Using 90791 vs 90792

Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor

May is Mental Health Awareness Month!

We continue to bring awareness to mental health, documentation, and coding for these services.  Per the CDC, more than 1 in 5 US adults live with a mental illness.  Over 1 in 5 youth (ages 13-18), either currently or at some point during their life, have had a seriously debilitating mental illness, and about 1 in 25 U.S. adults lives with a severe mental illness, such as schizophrenia, bipolar disorder, or major depression.  Patients may not be entirely sure what is affecting them and seek help from a professional to determine the cause and get a diagnosis and treatment for the issue.  Many mental health services are available to patients to treat these conditions; this blog will discuss Psychiatric diagnostic treatment.

What is a Psychiatric Diagnostic Evaluation?

Psychiatric diagnostic treatment describes services where the provider collects information about a patient’s present and past behavior and obtains a past family, medical, and social history for a diagnostic evaluation of that patient; these services can instill medical services such as a physical exam and medication management and administration.  Providers can utilize two CPT codes for these services, 90791 or 90792.

Psychiatric Diagnostic Evaluation

Psychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including history, mental status, and recommendations. In addition, the evaluation may include communication with family or other sources and review and ordering of diagnostic studies.

Psychiatric Diagnostic Evaluation w/ Medical Services

Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations. In addition, the evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies.”

Psychiatric Diagnostic Evaluation CPT Codes

There are two codes for psychiatric diagnostic evaluation:

  • 90791 Psychiatric diagnostic evaluation
  • 90792 Psychiatric diagnostic evaluation with medical services

Eligible Providers

  • Psychiatrists (MD, DO)
  • PhD. level psychologists (LP-PhD)
  • Master’s level psychologists (LP-MA)
  • Licensed independent clinical social workers (LICSW)
  • Certified nurse specialists in psychiatry (CNS-Psych)
  • Licensed marriage and family therapists (LMFT)
  • Licensed professional clinical counsellor (LPCC)
  • Psychiatric mental health nurse practitioners (PMHNP)

90791 is often utilized by following providers, psychologists, social workers and other licensed behavioral health professionals, and 90792 is used by psychiatrists, psychiatric nurse practitioners and physician assistants because it includes medical services, physical exams, medication management and modifying psychiatric treatment. When billing Medicare and Medicaid, organizations must follow their billing policies and state law regarding who can perform the work.

Can 90791 be billed with 90792

You can bill 90791 and 90792 on the same day if:

  • A clinical social worker completes the 90791 assessments, and the treating psychiatrist completes the 90792 assessments
  • Payer policy permits

Some may try to bill both codes on the same day for the same client; the payer may deny or question why two providers/clinicians did an initial evaluation on the same service date and may not be willing to reimburse for both codes. I have thought this to myself when coming across this at times.  But sometimes, the patient’s condition also warrants an evaluation from the psychiatrist or NPP.  In some cases, the 90791 is billed for the visit with the social workers, and the psychiatrist bills using the E/M consultant code 99242-99245, If their payer accepts those or 99202-99215 in the outpatient setting and 99221-99223 for the inpatient setting. 

Per CPT, the psychiatric diagnostic evaluation may include interactive complexity services when factors complicate the delivery of the psychiatric procedure.  These services should be reported with 90785 used in conjunction with the diagnostic psychiatric codes 90791, 90792

Medicare Billing Requirement

Some payers allow providers to bill for diagnostic psychiatric evaluation codes every six months, but most will only reimburse the code once per year per patient. Therefore, the organization must check the coverage and eligibility of these services before it is performed more than once a year.

Per CMS, “A psychiatric diagnostic evaluation or a psychiatric diagnostic evaluation with medical services can be conducted once, at the onset of an illness or suspected illness. However, the same provider may repeat it for the same patient if an extended break in treatment occurs, if the patient requires admission to inpatient status for a psychiatric illness, or if a significant change in mental status requires further assessment. This contractor considers an extended break of approximately six months from the last time the patient was seen or treated for their psychiatric condition. A psychiatric diagnostic evaluation may also be utilized again if the patient has a previously established neurological disorder or dementia and there has been an acute and marked mental status change. Alternatively, a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.

