• Angel Callaway, CPC, CPB

Challenges of Behavioral Health Coding

Mental health coding doesn't have to be so difficult. With the correct resources and information, you can simplify the coding process.


Understanding the regulations can lessen the complexity of behavioral health coding. Many factors affect coding, such as documentation, reimbursement guidelines, poor understanding of terminology, and payer contracts. federal laws, and scope of practice.


According to the 2021 Medicare FFS Supplemental Improper Payments Report, Psychiatry is the ninth highest for improper payments. Insufficient documentation remains the main reason for the improper payments at a 19.4% improper payment rate.


Documentation is the key to proper payments, the minimum requirements are below:

  • Start and stop times

  • If telehealth, documented consent for psychotherapy via telehealth

  • The patient’s name on each page of the record

  • The date of service on each page of the record

  • Type of service (individual, group, family, psychotherapy)

  • Problem statement including diagnosis

  • Support for medical necessity

  • Service rendered, including therapeutic interventions (e.g., insight-oriented, CBT, DBT, etc.)

  • Person-centered detail such as behavior, description, or quotes

  • Patient observation (e.g., mental status exam)

  • Summary of progress, or lack thereof toward identified goals, which should result in a change in plan or a new plan of care

  • In group therapy the number of participants with documentation in each individual medical record.

  • Many payers require a mental status exam to be documented.

Behavioral Health Assessment codes 96156-96171 are used by psychologists to provide an assessment and evaluation of the patient's response to a disease, illness, injury, coping strategies, and adherence to the treatment. These are time-based and coded on face-to-face time spent with the patient. If the family is present you need to document who was present for the psychotherapy codes.



HHS 2020 Medicare Fee-for-Service Supplemental Improper Payment Data: www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0

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