Documentation for 90785

[AD04]

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For those who uses 90785 billing code, how do you document to justify the billing code?

Would needing to get collateral to get the whole picture be "maladaptive communication"?

I bill this 1 or 2x / day. How closely do audits look at 90785?

 

[WisNeuro]

May depend on the insurer, BCBS audits that one a lot here.

 

[calvnandhobbs68]

For those who uses 90785 billing code, how do you document to justify the billing code?

Would needing to get collateral to get the whole picture be "maladaptive communication"?

I bill this 1 or 2x / day. How closely do audits look at 90785?

Yeah I'm wondering this too because I'm planning to try to utilize this more. Also not clear how much this typically reimburses either (aka how much it's even worth the time to try to justify it).

 

[clozareal]

For those who uses 90785 billing code, how do you document to justify the billing code?

Here are some documentation requirements:

1. The need to manage maladaptive communication (related to, e.g, high anxiety, high reactivity, repeated questions or disagreement) among participants (i.e., clinician + patient, caregiver + caregiver, patient + caregiver, clinician + caregiver), that complicates delivery of care.
2. Caregiver emotions or behaviors that interfere with implementation of the treatment plan
3. Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.
4. Use of play equipment, physical devices, interpreter or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not developed or lost expressive or receptive language skills to use or understand typical language. You should NOT bill this solely because you need an interpreter though since this violates federal laws prohibiting discrimination on the basis of beneficiary's ethnicity.

Complicating communication factor must be present during the visit.

Do NOT use the 90785 code when you're also billing with psychotherapy crisis codes or family psychotherapy. You're expected already to have interactive complexity with those two situations. Also, do not use it with only the E/M codes without psychotherapy add on. You can use 90785 in conjunction with psychiatric diagnostic evaluation codes and psychotherapy add on codes.

Would needing to get collateral to get the whole picture be "maladaptive communication"?

Probably. Depends on who that collateral is. If it's child welfare agencies, parole or probation officers, or schools then yes you can document interactive complexity. But usually if you just need to get a better picture (collateral to assess for mania history for example), then probably not unless that collateral really had maladaptive communication with you or the patient that you had to manage (disagreements, arguments, high anxiety/tension between you and them that was getting in the way of you getting information easily).

I bill this 1 or 2x / day. How closely do audits look at 90785?

I sometimes bill for this up to 4-6x per day for my patients, but it's much easier when you're working with children and adolescents since interactive complexity is commonly present.

 

[AD04]

Probably. Depends on who that collateral is. If it's child welfare agencies, parole or probation officers, or schools then yes you can document interactive complexity. But usually if you just need to get a better picture (collateral to assess for mania history for example), then probably not unless that collateral really had maladaptive communication with you or the patient that you had to manage (disagreements, arguments, high anxiety/tension between you and them that was getting in the way of you getting information easily).

Why does maladaptive communication depend on who the collateral is? Why isn't the inability to give the full picture thus needing collateral considered maladaptive communication? That complicates care. "E.g." signifies examples and the examples given do not comprise a comprehensive list. A comprehensive list would use "i.e." to clarify what maladaptive communication meant.

 

[clozareal]

Why does maladaptive communication depend on who the collateral is? Why isn't the inability to give the full picture thus needing collateral considered maladaptive communication? That complicates care. "E.g." signifies examples and the examples given do not comprise a comprehensive list. A comprehensive list would use "i.e." to clarify what maladaptive communication meant.

Because getting collateral is expected in certain situations, such as if it's a child or elderly patient who has a caregiver. You aren't going to bill for interactive complexity for every child patient because you needed to speak to their parents. What I was saying above was there wasn't enough information which is why I said it depends.

 

[nexus73]

shouldn’t there sometimes be a separate full bill for the difficult parents? Like, the kiddo is a 99214, and the parents are their own 99214 because seriously they can be a lot to handle.

 

[calvnandhobbs68]

shouldn’t there sometimes be a separate full bill for the difficult parents? Like, the kiddo is a 99214, and the parents are their own 99214 because seriously they can be a lot to handle.

