Psychiatry Coding & Reimbursement Alert

Published on Wed Jun 10, 2015 PDF

Question: An established patient in our psychiatry practice recently changed her insurance company to a new payer. Is it alright to report a new psychodiagnostic evaluation code such as 90792 to her new insurance?

Alabama Subscriber

Answer:  Just because the patient changed her insurance provider to a new one, you should not automatically report a fresh claim for psychodiagnostic evaluation using 90792 (Psychiatric diagnostic evaluation with medical services). You should only report this code for an encounter with the patient if it describes the service rendered and the service was medically necessary as supported by the documentation. To do otherwise may be unethical, and it might be considered fraud in the case of an audit.

From a CPT® perspective, code 90792 may be reported more than once for a patient when separate diagnostic evaluations are conducted with the patient and other informants. You should report the services as being provided to the patient and not the informant or other party in such circumstances. Also per CPT®, code 90792 may be reported only once per day and not on the same day as an evaluation and management service performed by the same individual for the same patient.

Some payers may have other limits on the reporting of 90792. For instance, some payers will pay for one 90792 per episode of illness, and Medicare will reportedly pay for only one 90792 per year for institutionalized patients unless medical necessity can be established for others. Examples of situations in which you might report an additional unit of 90792 include:

• Your psychiatrist is seeing the patient after a sufficiently long span (e.g. three years) that the patient is like a new patient and requires a new psychiatric diagnostic evaluation.

• There were some new developments, and your clinician had to review the patient’s mental status to help make changes in the patient’s treatment.

• The patient had not been conforming to his/ her medication regime, and it has had adverse effects on the patient’s treatment plan. Your clinician had to perform a fresh psychodiagnostic evaluation to check the adverse effects of discontinuation of her medication and to check for change in mental status.

So, don’t make the mistake of reporting a fresh claim for 90792 just because the patient now has new insurance. You can only make a fresh claim only if medical necessity for conducting the evaluation is proven, and you may need to provide documentation supporting your claim.