Risk Management: When Marital Therapy Is

By Jeffrey N. Younggren, Ph.D. and Eric A. Harris, J.D., Ed.D.
February 1, 2011



The article “When Marital Therapy Isn’t” in the September/October edition of The National Psychologist appears to have generated questions and concern on the part of many psychologists who read it. Some apparently thought that the article was stating the use of the CPT code 90847 was inappropriate for couple’s therapy.

That was not the case nor was that the essence of the article. The message in the article was that the use of creative billing, to include creative diagnostics, in order to provide marital therapy under an insurance plan is unwise and potentially problematic. Actually, the essence of the message in the article is best noted by the last sentence that appeared in it which stated: “To find a creative way to obtain reimbursement through the manipulation of both the insurance policy and the focus of therapy is unwise.”

A very common example of this occurs when a couple comes to a psychologist for marital therapy, a non-covered insurance benefit, and the treating therapist feels that the appropriate diagnosis for them was Partner Relational Problem (V61.10). However, the therapist finds a creative way to make marital therapy fit into the insurance benefit by giving one member of the couple a diagnosis and then bills the treatment under 90847. Not only is this inappropriate professional conduct it is arguably unethical and a violation of the standard of care.

Questions about whether a carrier provides coverage for marital therapy are actually easy to answer. A simple call to the insurance carrier or a review of the website will frequently provide the needed guidance. TRICARE (cited in the previous article) notes on their website: “Counseling services that are not medically necessary in the treatment of a diagnosed medical condition are excluded from TRICARE coverage.”

This means that TRICARE does not reimburse for marital therapy when the diagnosis is Partner-Relational Problem (V61.10). However, TRICARE also states that, “Family therapy (90847) is considered outpatient psychotherapy and is a TRICARE covered benefit when it is determined to be medically or psychologically necessary for treatment of a valid diagnosed behavioral health disorder.”

Thus, the use of the CPT code 90847 to provide family therapy to one member of a marital dyad who has a diagnosable condition, when the target of the treatment is alleviation of the symptoms and the dysfunction that are experienced as a result of the diagnosis, is appropriate professional conduct. What is important to remember here is that the choice to include the marital partner is based upon the professional’s conclusion that the diagnosable condition can best be addressed by treating the relationship between the patient and his or her partner.

While alleviation of those symptoms is the objective of the treatment, the focus of the treatment can be the dynamic of the couple, including their communication patterns. The use of this procedure code does not require specific focus on the diagnosed individual nor does the therapist have a duty to treat him/her as the primary focus of therapy. In fact, both of the partners may have diagnoses that are impacted by dysfunction in the couple’s relationship and, in this case, the choice of one over the other as the identified client can be somewhat arbitrary.

The use of this procedure code, however, is not without its risks, and care must be taken in the form of informed consent to clarify for all those involved what the rules are that would impact this therapy.

For example, confidentiality issues are matters of concern with this type of treatment. With true couples therapy, as opposed to individual therapy with the patient’s partner as collateral, equality of treatment and mutual protection of confidentiality is crucial for success.

This needs to be spelled out very clearly in the initial informed consent agreement and during the treatment conversations, along with the fact that no information about or records of the treatment will be released without both parties permission. The one exception is when the identified patient’s insurance company requests information to process the claim and this too must be in the contract and discussed when appropriate.

The establishment of agreement by all at the outset of treatment makes the enforcement of this rule, should one patient try to break it, much easier. While all of the information shared in treatment is arguably confidential, clarity at the outset is vital. Another caveat is whether the information is privileged under the state privilege statute. The majority of states would respect the privilege of both parties equally, but some states (e.g. New York, Washington) may be different. Knowledge of the state law is obviously crucial to providing adequate informed consent in these types of cases.

The use of 90847 with certain carriers can still prove to be problematic regardless of whether or not one party has a diagnosable condition. This is because definitions of medical necessity are derived from the medical system which does not have procedures that involve more than one patient. There are anecdotal stories told by some providers about certain insurance carrier’s lack of understanding in this area and their somewhat rigid requirements for documentation focusing on the diagnosed individual as the most important aspect of adequate charting.

Medicare’s definition of medical necessity is the most mechanistic of any the authors have encountered and, at this point, Medicare presents the most risk of problems for those providing couples treatment to its covered beneficiaries. The advance discussion about these issues with a provider representative for the patient’s insurance company is the best way to address these matters before they become problematic.

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Jeffrey N. Younggren, Ph.D., is a clinical and forensic psychologist practicing in Rolling Hills Estates, Calif. He is also a clinical professor at the UCLA School of Medicine. He can be reached by e-mail at: jeffyounggren@earthlink.net.

Eric A. Harris, J.D., Ed.D., is a lawyer and psychologist. He is in part time clinical practice. He is a consultant and has lectured on risk management and managed care issues. He may be reached by e-mail at Jegseah@aol.com.

This article was originally published in the November/December 2010 issue of The National Psychologist. It is Part 2 of 2.

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