info@mentalhealthbillingservice.com
Medicare has been paying clinical social workers since 1990. However, generic billers credential you using physician template codes, enter the incorrect taxonomies, and fail to capture the 75 percent allowable rate. We credential you using the correct non-physician template codes. We code your Medicare claims at 75 percent.
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Clinical social worker billing involves the coding and claims process for licensed clinical social workers. LCSWs bill 90791 for their diagnostic evaluation and use the time-based codes for psychotherapy for sessions. Group work is billed using code 90853. LCSWs do not bill E/M, psychological tests, and medication. LCSWs have billed Medicare since 1990. They are paid 75% of the rates for a clinical psychologist by Medicare.
A physician template contains an incorrect taxonomy and field structure for the LCSW. Primary-source verification fails, and the enrollment process is unsuccessful before billing can occur.
Medicare pays LCSWs 75% of the psychologists’ rate. For psychologists, it is 100%. If not checked against the allowed amount, underpayments go undetected.
LCSWs carry a heavier proportion of Medicaid than any other provider type.
Social Work billing losses can be attributed to a handful of mistakes that are all avoidable. Let’s talk about each problem, its cause, and our solution.
An automated billing company credentials you on a physician template. Taxonomy reads incorrectly, and the field structure is inappropriate for a non-physician provider. There is no way for the payer to verify the file against the state licensing board, resulting in delays in manual processing. The wrong NPI type itself adds 60 days to your waiting time until the effective date arrives.
We credential you on a proper template with taxonomy 1041C0700X. We verify your supervised clinical hours as a part of the enrollment. More information can be found on the credentialing and enrollment page.
Your NPPES record contains one set of codes. Your CAQH ProView profile contains the other. It is the most frequent reason for BCBS rejection at the credentialing stage. Later on, it pops up again on your live claim as a CO-16 denial. CAQH adds to this challenge by making any outdated attestation effectively invisible to the payer.
We have verified that taxonomy code 1041C0700X is matched on NPPES, in CAQH, and in the W-9. We maintain the CAQH attestation within the 120-day period. We retain one format name on all portals to ensure automation does not fall through.
The majority of the LCSW panels are high Medicaid volumes. The claim routed to the state program will be rejected since the member is enrolled in an MCO program. Being approved by the state does not necessarily mean being enrolled in Centene, Molina, and other MCOs. They will need a separate enrollment for the same, which needs to be done about 60-90 days after the state approval.
We validate the MCO and behavioral carve-out of the member prior to sending the claim. We route the claim to the right MCO right from the very start. We also confirm your enrollment in each MCO serving your caseload.
Many commercial plans segregate their behavioral health services in a carve-out. For a BCBS subscriber, a claim for behavioral health service can go to Carelon instead of the medical network. Be credentialed only with BCBS in a carve-out state and your medical claims will be paid while your behavioral claims will be denied. The carve-out uses its own portal and effective date. Missing out on this means lost therapy payments for months.
We determine if your state's commercial plan carves its behavioral health to Carelon, Optum, Evernorth or Magellan. We credential with the appropriate separate carve-out. Each claim we submit is sent to the entity responsible for it.
LCSW Medicare billing claims are paid at 75% of the psychologist rate. A short payment can easily go unnoticed when there is no reconciliation of the claim payment to the 75%. Being just a little below the allowed amount results in substantial loss of revenue when all the claims for a whole caseload are looked at.
We reconcile each remittance with the appropriate amount allowed up to 75%. We note any line item paying less. We re-work each underpayment and denial by payer and reason code.
Many insurance companies limit the number of psychotherapy visits per calendar year. The LCSW’s caseload will be consistent week in and week out. The limitation comes during the middle of the year and the claims get denied. Fee-for-service Medicare does not have a hard cap on outpatient limits, but commercial and Medicaid plans do. This denial usually shows up after some paid sessions are rendered.
We track the visit limit and authorizations in your EHR system. We notify your team when the client is near their visit limit. If the plan allows, we request an extension prior to the next visit.
Find out how the money is leaking before the totals pile up
Send us a recent set of denied or discounted LCSW claims. We check them against your credentials, your payer mix, and the 75% allowed rate. We get back to you in less than 48 hours.
Seven tasks that focus on the scope of social work practice. All seven address a particular reason why social work claims fall through.
We code 90791 for intake and time-based psychotherapy codes to actual documented duration of the session. We code 90853 for group therapy. We clean each claim before submission. We link the diagnosis and the procedure because a poor match means medical necessity deficiency.
