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Documenting Medical Necessity for Couple’s Counseling

PIMSY mental health EHR guest blog: documenting medical necessity for couples' counseling

by Beth Rontal, 5.20.16

Many couples presenting for couple’s therapy do not fit into a billable diagnostic category. How do I write a treatment plan and session notes -- or bill the insurance company -- if I don’t have a diagnosis?

Diagnosing for Couples

I’ve been getting a version of this question in my workshops, Misery or Mastery; Documenting Medical Necessity ever since I started leading them four years ago.

Couples don’t seek out therapy because they have a diagnosable mental health issue. They come to therapy because they’re having marital problems they want to solve. What they don’t know is that in order to use their insurance, they need a mental health diagnosis.

Unique Challenges

When it comes to billing an insurance company, diagnosing for couple’s counseling poses unique problems:
• If “the couple is the client”, which person do I use to bill the insurance company?
• What if there is no diagnosis?

Even though “the couple is the client”, in order to bill an insurance company, it’s necessary to have an identified client who has a mental health diagnosis. Once you meet the couple, you sometimes discover that indeed, at least one does meet criteria that supports an ICD 10 diagnosis. Bill the insurance company under that person.

Good News / Bad News

If there is clearly no mental health issue, the answer is simple. You explain the good news to the couple; that they aren’t sick because they don’t meet criteria for a mental health disorder. Then you explain the bad news; that you can’t ethically bill their insurance company for the same reason.

Though the answer is straight forward, it clearly poses a problem for those couples who can’t afford to pay out of pocket or expected to use their insurance, which is nearly everyone. And clinicians suffer the loss of income.

If you suspect there might be a mental health problem but aren’t yet sure or you need time to find out, there’s another option. Consider using Adjustment Disorder Unspecified and indicate that the adjustment is in regards to the issues in the marriage.

Universal Authorization

When completing the Universal Authorization, make sure to write a short narrative in the space provided on the form that explains the issues being addressed and how they impair the marriage. Use behavioral language that gives clear examples of the problems and their severity.

For example, “Couple engages in verbal fights multiple times per week.” Make sure to include any bio-psycho-social stressors that may impact treatment. Here are some examples:

> Their children find these fights very distressing and cause them to act out both at home and school, which causes further conflict between the parents.
> Client is on the verge of losing his or her job, which is contributing to conflicts between couple.
> Client's wife is the primary care taker of an aging parent who needs constant attention, causing wife to have increased irritability and greater friction between couple.

DSM-5 T and Z Codes

When a couple seeks help, there are often multiple stressors in their lives so finding some should not be difficult. Many of these stressors can be coded and found in the DSM 5 under T and Z Codes. Do not use T and Z Codes as a primary diagnosis because they aren’t medical in nature and therefore not reimbursable. But they do support continued treatment and are important to document in the authorization.

Adjustment Disorder Under DSM-5

There is a caveat to using the Adjustment Disorder strategy. An Adjustment Disorder has a six-month time limit so using it for more than six months may be a red flag for insurance companies, which could trigger a denial or telephonic review. Unspecified Disorders can also trigger a rejection or review because they do not meet criteria for any specific medical problem.

BUT – they are a good starting point and will buy you at least six months’ worth of time to gather information, make a diagnostic decision and help the couple at the same time. Lots of good work can be done in six months and by that time you may have discovered a way to continue justifying medical necessity and get the sessions needed to continue helping your couple.

Ask the Expert

We're giving you an exclusive opportunity to ask Beth your documenting questions. Email your inquiry to This email address is being protected from spambots. You need JavaScript enabled to view it. - and we might feature the answer in an upcoming blog post!

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beth-rontal

Beth Rontal, MSW, LICSW, has spent hundreds of hours teaching psychotherapists how to document medical necessity, get authorizations and pass audits by linking effective documentation with good clinical practice.  

An engaging speaker, Beth has presented Misery or Mastery; Documenting Medical Necessity to individuals, groups and clinics and at national conferences. She also serves on the Advisory Board of PIMSY Mental Health EHR. For more information, see Documentation Wizard

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