Clinical Preventive Services in Substance Abuse and Mental Health Update: From Science to Services

XV. Appendix C: Billing for Preventive Behavioral Services

Multiple sets of billing codes are provided—some for visits completely devoted to preventive services, and some for primary care physician use for mental health diagnosis and patient management. For most visits, the screening will take less than 3 minutes. Follow-up on screening results can then be billed as diagnosis and patient management.

Benefit packages will differ among and between insurance carriers and different policies offered by a single carrier. Practitioners will have to check with the insurance carrier or managed care plan to decide which codes to use to provide specific services to specific patients.

It is important to note that billing codes are expressed in terms of “encounters,” and that an outpatient visit may include multiple “encounters.” Here again, a provider must inquire with his or her managed care plan or insurance carrier to determine which encounters, within a single outpatient visit, are to be “bundled,” and which are to be billed separately.

Table 8: Preventive Medicine, Individual Counseling, and/or Risk Factor Reduction Intervention Provided to an Individual as a Separate Procedure

CPT Code	Approximate Duration of Procedure
99401	15 minutes
99402	30 minutes
99403	45 minutes
99404	60 minutes

Table 9: Preventive Medicine Comprehensive Evaluations

CPT Code for Initial Evaluation of New Patient	CPT Code for Periodic Reevaluation	Age Range
99381	99391	Under 1 year
99382	99392	1-4
99383	99393	5-11
99384	99394	12-17
99385	99395	18-39
99386	99396	40-64
99387	99397	65 and over

Coding of diagnoses and medical procedures for billing and for other purposes is a complex matter. International Classification of Disease (ICD-9 and ICD- 10) codes are most commonly used for diagnoses. Current Procedural Terminology (CPT) codes are most commonly used for visits, procedures, and billing—but there are at least two other sets of codes in common use. Health Care Common Procedure System (HCPCS) codes are standardized nationally and are used in addition to CPT codes in Medicare and Medicaid Programs. However, there are “Level III HCPC” codes developed by individual States for locally designated services. These are not yet standardized nationally, although government agencies are currently reviewing them to standardize, reduce in number, and streamline. The project to standardize the local Level III HCPC codes is being directed by the U.S. Centers for Medicare and Medicaid Services (CMS) in accordance with the “Administrative Simplification” transactions provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, P.L. 104-191 (see www.cms.gov/hipaa/hipaa2/regulations/transactions/default.asp). Once the HIPAA billing codes become final, providers may bill for mental health services in primary care as well as specialty services in the specialty sector (Tremper, 2003). Our appendix is limited to presentation of the CPT codes most important to primary care practitioners for preventive behavioral services.

Although psychologists, nurses, and other nonphysicians have a strictly defined scope of practice limitations, physicians do not. A primary care physician may bill for psychiatric services, since CPT code specifications for preventive services do not rule out prevention of mental illness. The limitation, if any, would be based on the interpretation of the State Medicaid office, a regional Medicare intermediary, or the specific benefits offered by a private insurance company. Whether or not mental health specialists can bill for screening for evidence of preclinical mental illness will depend on the benefit packages of the managed care or other health insurance plan, State Medicaid program, or Medicare intermediary. Here again, primary care practitioners are urged to check the resources available to them for patient referral, based on the patients plan membership or insurance policy.

The CPT coding for “Preventive Medicine, Individual Counseling” specifies that this is counseling provided as a separate encounter to promote health and prevent illness and injury for a patient without symptoms, and may be reimbursed using preventive medicine codes (Agency for Healthcare Quality Research, 2003). These codes run consecutively from 99401 for an approximate 15-minute encounter, through 99404 for an approximate 60-minute encounter.

Another possible approach, using general preventive medicine codes, are the codes for preventive medicine evaluation and management of an individual, including a comprehensive history, a comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and ordering appropriate laboratory/diagnostic procedures. There also are preventive medicine codes for counseling and risk factor interventions in group settings, with code 99411 for sessions of approximately 30 minutes, and 99412 for hour-long sessions.

Code 99420 is specific to administration and interpretation of health risk assessment instruments. Payers may or may not allow use of this code for behavior-related questionnaires such as the Pediatric Symptom Checklist or one of the longer alcohol- or depression-related questionnaires.

Finally, the last of the preventive medicine codes is 99429, Unlisted Preventive Medicine Service. Practitioners are urged to check with the managed care plan or insurance carrier before using this code.

There are a number of promising psychiatric codes that may be accessible to primary care physicians for follow-up on brief screening tests, especially for depression and any form of substance use. In these cases, the 1- or 2-minute screening interview would not be reimbursed separately. The diagnostic interview, counseling, and development of a treatment plan may be billable in the same manner as billing for diagnosis and management of a purely physical chronic disease.

The major codes of interest here are—

90801: Psychiatric interview examination
90804: Individual psychotherapy, insight-oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with patient
90805–90804: With medical evaluation and management services
90847: Family psychotherapy (conjoint psychotherapy) (with patient present)
90862: Pharmacologic management, including prescription use and review of medication with no more than minimal medical psychotherapy
90887: Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist the patient.

In addition, in the context of psychoeducational interventions, including simple biofeedback training for presurgical patients—

90875: Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (e.g., insight-oriented, behavior modifying, or supportive psychotherapy); approximately 20–30 minutes
90901: Biofeedback training by any modality

The material in this appendix was developed from the CPT 2000 Codebook of the American Medical Association (AMA CPT Editorial Panel and AMA CPT Advisory Committee, 1999) and the Ingenix 2003 update (Hopkins & Kachur, 2002). Additional guidance on codes to be used for Medicaid and Medicare can be secured from the U.S. Center for Medicaid and Medicare Services at http://cms.hhs.gov/.

More detailed guidelines for Medicare payments for Part B Mental Health Services can be accessed at http://oig.hhs.gov/oei/reports/oei-03-99-00130.pdf

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To secure CPT code books and related materials, a number of products and services may be found on the American Medical Association’s Web site at http://www.ama-assn.org/ama/pub/category/3116.html.

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