Behavioral Health Coding Compliance

Once again, with feeling: coding for behavioral health

• Coding for Behavioral Health
• Compliance lessons from the OIG
• Post-discharge Telephonic Follow-up Contacts Intervention | G0544
• Digital Mental Health Treatment | G0552, G0553, G0554
• Safety Planning Interventions | G0560

It’s been a year (seems like a minute) since the OIG released a report on coding for behavioral health service, all reported by a single psychiatrist. This year’s report is for psychotherapy services selected randomly from many practices. There are some of the same problems (time not noted for psychotherapy) and some original problems (documentation created 8 months after the encounter, when the OIG asked for records).

I’ve summarized it in this video. And, the OIG created a two page comparison of MACs LCDs for psychotherapy. We’ve excerpted that from the report for your convenience.

• Download slides
• OIG Appendix C – Psychotherapy

Compliance Lessons from the OIG

In March 2022, the Office of Inspector General (OIG) released a report outlining errors one psychiatrist made in billing for behavioral health services and assessing $1.1 million in overpayments. When considering the average fee for behavioral health service, $1.1 million represents what the government believes to be an overpayment for many, many encounters during an 18-month period.

How did this behavioral health practice come to the attention of the OIG? In its report, the OIG says that the New York City psychiatrist was “among the highest reimbursed individual providers in the Nation.”  This psychiatrist came to the attention of the OIG because of the sheer volume of the claims that were submitted. The psychiatrist submitted claims for services personally performed and for services done by social workers and a registered nurse and billed incident to the psychiatrist. This article will review what the OIG said about the documentation that did not meet Medicare requirements for the services. It should be noted that the practice disagrees with the findings and the extrapolation and repayment amount. In the meantime, let’s learn what the OIG stated were deficiencies.

Practices need to understand incident to guidelines. This practice billed all of the services performed by social workers under the provider number of the psychiatrist, incident to the psychiatrist’s services. Four of the five social workers in the group were eligible to enroll in Medicare themselves and could have billed Medicare directly. The payment would have been less, at 75% of the fee schedule instead of 100%. But, in order to collect the higher payment, practices need to meet the incident to requirements. It is allowable to bill social work services under the psychiatrist provider number if the requirements are met.

• The psychiatrist must see the patient first and establish a plan of care
• The psychiatrist must stay involved in the care of the patient
• The psychiatrist must be in the suite of offices when the service is performed
• The social worker must be an expense to the psychiatrist

The OIG notes that 95 of the 100 encounters did not meet the incident to guidelines. The reviewer at the OIG could not verify, based on the documentation, that the psychiatrist was in the office when the service was performed. The reviewer notes that there weren’t logs to verify the psychiatrist was in the office.  The appointment scheduled could support this, but over a period of a year, there would be times that the psychiatrist was not in the office. Everyone takes a day off now and then or goes on vacation. When the psychiatrist was not in the office, the incident to requirements would not be met. Based on the OIG report, it would be prudent for a clinician to note that the physician who is billing the service is in the office when the service is provided or provide appointment schedules to support that.

The OIG found that 100 of the 100 treatment plans did not comply with Medicare requirements. They found that some of the treatment plans were not signed and the others did not describe the frequency and duration of the psychotherapy that was planned. Although the report does not say this, I infer that the social worker signed the treatment plan but not the psychiatrist. It’s hard to believe that the social worker would not sign the treatment plan that they had developed. But since the services were billed under the psychiatrist’s provider number incident to, I suspect that the OIG wanted the psychiatrist to sign the treatment plan.

One of the social workers was not licensed or authorized to provide services in the state in which the practice was located.

For 26 services, the time spent in psychotherapy was not documented in the medical record. Any service that is selected based on time must have the time spent documented in the record. It is insufficient to simply select the code in the electronic health record that has the description of the time noted. The actual time spent in the provision of services must be documented.  Either document total time spent in the face-to-face service or start and stop times for psychotherapy.

The OIG also reviewed services in which both medication management – – an office visit – – and psychotherapy were reported at the same encounter. When a psychiatrist, psychiatric nurse practitioner, or psychiatric physician assistant provide medication management and psychotherapy on the same day, the psychotherapy must be documented in sufficient detail to support the service. The OIG said the documentation did not show both services. The OIG stated there should be a separate note for the psychotherapy. A separate note is not a CPT^® rule nor is it directly stated by Medicare. My recommendation has always been that after the medication management is described in the note that the practitioner start a separate section of the note headed “psychotherapy.” The practitioner must base the level of E/M service on medical decision making and may not include any of that time spent in the E/M service in the time of the psychotherapy. The detail in the psychotherapy note should be of the same quantity and quality as in a standalone psychotherapy service.  Include only the time of the psychotherapy, and select the psychotherapy code based on time.

• Avoid all psychotherapy of the same duration. “At least 16 minutes were spent in….”
• Describe the psychotherapy in detail.
• Periodically, review the goals from the treatment plan and progress towards meeting those goals.
• Be realistic: if the visit duration is 20 minutes, could psychotherapy be 16 minutes and medication management 4 minutes? Could that happen repeatedly?

If you perform or bill for behavioral health services, read the report carefully. Take this opportunity to do a self-review of the documentation and coding. If you identify gaps based on the OIG report, now is the time to address them.

Post-discharge Telephonic Follow-up Contacts Intervention

HCPCS code: G0544

Descriptor: “Post discharge telephonic follow-up contacts performed in conjunction with a discharge from the emergency department for behavioral health or other crisis encounter, 4 calls per calendar month.”