We check the patient’s eligibility before the first visit. We check for caps on psychotherapy in the plan and determine the exact number of sessions. We track session numbers and prior authorizations in your EHR. Your staff finds out about limits long before expiration.
We match each Medicare claim up to the 75% allowed amount. We determine the Medicaid MCO membership prior to billing. We correctly route claims for those panels that are primarily Medicaid in social work. Underpayments never count as payments made.
We route behavioral health services to the appropriate carve-out depending on whether it is Optum, Carelon, Evernorth, or Magellan. We scrub our claims for taxonomy and place of service. We enter the authorization number when needed by the plan.
LCSW telehealth is now permanent under Medicare for behavioral health. We use the correct place of service code according to where the patient is. We use modifier 95 when needed by a payer. We never bill telehealth services as an office visit.
In case you decide to bring an LCSW into the picture, we’ll manage license-appropriate credentialing through our own credentialing team. We do that the day the contract is signed, not the first day on the job. Sixteen weeks out of a full caseload of work is lost money.
A sole practitioner or a small social work practice can’t afford to use precious clinical time to handle claims. The scope of the LCSW work also involves nuances a generalist misses. The 75%, the Medicaid MCO process, and the carve-out split all come at a price if not done right. Collections as a percentage usually cost less than having an in-house biller. Session limits ensure consistent client payments all year long. And with hiring a new clinician, we provide credentialing along with the service.
Clinical social workers have been able to bill Medicare since 1990 through the OBRA statute. Medicare pays them 75% of the amount set for a clinical psychologist. Psychologists get their 100%. The patient contributes 20% coinsurance on top. This 75% rate appears in 42 CFR 414.53, and the figure remains the same for 2026. Having it handy becomes important when dealing with contracts and identifying short payments.
Clinical social workers obtained the Medicare billing authority in 1990. Counselors and marriage and family therapists got it only in 2024. It differentiates LCSWs from others in the master’s level category. It also means that LCSWs have decades of payer policies behind their claim.
This 75% rate establishes the Medicare allowed amount for an LCSW-covered service. It serves as the baseline for a reasonable contract payment. A quote well below that threshold deserves scrutiny. We evaluate every contract according to the position established by the fee schedule.
NASW proposed that CMS increase the CSW rate to 85% in the 2026 rule. However, CMS didn’t finalize it but mentioned it only for future rule making considerations. The current and accurate rate is 75%. We bill and reconcile on the basis of this rate and not on our objective rate.
CMS clarified that community health integration and principal illness navigation services can be billed by CSWs independently. LCSW must personally provide the services for the purpose of diagnosing and treating mental illness and substance abuse. We check whether we are eligible for providing the services before billing.
The onboarding process for a social work practice takes place in five stages. Almost all LCSWs practicing alone will have achieved a perfect first claim well within their period of credentialing.
We audit your claims and your payer mix and tell you about our findings.
We check your Medicare MHC eligibility and your taxonomy code across all systems.
We verify your Medicaid MCOs and carve-out and identify the correct flow of claims.
We connect to your EHR and configure your session limits and coding policies.
We submit, scrub, and reconcile against the allowable amount and report each month.
A generic biller treats a clinical social worker like any provider type. The template, the 75% position, and the Medicaid routing are where that breaks. Here is the difference on the parts that decide payment.
Credentialing template
Taxonomy across systems
Medicare positioning
Medicaid MCO routing
90791 vs 90792
Session-limit tracking
Pricing
Clinical Social Workers Code for the following Psychotherapy Codes. These are listed in the Table provided. It is the time range that determines which specific code to use.
| Service | What We Handle |
|---|---|
|
90791 |
Diagnostic evaluation without medical services, the counselor intake. Not 90792. |
|
90832 / 90834 / 90837 |
Individual psychotherapy at 16 to 37, 38 to 52, and 53+ minutes. Document start and stop times. |
|
90853 |
Group psychotherapy, per member per session. Some Medicaid plans want the HQ modifier. |
|
90839 / +90840 |
Crisis psychotherapy, first 60 minutes (30 to 74), then each added 30 minutes. |
|
90846 / 90847 |
Family therapy without and with the patient. See the MFT billing page for depth. |
It is either the credentialing form, the session cap, or Medicaid routing that social work practices suffering financial losses have no clue about. Our discovery only took less than 48 hours, and there was nothing to sign.
What you are not signing up for
Our services provide billing to LCSW offices in all 50 states of America. Since the social work panel has a heavy bias toward Medicaid, the state Medicaid agency and its MCOs become critical.
