Treating mental illness in primary care -- and still getting paid

Screening for mental illness and getting patients the treatment they need is increasingly a part of primary care, but reimbursement and billing rules can make the process financially challenging.

"The expanded awareness of the need for mental health screening and treatment has gotten ahead of the billing and reimbursement rules," said Danna Mauch, PhD, principal associate and scientist with Abt Associates in Cambridge, Mass. She is the lead author of the Substance Abuse and Mental Health Services Administration report, "Reimbursement of Mental Health Services in Primary Care Settings."

Measures can be taken to ensure that mental health treatment in the primary care setting is not an economic drain on a practice. "I think there is this perception that primary care physicians cannot get paid for mental health. I think that is incorrect," said William L. Bruning, president and CEO of the Mid-America Coalition on Health Care.

Experts say the first step is for practice members to determine who will be screened for mental illness. For example, the U.S. Preventive Services Task Force recommends screening of all adolescents for major depressive disorder and all adults for any form of depression. Other guidelines vary.

"If you're going to do mental health care, you're going to have to screen for it," said Lynn M. Wegner, MD, associate professor of pediatrics and developmental and behavioral pediatrics at the University of North Carolina in Chapel Hill. She spoke about obtaining payment for mental health services in a pediatric office during a recent online seminar sponsored by the TeenScreen National Center for Mental Health Checkups at Columbia University in New York and the American Academy of Pediatrics.

Practices also must establish who carries out the process. Mental illness screening tools are often designed to be administered by someone other than a physician, according to Dr. Wegner. Most screenings are completed by the patient or given by the medical assistant or nurse who conducts their intake, then passed along to a physician for evaluation. The payment, usually $5 to $15, reflects that the physician is not carrying out the screening personally. Some insurers allow separate payment in addition to a well-person visit. Others pay only if such screening occurs on a separate day.

"Because it's so complicated, I think a lot of [physicians] don't even bother trying to submit for reimbursement," said Leslie McGuire, deputy executive director of TeenScreen. "It should be noted though that many plans do pay, so [physicians] should be encouraged to submit for reimbursement. A lot of times physicians are pleasantly surprised because about half of plans will pay for it."

Pediatric mental health experts suggest that code 96110 for developmental screening with modifier 25 be on the bill to an insurer for a well-child visit, in addition to the evaluation and management code. If the code is rejected, it can be resubmitted with modifier 59.

McGuire said a copy of the screen should be kept in a patient's chart, along with notes about the discussion it triggered and follow-up plans.

The next step is getting patients access for needed services. In some cases, patients will have their treatment in the primary care setting, but getting paid for treatment after a positive screen and a diagnosis can be challenging. The Mental Health Parity and Addiction Equity Act bans group insurance plans from restricting patient access to such services, but the claims can still be denied.

When providing mental health treatment, experts recommend that physicians bill by using the CPT codes measuring the time spent on the visit rather than codes indicating the complexity.

For example, when Bruning's Mid-America Coalition studied reimbursement patterns for depression treatment, it discovered that the evaluation and management codes 99201-99205 for new patients and 99212-99215 for established patients were usually reimbursed when accompanied by the ICD-9 diagnosis codes for the condition. The codes 90801-90899 for psychiatric or psychotherapy services generally were not in the primary care setting.

"Physicians can bill for the extra time," Bruning said. "I don't think physicians realize that."