90791 CPT Code: Know Your Codes
Basics of 90791
90791 CPT Code is used for an initial diagnostic interview exam that does not include any medical services. In all likelihood,this code will not be used by psychiatrists. It includes a chief complaint, history of present illness, review of systems, family and psychosocial history, and complete mental status examination, as well as the order and medical interpretation of laboratory or other diagnostic studies. In the past,most insurers would reimburse for one 90791 (then a 90801) per episode of illness. The guidelines now allow for billing this on subsequent days when there is a medical necessity for an extended evaluation (i.e., when an evaluation of a child that requires that both the child and the parents be seen together and independently). Medicare will pay for only one 90791 per year for institutionalized patients unless medical necessity can be established for others.
90791 CPT Code: Psychiatric Diagnostic Evaluation without Medical Services
According to the CPT manual, 90791 CPT Code is an “integrated biopsychosocial assessment, including history, mental status, and recommendations.” The manual goes on to say that the evaluation may include “communication with family or other sources and review and ordering of diagnostic studies.” In general, the code can be used by psychiatrists, clinical psychologists, licensed professional counselors, licensed clinical social workers, and licensed marriage and family therapists. However, when billing to Medicare and Medicaid, certain states may not allow reimbursement for non-psychiatrists, so be sure to check your state’s laws first.
The psychiatric diagnostic evaluation is not considered to be medically reasonable and necessary:
- when it is rendered to a patient who has a medical/neurological condition such as dementia, delirium, or other psychiatric conditions, which have produced a severe enough cognitive defect to prevent effective communication and the ability to assess the patient; or
- when the patient has a previously established diagnosis of a neurological condition or dementia and is not amenable to the evaluation and therapy, unless there has been an acute and/or marked mental status change, a request for a second opinion, or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable; or
- when a patient is referred with an organic diagnosis and a mental health diagnosis is established, the mental health diagnosis should be billed. Routine performance of additional psychiatric diagnostic evaluation of patients with chronic conditions is not considered medically necessary.
A psychiatric diagnostic evaluation can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient if an extended hiatus in treatment occurs if the patient requires admission to inpatient status for a psychiatric illness, or for a significant change in mental status requiring further assessment. An extended hiatus is generally defined as approximately 6 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/or marked mental status change, or a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.
Comparing 90791 and 90792
There’s one major difference between CPT Codes 90791 and 90792: the use of medical services.
- Whereas both codes are used for psychiatric diagnostic evaluations, 90791 CPT Code can’t include medical services and 90792 CPT Code can. Medical services may consist of any medical activity, such as writing prescriptions, performing physical exams, and modifying psychiatric treatment.
- You can bill CPT Codes 90791 and 90792 in conjunction with the interactive complexity code (90785 CPT Code), but can’t bill both codes on the same day as psychotherapy or E/M (evaluation and management) service performed by the same individual for the same patient.
Billing 90791 with 90792
You can bill CPT Codes 90791 and 90792 on the same day if:
- The 90791 code assessment is completed by a clinician (like a social worker) and a 90792 code assessment is completed by a psychiatrist
- It aligns with the payer policy
- If you bill both codes on the same day, though, it’s possible the payer will question why two clinicians did an initial evaluation and may not be willing to reimburse for both codes.
For CPT Codes 90791 and 90792
- In certain circumstances, one or more other informants (family members, guardians, or significant others) may be seen in lieu of the patient.
- Both codes may be reported more than once for the patient when separate diagnostic evaluations are conducted with the patient and other informants on different days.
- Use the same codes, for later reassessment, as indicated.
- Do not report on the same day as psychotherapy or an E/M service.
- If present, the interactive complexity component of the diagnostic evaluation is captured by reporting the interactive complexity add-on code 90785 in conjunction with CPT Codes 90791 or 90792.
To possibly get around this, you could have the clinician bill for 90791 CPT Code and the psychiatrist bill using the E/M consult codes (CPT Codes 99241 – 99245). You could also have the psychiatrist use the initial hospital care E/M codes (CPT Codes 99221 – 99225), which would cover both the consult and initial psychiatric evaluation, but that requires the patient to be admitted to the inpatient psychiatric service.
CPT © Copyright 2021 American Medical Association
For accurate Mental/Behavioral Health medical billing, knowing your CPT codes is the most important thing. In our blog series of ‘Know Your Codes’ or ‘KYC,’ we will discuss the most common CPT codes in detail and when to use them. E2E Medical Billing Services is known for it’s accurate Mental/Behavioral Health medical billing and coding. To know more about our services call us at 888-552-1290 or write to us at [email protected]