Free evaluation of your E/M codes, intervention denials, and days in A/R.
The billing codes used by psychiatrists include E/M codes with psychotherapy modifiers as well as intervention and medication management and not just therapy codes or counseling billing.
The therapist would bill the psychotherapy encounter as one time-based code. Meanwhile, the prescriber codes the medical evaluation, a therapy add-on, and the medication management, with the use of TMS or Spravato in some cases. If the prescriber encounter is billed as the therapy encounter, the revenue would be lost and result in recoupment.
One of the highest denial rates is among psychiatrists, about 16 percent. Denial reasons for psychiatry are unique to prescribers. These include improper coding of E/M levels based on documentation, therapy add-on without proper therapy note, and intervention coding without waiting for prior authorization. A billing firm that is well versed with therapy codes but not prescriber codes would miss these issues.
Outsourcing of psychiatric billing means handling everything related to revenue cycle management for your prescribers on your behalf.
In almost all cases involving psychiatry and psychiatry/medication management practices, the benefits are quite straightforward. The clinical responsibilities require a lot of work, while the billing process, particularly E/M level selection and prior authorization, can be considered another full-time responsibility. Outsourcing this task leaves the clinical decision-making up to you and the administrative responsibilities up to the experts at RCM Xpert.
Scope is a complete end-to-end process and not just an individual step. Eligibility and benefits check done prior to visit. Documentation coded properly for E/M and add-ons according to the note. Authorization obtained for medications and procedures. Claims scrubbing and submission. Appeals for denials processed. Payment posting and reconciliation against contract.Â
KPIs delivered back to the practice, such that the practice knows their days in A/R, clean claims percentage, and collections without generating any reports.
This is the hand-it-off approach that the prescriber buyer seeks. The goal is reduction in time spent on the phone with insurance and capturing revenues from existing efforts.
The coding in psychiatry is based on the E/M codes ranging from 99212 to 99215. These codes are usually used together with a psychotherapy add-on code during the same visit together with code 90792 for the psychiatric interview.
The stack above represents the key to the prescriber billing process and the greatest source of lost revenue. The codes below represent the actual coding that the RCM Xpert team utilizes for psychiatry and medication management.
When a prescriber delivers a medical service (medication management) along with therapy in a single encounter, then two codes are combined for coding purposes. The E/M code (99212 to 99215) represents the medical evaluation and medication management component. The psychotherapy add-on (90833, 90836, and 90838) represents the therapy component and the add-on selected is based on the time documented for therapy. They are not interchangeable and there is no absorption of one by the other.
There are two criteria that determine the stack’s success in surviving an audit. First, the E/M level can be determined based on medical decision making or on total time depending on what documentation supports. Second, the add-on must have its own separate therapy note that will document time spent in therapy. The mistake of either miscoding the stack or selecting a wrong E/M level or billing an add-on not supported by the documentation is the biggest reason for psychiatric revenue loss and most frequently leads to audits. RCM Xpert staff codes based on the documentation through our medical coding services.
90867 is a per-course code and not per-day; therefore, a treatment course would have one 90867 and sessions of 90868. Billing another 90867 within the treatment course or billing 90869 along with a delivery session raises red flags. All 90868 claims must have the coil site, number of pulses and intensity or else that would be a denial waiting to happen. TMS also does not qualify for billing under telehealth.
The RCM Xpert verifies that Spravato REMS enrollment and prior authorization have been completed by the time of the first in-office administration, not after the denial of the claim. When it comes to such an expensive Buy-and-Bill product, verification matters greatly.
Procedure codes are used to bill interventional treatments and there is significant prior authorization required.Â
This is the area of psychiatric billing which the generalists simply can’t do correctly, and where doing it incorrectly will make the treatment be either paid for or cost money out-of-pocket to the practice providing the treatment. Each treatment requires its own set of coding considerations, its own set of rules as to when it is covered, and its own set of rules as to denial.
90867 initial session involving cortical mapping and determination of motor threshold, one time per course. 90868 subsequent delivery sessions. 90869 subsequent motor threshold determination. The three are not billed on the same day of service.
Esketamine through REMS program requiring in office administration and two hour observation. G2082 covers up to 56 mg and G2083 covers greater than 56 mg in Medicare; both bundle drugs, supervision, and observation of an established patient.
Usually uncovered for psychiatric purposes, thus often paid-for in full by the patient. Billing claims and superbills reflect this reality.
Dual Benefit issue. The drug might come under the pharmacy benefit while administration comes under the medical benefit, and claiming the claim incorrectly across the two is the top reason for denying the esketamine claims. The G codes can only be used on established patients and are all-inclusive; therefore, an additional E/M or prolonged service code for the same date of service is not appropriate. The codes and coverage changed in this arena: Coding for esketamine drug changed in January 2026 where S0013 is now changed to J0013 for non-Medicare insurance companies. Every claim is double-checked for compliance with current AMA CPT and CMS guidelines.
The RCM Xpert team takes responsibility for prior authorizations and intervention-based REMS validations, as well as coding of high revenue claims.
The RCM Xpert team is responsible for billing all psychiatric prescribers, who have a unique aspect of the claim due to the way they bill.
