Medical Coding and Auditing for Behavioral Health

Behavioral Health

Medical coding and auditing for behavioral health facilities differ from other healthcare specialties in several ways. For one, it is highly regulated and governed by federal laws.
Medicaid policies often differ by state, practicing regulations, and commercial buyer billing guidelines. Additionally, these facilities utilize specific sets of diagnostic codes, such as those found in the DSM-5, to capture mental health and substance use disorders.  

Coders and auditors must possess a deep understanding of these conditions and their associated coding guidelines. 

Documentation requirements for behavioral health encounters are unique, encompassing mental health history, assessments, treatment plans, progress notes, and outcomes. Compliance with regulations specific to behavioral health is crucial, requiring coders and auditors to stay updated with evolving rules and guidelines.  

Additionally, coding for therapeutic services, such as psychotherapy and counseling, requires precise knowledge of therapy modalities and duration. Reimbursement for behavioral health services can be challenging due to varying insurance coverage and coding rules, necessitating accurate coding for optimized reimbursement while adhering to payer guidelines. 

HIA offers medical coding support and audits for Behavioral Health and Psychiatric facilities in the United States. Our credentialed coders are up to date on all coding guidelines for behavioral health facilities. Our consulting service identifies specific areas of financial and compliance risk, provides pertinent information and educates clients on proper documentation, billing and coding practices. 


Our comprehensive approach

Behavioral Health facilities partner with us for:

Sample Action Plan E/M Office or Other Outpatient Services

Download Sample Action Plan

Evaluation and Management Office or Other Outpatient Services

Action Plans are designed to cover topic areas that impact coding, have been the frequent source of errors by coders and usually affect DRG assignments. This action plan reviews the clinical aspects of respiratory failure, respiratory insufficiency, causes and treatments. It covers official coding and sequencing advice as well as the coding pitfalls associated with respiratory failure diagnosis coding.


Profee Solutions from Health Information Associates


Are your providers documenting treatment time appropriately?

With time-based codes, poor documentation can affect reimbursement. HIA Consultants can educate your providers on the importance of documentation and accurate coding.

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