Specialty Billing Spotlight Five Coding Tips for Behavioral Health or Telehealth Services

Specialty Billing Spotlight: Five Coding Tips for Behavioral Health or Telehealth Services

A Practical Guide for Behavioral-Health Practices and Telehealth Providers

Navigating the world of medical coding is challenging for any specialty, but behavioral health and telehealth services come with their own unique complexities. From evolving CPT codes to strict documentation requirements, providers often find themselves spending more time decoding billing rules than delivering care. And with payers applying tighter scrutiny to behavioral-health claims, even small errors can delay reimbursements or trigger denials.
This guide highlights five practical coding tips tailored to behavioral health and telehealth practices. Whether you’re a solo provider, a group practice, or a fast-growing telehealth platform, these strategies can help you code more accurately, streamline billing, reduce compliance risks, and improve claim acceptance rates across the United States.

Know the Right CPT Codes for Behavioral Health

Behavioral-health billing relies heavily on time-based CPT codes, and even slight inaccuracies can result in denials.

Why time matters

Most psychotherapy and evaluation codes require you to document:
  • Total time spent
  • Therapeutic activity performed
  • Patient participation
  • Whether the session was in-person or virtual
Common examples include
90791
Psychiatric diagnostic evaluation
90832, 90834, 90837
Psychotherapy (30, 45, 60 minutes)
90853
Group Therapy
90856/90847
Family Therapy

Tip for accuracy

Always record start and end times, not just total minutes. Payers often request this during audits, especially for longer services such as 90837.

Use the Correct Modifiers for Telehealth Services

Telehealth billing expanded rapidly across the U.S., but rules vary by payer and state. Using the wrong modifiers is one of the biggest causes of denied telehealth claims.
Common Telehealth Modifiers
95
Synchronous telemedicine service
GT
Often required by certain private payers
93
Audio-only services (critical for states allowing phone visits)
POS 10
Telehealth services are provided in the patient’s home
POS 02
Telehealth outside the home

Tip for accuracy

Check payer-specific guidelines. Medicare, Medicaid, and commercial insurers sometimes require different combinations of modifier + POS codes. A one-size-fits-all approach to telehealth billing doesn’t work.

READ MORE : Best Billing Practices for Therapy, Psychiatry & Behavioral Health

Documentation checklist:
Reason for visit
Symptoms, severity, or changes
Interventions or therapeutic techniques
Progress toward treatment goals
Justification for extended sessions (e.g., 90837)
Any risk factors or safety concerns

Document Medical Necessity Clearly

Behavioral-health visits often involve complex conditions like anxiety disorders, depression, PTSD, substance abuse, ADHD, and dual diagnoses. Because these conditions vary widely, payers rely heavily on documentation to determine medical necessity.

Tip for accuracy

If you regularly bill longer psychotherapy sessions, create a template that captures:
  • Clearly explain the clinical need for extending the session time.
  • Describe the patient’s response and level of engagement during the session.
  • Detail the specific therapeutic interventions you provided.
This strengthens audit readiness and protects your reimbursements.

READ MORE : The Impact of Telehealth on Medical Billing and Coding

Stay Updated on E/M and Psychotherapy Combination Rules

Behavioral-health providers who offer medication management or combined therapy sessions must follow strict rules when using both E/M (99202–99215) and psychotherapy codes on the same day.

Key Guidelines

  • Only qualified prescribers are permitted to bill E/M services.
  • Psychotherapy must be documented as a clearly identifiable and separate service.
  • When an E/M visit and psychotherapy are provided on the same day, modifier +25 should be applied.

Tip for accuracy

Document the E/M portion and psychotherapy portion separately. Many denials occur because payers say the documentation was “blended” or lacked clear separation.
Stay Updated on E-M and Psychotherapy Combination Rules

Use Technology to Reduce Coding Errors

Behavioral-health and telehealth practices often struggle with:
  • High no-show rates
  • Inconsistent documentation
  • Incorrect time tracking
  • Modifier errors
  • Changing telehealth rules
  • Multistate payer variations

A specialized billing partner or software, like MaxRemind, can simplify compliance and automate coding checks before claims are submitted.

Use Technology to Reduce Coding Errors

How technology helps

  • Built-in behavioral-health templates
  • Automatic telehealth modifier suggestions
  • Time-based coding alerts
  • Real-time eligibility verification
  • Clearinghouse-integrated claim scrubbing
  • Compliance-ready documentation tools
These features help reduce administrative burden while improving the speed and accuracy of every claim you submit.

Simplify Behavioral Health Billing with MaxRemind

Streamline your behavioral-health and telehealth billing with MaxRemind’s AI-powered tools. Ensure coding accuracy, reduce denials, and get paid faster stress-free.
Book a Free Demo

Final Thoughts

Behavioral-health and telehealth providers play a critical role in today’s healthcare landscape. But accurate coding and billing require deep knowledge of specialty-specific rules, payer variations, and telehealth regulations across the U.S. By focusing on the right CPT codes, using correct telehealth modifiers, documenting thoroughly, and staying current with E/M guidelines, practices can significantly reduce denials and improve revenue flow.
For providers who want a scalable, stress-free approach to coding and billing, partnering with a trusted billing service offers consistency, compliance, and peace of mind. With transparent workflows and specialty-driven support, MaxRemind helps behavioral-health practices get paid accurately and on time.
FAQs
What are the most important CPT codes for behavioral-health billing?

The most important CPT codes for behavioral-health billing include 90791 for diagnostic evaluations, 90832–90837 for psychotherapy sessions, 90853 for group therapy, and 90846–90847 for family therapy. These codes are time-based, so accurate time documentation is essential.

How do I know which telehealth modifiers to use for my claims?

The correct telehealth modifiers depend on the payer and the state you’re billing in. Common modifiers like 95, GT, and 93, along with POS 10 or POS 02, may be required. Always check each payer’s guideline because one modifier combination will not work for every plan.

What counts as medical necessity for behavioral-health services?

Medical necessity is established when documentation shows the reason for the visit, the symptoms or severity, the treatment methods you used, the patient’s progress, and why additional or extended time was required. Clear documentation helps prevent denials.

Can I bill E/M and psychotherapy codes on the same day?

Yes, you can bill E/M and psychotherapy codes on the same day, but only if the prescriber is qualified and both services are clearly documented as separate. You must also include modifier +25 to show that the E/M service was distinct and medically necessary.

How can behavioral-health and telehealth practices reduce coding errors?

Practices can reduce coding errors by using behavioral-health billing software or partnering with a specialized billing service. Tools that offer automatic modifier suggestions, time-based alerts, payer rule updates, and claim scrubbing significantly improve accuracy and reduce denials.