What CPT code do you all use for a new inpatient consult on a demented patient?

[J ROD]

Usually the consult is for help with medication management of agitation etc. I am new to this and have been using 90792 and our coders have been changing it to 99214 or 99233 which is an outpatient follow up? and subsequent hospital, which is closer. I usually get most of the info from collateral after a cognitive exam, which I admit is usually not a full MoCA. I read where 90792 cannot be used unless there is an abrupt change in mental status. I am really confused bc I spend more time on these consults doing the med management and collateral. How are they billing those codes for that service? It is a new evaluation for me or should I just do a consult follow up note and use 99231-33. And not spend that much time trying to get information and just do med management. Thanks to anyone that can help. I know it is a detailed question but nobody teaches this. I just happened to look at my charges and was like wtf!

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[nexus73]

90792 should work for new evaluation anywhere. If patient is inpatient status use codes 99221-99223, if observation status you use outpatient codes 99203-99205. You’d never use a follow up code for a new eval... unless observation status and patient has been seen by you or member of your group on the last three years. In which case 90792 is usually allowed and simpler to remember.

 

[J ROD]

that's what I thought too but 90792 when i read the code closer it says it can only be used for neurocognitive if there is an abrupt change in mental status. Most of the ones I am seeing are what they are and cannot give me much info so I have to put cannot obtain over my ROS and most of HPI is chart and collateral. I still do not believe the coders are billing correctly. I tried to redo it with 99222. Bc it is the first time I am seeing them.....how can it be subsequent. And the outpatient billing makes no sense to me.

 

[hamstergang]

that's what I thought too but 90792 when i read the code closer it says it can only be used for neurocognitive if there is an abrupt change in mental status.

Can you post a link to this?

 

[Psych19]

I've never heard that 90792 can only be used for an abrupt change in mental status. I too would appreciate knowing where you read this.

New evaluation (patient admitted medically): I think you're allowed to use any of the following...
90792 (any insurance)
99254 or 99255 (private insurance, medicaid)
99222 or 99223 (medicare)

I think you could also bill 99222 or 99223 for private insurance or medicaid, but I'm not sure why you would because the inpatient consult codes are worth more RVUs, especially 99254 vs 99222 which I think represent exactly the same level of complexity and have the same documentation requirements. I think there's an argument to be made to just always bill 90792 unless you have a patient who meets the highest level of medical complexity (99255 or 99223).

New evaluation (patient seen on medical, observation status): 90792 or 99204 or 99205. Can't do either of the latter two if the patient has been seen by you or anyone in your group practice in the last 3 years. I pretty much always just bill 90792 because it's easy and it's worth more RVUs than 99205 anyways.

 

[J ROD]

CPT CODE 90791, 90792 ,90785 – Psychiatric diagnostic evaluation | Medicare Payment, Reimbursement, CPT code, ICD, Denial Guidelines

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 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.

 

[J ROD]

only reason I can find unless they are just wrong. Going to address Monday

 

[nexus73]

the language about Dementia “preventing effective communication“ is pretty nebulous. I mean I can have a mostly irrational conversation with a dementia patient for 30 minutes, but It can still be useful and effective. I can imagine they don’t want psychiatrists billing for 1 minute encounters due to communication problems and billing 90792.

 

[hamstergang]

CPT CODE 90791, 90792 ,90785 – Psychiatric diagnostic evaluation | Medicare Payment, Reimbursement, CPT code, ICD, Denial Guidelines

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 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.

Unless I'm reading this very repetitive website incorrectly, all of what you quoted is under 90791, not 90792.

 

[J ROD]

that's correct. But it is the only thing i can find that may be why? I am not really down with this coding crap

 

[nexus73]

that's correct. But it is the only thing i can find that may be why? I am not really down with this coding crap

Coders may not know the details as well as you even though it’s their job. Especially if they code for multiple specialties. Plus the coders are probably more worried about avoiding an audit than whether you bill a code worth 1.5 vs 3.76 RVUs. Because it doesn’t affect their income. The hospital is making so much more than your professional fee it’s a no brainer for them to be cautious about coding.

 

[FlowRate]

that's correct. But it is the only thing i can find that may be why? I am not really down with this coding crap

If I understand correctly, you've been billing 90792 and the front line coding staff have been changing it to a lower RVU code. Presumably you're being called for diagnostic clarification so that fits neatly into what you had posed as for reasons you can still bill 90792 with a demented patient. I would escalate to a coding manager or to your manager/admin rep if the billing at all affects your pay/productivity metrics, etc.

 

[J ROD]

If I understand correctly, you've been billing 90792 and the front line coding staff have been changing it to a lower RVU code. Presumably you're being called for diagnostic clarification so that fits neatly into what you had posed as for reasons you can still bill 90792 with a demented patient. I would escalate to a coding manager or to your manager/admin rep if the billing at all affects your pay/productivity metrics, etc.

Mainly it is for management of agitation. Medication. One did ask for depression in addition of the before mentioned. No matter it should not be a subsequent visit as I have never evaluated the patient before 99233 and definitely not a 99214 which is an outpatient code as I am definitely seeing an inpatient on the floor admitted. I have thought about using 99221-23 as it appears after reading through their materials suggested to me they are more familiar with that code. But, yeah, I am going to talk with their supervisor again. She gave me the materials I looked over from organization.

 

[J ROD]

Can you bill for delirium due to a medical condition under 90792? My billing manager said I could not and so what am I supposed to bill when I get consulted for a patient with dementia that is delirious and/or demented and they need help with agitation etc. She told me I basically could not bill for dementia either or neurocognitive disorder. Can I use 99221-23 as the codes as that would include more medical dx? Even if not a medicare pt? Any dx codes would be appreciated.

 

[NickNaylor]

I'm confused about the confusion... why are you being told that you can't bill a new consult code for a patient with dementia? That makes absolutely no sense. I do this all the time and have never had our billing folks harass me about it. I have never once billed 90792 and work in consult, ED, outpatient, and inpatient settings.

It sounds like your billing staff have no idea what they're doing or there's something that I'm missing here.

 

[J ROD]

Yeah, I am going to give it a month and see what happens. I spend more time worrying about billing than patients.

 

[clausewitz2]

This reminds me of when a biller insisted I couldn't bill an encounter with the primary diagnosis of insomnia....

...in a sleep clinic.

 

[michaelrack]

This reminds me of when a biller insisted I couldn't bill an encounter with the primary diagnosis of insomnia....

...in a sleep clinic.

Maybe you were credentialed with insurers who had mental health carve outs, and you weren't credentialed with the regular plan (of course the billing department should have taken care of the problem before you started working in the sleep clinic if that was the case).