Navigating the complexities of billing codes for behavioral health services can be confusing at times. Accurate billing is crucial for healthcare providers to ensure they are reimbursed correctly and timely for the services they provide. In the field of behavioral health, where treatment plans can vary significantly from one patient to another, understanding and correctly applying billing codes is essential.
This guide will provide a comprehensive overview of the billing codes used in various behavioral health services, including inpatient detox, residential treatment, partial hospitalization, and intensive outpatient programs. We will also explore the billing process, from submitting claims to the importance of verifying benefits and negotiating with third parties. Additionally, we will discuss the role of utilization review and provide best practices for maintaining accuracy and compliance in billing.
Table of Contents
The Ultimate Guide to Effectively billing Behavioral Health
What is ASAM Criteria?
The ASAM Criteria is the most widely used and comprehensive set of standards for placement, continued service, and transfer of patients with addiction and co-occurring conditions. Formerly known as the ASAM patient placement criteria, The ASAM Criteria is the result of a collaboration that began in the 1980s to define one national set of criteria for providing outcome-oriented and results-based care in the treatment of addiction.
Many states across the country are using The ASAM Criteria as the foundation of their efforts to improve the addiction treatment system. Level of care recommendations and treatment plans are developed based on multidimensional patient assessments that consider the patient’s biomedical, psychological, and social needs.
ASAM Framework
The framework below is the older model 3.0 and insurance carriers will be utilizing the framework 4.0 that was updated October of 2023 in the coming years.
ASAM 4.0: Acute Detoxification: Services are rendered in a 24-hour medically managed inpatient setting. Acute 4.0 inpatient settings are able to provide ancillary services to patients such as IV’s, MRI, and different type of tests for higher medical acuity patients while managing detoxification symptoms.
ASAM 4.0: Acute Detox Level of Care
- H0009: Alcohol and/or drug services; acute detoxification (hospital inpatient)
- 0116- Revenue Code
ASAM 3.7: Sub-Acute: Detoxification: Services are rendered in a sub-acute setting and in some cases residential homes providing 24-hour monitoring. Freestanding facilities are standalone facilities not attached to a hospital and operate as their own entity. Clients are detoxed off substances utilizing medically managed services.
Please check with carriers to ensure correct codes when billing residential services are many are interchangeable or not required.
Please utilize Revenue codes, if needed.
Common Billing Codes
The most common billing codes used are:
- H0008: Alcohol and/or drug services; sub-acute detoxification (inpatient non-hospital facility)
- H0010: Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient)
- H0012: Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient)
- 0126: Revenue Code
Tips for Accurate Billing
- Detailed Documentation: Ensure all patient interactions and services provided are thoroughly documented.
- Verify Coverage: Check the patient’s insurance coverage to confirm that detox services are included.
- Timely Submission: Submit claims promptly to avoid delays in reimbursement.
- After Detoxification: most clients will step down to residential level of care.
ASAM 3.5: Residential Treatment Billing Codes
ASAM 3.5: Residential treatment programs provide a structured environment for individuals requiring intensive behavioral health services. These programs offer round-the-clock care, making accurate billing crucial for maintaining operational sustainability.
Residential care provides a critical window of care between detoxification and returning to home or community-based services while withdrawals and cravings are high.
Key Billing Codes
Alcohol and/or drug services; residential (hospital residential treatment program)
Alcohol and/or drug services; short-term residential (non-hospital residential treatment program), without room and board
Alcohol and/or drug services; long-term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board
Revenue Code
Best Practices for Billing
Conduct and document thorough initial and ongoing assessments.
Update treatment plans regularly to reflect the patient’s progress and any changes in care.
Ensure the correct codes are used to reflect the intensity and duration of services provided.
Next, learn about Outpatient Billing PHP and IOP levels of care.
Outpatient Billing PHP and IOP Levels of Care
Partial hospitalization programs (PHP) offer intensive, structured care without requiring an overnight stay. These programs are designed for individuals who need more support than outpatient services but do not require inpatient care. PHP is a minimum of 20 hours per group weekly, typically 5-7 days per week, 6 hours per day. Please check with carriers to ensure accurate group hours are attended.
