when do you use 90792 code?

[Ahamis]

I wonder in what situations psychiatrists use 90792 code.

If you are doing an initial evaluation in two separate visits, would be ok to bill 99204/99205 for the first visit and 90792 for the second visit?
what is your approach for intakes that takes more time than you expected?

Thank you.

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[splik]

If you work in an RVU based practice, then using 90792 for initial evals makes sense. Otherwise, it doesn't make sense unless you have peculiar insurance contracts that reimburse more for it than the E&M codes.

Depending on the insurance you may be able to do Initial E&M for visit one and 90792 for visit 2. 90792 is a psych diagnostic eval code. It is not limited to use for initial sessions and can be used more than once (up to 3 times often depending on the insurance). However it would be unusual to do this. More common would be 90792 x2 OR 99205 and 99214+9083x for visit 2.

 

[calvinhobbes]

Initial visit eval for outpatient

 

[J ROD]

I was always taught that if they have been seen by your practice within the last 3 years outpatient you could not do an initial evaluation. However, I have heard others use the 90792 when seeing a new to them patient from a another provider in the practice. I did not do it as I was unaware when I took over couple hundred patients from NP that left the practice.

 

[psych_0]

On the inpatient unit 90792 is truly the burnout reducer for me. When I see the same malingerer I have discharged 4x in the last month, I used to feel an internal sense of annoyance and frustration. Now I celebrate these admissions because I know they will not take me long (90+% of the time) but still get me 4.16 wRVU.

 

[Stagg737]

Depending on the insurance you may be able to do Initial E&M for visit one and 90792 for visit 2. 90792 is a psych diagnostic eval code. It is not limited to use for initial sessions and can be used more than once (up to 3 times often depending on the insurance). However it would be unusual to do this. More common would be 90792 x2 OR 99205 and 99214+9083x for visit 2.

Is the bolded for the outpatient setting? How does that work? I thought each 90792 required "a full psychiatric evaluation with medical assessment" to use it, how do you justify doing that on back to back outpatient appointments when you're not completing a full eval during either one? Or am I misunderstanding?

To OP, we use this for ER evaluations and initial psych evals on the medical floors for consults. I can see a patient multiple times in a week or back to back days for separate ER visits. I also use this for initial evals outpatient unless I need to use time-based codes. I probably use it for 98%+ of new patient encounters. If intakes take too long then I just use 99205 + 99417x however many extra 15 minutes (need at least 2 to hit the same wRVUs as 90792, so at least 94 minutes). I'm paid based on RVU production.

 

[splik]

Is the bolded for the outpatient setting? How does that work? I thought each 90792 required "a full psychiatric evaluation with medical assessment" to use it, how do you justify doing that on back to back outpatient appointments when you're not completing a full eval during either one? Or am I misunderstanding?

Some people complete the diagnostic assessment over 2-3 visits. This is common in CAP and more complex cases.

 

[TexasPhysician]

Academic buddy gets bonuses based on RVU’s and 90792 has higher RVU’s.

I earn more with 99204 + 90833, so I use that.

 

[Stagg737]

Some people complete the diagnostic assessment over 2-3 visits. This is common in CAP and more complex cases.

So what are the restrictions here? What stops someone from just doing 3 30 minute "eval" appointments and billing a 90792 for each one since there's no time basis for 90792? Per CMS (their website) the requirements are:

- Elicitation of medical and psych hx (including past, family, and social)
- MSE
- Establishment of an initial diagnosis
- Eval of the patient's ability and capacity to respond to treatment
- Initial plan of treatment
- Reported once per day and NOT on the same day as an E/M service performed by the same individual for the same patient
- Covered once at the outset of an illness or suspected illness

That last line seems pretty clear that you can only bill this once for an eval, so how are people billing this twice? Or are they doing a full eval for different conditions/problems on each eval? I still don't understand how CMS wouldn't be coming after people for doing this...

