Mental Health Coding and Billing

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Dr. David E. Marcinko MBA

By Dr. David Marcinko MBA

Coding Classification

The classification and coding systems used by mental health insurers, both diagnosis-related groups (DRGs) through revenue codes for facility and program services and current procedural terminology (CPT) for in and out patient professional services and consultations, are still being defined through historical methodologies and are vague compared to the medical classification coding structure.


As an example, mental health insurers classify Tourette Syndrome (TS) as a “mental disorder.” In fact, TS is an inherited, neurobiological disorder, and both neurologists and psychiatrists treat TS with the same medications. If TS were reclassified under the medical coding structure, TS would not only receive potentially a better reimbursement but public perception of TS as a “mental disorder” would be changed.


The Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision), also known as the DSM-IV-TR, is a manual published by the American Psychiatric Association (APA) that includes all currently recognized mental health disorders. The coding system utilized by the DSM-IV is designed to correspond with codes from the International Classification of Diseases, commonly referred to as the ICD. Since early versions of the DSM did not correspond with ICD codes and updates of the publications for the ICD and the DSM are not simultaneous, some distinctions in the coding systems may still be present.

For this reason, it is recommended that users of these manuals consult the appropriate reference when accessing diagnostic codes. In addition, DSM5 was last updated in May 2013.  For more information, contact the APA at (800) 368-5777.


Besides the above coding manual, the International Statistical Classification of Diseases and Related Health Problems” produced by the World Health Organization (WHO) is another commonly used manual which includes criteria for mental health disorders.


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One Response

  1. 41% of Dual-Eligibles Have a Mental Health Diagnosis

    Avalere recently released an analysis of dual eligible beneficiaries. Here are some key findings from the report:

    • In 2015, 11.4 million people were enrolled in both Medicare and Medicaid.
    • 41% of dual-eligibles have at least 1 mental health diagnosis.
    • About 60% have been diagnosed with 3 or more chronic health conditions.
    • Duals accounted for 14% of Medicaid population, but 33% of spending in 2011.
    • 27% of duals receive institutional long-term services and supports.
    • 3 in 4 states spend >30% of their Medicaid budget on Medicare beneficiaries.

    Avalere, April 20, 2017


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