Commonly Used Billing Codes
The last level of care before General Outpatient is Intensive Outpatient.
ASAM 2.1 Intensive Outpatient
Intensive outpatient programs (IOP) provide a step-down level of care from inpatient or partial hospitalization programs. These programs offer therapy and support minimum 9 hours weekly, 3 hours per day allowing patients to continue with their daily lives while receiving treatment. IOP is an important level of care as client’s are transitioning back into society and utilizing new coping skills.
Commonly Used Billing Codes
Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and 3 days/week and is based on an individualized treatment plan), including assessment, counseling, crisis intervention, and activity therapies or education
Mental Health services; intensive outpatient (treatment program that operates at least 3 hours/day and 3 days/week and is based on an individualized treatment plan), including assessment, counseling, crisis intervention, and activity therapies or education
Overview of the Billing Process
The billing process for behavioral health services involves several steps to ensure accurate and timely reimbursement. Understanding this process is essential for maintaining the financial health of a practice.
Steps for Submitting Claims at a Clearinghouse
- Prepare Claims: Gather all necessary documentation and coding information.
- Ensure Services are completed.
- Submit Claims: Send claims to the clearinghouse for initial processing.
- Track Claims: Monitor the status of submitted claims and address any issues promptly.
Importance of Verifying Benefits and Third-Party Negotiations
- Verification of Benefits (VOB): Ensuring that a patient’s insurance covers the services provided is crucial to prevent claim denials. Conducting VOB helps in understanding coverage limits and patient responsibilities.
- Third-Party Negotiations: Negotiating with third-party payers can help secure better reimbursement rates and resolve disputes over denied claims.
Explanation of Beneits (EOB)
The Explanation of Benefits (EOB) is a statement from the insurance company detailing what services were covered, the amount paid, and any patient responsibility. Understanding the EOB is essential for:
- Identifying Discrepancies: Compare the EOB with the billed services to identify any discrepancies.
- Appealing Denied Claims: Use the information in the EOB to appeal denied claims effectively.
- Communicating with Patients: Help patients understand their financial responsibilities based on the EOB.
Utilization Review
Utilization review (UR) is the process of evaluating the medical necessity, appropriateness, and efficiency of the use of insurance benefits. In behavioral health, UR helps ensure that patients receive the right level of care at the right time. Ascension Billing provides expert Utilization Review maximizing lengths of stay’s assisting in prolonged recovery.
Learn more about the definition and purpose of utilization review
Role in Behavioral Health Billing
- Initial Authorization: Obtain prior authorization for services to ensure coverage and quality care is provided.
- Continued Stay Reviews: Conduct regular reviews to justify the need for ongoing treatment.
- Discharge Planning: Plan and document discharge to ensure continuity of care and appropriate billing. Client who complete post discharge recovery-based services have a higher likelihood of recovery.
Best Practices for Successful Utilization Reviews
- Stay Informed: Keep up-to-date with insurance policies and UR requirements.
- Effective Communication: Maintain clear communication with insurance companies and patients ensuring quality care is provided. Document all authorizations and date ranges accordingly.
- Accurate Documentation: Document all aspects of care and communication related to UR.
Assignment of Benefits
Assignment of Benefits is a legal document that transfers the rights of the insurance claims to the provider. Insured members assign claims payments, when allowed. Providers receive payments directly from the insurance company once this legal form is completed.
Accurate billing for billing behavioral health is essential for ensuring that healthcare providers receive appropriate reimbursement. By understanding and correctly applying billing codes, verifying benefits, and effectively managing the billing process, providers can maintain financial stability and focus on delivering quality care. Billing for Behavioral Health is Ascension Billing dedication, Contact us today.
Staying updated with billing codes and regulations, conducting regular audits, and engaging in continuous improvement practices will help providers navigate the complexities of behavioral health billing successfully. Visit Ascension’s Insight for more up to date information. Check out our Services page to find out more!
