Introduction
Group therapy offers unique benefits for both providers and patients, fostering shared support and cost-effectiveness. However, navigating insurance for group therapy sessions can feel like navigating a labyrinth. Medisys, your trusted partner in behavioral health billing, is here to clear the billing confusion and equip you with the knowledge to maximize reimbursement!
Know Your Coverage Territory
- Start with Verification: Before welcoming clients, verify their insurance coverage for group therapy. Understand specific limitations on sessions, diagnoses covered, and in-network provider requirements.
- Dive into the Details: Pay close attention to “bundled codes” that might combine individual and group therapy, potentially impacting reimbursement. Be familiar with exclusions or limitations specific to group therapy coverage.
- Embrace Transparency: Clearly communicate to clients about their financial responsibility, including co-pays, coinsurance, and potential out-of-network costs.
Coding Group Therapy Sessions
- Mastering the Codes: Group therapy requires specific CPT (Current Procedural Terminology) codes like 90853 for general group psychotherapy. Understand modifiers like “-59” for distinct procedural services when offering individual elements within the group session.
- Group Size: CPT codes vary depending on the number of participants. For example, 90849 covers 2-3 family members, while 90853 applies to groups of 4-6 individuals. Exceeding these limits requires additional codes and justifications.
- Time Considerations: Group sessions typically last 45-60 minutes, impacting the appropriate CPT code. Shorter or longer sessions might require different codes or modifiers.
- Diagnosis Drives Reimbursement: Accurately document diagnoses using ICD-10 codes that align with the group’s focus and individual client needs. Ensure diagnoses support the medical necessity of group therapy for each participant.
- Stay Up-to-Date: Coding guidelines and payer policies evolve. Regularly attend educational programs and consult reliable resources like Medisys’ dedicated support team to stay ahead of the curve.
Documentation Requirements
Maintain detailed session notes reflecting the therapeutic techniques used, group interactions, and individual client progress. Documentation for each group session, includes:
- Date and time
- Participants and their diagnoses
- Group theme and interventions
- Progress notes for each participant
- Documentation of individual services provided within the group (if applicable)
Treatment plan: Develop a specific treatment plan for each group, outlining goals, interventions, and anticipated duration.
Progress reports: Track progress and outcomes for each participant and the group as a whole. Periodically generate reports summarizing progress and justifying continued treatment.
Additional Considerations
- In-network vs. out-of-network billing: Understand the differences in reimbursement rates, patient responsibility, and billing procedures for in-network and out-of-network claims.
- Medicare and Medicaid billing: These programs have specific regulations and coding requirements for group therapy billing. If you treat Medicare or Medicaid patients, ensure you have the necessary knowledge and resources.
- State-specific regulations: Billing regulations can vary by state. Stay informed about any specific requirements in your state that impact group therapy billing.
We hope this article has provided you detailed information to bill for group sessions. Medisys, a leading behavioral health billing company, can assist you in accurately billing for behavioral health services. We understand the complexities of behavioral health billing, particularly for group therapy. Let’s navigate the world of group therapy billing together and ensure you receive the fair compensation your valuable services deserve.
*This article uses Current Procedural Terminology (CPT) codes, copyright 2024 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Reference:
Billing and Coding: Psychiatry and Psychology Services – CMS
