Advice on insurance in the USA and therapy

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Brainiac42
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15 Apr 2022, 2:47 pm

So, my mom told me that therapists have to diagnose you with something if you’re using insurance. Or, the insurance company won’t pay the claims. My therapist stated I have Autism after 2 sessions, I’m wondering if she’s just saying this because she has to. Has anyone else seen this happen?



kitesandtrainsandcats
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15 Apr 2022, 2:56 pm

I would say that is a bit of an exaggeration.
My personal experience with determining which codes to use was in late 1980s, early 1990s, and time and bureaucracy have moved on since then.

Logically there have to be billing codes to use while the provider is working to figure out what to diagnose.

Found this about billing codes which sheds some light on the thing;
https://myclientsplus.com/foolproof-gui ... ing-codes/

Note the following billing codes do not involve naming a diagnosis,
"
Common Mental Health CPT Codes

Having a thorough understanding of the most common mental health CPT codes will help ensure that you’re using the best code for the services you provide. Here are the most common codes that you’ll encounter as a therapist.

90837 – Psychotherapy, 60 minutes
90834 – Psychotherapy, 45 minutes
90791 – Psychiatric diagnostic evaluation without medical services
90847 – Family psychotherapy (with client present), 50 minutes
90853 – Group psychotherapy (other than of a multiple-family group)
90846 – Family psychotherapy (without the client present), 50 minutes
90875 – Under other psychiatric services or procedures
90832 – Psychotherapy, 30 minutes
90838 – Psychotherapy, 60 minutes, with E/M service
99404 – Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure)
"

Looks like there is what we'll call, an overabundance of different billing codes, and modifiers to those codes, not unlike the "12 billion IRS tax laws"; https://theranest.com/blog/top-icd-10-c ... al-health/

Quote:
Though it can be easy to become overwhelmed with the number of different codes out there when it comes to medical billing as a therapist, we hope this post has helped breakdown some of the confusion you may have been experiencing. There’s no doubt that billing can be an exhausting task, we’re here to help make it as easy as we can.


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blazingstar
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15 Apr 2022, 8:53 pm

Insurance claims are getting stricter and stricter. I know my doctor has to almost ‘make up’ diagnoses so that insurance will pay for a certain lab test, for example.

That said, I do read my clients’ files and autism is never the primary diagnosis. I don’t think you get therapy for autism, per se. The primary diagnoses are usually emotional type things. They come out of the DSM whatever number it is on now. I don’t have a file in front of me now; sorry I’m not more specific.


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Brainiac42
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15 Apr 2022, 9:20 pm

blazingstar wrote:
Insurance claims are getting stricter and stricter. I know my doctor has to almost ‘make up’ diagnoses so that insurance will pay for a certain lab test, for example.

That said, I do read my clients’ files and autism is never the primary diagnosis. I don’t think you get therapy for autism, per se. The primary diagnoses are usually emotional type things. They come out of the DSM whatever number it is on now. I don’t have a file in front of me now; sorry I’m not more specific.


What do you mean you don’t get therapy for Autism, per se?



blazingstar
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23 Apr 2022, 7:44 pm

My apologies, this thread dropped off my radar.

What I mean is that in talk therapy, the primary diagnosis is not autism. The primary diagnosis would be a mental health diagnosis. Not a neurophysiological one.

Does that make sense?


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SharonB
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23 Apr 2022, 8:52 pm

Before Autism was on the radar for me (I'm older), I was given a "mild mood disorder" DX. Now my primary DX is "general anxiety order" which is more acceptable --- my evaluator says that in reality my GAD is secondary to my Autism, and my depression was out-of-control anxiety. That resonates with me.

Are you doubting your DX?