Psychiatry Coding & Reimbursement Alert

Published on Thu Jul 16, 2015 PDF

Question: I have recently joined a new psychiatry practice, and most of our services are self-pay. This means we get the patients to pay us before hand and then provide documentation and billing to them, so that they can claim for the services later. However, as I am responsible to provide the details to the patient, I want to make sure that they will be properly reimbursed for the services that are received. How do I ensure this?

Nebraska Subscriber

Answer: Your work of submitting documentation and other claim details will not vary much from the way you would do it if you were directly sending all the details to the payer. However, you will have to pay a little more attention to some details if you want to ensure that the patient receives the amount that he is due from his insurer for services received.

First and foremost, you will need to provide documentation supporting the details of what procedure or service was performed, the medical necessity of the procedure or service, and the bill with the amount that you have received for the procedure or service.

For supporting medical necessity, you should have a proper ICD-9 or ICD-10 (when you begin using these codes) diagnosis code that supports the CPT® code that you are claiming for the procedure or service performed. These codes should also be clearly included in the information or material that you provide to the patient, since the patient’s insurer will likely need them to appropriately adjudicate the patient’s claim.

Finally, in addition to regular documentation and billing, you may want to ensure that the patient understands:

• how (or “if”) he can obtain services from an “out of network” provider such as your practice

• whether or not prior authorization is required for the service(s) being provided

• whether or not the patient has satisfied any applicable deductibles

Failure on the part of the patient to understand these and other aspects of his health insurance may result in denial of payment for the services he is claiming. Ultimately, it is the patient’s responsibility to what his health plan does and does not cover or pay, especially when dealing with physician practices that are not contracted with the health plan.