You can technically bill a 90792 as a “diagnostic assessment” using just parents as informants (but pretty sure you can only do this once per certain time period).

I think there’s also separate codes for visits without the patient if needed (so like to deal with difficult caregivers all by themselves) but not sure what the codes/reimbursement are for those.

 

[AD04]

I found a YT video that explained 90785 a bit more:




The lady gave an example of a recovering addict bringing another person to the session to help with sobriety as counting as interactive complexity. She also mentioned that if the children are young enough, all of them can qualify for 90785.

The phrase "maladaptive communication" is so broad. So here a few cases with impairment in communication and let me know if the cases would meet the criteria for 90785 and explain why or why not each case meets the criteria:

1. 65 yo man with mild dementia living in ALF has telepsychiatry outpatient appointment. During the session, the man and staff from ALF participated. Information from man was limited and extra information had to be provided by staff. Psychiatrist had to explain treatment to staff.

2. 23 yo female with acute mania on inpatient unit. During the session, information from patient was limited as she had severe flight of ideas. Patient gave the ok to contact her parents and to discuss care. Dad provided more information including medication history and therefore, the best treatment was determined with help of dad's information and with dad's approval.

3. 37 yo female comes to outpatient appointment with husband. Wife wanted husband to be in the appointment with her. The wife suffers from severe depression and is sometimes not even motivated enough to take her medications. Wife answers, "I don't know," to many questions. Husband is able to give collateral and will help administer medications to wife to ensure compliance. Psychiatrist explains treatment to wife and husband.

 

[nrmp]

I found a YT video that explained 90785 a bit more:




The lady gave an example of a recovering addict bringing another person to the session to help with sobriety as counting as interactive complexity. She also mentioned that if the children are young enough, all of them can qualify for 90785.

The phrase "maladaptive communication" is so broad. So here a few cases with impairment in communication and let me know if the cases would meet the criteria for 90785 and explain why or why not each case meets the criteria:

1. 65 yo man with mild dementia living in ALF has telepsychiatry outpatient appointment. During the session, the man and staff from ALF participated. Information from man was limited and extra information had to be provided by staff. Psychiatrist had to explain treatment to staff.

2. 23 yo female with acute mania on inpatient unit. During the session, information from patient was limited as she had severe flight of ideas. Patient gave the ok to contact her parents and to discuss care. Dad provided more information including medication history and therefore, the best treatment was determined with help of dad's information and with dad's approval.

3. 37 yo female comes to outpatient appointment with husband. Wife wanted husband to be in the appointment with her. The wife suffers from severe depression and is sometimes not even motivated enough to take her medications. Wife answers, "I don't know," to many questions. Husband is able to give collateral and will help administer medications to wife to ensure compliance. Psychiatrist explains treatment to wife and husband.

Good examples but the problem is how do use for E/M f/u visit where you didn't provide any therapy so you can't use 90833.

 

[AD04]

Assuming you're billing 90792.

Or assuming you're billing for psychotherapy as well.

 

[calvnandhobbs68]

Good examples but the problem is how do use for E/M f/u visit where you didn't provide any therapy so you can't use 90833.

Yep you can't do it unless you're billing some kind of psychiatry code (not just a regular E+M code). So has to be 90792 or a therapy add on code.

 

[Stagg737]

Bit of a necro-bump, but wanted to clarify since I never used this code in residency. Say you see a patient in the ER who is acutely psychotic/manic/AMS who is refusing treatment, there should be no problems billing 90785, correct?

What about a case when you're doing an initial consult for capacity and the patient clearly has AMS and is not agreeable to treatment? Can you add 90785 onto the 90792 here? Seems like many cases where a patient lacks capacity would meet the first point for use of 90785.

 

[splik]

Bit of a necro-bump, but wanted to clarify since I never used this code in residency. Say you see a patient in the ER who is acutely psychotic/manic/AMS who is refusing treatment, there should be no problems billing 90785, correct?

What about a case when you're doing an initial consult for capacity and the patient clearly has AMS and is not agreeable to treatment? Can you add 90785 onto the 90792 here? Seems like many cases where a patient lacks capacity would meet the first point for use of 90785.

