AUTHORS:

Mental Health Professionals Group (MHPG) and Coding Committee of the American Society for Reproductive Medicine (ASRM)

BACKGROUND

Appropriate coding is an issue of ethical practice and provides the best opportunity for insurance coverage/reimbursement for fertility patients.

The 2021 ASRM Gamete and Embryo Donation Guidance document strongly recommends psychoeducational consultation for all intended parents  conducted by a qualified, licensed mental health professional (MHP) who has training and education in third party reproduction (1).

The Mental Health Professionals Group (MHPG) Demographics and Coding Task Force conducted a survey in 2020 (2) of its members and found a lack of consistency in how MHPs code donor-recipient psychoeducational consultations. The Task Force recommended that ASRM/MHPG provide guidance on how MHPs should code donor-recipient psychoeducational consultations.

GUIDANCE

Note: this document will not cover psychoeducational evaluations for embryo or gamete donors or gestational carriers. Psychoeducational consultation before fertility therapy is often provided by personnel inside fertility clinics, but many psychoeducational consultations are provided by independent MHPs not embedded within fertility clinics. For these consultations, the following CPT codes are utilized for appropriate billing:

1. EVALUATION AND MANAGEMENT E/M SERVICES

E/M codes are specific to medical personnel and cannot be used by MHPs.

2. HEALTH BEHAVIOR ASSESSMENT AND INTERVENTION SERVICES (HBAI codes)

The American Psychological Association (APA) states that, as of Jan. 1, 2020, psychologists must use new CPT codes when billing all third-party payers for HBAI services (3). The National Association of Social Workers provides similar coding guidance (4). The new codes have increased values that put them in line with the Medicare payments for psychotherapy services. New HBAI CPT codes should be utilized if the consult is provided by an MHP, regardless of type of practice (independent or affiliated with an infertility clinic). HBAI codes may be most appropriate for MHPs to use for the recommended psychoeducational consultation that occurs for patients pursuing treatment with donor gametes.

Health behavior assessment, or re-assessment includes evaluation of the patient’s responses to disease, illness or injury, outlook, coping strategies, motivation, and adherence to medical treatment. Assessment is no longer a time-based service. Performance of the new event-based assessment service is conducted through healthfocused clinical interviews, observation, and clinical decision-making, and is billed with CPT code 96156. Intervention services include promotion of functional improvement, minimization of psychological and/or psychosocial barriers to recovery, and management of and improved coping with medical conditions. These services emphasize active patient/family engagement and involvement, for example:

• 96158 (health behavior intervention-individual) -- initial 30 minutes
  • +96159 --each additional fifteen minutes
• 96167 (health behavior intervention -family with patient present) -- initial 30 minutes
  • +96168 each additional 15 minutes

NOTE: The proper use of HBAI codes requires a physical health diagnosis as the primary diagnosis (3). The MHPG Demographics and Coding Task Force survey results indicate that more than 80% of MHPG members are not embedded in a fertility clinic and may not have access to this information.

• A referral letter including the ICD-10 physical health diagnosis sent by the fertility clinic to the MHP working in an independent setting may provide access to this information.

3. Codes for psychotherapy (90832-38), family psychotherapy (90846-7) and biofeedback therapy (90875-6)

can be used if these are the primary services provided during these patient visits; however, these codes require the majority of time be spent in psychotherapy, which may not be the case for most psychoeducational consults.

MENTAL HEALTH COUNSELING FOR AN ISSUE SEPARATE FROM FERTILITY TREATMENT

For patients receiving mental health counseling due to a diagnosis or issue that is separate from fertility treatment but may be playing a role in the patient’s fertility therapy, the appropriate ICD-10 codes will be based on specific mental, behavioral and neurodevelopmental disorders.

REFERENCES

1. Practice Committee of the American Society for Reproductive Medicine and the Practice Committee for the Society for Assisted Reproductive Technology. Guidance regarding gamete and embryo donation. Fertil Steril April 7, 2021 DOI: https://doi.org/10.1016/j.fertnstert.2021.01.045.
2. MHPG Demographics and Coding Task Force. MHPG Demographics and Coding Survey 2020. Available at http://higherlogicdownload.s3.amazonaws.com/ASRM/UploadedImages/5950535b-1ce0-442a-9a93-38084fbdf00d/2020_MHPGH_Demographic_and_Coding_Survey.
3. American Psychological Association. Health and Behavior Assessment and Intervention Services. Accessible at https://www.apaservices.org/practice/reimbursement/health-codes/health-behavior.
4. National Association of Social Workers. Practice Perspective: New Health Behavior Assessment and Intervention Current Procedural Terminology (CPT) Accessible at https://www.socialworkers.org/LinkClick.aspx?fileticket=hhJ51C8bEHc=&portalid=0

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