California
Texas
Florida
New York
Pennsylvania
Ohio
Georgia
North Carolina
Michigan
New Jersey
Washington
Arizona
Massachusetts
Virginia
Colorado
Tennessee
Running a social work practice in a metro and searching nearby? We bill for LCSW practices in New York City, Los Angeles, Chicago, Houston, Dallas, Phoenix, Philadelphia, San Diego, Miami, Atlanta, Boston, Seattle, Denver, Washington DC, the Bay Area, Minneapolis, Charlotte, Nashville, Austin, Detroit, Tampa, and Columbus. Our coverage is national, so your state never limits us.
Proper LCSW credentialing for licensing, CAQH attestation, and payer enrollment in all 50 states.
Benefit verification, session cap verification, and managed care organization verification prior to treatment.
The whole denial process, from EOB code analysis to parity and session limit denials.
Where clinical social work, counseling, and other aspects of behavioral revenue cycle come together.
It is either the credentialing form, the session cap, or Medicaid routing that social work practices suffering financial losses have no clue about. Our discovery only took less than 48 hours, and there was nothing to sign.
The intake is billed at 90791. Individual psychotherapy services are billed with 90832, 90834, and 90837 based on the units of time. Group psychotherapy is coded with 90853 and 90839 together with 90840 for crises. Family therapy may be billed using 90846 and 90847. They don’t use E/M codes, testing codes, or prescribing codes.
LCSW's bill 90791 which covers diagnostic evaluation without medical services. 90792 includes medical services performed by the prescribers only. Hence, LCSWs never use it. An incorrect code 90792 on the LCSW billing form gets denied as a scope of practice error. Intake assessment is actually the same clinical procedure coded with 90791.
LCSWs get paid at 75% of the fee schedule of the same service provided by a physician according to 42 CFR 414.53. Psychologists are paid 100%. Clients pay 20% coinsurance. This rate will be valid in 2026 as well.
Clinical Social Workers received the independent right to bill Medicare in 1990 through the OBRA law. This makes them the oldest master's-level clinician in the Medicare program. Counselors and Marriage Family Therapists were allowed into the program in 2024. There are many years of payment laws behind any social work claim.
No. Medicare reimburses Clinical Social Workers for 75 percent of what a Clinical Psychologist earns for the same service. Clinicians in the psychology category get 100 percent. NASW has requested CMS increase the CSW reimbursement to 85 percent, but CMS has not done so yet. The reimbursement is at 75 percent currently.
Yes. Clinical social workers can bill 90853 for group psychotherapy, billed at per member rate per session. This code is used by social work practices for skills groups and support groups. Some states require Medicaid plan claims for a group to include the HQ modifier. We verify this requirement before billing for the session.
While Medicare FFS does not place a hard cap on outpatient psychotherapy, many private and Medicaid plans do have caps on psychotherapy visits and/or require authorization for continuing therapy. Authorization is required depending on the specific plan or state. We keep track of the number of visits and obtain an authorization prior to the visit cap being reached.
Wrong taxonomy in a physician template is the most frequent reason. Inconsistent information between NPPES and CAQH profile causes an application rejection as well. Expired attestation, more than 120 days old, cannot be recognized by the payer. We make sure all three are consistent.
The taxonomic code for LCSW and LICSW is 1041C0700X. It needs to be consistent on your NPPES profile, your CAQH profile, and your claims. Any error in the NPI type and taxonomic code delays the application and extends the process for weeks. We always check that it is consistent before we bill.
Yes. The telemedicine flexibility of Medicare for behavioral health is permanent, even including audio-only visits. We use place of service code 10 when the patient is at home and code 02 otherwise. We use modifier 95 if it is needed by any payer. Bill for telemedicine using the office visit code is one denial we avoid.
I verify that the patient has the MCO membership before sending the claims. Medicaid state approval will not mean that you are a provider with each of the MCOs. I credential you with MCOs serving your case load. Each MCO will be about 60-90 days after the state approval. I send all of your claims to the MCO of your member.
There are no monthly fees or annual fees or software fees as I work on a percentage basis and I get paid only if you collect from insurance companies. The first step is always a free LCSW billing audit. The exact percentage will depend on the volume and payers.
Yes. I can work within TherapyNotes, SimplePractice, Valant, Kareo or Tebra or any other EHR. I count the number of sessions per year and check authorizations through your EHR documentation.
Simplifying mental health billing with accurate claims, faster reimbursements, and seamless revenue cycle management.
info@mentalhealthbillingservice.com
(860) 500-1471
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