Using the correct enrollment and coding criteria for each of the providers is how the prescriber claims remain free of issues. These are the billing practices RCM Xpert handles.
Incident to billing is the one that almost all prescriber practices miss. It can be billed right and paid as a physician’s charge or denied because the conditions of the supervision weren’t fulfilled. Our team checks the arrangement before billing.
Details determine psychiatric insurance coverage. Medicare takes care of medication management and interventional treatment while for Medicaid the details are very complex because TMS and Spravato vary by state.
While the payer mix of the prescriber may have specifics that a generalist will miss, it is true in the case of Medicare, which covers medication management on an E/M basis and interventional treatments such as TMS and Spravato on the basis of medical necessity. Medicaid has different coverage for TMS and Esketamine.
Aetna Cigna
Medicare Part B State Medicaid (coverage varies)
Blue Cross Blue Shield (BCBS)
Behavioral carve-outs
Optum Behavioral Health
Carelon
Magellan
Behavioral care exclusions are typically created for a managed entity like Optum Behavioral Health, Carelon, or Magellan, so that a prescriber claim must go to the carve-out payer rather than the medical insurer on the patient’s card. All the particulars of carve-out processing and parity exist in our behavioral healthcare billing services website. Where we aren’t contracted with the practice, our out-of-network billing gets money flowing.
Outsourcing the prescriber revenue cycle entails delegation of six phases, starting from onboarding and audit all the way to reporting, ensuring that the practice retains the clinical functions while outsourcing the billing.
The process has been designed to reduce friction as much as possible. The RCM Xpert team begins within the same platform being used by the practice, audits the status quo, and picks up the revenue cycle right from there. The following are the phases managed by the RCM Xpert team.
Prescriber billing is a specialty and RCM Xpert takes it as such. That is because of the exact nature of the codes that are being ignored by generalist physicians: the E/M stack, the add-on code set, and interventional billing codes.
RCM Xpert charges for psychiatry and medication management practice in all 50 states from New York. The interventions reimbursed by insurance and the laws related to Medicaid differ in each state. Hence, the payers are managed state-wise.
State boundaries are significant when it comes to prescriber billing. Coverage of TMS/Spravato under Medicaid, as well as telepsychiatry laws, varies by market. Below are some states that have dedicated pages, with many more to follow as we grow the team. For example, Florida is one such state where there is maximum demand for prescribers.
Practicing in an unlisted state? The team also bills in those states. Mention the name of your state in the audit form, and we will verify the interventions covered and details of the payer in your market.
Psychiatric billing is the coding and claims submission for the prescriber services, which include the evaluation and management visit, psychotherapy add-on on the same encounter, medication management, and interventions including TMS and Spravato. It focuses more on E/M coding and medication administration billing compared to pure psychotherapy coding.
Psychotherapy billing involves codes related to psychotherapy time such as 90834 and 90837. Psychiatric billing involves E/M codes of 99212 to 99215 with psychotherapy add-on on the same visit along with medication management and interventional procedures. In short, it is the prescriber stack along with its auditing guidelines.
When you lose revenue or many hours due to proper E/M level selection, add-on codes, or intervention prior authorizations, it makes sense to consider outsourcing your billing. Simple billing including E/M codes by a solo prescriber with basic medication management can be done in-house. With TMS or Spravato comes into play, it warrants a specialist team.
99212-99215 is the E/M code that is billed for medical examination and medication management, whereas a psychotherapy add-on 90833, 90836 or 90838 will be added for billing of the therapy component. The level of the E/M code depends on the medical decision making while the add-on shows the actual time spent on therapy.
TMS is coded by 90867 for the first session which involves cortical mapping and motor threshold identification, 90868 for the consecutive delivery sessions and 90869 for a follow-up motor threshold re-identification. 90867 is billed one time during the course of treatment and not per day. The codes have a significant requirement of prior authorization and documentation.
Spravato is billed using G2082 if it does not exceed 56 mg and G2083 if it exceeds 56 mg per the single treatment session for an established patient. Medicare covers and codes vary therefore prior authorization and REMS enrollment needs to be done before the in-office administration of the first dose.
Yes. PMHNPs and psychiatric physician assistants can bill independently, or if the requirements are satisfied, as incident-to a supervising psychiatrist under the physician fee schedule. The rules for incident-to billing are strict, therefore, the supervision agreement and documentation are checked before any claims are submitted.
The fee for psychiatric billing is usually calculated as a percentage of the collections, hence, the more collections, the higher the fee charged by the billing company to the practice. The rate of fee will depend on the number of encounters per day, payer mixes, and whether interventional billing for TMS and Spravato are needed because they require additional prior authorization and documentation.
Yes. Prior authorization is among the most critical aspects of psychiatric billing, especially when it comes to interventional treatments such as TMS and Spravato because the prior authorization and REMS must be approved before the intervention can be administered.
Yes, RCM Xpert charges for psychiatry and med management practices in all 50 states out of a New York office. Rules for interventions and Medicaid coverage vary by state, so payor configurations are set up on a state-by-state basis. See our States We Serve module at the top for locations with individual webpages.
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