H&B codes, challenges with using F54 (psychological factors affecting medical conditions)

Therapists providing services to patients with complex medical problems or co-occuring medical and mental health problems often have to work with behaviors that are impacting the medical problems. In the past, we could use the DMS code 316 (psychological factors affecting general medical conditions) and this was usually reimbursed.  The comparable ICD 10 code is F54, but the guidelines for using this code limit it to associating it with medical diagnoses.  As information about reimbursement since the implementation of ICD 10 has evolved, it appears that payers are NOT reimbursing for claim with F54 associated with mental health diagnoses (diagnoses beginning with “F”).  Just to complicate things, I believe that some payers do make an exception and reimburse claims using F54 and mental health diagnoses.  In general, however, it appears that the most accurate way to use F54 is to have it follow a non-psychiatric diagnosis (general medical diagnosis).  Most payers, however, appear to not be reimbursing claims with general medical diagnoses and psychiatric therapy codes.  For example, a claim with diagnoses E66.01 (obesity due to excess calories) and F54 (psychological factors affecting obesity) and a diagnostic intake billed with the psychiatric code 90791 may be denied.  On the other hand a claim with E66.01 and F54, and a H&B code, 96150 (health and behavioral assessment billed in 15 minute units) is more likely to be paid.

mhconcierge’s take: there is not a clear consensus on how to bill for services for patients with unhealthy behaviors contributing to medical problems, but it seems that most payers require H&B codes rather than psychiatric codes for the therapy service. Being familiar with these codes may enable you to expand your practice and increase your reimbursement.  For more info about H&B codes, see the website of Tony Puente, Ph.D, president-elect of the American Psychological Association and CBT coding expert.  He provides slides from his very though presentations on CBT issues, and the latest was done in Oct.,’15.  His presentation is very thorough – has 588 slides! – and the slides on H&B coding begin on 194,  and also there is more info on slides 265-267. 

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>