Behavioral health disorders are increasingly prevalent among children and adolescents, with the CDC reporting that nearly 1 in 5 children experience a mental or behavioral disorder. As a group practice providing pediatric behavioral health services, managing your revenue cycle is crucial for practice sustainability and meeting the growing need for quality pediatric behavioral health services.
This blog will guide you through essential aspects of pediatric behavioral health billing, identify common provider and billing challenges, and provide actionable strategies to improve and streamline your reimbursement processes.
The Unique Nature of Pediatric Behavioral Health Billing
Pediatric behavioral health involves specialized coding, extensive documentation, and often multiple participants in therapy sessions (such as family members). Your clinical and administrative staff need a good understanding of these behavioral health nuances to ensure compliance, accurate reimbursement, and clean claims.
Common Challenges Pediatric Behavioral Health Providers Face
Differentiating Individual vs. Family Psychotherapy
Providers frequently struggle to decide whether to bill for individual psychotherapy (CPT® codes 90832-90838) or family psychotherapy (90846, 90847). This choice depends mainly on who is present and the session’s primary focus.
- Individual psychotherapy: Use individual codes when services primarily address the child’s individual mental health needs, even if parents are present.
- Family psychotherapy: Use family codes when sessions focus primarily on family dynamics and relationships.
Documenting Session Time Accurately
Incorrect time documentation can result in denied claims or audits. Pediatric behavioral health billing requires precise documentation of session times:
- Individual Sessions: Minimum 16 minutes, ranging to 53+ minutes depending on the service provided.
- Family Sessions: Minimum of 26 minutes.
Prior Authorization and Documentation
Many behavioral health services require prior authorization and extensive documentation of medical necessity. Providers often face delays or denials due to incomplete documentation or missing authorizations.
Practical Strategies to Simplify Your Billing Process
Utilize Standardized Screening Tools
Implementing standardized screening tools recommended by the CDC—such as the Pediatric Symptom Checklist (PSC) or the Patient Health Questionnaire (PHQ-9)—not only aids clinical diagnosis but also supports accurate coding and reimbursement.
Commonly used tools include:
- M-CHAT-R: Autism screening for ages 16-30 months.
- PSC: General behavioral health screening from ages 4-16 years.
- PHQ-9: Depression screening for youth aged 13+ years.
Use Modifiers and Report Multiple Screenings
- Modifier 25: When an evaluation and management (E/M) service and developmental screening occur together, append modifier 25 to signify the E/M service was separate, significant, and medically necessary during the same visit.
- Multiple Screens: If you perform several screenings during one visit (like the M-CHAT and ASQ), bill each screening separately using code 96110, and apply modifier 59 to clarify that each represents a distinct and separate screening tool.
Use Correct Codes and Modifiers for Pediatric Behavioral & Developmental Testing
Developmental testing, reported using CPT code 96111, involves assessing a child’s motor, language, cognitive, social, and adaptive abilities through standardized assessments such as Bayley Scales, Woodcock-Johnson, or CELF. Here are some reporting guidelines to use.
- Standalone Testing: Report when conducted independently.
- With Evaluation & Management Visits: Use modifier 25 for (E/M) services and modifier 59 to indicate testing as distinct.
Implement Regular Staff Training on Behavioral Health Codes & Guidelines
Coding and billing guidelines change regularly. Conduct periodic training sessions with your clinicians and administrative team to inform them of the latest billing updates, payer-specific guidelines, and coding standards for pediatric behavioral health.
Maintain Complete and Ongoing Documentation
From prior authorizations to evaluation records and clinical notes, ensure your records are in good order. Insurance companies often request many pieces of documentation for authorizing behavioral health services beyond screenings and evaluations or to continue reimbursement for ongoing clinical sessions. Well-organized documentation will immensely help your revenue cycle management (RCM)
Proactively Manage Denials
Create a structured denial management system to identify denial patterns, promptly appeal unjustified denials, and implement preventive measures. Swift and proactive responses minimize revenue disruption and improve overall cash flow.
Why Consider Outsourcing Your Pediatric Behavioral Health Billing?
Given the challenges and time required for pediatric behavioral health billing, many practices find that outsourcing billing tasks to specialized medical billing companies helps them concentrate more on patient care rather than administrative burdens.
Outsourcing benefits include:
- Improved billing accuracy
- Reduced denial rates
- Enhanced cash flow and revenue
- Greater compliance assurance
Simplify Your Pediatric Behavioral Health Billing and Increase Your Revenue.
At 4D Global, we specialize in simplifying billing processes so pediatric behavioral health providers can spend more time with patients and less time worrying about paperwork. Let us help you streamline your billing, reduce denials, and improve your bottom line.
Contact 4D Global today to discuss how we can enhance your pediatric behavioral health practice’s operations.