• Skip to primary navigation
  • Skip to main content
  • Skip to footer
Documentation Wizard Logo with Registered Trademark

Documentation Wizard, LLC

Documenting Medical Necessity for Psychotherapists

  • Home
  • About
    • About Beth
    • Hire Beth
    • Testimonials
  • Products
    • Trainings
    • Forms
    • Membership Circle
    • Hire Beth
  • Blog
  • Shop
    • Purchase Products
    • Cart
    • Account
  • Help
    • FAQ – Technical Issues
    • FAQ – Documentation Issues
  • Account
  • Contact
  • Facebook
  • Instagram
  • LinkedIn

How to Diagnose for Couple’s Counseling

May 17, 2016 by Beth Rontal

Many couples presenting for couple’s counseling 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?

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. 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.

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.

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 two 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.

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.

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.

My course, Misery or Mastery: Documenting Medical Necessity for Psychotherapists covers this issue in more and much much more.

Billing for Couples Counseling,  Clinical Documentation,  Couple's Counseling,  Diagnosis,  Documenting Medical Necessity,  Progress Notes

Reader Interactions

Comments

  1. Ethan Hansen says

    December 28, 2019 at 10:33 am

    I never thought that couples could need therapy because of underlying and hidden problems! A close friend of mine feels like something may be off with his relationship. We’ll be sure to look into methods to diagnose whether or not therapy is worthwhile!

Documentation News for Therapists

Get the Latest News

Stay up to date on documentation wizardry with correspondence from our blog.

Footer

Contact

Documentation Wizard, LLC
42 Southbourne Road
Boston, MA 02130

Phone: (617) 522-6611
Email: bethrontal@documentationwizard.com

Follow Us

  • Facebook
  • Instagram
  • LinkedIn

Recent Articles

  • Mental Health Documentation in an Uncertain World
  • Medicare and Telehealth Coverage: Clearing Up the Confusion
  • Essential Admin Forms for Therapists: Stay Legal, Ethical, and Protected

Copyright © 2025 · Beth Rontal. · Documentation Wizard®, Misery or Mastery®, and the Documentation Wizard Logo are service marks of Beth Rontal. · Terms and Conditions
Designed and Hosted by Coastal Waters Creative - Local Business Websites and Digital Marketing