2025 fee: $61.78

Key details: Seeking to address mental health issues, CMS finalized a telephone follow-up contacts intervention (FCI) specifically for individuals with suicide risk or risk of deliberate self-harm or intentional overdose. The FCI model involves a series of telephone follow-ups in the weeks and months following a patient’s discharge from the emergency department. This is not considered a telehealth service, because they are audio-only and are not a substitute for an in-person service.

The purpose of the calls is to encourage the use of a Safety Plan, update the plan to optimize effectiveness, express psychosocial support and help to facilitate engagement in any needed follow up care. These are the activities that should be documented.

G0544 is a monthly billing code when furnishing follow-up contacts intervention following a crisis encounter in the ED. Under the rule, CMS finalized several important billing requirements. The code is considered a “monthly bundle,” consisting of four calls per month, with each call lasting between 10-20 minutes, according to CMS. CMS did not limit the number of months the service could be billed. “We are finalizing that we will allow for this code to be billed and paid for as long as the service is medically reasonable and necessary.” P. 580 Display Copy, Final Rule 2025.

This code may be billed regardless of whether HCPCS code G0560 (safety planning) was also furnished for the patient.  The practitioner must meet the threshold of “at least one real-time telephone interaction with the patient in order to bill HCPCS code G0544, and that unsuccessful attempts to reach the patient will not qualify as a real-time telephone interaction.” P. 579, Display Copy, Final Rule 2025.

• The service may be billed after an ED or other crisis encounter, including discharge from psychiatric inpatient care or crisis stabilization.
• Verbal or written consent is required. Consent may be obtained at the first phone call. Consent includes ensuring the patient is aware of cost sharing, obtaining the patient’s phone number, and confirming that the patient consents to these contacts.

Also, CMS clarified that G0544 can be provided by auxiliary personnel incident to the services of the billing practitioner, and that the patient’s discharge can come from locations other than the ED. The code “can be billed by practitioners in any instance in which the beneficiary has been discharged following a crisis encounter, including discharge from psychiatric inpatient care, or crisis stabilization,” CMS states.

Digital Mental Health Treatment

HCPCS codes: G0552, G0553, G0554

Descriptor:

• G0552 (Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan)
• G0553 (First 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month)
• G0554 (Each additional 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month. [List separately in addition to HCPCS code G0553])

2025 fees: G0552 (carrier-priced), G0553 ($51.75), G0554 ($39.79)

Key details: These proposed codes cover two therapeutic treatment management services (G0553 and +G0554) as well as a supply code for behavioral health treatment device (G0552). The therapeutic codes may be billed only when there is ongoing use of the digital mental health treatment (DHMT) device. Reporting the supply code G0552 comes with multiple preconditions:

• The DMHT device must cleared under section 510(k) of the FD&C Act or granted De Novo authorization by FDA.
• Supplying the device “must be incident to the billing practitioner’s professional services in association with ongoing treatment under a plan of care by the billing practitioner,” CMS says.
• For G0552 to be payable, the billing practitioner must incur a cost to acquire and furnish the DMHT device.
• The billing practitioner must diagnose the patient and prescribe or order the DMHT device.
• The patient would be eligible to use the device in an office or outpatient setting or in the patient’s home, depending on how the FDA has cleared the device for use.

In the final rule, CMS made several revisions to the code descriptors for G0553 and G0554 as a way to differentiate the services from remote therapeutic monitoring (RTM) codes. “We are finalizing refinements to HCPCS codes G0553 and G0554 to clarify that these codes are for treatment management with a DMHT device which is intended as a therapeutic intervention as opposed to RTM devices which, beginning January 1, 2024, will describe devices that may have a digital therapeutic intent as well as be intended to monitor response to a therapeutic intervention not necessarily delivered by an RTM device,” the rule states.

Safety Planning Interventions

HCPCS code: G0560

Descriptor: “Safety planning interventions, each 20 minutes personally performed by the billing practitioner, including assisting the patient in the identification of the following personalized elements of a safety plan: recognizing warning signs of an impending suicidal or substance use-related crisis; employing internal coping strategies; utilizing social contacts and social settings as a means of distraction from suicidal thoughts or risky substance use; utilizing family members, significant others, caregivers, and/or friends to help resolve the crisis; contacting mental health or substance use disorder professionals or agencies; and making the environment safe”

2025 fee: $41.40

Key details: HCPCS code G0560 will establish separate payment for safety planning interventions addressing a patient’s risk of harm to themselves or others. The elements of the code involve various “coping strategies” and “sources of support” for individuals. Several elements, including “recognizing warning signs of an impending substance-use related crisis,” and “contacting mental health or substance use disorder professionals or agencies,” have been added to the code descriptor based on public feedback.

The agency made several critical clarifications in the final rule. The code will be effective as a standalone code effective Jan. 1, as opposed to an add-on code. Also, the code can be reported in 20-minute increments.

CMS noted that the code “would need to be personally performed by the billing practitioner for CY 2025,” and that opens the door to any practitioner who is authorized to furnish services for the diagnosis and treatment of mental illness, such as clinical social workers, mental health counselors, marriage and family therapists, clinical psychologists and physicians and non-physician practitioners.

The code is now added to the Medicare Telehealth list.

CodingIntel members, download the Behavioral Health Coding Guide for additional information.

You can download the OIG report here.