Psychiatry Coding & Reimbursement Alert

Look out for opportunities where you can add an interactive complexity component.

When your psychologist performs an initial psychodiagnostic evaluation of a patient, knowing the other codes you can and cannot report along with the CPT^® code 90791 will help improve your claims success for assessment services.

Understand the Scope of Service Provided

You report 90791 (Psychiatric diagnostic evaluation) when your clinician performs an assessment of the patient but the extent of the service does not include any medical services.

If any medical services such as an extended physical examination, review of systems (ROS), checking vital signs, assessment of the patient’s condition, prescription of psychiatric medication (as needed), assessing the patient for any adverse effect of drugs, ordering and interpreting lab tests and other imaging studies, and assessment of other medications that the patient is currently on and as well as possible drug interactions is performed, you’ll report those services with 90792 (Psychiatric diagnostic evaluation with medical services).

Keep in mind that 90791’s scope of services includes:

• History and mental status examination;
• Review and order of diagnostic studies as needed;
• Recommendations (including communication with family or other sources)

Caveat: Clinical social workers and clinical psychologists should not bill out 90792 as they cannot bill E/M codes for their services. They should only bill 90791 for an initial psychiatric diagnostic evaluation that they perform. The other professionals that can bill out 90791 for an initial diagnostic evaluation include registered nurse (RN), licensed mental health counselor (LMHC), licensed marriage and family therapist (LMFT), licensed psychoanalysts, and licensed creative arts therapist (LCAT).

Understand When to Bill More Than One Unit of 90791

Unlike many other psychiatry codes, 90791 is not a time-based code. So, regardless of the amount of time that your clinician spends in performing this service in a session, you’ll report only one unit of 90791. Even if your practitioner performs this service in more than one session in a single day, you’ll still report only one unit of 90791.

In the past, most payers would allow you to only report one unit of psychiatric diagnostic evaluation code per patient. Now, guidelines have been revised and payers will allow you to claim for more than one unit of 90791. So, if the sessions that your clinician performs were to be on different dates, you can claim for more than one unit of 90791. 

For example:  Your psychologist may see a patient during one session and then communicate in another session with family members to assess the patient’s condition and how their interactions are affecting the patient. But, when reporting more than one unit of 90791, you should provide documentation that specifies the medical necessity of having to extend the initial evaluation to be performed in multiple sessions on different dates.

Reminder: Medicare will allow only one claim of 90791 or 90792 in a year. However, in some cases, depending on medical necessity, Medicare might allow reimbursement for more than one unit of 90791. You can also report these codes when your psychiatrist is seeing the patient after a span of three years.

Claim Interactive Complexity When There are Communication Issues

If your clinician is performing an initial psychiatric evaluation and the service is complicated by communication factors, you can turn to add-on code +90785 (Interactive complexity [List separately in addition to the code for primary procedure]) when you are reporting 90791.

“Before 2013 the psychotherapy codes were differentiated based on if the service was interactive or non-interactive,” says Dreama Sloan-Kelly, MD, CCS, President of Kelly, Sloan and Associates, LLC whose offices are in Shirley, MA and Dallas, TX.  “When interactive complexity took place, code +90785 can be added to any psychiatry code except 90839, 90840, 90846, 90847, and 90849 when the main service is complicated usually by an issue with communication and there is a need for others to be involved in the treatment of the patient.”  This will help compensate for the extra time and effort that your clinician had to spend to overcome the communication difficulties that complicated the conduction of the diagnostic evaluation.

Example: Your psychologist reviews a six year old boy who has been referred by his pediatrician for psychotherapy and physical therapy as he is suffering from autistic disorder. Your psychologist reviews the patient’s history and performs a mental status examination. Since the child presents with communication difficulties your psychologist uses play equipment to assess and communicate with the child. Your psychologist also reviews assessment questionnaires that have been filled in by the parents. Since your psychologist used play equipment to overcome the difficulty of communication with the child, you report +90785 along with 90791.

Check What Services Cannot be Reported With 90791

If you clinician performs an initial psychodiagnostic evaluation and then plans to provide psychotherapy to the patient in the same session, you cannot use 90791 and the psychotherapy codes together, as Correct Coding Initiative (CCI) Edits do not allow these services to be billed together under any circumstances.

You should also keep in mind that CCI edits do not allow you to report 90791 and 90792 for the same patient on a single day unless the service is provided by two different clinicians. For example, you claim 90791 for services provided by your social worker and 90792 for assessment of the patient including medical services provided by your psychiatrist. Otherwise, if they are billed together, the claim for 90791 will be denied and only the claim for 90792 will be paid out.

Red flag: You are not allowed to bill out 90791 with any evaluation and management (E/M) service codes. Also, you cannot claim for crisis psychotherapy codes, 90839 (Psychotherapy for crisis; first 60 minutes) and +90840 (Psychotherapy for crisis; each additional 30 minutes [List separately in addition to code for primary service]) along with 90791.