Follow These Rules of Thumb for Coding E/M or Psychiatric Evaluation
See which specific services distinguish an E/M encounter from a psychiatric visit. Accurate coding in behavioral health requires a clear understanding of how evaluation and management (E/M) services intersect with psychiatric diagnostic evaluations. Missteps in this area are a frequent source of claim denials, compliance risks, and adverse audit findings. This article clarifies whether you can or cannot bill an E/M service on the same date of service as a psychiatric diagnostic evaluation and how to appropriately distinguish between these coding pathways. Check back next month for more information on how to ensure accuracy and compliance. Understanding the Code Sets Psychiatric diagnostic evaluation CPT® codes 90791 (Psychiatric diagnostic evaluation) and 90792 (Psychiatric diagnostic evaluation with medical services) are specifically designed for initial intake assessments when a patient begins mental health treatment. A comprehensive medical and mental health history, a mental status examination, risk assessment, diagnostic formulation, and treatment plan of care are included with each. CPT® code 90792 includes all of the components of 90791 with the addition of medical services, such as prescribing medication and ordering lab tests or other medical workup. The provider may also evaluate the patient for adverse drug reactions. While both codes establish a treatment plan through a comprehensive evaluation, 90791 is typically used for psychotherapy-focused assessments, while 90792 is used for medically oriented psychiatric evaluations. Correspondingly, 90792 may be used by medical practitioners such as psychiatrists, medical doctors (MDs) and doctors of osteopathy (DOs); and nonphysician practitioners (NPPs) such as nurse practitioners (NPs) and physician assistants (PAs). CPT® code 90791 may be used by psychologists, licensed professional counselors (LPCs), licensed clinical social workers (LCSWs), licensed marriage and family therapists (LMFTs), and other licensed nonprescribing behavioral health professionals, in addition to MDs, DOs, and NPPs. Importantly, both codes may also be used for reassessments for a patient after an extended break in treatment occurs or for a new episode of care for an existing patient. Consider Differences for E/M Codes E/M codes represent medical visits driven by medical decision making (MDM) or total time, and in the setting of behavioral health, are typically used for: E/M services may only be reported by qualified medical providers with prescribing authority. Key considerations for practitioners who may report either an E/M or a psychiatric diagnostic evaluation are: The Core Rule: No Same-Day Reporting of 90791/90792 and E/M Services E/M services and psychiatric diagnostic evaluations are mutually exclusive and may not be reported together. Per guidance from the Centers for Medicare & Medicaid Services (CMS) and the National Correct Coding Initiative (NCCI edits): E/M codes are considered column 2 codes to 90791 and 90792 and cannot be reported on the same date of service by the same provider. These edits carry a modifier indicator of “0,” meaning they cannot be overridden under any circumstances. This rule exists because psychiatric diagnostic evaluations are comprehensive services that already include the evaluation components of E/M services. Reporting both services would constitute duplicative billing, often referred to as “double-dipping,” and may trigger payer denials or audit scrutiny. Do This When 2 Providers See Patient on Same Day An important distinction to the same-day billing restriction applies when services are performed by two different providers. In these situations, it may be appropriate to report both a psychiatric diagnostic evaluation (90791 or 90792) and an E/M service on the same date of service, provided specific criteria are met. The NCCI edits apply to services reported by the same provider or providers of the same specialty within the same group practice. When two separate providers are involved, billing both services may be allowable if the services are distinct, medically necessary, and separately documented. Check back next month for more information on maintaining compliance when coding psychiatric evaluations and E/M services, as well as some scenarios where you can check your understanding. Sarah Jakubowski, RHIT, CPC, CPMA, Consultant,
Pinnacle Enterprise Risk Consulting Services
