Marriage ~ Couples ~ Relationship Counseling & Therapy

The short answer is couples therapy is not covered by medical insurance. (I know this may contradict what you've been told. Please continue reading to understand why.)  Couples therapy is not considered "medically necessary" (one of several criteria for insurance reimbursement) because the problem lies within the relationship dynamic between two people not within an individual identified patient who is the focus of mental health treatment.  If you have any questions about this contact your insurance provider and ask specifically if diagnostic code V61.10 Relationship Distress with Spouse or Intimate Partner (the appropriate diagnostic code for couples therapy and marriage counseling) is covered. “V-Codes”, as they are commonly referred to, are usually not covered by insurance. (I've seen exactly one exception in twenty-five years through one company’s in-house employee insurance plan.) Feel free to contact me with any questions you have about this. For a more thorough explanation please continue reading below. 

Medical insurance is concerned with the identification and remediation of disease and illness. All psychiatric/mental health/psychotherapy/counseling insurance reimbursement requires four things from the clinician: 1. Documentation of an individual identified patient who receives the focus of treatment through an individualized treatment plan, 2. A psychiatric/mental health diagnosis for that identified patient to receive mental health treatment, 3. An assessment and documented finding of medical necessity relevant to the diagnosis for the identified patient, and 4. A CPT code (Current Procedural Terminology) describing the method of intervention. There is no CPT code for couples therapy.

While some therapists code couples therapy as "family therapy" (administratively, for insurance purposes) and use  CPT code “Family Therapy 90847” for insurance reimbursement, my experience demonstrates that is an error, ignore's a handful of important circumstances unique to couples therapy, and puts the clinician who uses 90847 at professional risk when billing insurance. Insurance reimbursement utilizing Family Therapy 90847 still requires an identified patient be assigned a psychiatric mental health diagnosis with an individualized treatment plan linked to medical necessity (and once again V61.10 is the correct diagnostic code for Relationship Distress). Moreover, when the focus of therapy is specifically dysfunctional/problematic relationship dynamics, the insurance industry does not consider treatment to be medically necessary. Many therapists are surprisingly unaware or ill-informed about these criteria, and the implications, when billing insurance for couples therapy. Receiving a records audit by an insurance company may be the first time a clinician fully understands these criteria and the consequences imposed for mismanaging them.

Obviously relationship problems are emotionally painful and sometimes psychologically disturbing for individuals. It is widely understood that healthy relationships across all domains of life improve individual wellbeing. Our society could better serve individual health by acknowledging how problematic relationships of all kind contribute to individual illness (i.e.,depression or anxiety) and by facilitating processes that improve relationships before problems lead to distress and disease. The insurance industry does not promote such levels of care, however; it is fundamentally reactive to disease rather than proactive towards health. Insurance reimbursement for relationship distress would cost society much less in chronic disease and long-term financial outlays than our current dysfunctional system.

Couples therapy and marriage counseling focus on your relationship. There is no medically “identified patient.” I work to understand both of you as individuals so I can help you relate with yourself and with each other in new ways that improve your relationship. Professionally, both you and your partner are my clients and it is the relationship that may be thought of as the figurative patient. Furthermore, the standard for medical records and insurance reimbursement stipulates that documentation should only reflect the condition and concerns of the identified patient; it should not reflect on the behaviors or problems of anyone else, including family members. Because medical charts are linked to an individual identified patient, any documentation, or lack thereof, for insurance reimbursement that misrepresents the context of therapeutic services is unethical and may be legally fraudulent.

While I believe couples therapy should be covered by medical insurance, its practice orientation does not fit within the rigid medical disease model of America’s insurance industry. (It’s interesting to note that both TriCare and Medicare insurance programs -- both federal government programs that usually set standards for insurance reimbursement  industry wide-- specifically prohibit insurance reimbursement for relationship counseling.) Given all the above, I choose to not risk my license and my livelihood facilitating insurance reimbursement for marital/relationship counseling. Some Flex Fund Accounts, however, may be used for couples counseling, so ask your plan administrator. Please inform me if you would like a receipt for your account.

As a couples therapist I am focused on your relationship first and foremost. That intent is not congruent with insurance mandates that require me to assign you a Psychiatric/Mental Health Diagnosis, focus treatment and documentation on one individual’s diagnostic label (like depression or anxiety, etc.), create a written determination that treatment is Medically Necessary for the identified patient, and document the patient’s course of treatment whether improved or deteriorated. It’s also important to know that there are a handful of potential conflicts of interest and confidentiality issues that are unique to couples/marital therapy because there are two adults equally participating and invested in therapy. The medical insurance industry does not account for these unique circumstances.

Understanding these conditions means:

• You and your partner/spouse both have joint control of the therapist’s file; your private issues are not accessible to third parties (attorneys, employers, etc.) without both of you giving your written permission.
• You will not have a psychiatric/mental health diagnosis in your medical record.
• The focus of couples therapy will genuinely be on the relationship not on fulfilling insurance mandates.
• Making your relationship the focus of therapy encourages honesty and integrity; you are both responsible to the relationship.
• Your personal information and records will not be vulnerable to an electronic database breach or unauthorized access in ‘the cloud’.