Documentation, Diagnosis and Billing in Behavioral Health Settings

A Framework for Successful Billing and Documentation

An important component of integrating tobacco use treatment into services provided to people with behavioral health conditions is ensuring that the provider is compensated, which is uniquely challenging for many behavioral health providers.

There are some key areas of consideration for Tobacco Control Program Staff who are supporting the integration of tobacco treatment services in inpatient, outpatient or behavioral health settings: Insurance, Diagnosis Codes, Documentation Requirements and Billing Codes.

It is important for Tobacco Control Program staff and other public health professionals to have a general understanding of:

  • Tobacco Screening, Cessation Counseling and Tobacco Treatment Coverage (which can vary from state to state, from payor to payor and from plan-to-plan)
  • The payors that a behavioral health provider or organization are contracted with
  • The population being served

Coverage of tobacco cessation treatment (or tobacco dependency treatment) is needed to be able to bill the insurance plan (also called the payor) for these services. Additionally, it is important to understand which types of providers are able to bill for theses services, even if a treatment is covered. There is extensive information on how to assess coverage of these treatments in your state, that you can find on the Lung Association website.

Most insurance plans are required to cover at least some tobacco cessation treatment, however payors can impose barriers to access that care, such as limiting the number of refills a patient can get per year or requiring prior authorization. It is important to understand these requirements, as they may result in the provider not being reimbursed. Understanding coverage can be complicated, but there are many tools and resources to help.

Some key questions to behavioral health providers: 

  • What types of insurance coverage do your patients have? 
  • Are you currently billing for tobacco screening, cessation counseling, and treatment services? 
  • If the provider answers “Yes”:
    • What codes are being used? Are you being reimbursed? Are claims being denied?
Resources for Insurance & Coverage  
Format
Developed By
About This Resource

Technical Assistance Resource Library (2021)

Online Searchable Resource Library
American Lung Association 
The Resource Library houses multiple resources on coverage, billing and more. Resources from American Lung Association and trusted national partners are available to access on demand and includes various formats including factsheets, guides, toolkits, on-demand webcasts/podcasts, and journal articles.
Glossary of Terms: Tobacco Cessation Coverage and Health Insurance (2021)
Downloadable .PDF Glossary
American Lung Association
This easy-to-read glossary provide foundational information related to coverage and insurance, to empower Tobacco Control Program staff to “speak the language” of billing, coverage and insurance. Includes information on terms specific to Medicaid/Medicare/Private Insurance and other terms that are relevant to all settings (inpatient/outpatient/behavioral health) 
State Tobacco Cessation Coverage Database
Online Searchable DatabaseAmerican Lung Association
This database is a collection of public health data on tobacco cessation treatment coverage and barriers to access that coverage in state Medicaid plans, state Medicaid expansion plans and State Employee Health plans.  

Visit Lung.org/CessationTA  for additional information and resources on tobacco treatment coverage

The current set of diagnostic codes used in the United States are the ICD-10-CM codes. They were developed based on the World Health Organization’s (WHO) ICD-10 codes. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)developed a new Procedure Coding System (ICD-10-PCS) for inpatient procedures. These codes are an important part of the billing process.

The assignment of proper diagnostic codes is required to successfully bill for tobacco treatment services. For example, the F17 code series are used when providing tobacco treatment to a person who has a nicotine dependence. F17 is a code in the 10th revision of the International Statistical Classification of Diseases and Related Health problems (ICD-10). The code is used to indicate a person’s dependence on nicotine. This indication of nicotine dependence is what establishes medical necessity for the tobacco treatment service being provided. Medical necessity allows providers to bill for the service. See the Diagnosis Coding Guide on page 7 of the American Lung Association Billing Guide for additional information.

ICD-10 codes are the cornerstone of classifying diseases, injuries, health encounters and inpatient procedures in healthcare settings. U.S. public health officials at the federal, state, and local level rely on the receipt of ICD-10 coded data from healthcare providers to conduct many disease-related activities. The Centers for Disease Control and Prevention (CDC) programs use the ICD-10 codes to conduct surveillance (e.g., chronic disease and injury surveillance, health care utilization, health care-associated adverse events), for case findings lists to identify cases of reportable cancers and certain birth defects and disabilities, and to provide public use data files for public analysis.

A primary user of ICD codes includes health care personnel, such as physicians and nurses, as well as medical coders, who assign ICD-10 codes to verbatim or abstracted diagnosis or procedure information, and thus are originators of the ICD-10 codes. The codes are used for a variety of purposes, including statistics, billing and claims reimbursement.

A secondary user of ICD-10 codes is someone who uses already coded data from hospitals, health care providers, or health plans to conduct surveillance and/or research activities. Public health is largely a secondary user of ICD-10 coded data.

