Billing for Couples and Family Therapy
By Barbara Griswold, LMFT (Updated Sept 8, 2020)
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? My experience is that most do, but don’t make assumptions (ex. one client with ABC insurance may have this benefit and another might not). The way it is viewed by insurance plans is that couples or family therapy may be covered when it is necessary to assess and treat the diagnosis of one family member. This means the goal of treatment can’t be solely relationship growth or communication skills — for insurance to cover it, you’ll need to have someone in the room who is your identified patient (IP) who has a diagnosis (typically something more than a DSM-V Z-code). Contrary to some popular rumors, an Adjustment Disorder is covered by most plans, if present. Now, when you call to check coverage, don’t ask if they cover couples or family counseling (which to them may sound like you are doing couples communication work) — ask instead if the plan covers CPT code 90847 for a client with a diagnosis.
How is a couples or family session listed on a claim? Assess 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 may choose , though you may want to choose the one with the more severe symptoms, 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 if you are out of network, or if using the CMS-1500 form put it in Box 2 under “Patient’s Name” (the name of the primary holder of the insurance goes in Box 4). The CPT code 90847 on the claim reflects a couples or family session therapy session took place. The names of other session attendees should not be 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 think of our couples and families from a systems point of view — each is part of a familial “dance.” But it shouldn’t change the way you think of your clients. It is merely the limitations of a system where someone’s name has to go on the claim form in the box for “client name,” and that someone in the room has to be reflecting enough distress for insurance to cover it.
Can I use CPT codes 90832, 90834, and 90837 for family sessions? Not for ongoing family or couples sessions. 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 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 could still be used instead of a family therapy code (90847). The IP has to be present for most of the session. However, I repeat: use code 90847 instead for ongoing couples or family therapy.
How would I code it if I saw one member of the couple or family alone one time? If you see the IP alone, use a psychotherapy CPT code as you would for an individual session (e.g. 90832, 90834, or 90837). If you see a non-IP family member alone, you continue to list your IP as the patient on the claim form, but use CPT code 90846, which is for “family/couples therapy w/o 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, as it is both “double-dipping” and a misrepresentation of what took place (you’d have to change the CPT code to an individual therapy code). You would clearly be trying to get around a coverage limit.
Will an insurance plan cover a client for couples counseling if s/he is in individual counseling, also? I have never found this to be a problem, if the client has coverage for couples counseling. Of course, if the plan calls to review your treatment you may need to defend why both types of treatment are medically necessary.
How do I handle charts? All notes on the family or couples sessions should be in a chart under the IP’s name unless you are treating separate family members in individual therapy. I strongly recommend a separate informed consent/treatment agreement that you use with couples — 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). 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 if the IP is covered by two insurance plans (ex. a child is covered by both parents’ plans, or a wife is covered by her own plan and her husband’s)? This can be complicated. You’ll need to figure out which plan is primary, bill that plan first, then bill the secondary plan, enclosing a copy of the Explanation of Benefits (EOB) from the primary plan which outlines how much they paid (to learn more about double coverage, get my book)
What is the time length on the 90847 or 90846 Couples/Family Therapy CPT Codes? These codes historically had no time length, but in 2016 the AMA clarified that these sessions were 50 minutes long.
I do longer couples/family Sessions. How would I code these? While most plans will only pay for a standard 50 minute session, if you do longer session a new option has emerged that you might try for extended couples and family sessions (longer than 80 minutes). For more information on billing for extended couples and family sessions, read my article here and check out my CPT Coding webinar here.
What about fees? Due to their increased complexity, documentation time, and case coordination, you might want to charge more for these services. While some plans actually pay less for 90847 and 90846 than they do for 60 minute individual sessions, many insurance plans reimburse at a higher rate for couples/family therapy .
9/8/20 Update: I just put together my latest webinar, “Couples Therapy: Billing, Documentation, and Ethical Dilemmas. Check out this overview of common areas of confusion and how to handle difficult situations with couples — learn more about the webinar here.
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