An E/M service may be substituted for the initial interview procedure provided required elements of the E/M service billed are fulfilled. E/M services require, in addition to the interview and examination, E/M services require a written opinion and advice. E/M CPT codes do not include a psychotherapy service”.

Both codes are on the list that can be performed using audio and visual communication and audio-only telecommunication with documentation in the record stating why the patient is using audio-only requirements post PHE.

Documentation Requirements of 90791

Medicare also has specific documentation rules associated with code 90791; most payers follow these requirements. Here’s what your documentation should include:

  • Elicitation of a complete medical and psychiatric history
  • Mental status examination
  • Evaluation of the patient’s ability and capacity to respond to treatment
  • The initial plan of treatment
  • Reported once per day
  • Not reported say day as E/M service performed by the same provider
  • Covered at the outset
  • Exact time record
  • Modalities and frequency 
  • Clinical notes that summarize:
  • Diagnosis
  • Symptoms
  • Functional status
  • Focused mental status examination
  • A treatment plan, prognosis, and progress
  • Name, signature, and credentials of the person providing the service

Documentation Requirements of 90792

The above is listed for 90792, in addition to the below:

  • Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations.
  • Additional exam elements (pertinent to care). Prescription of medication or coordination of medications as part of medical care.
  • Order/review of medical diagnostic studies – Lab, imaging, and other diagnostic studies.
  • Medical thought processes must be clearly reflected in the assessment and plan.

Diagnosis codes

Diagnosis codes should be coded to the highest level of specificity. Any signs or symptoms that may show progression or side effects to treatment.

Coding Example

The APA (American Psychiatric Association) has a great Q/A:

Q: What CPT code is appropriate for a psychiatrist to bill to evaluate a patient in the emergency room (ER) setting? Would the ER E/M CPT codes (99282-99291) be appropriate if the patient was already seen by a clinical social worker and the clinical social worker was billing for the psychiatric evaluation using 90791? Or would the psychiatrist be allowed to bill for CPT code 90792 on the same day the clinical social worker used 90791?

A: Usually, the ER codes are billed by the ER physician who sees the patient in the ER. The psychiatrist who sees the patient in the ER is doing so as an outpatient consultation. He/she could use the E/M outpatient consult codes (99242-99245) or 90792, the code for a psychiatric diagnostic evaluation with medical services. If the patient has Medicare, you can’t bill the consult codes; instead, use the new outpatient E/M patient codes, 99202-99205 or 90792.

If a social worker and psychiatrist each did a complete patient evaluation, the social worker could bill a 90791 (the code for a psychiatric diagnostic evaluation that does not include a medical component) and the psychiatrist a 90792. However, even with this, many payers would likely question why both clinicians needed to do an initial evaluation, and some payers may have a policy against paying for two evaluations on the same day and, therefore, may not reimburse for both.

Sometimes if a social worker bills for a 90791 and psychiatrist bills using the E/M consult codes (99242-99245), the payer accepts this combination even if it wouldn’t accept the 90791 + 90792 combination. For example, if the patient is admitted to the inpatient psychiatry service and the same psychiatrist cares for them, the psychiatrist can use the initial hospital care E/M codes (99221-99225) to cover both the consult and initial psychiatric evaluation.

Summary

Various resources and mental health locations are available nationwide to support people suffering from mental health. Unfortunately, so many people continue to suffer in silence. No one should feel alone or do not know where to go for help. Check out the National Institute of Mental Health (NIH) for more tips and referrals. Also listed is the number for the suicide hotline:

988 (Suicide Hotline) 
SAMHSA’s National Helpline, 1-800-662-HELP (4357)

To schedule training for your organization or private practice providers or schedule a chart review email us today at info@kwadvancedconsulting.comschedule a call or visit the website and fill out the “contact us” form.

Resources

https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/coding-and-reimbursement/frequently-asked-questions

https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/31887_33/Outpatient_Psych_Fact_Sheet09.18.14.pdf

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57480#:~:text=Psychiatric%20Diagnostic%20Interview%20Examination%20(90791,an%20illness%20or%20suspected%20illness.

https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.12a27

2 thoughts on “Using 90791 vs 90792”

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