As a discipline, behavioral health refers to mental health, psychiatric, marriage and family counseling and addictions treatment, and it includes services provided by social workers, counselors, psychiatrists, neurologists and physicians. Behavioral health also includes both mental health and substance use, encompassing a continuum of prevention, intervention, treatment and recovery support services.
All psychotherapy CPT codes are time-based. The time for a psychotherapy code is defined as the time spent with the patient and/or patient’s family.
While time for each code is specified in increments of 30, 45, or 60 minutes, the coding manual actually allows for some flexibility. Luckily, the American Academy of Child & Adolescent Psychiatry (AACAP) has developed a rule for recording time accurately when it does not match the exact time increments specified in the CPT code. The rule is:
|53 minutes”}”>> 53 minutes
|26 minutes”}”>> 26 minutes
There are many CPT codes currently used by mental health professional that can be reported under the following categories:
Documentation plays the essential role of explaining the medical necessity of procedures rendered by the provider. All documentation must comply with legal/regulatory requirements of the state in which the provider practices.
All medical records should include:
If you’re a little uncertain about documentation, or just don’t have the time, consider hiring Synergy HCLS. We can handle all sorts of administrative and clerical tasks with expertise and efficiency.
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