This article provides a definition of and examples of a mental health crisis. As well as a description of crisis counseling and guidance on documenting and coding a crisis counseling session.
Definition of a mental health crisis
A mental health crisis is generally defined as an acute situation that could result in imminent harm occurring to a client and/or others without urgent intervention by a mental health professional.
Let’s break down the important parts of that definition:
- “Acute” indicates that the client has active access to a means to cause harm, a plan to enact that harm, and an intention to cause harm.
- “Imminent” refers to the urgency of the situation, in that harm is likely to occur to the client/another person between now and the next 72 hours unless intervention occurs.
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“Harm” can include:
- life-threatening circumstances such as danger to self, grievous self-harm, danger to others, child/teen endangerment, as well as
- grave impairment, like psychosis or debilitating health problems caused by mental health symptoms (for example, the client is unable to complete activities of daily living)
- “Urgent intervention” means that any and all mental healthcare professionals who are aware of the crisis situation are compelled to respond as soon as they become aware of the crisis event, as outlined by their relevant legal, ethical, and compliance mandates.
Examples of a mental health crisis
These are some situations that meet all the above criteria, and would be considered a mental health crisis:
- A client shares with their therapist that they have access to a gun and plan to use it on themselves tonight in order to die by suicide.
- A client recently took opiates to relax, but is now having difficulty staying awake during the session and is turning blue.
- A client’s depression is so debilitating that they have not showered for weeks, are not eating, and have developed a urinary tract infection due to hygiene concerns.
- A client is in the middle of leaving their abusive partner’s home, and the abusive partner is now actively threatening the life of the client.
What may not necessarily qualify as a mental health crisis?
These are some situations that could potentially not meet the criteria for a mental health crisis, as these situations are missing one or more of the above criteria:
- A client shares a history of struggling with suicidal thoughts but does not have any plan, means, or intent to die by suicide.
- Although the client is struggling, the absence of a plan and intent suggests there is no immediate risk. The situation would not qualify as a crisis but should be closely monitored.
- A client is emotionally escalated or having a panic attack, and there is no concern about health impacts.
- While the symptoms are distressing, they do not pose an immediate threat to the client’s life or health. The therapist can help the client manage the panic attack through breathing exercises and grounding techniques, but it is not considered a crisis.
- A client says they are in crisis or having an emotional breakdown, but after assessment from the therapist, there are no identified patient safety risks or harm that could occur.
- A client uses substances or is engaged in substance abuse.
- Although substance use can be a significant concern, it does not typically constitute an immediate crisis unless there is a risk of overdose, severe withdrawal, or related complications.
- A client engages in self-injurious behavior (e.g. cutting, burning, etc), but their intent is not to die and do not cause life-threatening injury.
- A client has an eating disorder that can be effectively managed at the outpatient level of care.
Ultimately, Rula looks to you as the client’s therapist to understand the patient’s history, thoroughly grasp their fixed and mutable risk factors, assess the patient’s current presentation and circumstances, and use this data to make an informed determination about how to respond to a mental health crisis. Rula also requires documentation of the crisis situation in the chart and reporting the clinical risk/event here.
What does a crisis counseling session look like?
These crisis sessions are often unscheduled and involve different clinical tasks compared to typical sessions. Crisis sessions tend to focus on rapid assessment, stabilization, safety planning, resourcing, and rapid referral to crisis resources.
What information is helpful in establishing that a crisis is occurring?
- Documentation of risk factors at intake
- Documentation of current symptoms and how they are impairing the client’s quality of life
- Documentation of the safety risk, including the client’s imminent risk of harm
- With suicidal ideation, this includes access to a means to harm, their intent to die, and their plan to die
- Documentation of any adverse events that have occurred in the client’s life recently
- Recent MIC scores (including high GAD, PHQ, and any positive C-SSRS score)
- Recent risk assessment in the chart
- Safety plan in the chart
- Treatment plan goals target crisis considerations (e.g. “Client plans to use 5 DBT coping skills if they have a suicidal thought”).
- Document that you have provided 24-hour resources for the patient
Documentation and Mental Health Crisis
Thorough documentation is an absolutely vital tool for capturing data that demonstrates the nature of the crisis and documenting your efforts to mitigate risk and respond to it. In addition to being important for capturing this milestone moment in the patient’s care, thorough documentation is also necessary for crisis billing to be covered by insurance and to reduce liability in the event of an adverse patient experience.
Crisis Coding
There are two unique codes specific to a crisis: 90839 and 90840. Some things to note about these codes:
- They cannot be combined with CPT codes like 90837 (typical 53+ minute individual session), 90791 (initial assessment), or 90847 (couples/family session with patient present).
- 90839 and 90840 can be “stacked” with one another if the crisis session goes past 74 minutes- but please note that this is very atypical for a crisis session to extend for that long!
- Using 90839/40 if there is no crisis present is not allowable, and is technically considered insurance fraud. For that reason, we ask that providers thoroughly document the nature of the crisis, safety risks, and the imminent nature of the crisis, as well as all the interventions taken to mitigate risk to the client/others.
For more information on how to respond to patient safety concerns or how to bill for crisis sessions at Rula, please feel free to visit our HELP resource guide or contact our Patient Safety team at patient.safety@rula.com.