 

[calvnandhobbs68]

So what are the restrictions here? What stops someone from just doing 3 30 minute "eval" appointments and billing a 90792 for each one since there's no time basis for 90792? Per CMS (their website) the requirements are:

- Elicitation of medical and psych hx (including past, family, and social)
- MSE
- Establishment of an initial diagnosis
- Eval of the patient's ability and capacity to respond to treatment
- Initial plan of treatment
- Reported once per day and NOT on the same day as an E/M service performed by the same individual for the same patient
- Covered once at the outset of an illness or suspected illness

That last line seems pretty clear that you can only bill this once for an eval, so how are people billing this twice? Or are they doing a full eval for different conditions/problems on each eval? I still don't understand how CMS wouldn't be coming after people for doing this...

Codes 90791, 90792 may be reported more than once for the patient when separate diagnostic evaluations are conducted with the patient and other informants

https://zerosuicide.edc.org/sites/default/files/Safer%20Suicide%20Care%20Billing%20Tip%20Sheet.pdf

Not with CMS though, CMS only lets you do this once as you pointed out but a lot of private insurances will let you do it more than once.

This is pretty common in CAP I’ve known a couple people who would do 2x 90792s for intakes, once primarily with parents and one primarily with the patient.

 

[Stagg737]

Codes 90791, 90792 may be reported more than once for the patient when separate diagnostic evaluations are conducted with the patient and other informants

https://zerosuicide.edc.org/sites/default/files/Safer%20Suicide%20Care%20Billing%20Tip%20Sheet.pdf

Not with CMS though, CMS only lets you do this once as you pointed out but a lot of private insurances will let you do it more than once.

This is pretty common in CAP I’ve known a couple people who would do 2x 90792s for intakes, once primarily with parents and one primarily with the patient.

Makes sense. I was always taught to just use it for the initial eval, but billing education in residency was grossly oversimplified and overly conservative in some aspects.

 

[Sushirolls]

I use 90792 in my private practice when I have the rare very fast consult that doesn't hit an hour. Or for some reason the note itself is very anemic. Typically I do 90 minutes 99205 with two 99417 add ons.

 

[lol.psych]

I use 90792 in my private practice when I have the rare very fast consult that doesn't hit an hour. Or for some reason the note itself is very anemic. Typically I do 90 minutes 99205 with two 99417 add ons.

Seconded.
(Though I haven’t had a consult take less than an hour, esp since the codes include stuff outside the appointment — reading the extensive intake questionnaire, reviewing labs if they have them, documentation, reaching out to their therapist/sending ROIs to establish contact…)
My typical intake is 99205+99417+99417.

 

[Merovinge]

Seconded.
(Though I haven’t had a consult take less than an hour, esp since the codes include stuff outside the appointment — reading the extensive intake questionnaire, reviewing labs if they have them, documentation, reaching out to their therapist/sending ROIs to establish contact…)
My typical intake is 99205+99417+99417.

I use 90792 in my private practice when I have the rare very fast consult that doesn't hit an hour. Or for some reason the note itself is very anemic. Typically I do 90 minutes 99205 with two 99417 add ons.

It's wild how good psychiatric care makes me excited, I get a little beaten down by reading awful records from other places/doctors. Awesome you both do evals like that for your patients.

 

[nexus73]

On the inpatient unit 90792 is truly the burnout reducer for me. When I see the same malingerer I have discharged 4x in the last month, I used to feel an internal sense of annoyance and frustration. Now I celebrate these admissions because I know they will not take me long (90+% of the time) but still get me 4.16 wRVU.

is 90792 still 4.16 RVUs?

 

[Stagg737]

is 90792 still 4.16 RVUs?

Yes

 

[Geraltofrivia]

In the ED, 99285 is the best code to use and what I was told. Basically if you do crisis work, you should be using two codes: 99285 or 99283. I could be wrong on this, but that's what billing people told me. Also btw, 90792 can only be used once per year.

99285: 4
99283: 1.6
90792: 4.16

 

[psych_0]

Also btw, 90792 can only be used once per year.

90792: 4.16

It can be used every single time they come back on inpatient. Even 2-3 days in a row if they keep discharging and coming back.

Source: Me, an inpatient doc

 

[Stagg737]

In the ED, 99285 is the best code to use and what I was told. Basically if you do crisis work, you should be using two codes: 99285 or 99283. I could be wrong on this, but that's what billing people told me. Also btw, 90792 can only be used once per year.