I don’t think either of these instances would qualify since they are very straightforward situations.

 

[Stagg737]

I don’t think either of these instances would qualify since they are very straightforward situations.

I thought that, but looking at the actual CMS website criteria only one of the four listed conditions above needs to be met and doesn't say anything about the actual level of complexity. For the former situation an involuntary hold would be filed, so technically getting the legal system involved. For the capacity one, if they don't have capacity then someone else is taking over medical decision-making which definitely increases complexity if there's a DPOA involved.

ETA: Looking into it more, it looks like there were updates for 2022 because CMS felt it was being over-utilized. The manual now specifically says there has to be "increased complexity of the service due to specific communication factors which can result in barriers to diagnostic or therapeutic interaction with the patient". It looks like 90785 also can no longer be used just because translation or interpreter services are used. So looks like my examples may have been acceptable previously but not anymore due to the newer clarifications.

 

[splik]

ETA: Looking into it more, it looks like there were updates for 2022 because CMS felt it was being over-utilized. The manual now specifically says there has to be "increased complexity of the service due to specific communication factors which can result in barriers to diagnostic or therapeutic interaction with the patient". It looks like 90785 also can no longer be used just because translation or interpreter services are used. So looks like my examples may have been acceptable previously but not anymore due to the newer clarifications.

your examples were never allowable. And billing 90785 (or anything for that matter) for using an interpreter was always a violation of discrimination laws.

 

[AD04]

Bit of a necro-bump, but wanted to clarify since I never used this code in residency. Say you see a patient in the ER who is acutely psychotic/manic/AMS who is refusing treatment, there should be no problems billing 90785, correct?

What about a case when you're doing an initial consult for capacity and the patient clearly has AMS and is not agreeable to treatment? Can you add 90785 onto the 90792 here? Seems like many cases where a patient lacks capacity would meet the first point for use of 90785.

I would read through the guideline for 90785 and go through the YouTube video I posted back in February 2021 upthread. Communication with someone who has acute psychosis / mania / AMS is not straight forward. Someone who is refusing treatment due to aforementioned symptoms will fall into maladapative communication of disagreeing with prudent treatment and / or lack of understanding. So it would qualify, especially if a third party is involved to help make medical decisions.

Main thing is to document it. Again, the YouTube video is very helpful so go through it.

 

[Stagg737]

your examples were never allowable. And billing 90785 (or anything for that matter) for using an interpreter was always a violation of discrimination laws.

I would read through the guideline for 90785 and go through the YouTube video I posted back in February 2021 upthread. Communication with someone who has acute psychosis / mania / AMS is not straight forward. Someone who is refusing treatment due to aforementioned symptoms will fall into maladapative communication of disagreeing with prudent treatment and / or lack of understanding. So it would qualify, especially if a third party is involved to help make medical decisions.

Main thing is to document it. Again, the YouTube video is very helpful so go through it.

I'm having a hard time reconciling these two posts. I'll check out the video, but language from the primary document sounds pretty clear to me but obviously is not. @splik , why were those examples not allowable? Per plain language in the CPT coding guide, there's nothing stating it couldn't be allowable until the 2022 update when clarifications were made, which I assume would be because people were utilizing them in ways CMS just didn't like. Why would they not have been allowable?

 

[rjs2131]

Are people actually seeing a significant difference in reimbursement with using the 90785? Seems like this would add maybe a few hundred dollars over the course of a year (unless you're using it for most patients, but even then maybe like 2-3k at best). Not worth the hassle for me but interested to hear how this varies across practices/regions.

 

[Stagg737]

Are people actually seeing a significant difference in reimbursement with using the 90785? Seems like this would add maybe a few hundred dollars over the course of a year (unless you're using it for most patients, but even then maybe like 2-3k at best). Not worth the hassle for me but interested to hear how this varies across practices/regions.

I'm curious because in my current position I could see myself using this 4-5x per day on some days and likely at least once or twice per day, so could potentially add a couple of hundred RVUs to the total.