What is the difference between 90791 and 90792? Do you know if it is allowed to bill a 90792 prior to a 99205? Or does the order of codes matter? MGMA members have been asking about psychiatric assessment coding as more primary care practices have added behavioral health services to their practice.
CPT® code 99205 represents an E/M service for a new patient with a comprehensive history, examination, and medical decision-making of high complexity.
CPT® code 90792 represents a Psychiatric Diagnosis Interview Examination (PDE) performed by a licensed mental health provider, including:
- Licensed Clinical Social Workers (LCSWs)
- Licensed Professional Counselors (LPCs)
- Licensed Mental Counselors (LMHCs)
- Licensed Marriage Family Therapists (LMFTs)
- Clinical Psychologists (PhDs or PsyDs)
- Psychiatrists (MDs)
For coding CPT® 90792, the visit requires:
- Elicitation of complete medical and psychiatric history (including past, family, social)
- Mental status examination
- Establishment of an initial diagnosis
- Evaluation 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 Evaluation and Management services performed by the same provider for the same client (99202-99205, 99212-99215)
- Covered once at the outset of an illness
Key points to remember
- CPT® 90792 adds a medical assessment or physical exam component to the evaluation of the client, limiting the licenses able to bill 90792.
- The diagnostic evaluation is not coded by duration of time, so note the requirements for your intake session depend on performing services, not duration of visit.
- Providers require at least 60 minutes and up to 120 minutes to render an exhaustive diagnostic interview and examination of their mental health clients in order to code 90792.
If you are not performing a medical evaluation as you would when coding 90792 (because you are not licensed to do so), use CPT® code 90791. This applies to all non-MD mental health providers. This procedure code is used for diagnostic evaluation of new behavioral health concerns and/or illnesses, or upon treatment of a new client. CPT® code 90791 is typically billed for the initial intake appointment a client will have. 90791 is considered a routine outpatient appointment, so typically no authorization is required. Like many procedure codes, exceptions do exist depending on the plan and insurance company. The Centers for Medicare & Medicaid Services (CMS) require at least 16 minutes and up to 90 minutes to code CPT® 90791 before using an add-on CPT® code to designate session time.
The key to billing an E/M visit and a psych evaluation on the same visit is to ensure that the services provided under each code are distinct and separate and both were performed independently. If the psychiatric diagnostic evaluation (90792) is performed on the same day as a significant, separately identifiable E/M service, you may need to append modifier -25 to the E/M code (99205). This indicates that the E/M service was a distinct and separately identifiable service from the psychiatric evaluation.
Sequence the codes in the correct order on the claim form, typically listing the primary E/M code first followed by the psychiatric evaluation code.
Be aware of the specific guidelines and requirements of the payer you are billing. Some payers may have specific rules or restrictions on billing certain services together, so it's important to review their policies.