99285: 4
99283: 1.6
90792: 4.16

Yea, this is only applicable for certain settings (outpt). I've had patients that I saw for 3-4 unique ER encounters in a week and billed 90792 each time. I used to get my full monthly billing report from our financial person in our department and all of them were approved. If you're doing ER or inpatient work your billing people are wrong. If you're at an outpatient clinic then there's more nuance but that's generally correct.

 

[Wheatbread]

It can be used every single time they come back on inpatient. Even 2-3 days in a row if they keep discharging and coming back.

Source: Me, an inpatient doc

My coders won’t let us do this if used within one year.

 

[psych_0]

My coders won’t let us do this if used within one year.

Respectfully, you're getting hosed if you're getting paid via an wRVU bonus.

 

[Stagg737]

In the ED, 99285 is the best code to use and what I was told. Basically if you do crisis work, you should be using two codes: 99285 or 99283. I could be wrong on this, but that's what billing people told me. Also btw, 90792 can only be used once per year.

99285: 4
99283: 1.6
90792: 4.16

My coders won’t let us do this if used within one year.

So since multiple people are having this issue, it's good to review the actual federal guidelines for this. From CMS page on psychiatric and psychological services L34616:

"Psychiatric Diagnostic Evaluation
A psychiatric diagnostic evaluation is an integrated assessment that includes history, mental status and recommendations. It may include communicating with the family and ordering further diagnostic studies. A psychiatric diagnostic evaluation with medical services includes a psychiatric diagnostic evaluation and a medical assessment. It may require a physical exam, communication with the family, prescription medications and ordering laboratory or other diagnostic studies. A psychiatric diagnostic evaluation with medical services also includes physical examination elements.

Patients may need an evaluation and diagnosis by a multidisciplinary team prior to implantation of peripheral and central nervous system stimulators for chronic intractable pain. (See NCD 160.7 Electrical Nerve Stimulators.)

The following information pertains to both psychiatric diagnostic evaluation; and psychiatric diagnostic evaluation with medical services:

1. Cannot be reported with an E/M code on the same day by the same provider
2. Cannot be reported with a psychotherapy service code on the same day
3. May only be reported once per day
4. May be reported more than once for a patient when separate evaluations are conducted with the patient and other informants (i.e., family members, guardians, significant others) on different days. This service is considered medically necessary once every 6 months per episode of illness. *However, if reported more than once per episode of illness, documentation will be required for the establishment of medical necessity.
5. In certain circumstances family members, guardians, or significant others may be seen in lieu of the patient."

Note section D. General guideline is that it can only be used once every 6 months per episode of illness, so the 1 year mark is incorrect. However, the asterisk denotes that you can bill this more frequently if required for medical necessity, ie separate ER visits or new inpatient psych admissions requiring medical conditions to be ruled out.

This is fresh in my mind as I'm currently dealing with coders who don't seem to understand psychiatric billing.

 

[psych_0]

So since multiple people are having this issue, it's good to review the actual federal guidelines for this. From CMS page on psychiatric and psychological services L34616:

"Psychiatric Diagnostic Evaluation
A psychiatric diagnostic evaluation is an integrated assessment that includes history, mental status and recommendations. It may include communicating with the family and ordering further diagnostic studies. A psychiatric diagnostic evaluation with medical services includes a psychiatric diagnostic evaluation and a medical assessment. It may require a physical exam, communication with the family, prescription medications and ordering laboratory or other diagnostic studies. A psychiatric diagnostic evaluation with medical services also includes physical examination elements.

Patients may need an evaluation and diagnosis by a multidisciplinary team prior to implantation of peripheral and central nervous system stimulators for chronic intractable pain. (See NCD 160.7 Electrical Nerve Stimulators.)

The following information pertains to both psychiatric diagnostic evaluation; and psychiatric diagnostic evaluation with medical services:

1. Cannot be reported with an E/M code on the same day by the same provider
2. Cannot be reported with a psychotherapy service code on the same day
3. May only be reported once per day
4. May be reported more than once for a patient when separate evaluations are conducted with the patient and other informants (i.e., family members, guardians, significant others) on different days. This service is considered medically necessary once every 6 months per episode of illness. *However, if reported more than once per episode of illness, documentation will be required for the establishment of medical necessity.
5. In certain circumstances family members, guardians, or significant others may be seen in lieu of the patient."

