If you're living with a chronic illness, you're in the right place.

Friday, May 12, 2017

Yes, Insurance Covers Seeing a Therapist for Your Medical Illness

Well hey there boys and girls!  Long time, no blog.  I could get into the reasons why I fell off the wagon, but there are many and it'd be a long, drawn out story that isn't very interesting.  So instead of rehashing the past, I'd like to jump right into this post on a dry but critical topic.

Health insurance.

In the news a lot the past few months, isn't it?  That's not why I'm here.  I'm here for more pressing things like CPT codes.

I've been to a couple of conferences in the past few weeks and this has come up more than once, from both my physician peers and patient advocates:

Will insurance cover visits to a mental health clinician for issues dealing with a chronic medical illness?

The answer, Virginia, is yes.

Who the hell is Virginia?

In case you missed it, I'm a licensed clinical psychologist.  One of several types of clinicians qualified to do psychotherapy.  I hold a doctorate in clinical psychology (PsyD) which means I did 5 years of graduate school and at least 1 year of post-doctoral training before I took the licensing exam and actually passed it.  Clinicians with a PhD (doctor of philosophy in clinical psychology or counseling psychology) after their name have the same training.  The PsyD is a newer degree and has been around since the 1970s or so while the PhD has been around since forever (rough estimate).

Factoid:  By the time someone graduates with a PhD or PsyD in clinical psychology, they've completed around 5000 hours of clinical work.  Over half of it is done for free.

There are also people with a Master's degree who can get a license and will have the letters LCPC (licensed clinical professional counselor), LPC (licensed professional counselor), LMFT (licensed marriage and family therapist), LCSW (licensed clinical social worker), or LMSW (licensed medical social worker) after their name.

Factoid:  LCSWs have to complete 2000+ hours of supervised clinical work after finishing their degree before they can take the licensing exam.

Last, but not least, are psychiatrists (MDs).  Some psychiatrists still do therapy in addition to prescribing medications, but this seems to be getting more rare.

Stay with me, there's a reason for going into that.

Depending on what level of training the therapist has, they can bill insurance for seeing a person coming in for a medical illness differently.  I don't know who set up the rules, and they may vary by state.  My frame of reference is Illinois.  So please learn from me then investigate the rules in your home state.

When you receive medical care for any type of service the clinician will bill your insurance using Current Procedural Terminology (CPT) codes - 5 digits that magically convey to the insurance company what the clinician did during the visit.  Depending on what you're going in for, several CPT codes can be listed for one trip to the doctor's office.  There are LOTS of CPT codes.

In the mental health world, there are CPT codes specific to counseling/psychotherapy, psychological testing, family therapy, and medication management.  So if someone comes in to see me for just depression or just anxiety or just OCD, or all three at once, I use either 90834 or 90837.  The difference lies solely in how long I spend in the session - 90834 is for around 45 minutes, 90837 is for an hour or so.

In my little world of mental health + medical illness, there are very specific CPT codes called "Health and Behavior Codes." Remember that term.

H&B codes are 96150 for the initial consultation, 96152 for the therapy session, and 96154 if I meet with family members.  So if someone comes in to see me for Crohn's disease or lupus or cancer, whether they're depressed or just need a little help coping, I bill using H&B codes.

There is no session limit for my seeing a patient with H&B codes.  I can see you weekly for 27 years using H&B codes (might reflect poorly on my therapist skills, but that's beside the point of this blog entry).

Side note:  There also is no limit for outpatient therapy and the same 27 year scenario applies thanks to the Mental Health Parity and Addiction Equity Act of 1996 and 2008, as well as the Affordable Care Act.  However, some insurance companies still tend to be difficult about unlimited mental health services.  I rarely run into session limits in my practice, but I also don't bill with mental health codes that often.  Back to H&B.

The other cool part of H&B codes is I bill using your Medical Diagnosis not a new mental health diagnosis.  Whoa.  I'll try to summarize this in a simple example:

Joe was recently diagnosed with Crohn's disease and is feeling overwhelmed.  Joe gets a referral to see me because his gastroenterologist is on her game and recognizes the importance of mental health. He has Blue Cross Blue Shield of Illinois PPO, a plan I am in-network with.  Joe's initial visit is billed using the CPT code 96150 under his Crohn's diagnosis code (yep, more codes:  K5010).  He sees me for 12 sessions, each billed under 96152 and K5010.  Joe has a $20 co-pay for each visit so his out of pocket expense is 20 x 13, or $260.

These are the basics of health insurance and seeing a therapist when you're struggling with a medical illness.  There are differences between insurance carriers and even between plans at the same carrier.  I'll try to summarize some of the main ones but ALWAYS verify with your own insurance carrier that seeing a therapist is covered.
  • Network restrictions to benefits (in-network, out-of-network) also apply to therapists just as they apply to physicians.
  • Co-pays, co-insurance, and deductibles all apply to H&B code services, much like they'd apply to seeing your rheumatologist or gastroenterologist.
  • Therapists with an LCSW or LMSW cannot bill using H&B codes, at least in Illinois.  So my practice partner, Stephanie, uses mental health codes with a benign diagnosis of "adjustment disorder" when seeing the majority of people with medical illness in our practice.
  • Not all insurance companies recognize H&B codes.  Medicare does.  As does Blue Cross Blue Shield.  
  • Some therapists may opt to bill with mental health codes versus H&B codes due to differences in reimbursement.  This isn't illegal or unethical, rather up to the individual clinician or practice policies.
  • Most insurance companies recognize, and pay for, H&B services delivered via tele-mental health (e.g. FaceTime or other HIPAA compliant video chat). This is a whole other blog post, but the therapist must live in the same state as you.  We use it in our practice.

Calling insurance?  Here's what to say:  Hi, I'd like to see if I have coverage for specific CPT codes under my plan. When asked which ones, list these: 96150, 96152 (H&B) or 90791, 90834, 90837 (mental health)

I hope this was helpful.  Insurance is insanely complicated and can feel overwhelming.  The good news is it is very highly likely that you have access to mental health care for coping with chronic medical illness under your insurance plan.  I don't know what the changes happening in Washington DC will do to impact this, if anything.  If something shifts, I'll be sure to update ya.