The Difference Between Behavioral Health And Medical Billing Format

Contrary to many beliefs mental health and behavioral health aren’t covered the same way in medical insurance the way any other medical service is covered. Unluckily, it creates a significant headache when billing for mental and behavioral health falls in front of providers. In terms of receiving reimbursements, providers indeed look for health and medical billing services.

With the myriad of changes and updates in the billing and reimbursement guidelines for mental and behavioral health billing, providers have become more reluctant towards accepting insurance plans. Besides, if some providers accept insurance, they go only for some plans because the billing for mental and behavioral health has become tedious and complex to go about.

To help yourself as a provider, understanding how the process of mental insurance works, its benefit, and its eligibility will enable you to look beyond the overall frustration and work for gaining complete reimbursement. Also, the uniqueness of billing for mental and behavioral health billing ensures what to focus on.

What are mental and behavioral health and medical billing?

When reimbursement claims are meant to be submitted they are processed in a standard way primarily focusing on the services rendered physically like diagnostic testing, follow-up visits, and other physical examinations for chronic conditions. On the flip side, behavioral and mental health care vary over a range of treatments including therapies, psychological testing, and other attached necessary treatments.

Apart from that, many insurance plans may have no restrictions or limitations on the number of visits that a patient can have in a month or week. But when it comes to mental and behavioral health treatments, many insurance companies and plans have a limited number of patients to visit each week or month. Plus, there’s a requirement of having pre-authorization prior to receiving the medical service. To gain or earn more from the service as a provider of mental healthcare, understanding the key difference in medical and behavioral billing is a must.

What is covered in mental and behavioral health medical billing?

 Medical billing for mental and behavioral health signifies the treatments given for anxiety, depression, substance abuse, bipolar disorder, and schizophrenia. The most important thing that a biller needs to keep in mind is to keep the restrictions given to providers and patients. This includes the number of visits for patients and the limited per-visit duration for providers. Also, the treatment would only be covered if the pre-authorization is obtained before a visit. 

As said earlier that not all insurance providers cover mental and behavioral health services and oftentimes, it also happens that providers are out of the network from a patient’s plan. So even if a patient has mental insurance coverage, it becomes impossible to have the treatment under coverage. Therefore, before treating patients who are paying out-of-pocket, providers need to be prepared for future circumstances.

For behavioral health services billing, it is also required to have a focused entity that considers the main components of patients’ billing related to mental health services with a good knowledge of codes and claims. Most mental health providers spend a lot of time in the administrative process of billing which diverts the focus from the vital care of patients.

Outsourcing the tasks to a health and medical billing service can ensure providers eliminate challenges and gain more from the range of services they provide to mental healthcare seekers.

The significant difference in medical billing for health care services

 No matter what type of medical billing you are involved in, it is essential to understand the federal guidelines of associated CPT and ICD codes and to reduce the denial rates to increase the rate of reimbursement for a practice.

This is what the billing for medical healthcare requires;

  • Verification of the services that are covered or not i.e. the need of confirming if a patient had taken pre-authorization for the visit and receiving service. 
  • The use of CPT codes for the evaluation of the visit and treatment rendered using E&M – evaluation and management codes. This is essential because it requires extensive knowledge and the significant difference between psychiatric evaluation and standard E&M codes.
  • Special attention must be needed when time spent is listed with E&M codes as they cannot attribute the time provided for the psychotherapy service.
  • Understanding the standard CPT codes and their accurate use for complete and undeniable reimbursement which eventually reduce the delay that occurs in accounts receivable.

Coding guidelines for mental and behavioral health medical billing

Medical billing for mental and behavioral health is more than just CPT codes and diagnosis; there could be a range of challenges for someone who is not well-versed in the terms of medical billing. Plus, claim submission can also differ from one payer to another. This is why it is important to keep in mind the level of care received and if it is covered by the patient’s insurance plan. Some of the things that are needed to keep in mind are;

  • Time spent on psychotherapy in a visit will be included in the claim
  • E&M codes are not written directly as CPT codes might be written.
  • Billing format may also need to be considered as they can be personalized and differ from one payer to another.
  • Many payers require providers to attach certain codes to the claims submission to have a clear understanding of where the bill falls perfectly.


The main difference between mental and behavioral health and medical billing sums up the number of services rendered. Medical billing focuses on services provided physically like diagnostic, radiology, and scans while mental billing ranges from psychotherapy to treatment and medical management. The significant difference between coding for mental healthcare and standard medical care is the understanding of accurate coding and the deliverance of treatment on the limited and restricted guidelines.

These differences will make a huge pile of work for providers where day-to-day tasks become hectic to associate with. For this, hiring a health and medical billing service provider is always a helpful option to look for.