F Code Misclassification by Certain Payers

May 24, 2024

Update: January 13, 2025

At the National Association of Insurance Commissioners meeting last year, ASHA met with a few insurance commissioners to describe the inappropriate implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA). ASHA has followed up with the commissioners with a detailed explanation of the issue and its impact on ASHA members and the beneficiaries they serve.

While insurance commissioners have limited scope, part of their job is to ensure appropriate implementation of state and federal laws that impact private insurance companies. Your local insurance commissioner’s office should offer guidance on what complaints it can and cannot address. Commissioners have asked that providers and consumers (the beneficiaries being served) submit complaints about F codes being misclassified as “mental-health only” codes. ASHA has a template letter that providers can use to start drafting their complaints.

ASHA has received reports from members that a small number of insurance plans are misclassifying codes found in Chapter 5 (F codes)―“Mental, behavioral, and neurodevelopmental disorders (F01-F99)” of the 2024 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Speech-language pathologists (SLPs) are reporting denials of speech-language pathology services when billed with F codes while others are being reimbursed under the mental health benefit.

ASHA has tried to seek clarification directly from the insurance plans several times, but we are still waiting for an explanation. We’ve submitted a letter requesting clarification and reconsideration to multiple insurance plans and continue to follow up as they review our requests.

Based on remittance advice shared by providers, we believe the claims processing issues may come from a misinterpretation of the proposed amendments to the Mental Health Parity and Addiction Equity Act (MHPAEA) [PDF]. These new amendments cite “the plan’s or coverage’s definition of ‘mental health benefits’ must include all conditions covered under the plan or coverage, except for substance use disorders, that fall under any of the diagnostic categories listed in the mental, behavioral, and neurodevelopmental disorders chapter (or equivalent chapter) of the most current version of the ICD or that are listed in the most current version of the DSM.”

However, the act also states, “any condition defined by the plan as being or as not being a mental health condition must be defined consistent with generally recognized independent standards of current medical practice.” The amendments to the MHPAEA did not change the nature and classification of every code within Chapter 5 of the ICD-10, nor did they reclassify the nature of the SLP’s role in treating conditions within this chapter.

ASHA’s scope of practice in speech-language pathology includes treatment of various conditions under Chapter 5 of the ICD-10-CM. For example, while the amendments to MHPAEA do classify autism spectrum disorder (ASD) as a mental health diagnosis, not all treatment for ASD is mental health treatment. SLPs play a central role in screening, evaluating, and treating individuals with ASD in areas including speech, language, social communication, swallowing, and feeding.

There are also codes in a particular section of the chapter―“Pervasive and specific developmental disorders (F80-F89)”―that include conditions commonly treated by SLPs. For example, SLPs are the preeminent providers treating communication disorders that are captured in section F80 for specific developmental disorders of speech and language. Unless a patient has an underlying medical diagnosis or there is no F code to represent a specific condition, codes from the F80-F89 section are the correct options for SLPs to assign and bill. Coverage of these F codes under the speech-language pathology benefit is considered an essential health benefit and is still included by many insurance plans, including marketplace plans, commercial plans, Medicaid plans, and Medicare plans.

What's Next?

ASHA will continue to urge insurance plans that already have or are considering reclassifying F codes to review our letter and contact us with any questions.

We urge ASHA members who encounter processing issues related to the classification of F diagnosis codes to contact reimbursement@asha.org.