Note section D. General guideline is that it can only be used once every 6 months per episode of illness, so the 1 year mark is incorrect. However, the asterisk denotes that you can bill this more frequently if required for medical necessity, ie separate ER visits or new inpatient psych admissions requiring medical conditions to be ruled out.

This is fresh in my mind as I'm currently dealing with coders who don't seem to understand psychiatric billing.

90792 can also be billed for every level of care change.

Day 1 Inpatient = 90792
Day 3 IOP intake = 90792
Day 10 attempts suicide in IOP and gets sent back to inpatient = 90792
Day 20 down to PHP = 90792

etc, etc

 

[Wheatbread]

Thank you for this. What exactly denotes “medical necessity” for inpatient admits?? SI/HI, mania, psychosis, etc?

 

[Stagg737]

Thank you for this. What exactly denotes “medical necessity” for inpatient admits?? SI/HI, mania, psychosis, etc?

Do you rule out medical causes of a patient's symptoms before diagnosing psychiatric conditions? Do you order or review basic labs to ensure they're medically stable? Do you perform a basic physical exam (even just visual) to ensure they're not in acute distress and actively dying in front of you? (rhetorical questions as I hope we're all doing these)

Straight from this document, any of the codes included: Article - Billing and Coding: Psychiatry and Psychology Services (A57480)

 

[mistafab]

Yeah I 90792 all the time for initial evals. Doesn't take long and good bang for the buck.

 

[Merovinge]

90792 can also be billed for every level of care change.

Day 1 Inpatient = 90792
Day 3 IOP intake = 90792
Day 10 attempts suicide in IOP and gets sent back to inpatient = 90792
Day 20 down to PHP = 90792

etc, etc

Can you explain further how this meets ". *However, if reported more than once per episode of illness, documentation will be required for the establishment of medical necessity." When done 3 days after an IP stay for a PHP stepdown? I definitely agree that if someone is stepped UP it would make sense.

 

[Stagg737]

Can you explain further how this meets ". *However, if reported more than once per episode of illness, documentation will be required for the establishment of medical necessity." When done 3 days after an IP stay for a PHP stepdown? I definitely agree that if someone is stepped UP it would make sense.

When you accept a patient into your PHP you do an intake eval, correct? On your intake do you not do a brief medical work-up? Surely your PHP/IOP does not monitor patients as closely as an inpatient unit and you'd be making sure they're appropriate for that level of care. Want updated labs? UDS? Etc? Why would this not count as a medically necessary eval?

 

[Merovinge]

When you accept a patient into your PHP you do an intake eval, correct? On your intake do you not do a brief medical work-up? Surely your PHP/IOP does not monitor patients as closely as an inpatient unit and you'd be making sure they're appropriate for that level of care. Want updated labs? UDS? Etc? Why would this not count as a medically necessary eval?

No, if we accept an internal RTC to PHP stepdown we just do a 99214/99215 f/u note. It would not re-review the same initial eval questions as those were just recently asked. If people really were seeing these being accepted for any LoC change internally I would love to hear about it because it would certainly improve our billing and much of the note could be copied forward.

 

[MedMan80]

No, if we accept an internal RTC to PHP stepdown we just do a 99214/99215 f/u note. It would not re-review the same initial eval questions as those were just recently asked. If people really were seeing these being accepted for any LoC change internally I would love to hear about it because it would certainly improve our billing and much of the note could be copied forward.

Same here, if internally same step-down we just use a f/u code.

 

[Stagg737]

No, if we accept an internal RTC to PHP stepdown we just do a 99214/99215 f/u note. It would not re-review the same initial eval questions as those were just recently asked. If people really were seeing these being accepted for any LoC change internally I would love to hear about it because it would certainly improve our billing and much of the note could be copied forward.

So maybe not exactly the same, but when my consult team sees someone on our medical floors who is then transferred to the hospital's rehab facility across the street, the neuro-rehab psychology team bills a 90791 even when we've already billed a 90792 for our services. When we continue seeing them we just bill follow-ups because we are part of the same team, but they are able to bill 90791 as a separate team performing their own eval even though they are part of our department. The addiction psychiatry team here specifically handles certain substance consults on our medical floors and they will also bill a 90792 for their evals separate from our 90792 and CMS reimburses for both.