CPT Code 90792: Know Your Codes
CPT Code 90792: Psychiatric Diagnostic Evaluation with Medical Services
CPT Code 90792 is used for an initial diagnostic interview exam for an adult or adolescent patient that includes medical services. 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 ordering and medical interpretation of laboratory or other diagnostic studies.
In the past, most insurers would reimburse for one 90792 (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 90792 per year for institutionalized patients unless medical necessity can be established for others. Medicare permits the use of this code or the appropriate level of the E/M codes to denote the initial evaluation or first-day services for hospitalized patients. Medicare also allows for the use of 90792 if there has been an absence of service for a three-year period.
FAQs on CPT Code 90792
There are two codes to use for a standard initial psychiatric diagnostic evaluation, 90791 and 90792. Why was this done?
Previously all mental health clinicians use the same initial evaluation codes, 90801 and 90802, even though nonmedical providers could not provide the medical work that was described in those codes. In 2013, psychiatrists can use code 90792, which indicates medical services were provided, while nonmedical providers will use 90791, which does not include medical services. Medical services may consist of any medical activities such as performing elements of a physical exam or considering writing a prescription or modifying psychiatric treatment based on medical comorbidities.
In looking at the 2013 Medicare Physician Fee Schedule, one can notice that Medicare is paying more for CPT code 90791, the code for the psychiatric diagnostic evaluation without medical services, than it is for 90792, the same code with medical services. How could this be?
These two codes were created to distinguish the work done by psychiatrists from that done by nonphysicians. They replace 90801, which was used by all mental health providers even though its descriptor included medical services that many of them were not qualified to perform. Unfortunately, and completely contrary to the usual procedure for newly created CPT codes, the Centers for Medicare and Medicaid service (CMS) chose to implement the new CPT coding structure for psychiatry without finalizing new values (RVUs), as is normally the case.
Instead, CMS created interim values for the new codes based on the 2012 code values and applied them to the 2013 coding structure. In order to maintain budget neutrality for 2013, CMS reduced the practice expense component for codes billed exclusively by medical professionals even though other changes to the code values were not made, while letting the practice expense value remain the same for nonphysician codes. The rationale given by CMS for this was that those providers are now able to bill evaluation and management (E/M) services would benefit from higher practice expense payments any time they billed an E/M code. Oddly, CMS chose to apply this rationale not only to the values for the psychotherapy add-on codes that are used with E/M codes but also to apply it to the initial diagnostic evaluation (90792) that includes medical services – a service that cannot be billed with an E/M code.
As a result of this formula, the total payment for the 90792 is less (by about $25) than that for the 90791 even though the work is greater, the malpractice liability is greater, and the practice expense values are certainly no less than that for all mental health clinicians. Once the values are finalized and the practice expense is calculated equally, 90792 will pay more than 90791. Regardless of this, APA has made it clear to CMS that it is unacceptable for this current inequity to be in place even on an interim basis. This anomaly incentivizes psychiatrists to code differently than they otherwise should. APA has asked CMS in multiple written communiqués and telephone conversations to correct this discrepancy but to date, they have stood behind their decision despite the inequity and perverse incentives it has created in valuing a more complex service lower than the same service done without medical services.
What CPT code would be appropriate for a psychiatrist to bill for the evaluation of a patient in the emergency room setting? Would the ER evaluation and management CPT codes (99281- 99291) be appropriate if the patient was already seen by a clinical social worker and the clinical social worker is billing for the psychiatric evaluation by using CPT 90791? Or, would the psychiatrist be allowed to bill for CPT code 90792 on the same day the clinical social worker used CPT 90791?
Usually, the ER codes would be 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 (99241-99245) or 90792. (If the patient has Medicare, you can’t bill the consult codes, but can use the outpatient E/M new patient visit codes, 99201-99205, instead, or 90792). If both a social worker and a psychiatrist each did a complete evaluation on a patient, the social worker could bill a 90791 and the psychiatrist a 90792. That said. Although you could code this way, it is likely that many payers would question why it was necessary for both clinicians to do an initial evaluation and they may not be willing to reimburse for both. If the patient is admitted to the inpatient psychiatry service, the psychiatrist would use the initial hospital care E/M codes (99221-99225), which would cover both the consult and initial psychiatric evaluation.
Do we recommend using the E/M new patient codes or 90792?
You could use either. There may be times, based and the presenting problem and the complexity of the work performed, when a higher-level E/M code may be more appropriate.
Does 90792 cover deciding and prescribing medications in the session?
Yes, that could be one component of the medical service that differentiates 90792 from 90791.
Are there specific requirements for 90792, and are there other codes for new patients beyond 90791 and 90792?
The documentation requirements for the 90792 are really the same as the documentation for 90801. The only difference is you will want to be sure to list any of the medical work when billing the 90792. Psychiatrists and others who can bill E/M codes may also choose to bill an initial evaluation with the appropriate E/M code.
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 info@e2eMedicalBilling.com