Billing and insurance processes

“Engage in billing, third-party reimbursement and other insurance panel processes” (NBCC, 2027 task 6.7)

Most counselors bill clients, insurers or both, and must do so accurately and ethically. This includes credentialing with insurance panels, using correct codes, documenting medical necessity and handling client financial responsibility. The exam tests billing basics and common compliance problems.

Key points

Credentialing with insurers usually requires an NPI, a current license, liability insurance and, for many plans, a CAQH ProView profile.
Common CPT codes for counseling include 90791 (psychiatric diagnostic evaluation), 90832, 90834 and 90837 (psychotherapy of about 30, 45 and 60 minutes, defined by time ranges), 90846 and 90847 (family psychotherapy without and with the patient present), 90853 (group psychotherapy) and 90839 (psychotherapy for crisis).
Diagnoses on claims use ICD-10-CM codes.
Bill only for services actually provided, with the correct code for the service and time; upcoding, billing for missed sessions as if provided, or changing a diagnosis to obtain coverage is fraud.
Since January 1, 2024, licensed mental health counselors have been able to enroll as Medicare providers.
Explain fees, copays, deductibles and what happens if insurance denies a claim during informed consent; self-pay and uninsured clients are entitled to a good faith estimate.
The ACA Code of Ethics addresses fees and bartering, and asks counselors to consider clients' financial situations when setting fees.

In practice

A counselor's 50-minute session meets the time range for 90834, not 90837. She bills 90834 and documents the start and end time.

A client asks his counselor to use a more serious diagnosis so his insurer will cover more sessions. The counselor explains that she must report the diagnosis that accurately fits his condition and discusses other options, such as a sliding fee.

Check yourself

Which CPT code is used for an initial psychiatric diagnostic evaluation?

90791.

Is it acceptable to change a diagnosis to obtain insurance coverage?

No, reporting an inaccurate diagnosis to obtain payment is insurance fraud and unethical.

What profile do many insurers use for provider credentialing data?

CAQH ProView.

NBCC's knowledge and skills for Domain 6

Knowledge of: State laws (state licensure law, supervision requirements, abuse reporting, license renewal, CAQH); Federal laws (e.g., HIPAA, FERPA, immigration policy, HI-TECH, ADA, NPI); Codes of ethics; Third-party reimbursement, insurance and billing (e.g., CPT codes); Counseling Compact; Emerging technologies in Counseling; Crisis policies and procedures; Recording keeping and reporting requirements and procedures; Appropriate logistics for telemental health services; Scope of practice (e.g., letters of support, working with special populations); Alternative medical-assisted/pharmacological interventions; Accessing state licensure board; Executing voluntary and involuntary commitments.

Skill in: Maintaining confidentiality; Discerning reputable training providers and programs; Troubleshooting technological difficulties during telemental health session (e.g., session disconnects, video not working); Billing and third-party reimbursement.

A study guide written by ExamDragon from NBCC's published task; not NBCC material and not part of the exam.