The Coding Complexities of Mental Health

The key is to focus on capturing everything relevant to a patient’s condition.

As we observe Mental Health Awareness Month this May, what better time to discuss some common trends and challenges associated with mental health and behavioral health coding?

The key to behavioral health coding is to focus on capturing everything relevant to a patient’s condition – whether an underlying medical condition, a substance abuse disorder on top of a psych diagnosis or dual diagnosis, or history codes indicating issues such as trauma and stress.

Those history codes are key, and some may be hesitant to capture so many Z codes, but it helps tell the story of the patient’s overall mental and physical health – and I have seen them be helpful in arguing some denials as well. Doing so really makes you feel like you are a patient advocate contributing to the patient’s ability to achieve access and receive adequate care, and ensuring that your facility gets properly reimbursed so it can continue to provide that care. So you have to navigate the applicable rules to make sure nothing is left on the table.

Everyone knows that mental health disorders are not often seen as a visible sign on the surface, as you might encounter with other medical conditions, so behavioral healthcare is very verbose, heavy on the conversation between a psychiatrist, psychologist, or therapist and the patient (and often times, their families, too). This is crucial to identifying an accurate diagnosis. But with this dialogue-heavy specialty, we also need very good documentation to support each level of care, and proper reimbursement.

Telehealth, or “telepsych,” has been really beneficial during COVID, and it helps address the crucial accessibility factor in behavioral healthcare. As coders, we need to make sure to provide feedback to those documenting for specificity in diagnoses; sometimes they want to throw around a bunch of nonspecific or “possible” diagnoses, so we want to provide good documentation guidance by using the coding guidelines for education to help them document more clearly.

Switching gears to inpatient psych coding, I often hear of coders struggling to bridge the gap between general acute-care coding with MS-DRGs and the inpatient psych facility payment system. And it’s not just coders who need to educate themselves on these rules; the billing team needs to fully understand how to capture the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) adjustment factors on the bill. On the CMS.gov website, you can download the current list of adjustment comorbidities and keep it handy – and of course, download the latest version annually, once the final rule is published. I want you to take special notice of some of the common comorbidities on the list, such as eating disorders, chronic conditions such as COPD, substance abuse or dependence disorders, and poisonings due to suicide attempts. A key example of something commonly missed is nicotine dependence with withdrawal: this has a significant adjustment factor of up to 1.03 times the normal expected reimbursement rate. So missing the documentation supporting the withdrawal or failing to code this properly will definitely result in less reimbursement. So again, work closely with your physicians to make sure they take those diagnoses to the highest specificity to avoid leaving hundreds of dollars of reimbursement on the table. If you don’t have a clinical documentation integrity (CDI) program for psych, it’s a good idea to at least take some of the concepts and put a process in place for education and queries at a minimum. And also, that education has to be provided to the billing team, so they can check the appropriate boxes on the bill. Someone should audit that regularly to make sure what you expected to get reimbursed is actually received.

Hopefully this small bit of information is helpful in continuing to ensure our communities can adequately care for and be reimbursed for behavioral health and substance abuse patients. This care specialty should be just as accessible to patients as other specialties, without the stigma, and we should continue advocating for this patient population – this Mental Health Awareness Month and always.