Resources for Diagnosis Codes    FormatDeveloped ByAbout This Resource

Billing Guide Addendum for Behavioral Health  (2021)

Downloadable .PDF Guide

This guide is specific to behavioral health settings and clarifies distinctions that are unique to behavioral health settings and providers. This resource is relevant to both public health professionals and behavioral health care teams. Diagnostic Codes specific to behavioral health can be found within this guide. 

Billing Guide for Tobacco Screening and Cessation (2021)
Downloadable .PDF GlossaryAmerican Lung AssociationThis easy-to-read glossary provide foundational information related to coverage and insurance, to empower Tobacco Control Program staff to “speak the language” of billing, coverage and insurance. Includes information on terms specific to Medicaid/Medicare/Private Insurance and other terms that are relevant to all settings (inpatient/outpatient/behavioral health) 

ICD-10 Browser Tool (updated annually) 

User-Friendly web-based query application  
The National Center for Health Statistics
Additional information on both the use of ICD-10 codes and the ICD-10 Browser tool can be found at CDC.gov  
International Classification of Diseases (ICD)-10 Codes Tobacco/Nicotine Dependence, and Secondhand Smoke Exposure (2015)
Downloadable .PDF Guide
University of Wisconsin- Center for Tobacco Research and Intervention (UW-CTRI)
This concise document outlines ICD-10 codes for patients who use, are dependent on, or are exposed to nicotine/tobacco.

Regardless of the payor (e.g., Medicare, Medicaid, private insurance), providers need to use ICD-10 codes and provide documentation regarding medical necessity and the specifics of what was provided. The goal is to clearly establish medical necessity and ensure payment for services. Diagnosis Coding alone is not sufficient.

Medicare and other payors find improper payments by selecting a sample of claims or flagging suspicious claims and requesting medical documentation from the provider. The claim is reviewed against the provider’s medical documentation – either an electronic medical record or paper record.

As such, the following items should be documented in the medical record:

  • The patient/client’s willingness to attempt to quit
  • What was discussed during counseling/treatment planning
  • Amount of time spent counseling the patient/client
  • Tobacco use   
  • Advice to quit and impact of smoking provided to patient
  • Methods and skills suggested to support cessation
  • Medication management
  • Setting a quit date with the patient
  • Follow-up arranged
  • Resources made available to the patient

The Lung Association’s Billing Guide Addendum for Behavioral Health has additional information on documentation requirements, including tips for behavioral health providers. 

A fundamental decision that influences how a provider codes is whether tobacco treatment services constitute counseling that merits a separate code or will be included in a time-based Evaluation and Management (E/M) service code (which could be considered a “typical” provider visit). An additional decision is whether the tobacco service should be considered an “incident to” service; these are services that are important for achieving a desired outcome but “incidental” to the services initially provided by the provider.  

Below is a table of recommended resources with clickable links for more information on billing codes:

Resources for Diagnosis Codes    FormatDeveloped ByAbout This Resource

Billing Guide Addendum for Behavioral Health (2021)

Downloadable .PDF Guide

This guide is specific to behavioral health settings and clarifies distinctions that are unique to behavioral health settings and providers. This resource is relevant to both public health professionals and behavioral health care teams. Billing Codes, specific to behavioral health can be found within this guide. This is a great guide for Tobacco Control Program Staff to share with behavioral health care teams. 

Billing Guide for Tobacco Screening and Cessation (2021)
Downloadable .PDF GlossaryAmerican Lung AssociationThis guide is applicable to most settings -with some variances for behavioral health being covered in the Addendum for Behavioral Health. The guide provides information on coverage, coding, and documentation requirements, along with a section on the common reasons for claim denials and additional recommended resources. This is a great guide for Tobacco Control Program staff to share with both behavioral health care and clinical care teams.

Federally Qualified Health Centers (FQHC) (continually updated)  

WebsiteCenters for Medicare & Medicaid Services (CMS.gov)
This site page has information specific to Federally Qualified Health Centers, including information on FQHC payment rates and FQHC Specific billing codes.
Behavioral Health Integration Services (2018)
Downloadable .PDF: Guide
Centers for Medicare & Medicaid Services (CMS.gov)
This guide provides information on Medicare making separate payments to physicians and non-physician practitioners for behavioral health services that they furnish to beneficiaries over a calendar month service period. Includes billing information for providers including codes, descriptors of services and additional resources.
State Specific “Provider Manual
Varies
Varies from state to state, may be available from the State Medicaid Office, The Department of Human Services, or The Department of Health
Note: A quick google search of your state’s name + “provider manual” will usually locate a state-specific guide for billing and coverage information that is very valuable in all settings, for providers that serve the patients/clients that have insurance coverage through Medicaid. This guide will also provide information on what providers can bill services to Medicaid (state-specific). 
  1. Throughout this document insurance coverage will refer to private insurance, Medicare, Medicaid and other government-sponsored health programs in the United States. For more information on cessation coverage requirements by insurance type, please visit www.lung.org/cessationcoverage.

Page last updated: June 8, 2021

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