If caregivers are to receive the psychological services they require, psychologists and other mental health providers must be able to be paid for these services, which sometimes do not fit easily into traditional billing codes. This section illustrates some of the issues which may arise in billing for providing care to a patient and to family caregivers and other family members and offers some suggestions for ways to arrange family meetings and structure billing for services rendered.
- Many caregiver interventions are conducted with a single person, regardless of whether the focus of conversation is about that person or about the family system more broadly construed. Even when the conceptual frame is addressing the family structure or functioning, interventions can be implemented with a single person if strategically applied.
- Interventions that involve multiple family members can engage those members in various ways
- Multi-person meetings may occur during holiday or vacation periods when family members have travelled home from significant geographic distances. These meetings may take longer than a typical therapeutic hour. Many hours of planning with the local caregiver or care-recipient beforehand may be necessary to prepare for them.
- An important family intervention is creating consensus among family members about the medical situation by sharing all available information. Communication technologies can disseminate such information broadly (e.g., faxing medical reports; maintaining a web-based medical record that all members can see), or link people in conversation (e.g., Skype videoconferencing; using the speaker phone in your office to link local people with others at a distance; setting up conference phone calls).
- For example, psychologists or family members may fax materials to other family members to help them understand the condition and needs of the care-recipient. A follow-up telephone conference call may be useful to review the findings in detail for the purpose of getting all family members on the same page.
- Psychologists can coach family members to exchange emails with concerned relatives. This type of communication tends to decrease family members’ reactivity toward one another because of the inherent slowness of the medium. Using email can be viewed as an extension of telemedicine—a means for intervening with the family and/or including members as part of the healthcare team.
Who is Client
Imagine that a chronically ill man has come to you for psychological services. As part of your normal intake procedure, you ask him to sign a consent-for-treatment form and then explain how confidentiality works. Those are part of your ethical responsibilities.
What happens then when you make the clinical recommendation to invite some of his family members to future sessions? You may explain the clinical rationale that having a family meeting will allow you to help garner support for him, persuade a specific relative to do a particular task or work toward achieving consensus among family members about an important decision. But you will have to assure him that he is your client and that you won’t be abandoning him in favor of one or more of his relatives. You will also need to assure him that he is the one who holds the right of confidentiality—to determine what information about him you will and will not be allowed to share with others during the family session.
Caregiver interventions are typically reimbursed in the following ways:
- The caregiver pays out-of-pocket for the clinical services
- The caregiver’s health insurance is billed for services to treat depression, anxiety, an adjustment disorder, or another diagnosable condition
- The care-recipient’s health insurance is billed using CPT code 90847 --family psychotherapy with patient present. This assumes that the care-recipient is continuing to meet with you and the caregiver. If you bill using the CPT code 90846--family psychotherapy without patient present—you will NOT be reimbursed by Medicare carriers.
- Clinical services are reimbursed through a previously established contract to assist families associated with a particular agency or a company’s clientele (e.g., nursing home or assisted living).
- Clinical services are reimbursed through a previously established contract with the local Area Agency on Aging to provide caregiver counseling in a particular region
- If a memory-impaired care-recipient is depressed, apathetic, irritable, etc. and you can justify treatment as medically necessary, then you may bill the care-recipient’s health insurance for individual therapy even if the caregiver is present in the session for the purposes of learning to implement a therapeutic strategy. For example, if you use behavioral activation techniques and review a Pleasant Event Schedule with input from the caregiver, your treatment is focused on the memory-impaired patient.
- On the other hand, if the focus of the treatment is on the caregiver because of his other symptoms of depression, anxiety, etc., then you must bill the caregiver’s health insurance, not the care recipient’s.
- You can bill a care recipient’s health insurance under CPT 90847 --family psychotherapy with patient present, assuming an ongoing services relationship with the patient. Some managed care companies reimburse for this code. Be sure to include in your note the words that the service is primarily for the benefit of the patient. HOWEVER, when billing traditional Medicare, it is best to check with the regional carrier first to see if it is a reimbursable service; even if it should be reimbursable, this code can be an audit trigger with some carriers.
- CPT 90846--family psychotherapy without patient present--is generally NOT a reimbursable service.
- If you bill the health insurance of a patient for whom you gave a diagnosis that connotes cognitive impairment, be sure to note whether the patient was alert, responsive and able to participate in the session. The clinician must be clear that the patient was able to benefit from the treatment session in order to receive reimbursement for the service.
- Billing Medicare or other third-party payors for a 90-minute session can be a red flag for an audit. Use such codes sparingly. If the family is requesting an extended psychoeducational session, make it clear that Medicare and other insurance companies do not pay for education. Request instead that they pay privately for these types of lengthy sessions.