavioral health care, yet they remain among the most scrutinized areas in medical billing and compliance. Recent audits by the Office of Inspector General (OIG), Comprehensive Error Rate Testing (CERT), and Targeted Probe and Educate (TPE) programs have revealed widespread documentation deficiencies, improper billing practices, and significant overpayments—particularly in psychotherapy services.
These findings underscore the urgent need for providers to align with CMS and Texas Medicaid standards, especially regarding time-based CPT codes, medical necessity, and supervision requirements. With commercial payers like BCBS, Aetna, and UnitedHealthcare also tightening their review criteria, compliance teams must proactively audit documentation, credentialing, and billing workflows to mitigate risk and ensure regulatory integrity across all psychiatric service lines.
Approved Psychiatric Providers
CMS recognizes the following professionals for billing psychiatric services:
- Physicians (MD/DO) – including psychiatrists
- Clinical Psychologists
- Clinical Social Workers
- Nurse Practitioners (NPs) and Physician Assistants (PAs)
- Marriage & Family Therapists (MFTs) and Mental Health Counselors (MHCs) (as of 2024)
- Auxiliary personnel (e.g., peer support specialists) under incident-to billing rules with general supervision
While CMS recognizes a range of licensed professionals as eligible to provide psychiatric services, it’s important to note that not all providers are authorized to perform or bill for every psychiatric CPT or HCPCS code. Each provider must operate within the scope of their licensure, credentialing, and payer-specific guidelines, which may limit the types of services they can report—even if those services fall under the broader category of psychiatry.
Most Common CPT/HCPCS – (not an all-inclusive list)
| Service Type | CPT/HCPCS Codes | Description |
|---|---|---|
| Psychiatric Diagnostic Evaluation | 90791, 90792 | With/without medical services |
| Psychotherapy (Individual) | 90832, 90834, 90837 | 30, 45, 60 minutes respectively |
| Psychotherapy with E/M | 90833, 90836, 90838 | Add-on codes for E/M visits |
| Family Psychotherapy | 90846, 90847 | Without/with patient present |
| Group Psychotherapy | 90853 | Non-family group therapy |
| Crisis Psychotherapy | 90839 + 90840 | Initial 60 min + each additional 30 min |
| Psychiatric Collaborative Care | 99492–99494, G0512 | Team-based care management |
| Behavioral Health Integration | 99484, G0511 | General BHI services |
| Health Behavior Assessment & Intervention | 96156–96171 | Psychological factors affecting health |
| Developmental Screening | 96110, 96127 | ASQ, PHQ-9, Vanderbilt, etc. |
| Cognitive Assessment | 99483 | For cognitive impairment |
| SBIRT Services | G0396–G0397 | Substance use screening/intervention |
| Telehealth Psychiatry | G2212, G2214 | Prolonged or complex care via telehealth |
Documentation Standards
- Start/stop times for time-based codes (e.g., 90837 must document ≥53 minutes) and/or total time spent.
- Mental status exam, history, diagnosis, and treatment plan for 90791/90792
- Medical necessity and clinical rationale
- Progress notes for each session
- Treatment plan with goals, frequency, and duration
- Signature and credentials of provider
- Consent forms for minors or telehealth
- Coordination of care documentation when applicable
Compliance Notes
Pediatric Psychiatry Considerations
While adult psychiatric services often focus on mood disorders, trauma, and chronic mental health management, pediatric psychiatry presents unique clinical and compliance challenges. Services frequently include developmental screenings, ADHD evaluation and treatment, family therapy, and school-based behavioral interventions.Additionally, more intensive levels of care—such as Intensive Outpatient Programs (IOP) and Partial Hospitalization Programs (PHP)—are covered under specific CMS guidelines when medically necessary. For inpatient psychiatric services involving patients under age 21, providers must ensure certification and facility accreditation standards are met, as required by CMS and Texas Medicaid.
Psychotherapy Errors
- Incident-to billing must meet supervision and documentation standards
- Modifier misuse (e.g., missing 25 when psychotherapy is added to E/M)
- Over-coding time-based psychotherapy without supporting documentation
- Under-documenting group therapy or family therapy sessions
- HIPAA violations in psychotherapy notes
- Telehealth must meet CMS technology and documentation standards
Compliance Audit Findings and Risk Areas
- OIG: Psychotherapy – $580M in improper payments (documentation & telehealth)
- CERT: Missing psychiatric evaluations and certifications
- TPE: Denials due to insufficient documentation and medical necessity
- Texas Medicaid: Telehealth billing errors and unenrolled providers
As psychiatric services continue to expand across telehealth, outpatient, and integrated care settings, compliance professionals must remain vigilant in monitoring documentation, billing accuracy, and payer-specific requirements. The recent findings from federal and state audits serve as a clear reminder that even clinically appropriate care can result in denials or overpayments if not properly supported. By implementing robust audit protocols, educating providers, and aligning with CMS and Texas Medicaid standards, organizations can safeguard reimbursement and uphold the integrity of behavioral health services.
The next article in our series will take a close look at clinical coding examples for each provider type performing psychiatric care services. Coming soon.
Resources
Novitas TPE – Psychotherapy Services Review
Novitas CERT – Insider’s Guide