One of the most common topics of my consultations is how to bill for couples and family therapy. Here are some frequently asked questions:

“Do insurance plans cover couples and family therapy? I was told they didn’t.”   I get upset when I hear that folks are getting the idea that insurance won’t cover couples and family therapy.  I’ve even heard that in some Facebook groups people say it is fraud to bill for these types of therapy.  As with most things, the answer is that you can’t make blanket statements like these.

My experience is that most insurance plans will cover couples and family therapy when certain conditions are met.  In fact, I have documentation from several insurance plans (including Medicare) that explains when they will cover couples and family therapy.   And those lists are not terribly restrictive.

So, when is it covered?  The way insurance plan typically view couples or family therapy is that it may be covered when:

• One member of the couple who is covered by insurance has a diagnosis, typically something more than a DSM-V-TR Z-code.  Contrary to popular rumors, an Adjustment Disorder IS typically covered, if present.  When you call the health plan to check coverage, don’t ask if they cover couples or family counseling (which may sound to them like you are doing couples communication work) —  ask instead if the plan covers CPT code 90847 for a client with a diagnosis.
• The goals of the treatment you are doing in the couples or family sessions is aimed — at least in part — at the reduction of symptoms of the identified patient’s diagnosis. This means the goal of treatment CANNOT be SOLELY to improve a relationship, build closeness, reduce fighting, or to improve their sex life  or communication skills.  See my article on insurance-pleasing couples and family goals here

I rarely found it difficult to meet these criteria when working with couples and families.  I always seemed to be working with a couple to reduce the anxiety, depression, grief, substance abuse, or adjustment difficulties of one or both members, so sessions were easily covered.

“How is a couples or family session listed on a claim?”   After sssessing all members of the couples or family for diagnoses, and choose one client with a diagnosis as your identified patient.  If two or more clients have diagnoses, you must choose one as your IP.    You may want to choose the one with the more severe symptoms, the better insurance, or ask the clients if they have a preference.   If one client is the primary holder of their insurance you might choose him/her.

Put the name of your IP on your statement/invoice.  The CPT code 90847 on the claim reflects a couples or family session therapy session took place.  The names of other session attendees are not listed on the claim. Put only your IP’s diagnosis code on the claim (not the name of the diagnosis).

“I don’t feel comfortable making one of my clients the Identified Patient.  That isn’t how I think of them.”   I get it.  Most of us conceptualize the issues our couples and families are dealing with using a systems point of view.  But having an IP on a claim form doesn’t mean you need to change how you think of your clients.   The insurance plan system is just limited — they just need someone’s name on the claim form in the box for “client name,” and to know that someone in the room has a diagnosis and symptoms so that insurance may cover it.

“Can I use CPT codes 90832, 90834, and 90837 for ongoing family sessions?”  Definitely not.  For a period of time it got confusing when the title of these CPT codes was “psychotherapy with patient and/or family member.”  However, it was clarified by the AMA in 2016 that these codes were to be used for individual sessions (30 minutes, 45 minutes, and 60 minutes respectively), or when you bring a family member intermittently or briefly as an “informant” into your ongoing individual sessions with the Identified Patient.

For example, if your client is a child and you bring his parent in for the final portion of every session, or once a month to update the parent on the child’s progress, these individual therapy codes (90832, 90834, 90837) could still be used instead of a family therapy code (90847). The IP has to be present for most or all of the session to use an individual code. However, I repeat: use code 90847 instead for ongoing couples or family therapy.  I have seen audits where therapists were forced to give back money when they used 90837 instead of 90847 for ongoing couples work.

“How would I code a session if I saw one member of the couple or family alone one time?” If you see the IP alone, use the psychotherapy CPT code that you would use for an individual session (e.g. 90832, 90834, or 90837). If you see a non-IP family member or partner alone, you continue to list your IP as the patient on the claim form, but use CPT code 90846, which is for family or couples therapy without the patient present.

“When I see a couple, can I bill each of their insurance plans for a couples session?”   Not unless you want to risk losing your license. This is insurance fraud.  This would would be charging twice for the same session, and in each case claiming that a different person was the client.

“Can I bill each plan for an individual session if the plan doesn’t cover couples therapy?”  Sorry.  This is an even clearer type of fraud.  It is “double-dipping,” and also misrepresenting the type of treatment that took place.  You would clearly be trying to “get around” a coverage limit.

“Will an insurance plan cover a client for couples counseling if the client is in individual counseling, also?”  I have never found this to be a problem, if the client has coverage for couples counseling, though it may be a problem if the two sessions are on the same day.  Of course, if the plan calls to review your treatment you may need to defend why both types of treatment are medically necessary, so it’s a good idea to document this.

“How do I handle charts?”  It is up to you if you want to keep two separate charts, one for each member of the couple. Usually notes on the family or couples sessions would be in one chart under the IP’s name unless you are also treating separate family members in individual therapy.   You only need one session note per sessions and while the note should focus more heavily on the IP’s symptoms and treatment, you should record interactions with the IP’s partner.  List the names of all session attendees in your session note, along with their relationship to the IP.  .

I strongly recommend a unique Couples Therapy Informed Consent or Treatment Agreement, one that is different than the one you use with individuals.  There are policies you need to outline about confidentiality, records requests, identified patients, whether you will meet with them individually, your approach to couples work, etc.  (You can get a copy of my Couples Therapy Treatment Agreement as part of my Practice Forms Packet or in my Couples Forms and Handouts Mini-Packet).   You should get all adult members of a couple or family to sign allowing release of information to their insurance plan.  If the chart is ever requested, it may be a good idea to seek legal consultation about releases, as you may need both members of a couple to release charts.

“What is the time length on the 90847  or 90846 Couples/Family Therapy CPT Codes?”  These sessions are both 50 minutes long, technically 26 minutes and above.

“I do longer couples/family sessions.  How would I code these?”  At the time of this writing, there are no CPT billing codes for longer sessions of any kind, including individual, couples, or family.  Unfortunately, whether you do a 26 minute session or 26 hour session, most plans will only pay what they would for a standard 50 minute session.  However, I will post any updates on billing for longer sessions at the following article link — check out my article here.

“What do plans reimburse for couples sessions?” Due to their increased complexity, documentation time, and case coordination, you might want to charge more for these services.  Yet many insurance plans actually pay less for 90847 and 90846 than they do for 60 minute individual sessions, probably because it is defined as a 50 minute session, and can be reimbursed for a session as short as 26 minutes.  

“I have so many questions!” I know!  It’s a complex topic.  Check out my pre-recorded webinar “Couples Therapy:  Billing, Documentation, and Ethical Dilemmas” which covers when it is and isn’t ethical to bill for couples therapy, common areas of confusion, and how to handle difficult ethical quagmires with couples —  it’s guaranteed to make you rethink your policies!  Check out the webinar on the store page here.