CPT CODE and Description

90785 – Interactive complexity (List separately in addition to the code for primary procedure)

90791 – Psychiatric diagnostic evaluation – Average fee amount $120 -$150

90792 – Psychiatric diagnostic evaluation with medical services – $140 – 160



Correct DOS FOR Psychiatric testing and evaluations

In some cases, for various reasons, psychiatric evaluations (CPT® codes 90791/90792) are completed in multiple sessions that occur on different days. In this situation, the DOS that should be reported on the claim is the DOS on which the service (based on CPT® code description) concluded. In this case, documentation will confirm that the service began on one day and concluded on another day (the DOS reported on the claim). If documentation is requested, medical records for both days should be submitted.

Psychiatric testing when provided over multiple days based on the patient being able to provide information, is billed based on the time involved as described by the CPT® and the last date of the test.

Frequently Asked Question CPT CODE 90791

CPT 90791 documentation requirements?

  • Detailed information of a complete medical and psychiatric history
  • Mental status examination
  • Evaluation of the patient’s ability and capacity to respond to treatment
  • The initial plan of treatment
  • Reported once per day
  • Not reported on the same day as E/M service performed by the same provider
  • Covered at the outset

How often can you bill CPT codes 90791 and 90792?

More than one unit of 90791 or 90792 if the initial psychiatric diagnostic evaluations extend beyond one session, as long as the sessions are on different dates

what is the difference between CPT code 90791 and 90792

The major difference is the use of medical services for CPT 90792. Medical service is any medical activity such as providing prescriptions, performing physical exams, and modifying psychiatric treatment.

how much does medicare pay for CPT code 90791?
Yes, Medicare allowable is $178.91

What is a “new” patient?
Using new patient E/M codes (99201 to 99205) is more restrictive than using psychiatric diagnostic evaluation codes (90791, 90792; described in the following section.). New patients must not have received any professional services in the past three years by the physician OR another physician in the same group practice of the exact same specialty and sub-specialty.  Advanced practice nurses, physician assistants and covering professionals working with physicians are considered as working in the exact same specialty and exact same subspecialties as the physician.
 
Psychiatric Diagnostic Evaluation
 
Psychiatric Diagnostic Evaluation without medical services (90791) The evaluation may include communicating with family or other sources, as well as reviewing and ordering non-medical diagnostic studies. Psychiatric Diagnostic Evaluation with medical services (90792) As above (90791), the evaluation may include communicating with family or other sources, as well as reviewing and ordering diagnostic studies. It must include medical services. “Medical services” refers to “medical thinking” as well as medical activities (eg, physical examination, prescription of medication, and review and ordering of medical diagnostic tests). Medical thinking must be documented (eg, consideration of a differential diagnosis, medication change, change in dose of medication, drug-drug interactions).
For both 90791 and 90792:
• In certain circumstances one or more other informants (family members, guardians, or significant others) may be seen in lieu of the patient.
• Both codes may be reported more than once for the patient when separate diagnostic evaluations are conducted with the patient and other informants on different days.
• Use the same codes, for later reassessment, as indicated.
• Do not report on the same day as psychotherapy or an E/M service.
• If present, the interactive complexity component of the diagnostic evaluation is captured by reporting the interactive complexity add-on code 90785 in conjunction with 90791 or 90792.
Do not report with 90839, 90840, 0364T, 0365T, 0366T, 0367T, 0373T, 0374T Do not report with 99201, 99337, 99341-99350, 99366-99368, 99401-99444, 0368T, 0369T,
370T, 0371T

Coverage Indications, Limitations, and/or Medical Necessity

Psychiatry and Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases.

References to providers throughout this policy include physicians, and non-physicians, such as clinical psychologists, independent psychologist, nurse practitioners, clinical nurse specialists, and physician assistants when the services performed are within the scope of their clinical practice/education and authorized under the state law.

Psychiatry Services with Evaluation and Management (E/M)

Some psychiatry services may be reported with evaluation and management (E/M) services or other services when performed. An E/M code may be used to report evaluation and management services alone (no other service reported that day) or used to report an E/M service with psychotherapy. An E/M service is based on the physician’s work and includes services medically necessary to evaluate and treat the patient.


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 the 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:
Cannot be reported with an E/M code on the same day by the same provider

Cannot be reported with a psychotherapy service code on the same day

May only be reported once per day

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.

In certain circumstances family members, guardians, or significant others may be seen in lieu of the patient.

Interactive Complexity

Interactive Complexity refers to communication difficulties during the psychiatric procedure.

When performed with psychotherapy, the interactive complexity component relates only to the increased work intensity of the psychotherapy service, but does not change the time for the psychotherapy service.

The medical record for interactive complexity reported with the psychiatric procedures must indicate that the person being evaluated does not have the ability to interact through normal verbal communicative channels, include adaptations utilized in the session and the rationale for employing these interactive techniques, and recommendations for future care.

* What is the difference between 90791 and 90792?
90791: psychiatric diagnostic evaluation (without medical services), is an “integrated biopsychosocial assessment, including history, mental status, and recommendations. The evaluation may include communication with family or other sources and review and ordering of diagnostic studies.” (CPT 2013 guidelines)
90792: psychiatric diagnostic evaluation with medical services is “an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations. The evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies.” (CPT 2013 guidelines)
*  Can a 90791 assessment by a clinician (e.g., social worker) AND a 90792 assessment with medical completed by a psychiatrist be provided and billed on the same day?
Yes, they can both be reported on the same day, provided that: it aligns with payer policy (including for same-day billing), and that it is not reported on the same day as an E/M service performed by the same individual for the same patient.
* Can 90791 and 90792 be used even if a patient has been seen within the past three years?
Yes, the “past three years” restriction applies only to the use of New Patient Evaluation and Management codes, and does not apply to the psychiatric codes 90791 and 90792. However, payers may establish benefit limitations on the frequency of assessments and reassessments.
* Can non-psychiatrists (psychologists, LPCs, LCSWs) bill for 90791 even though its description is “psychiatric diagnostic evaluation,” or will they no longer be able to bill for evaluations?
Use of code 90791 is not limited to physicians. The CPT code book says that 90791 includes “an integrated biopsychosocial assessment, including history, mental status, and recommendations.” There is a separate piece that describes the medical services to make it 90792.
* Can our patients see a Psychiatric Nurse Practitioner for medication review, and then see their therapist following that appointment for psychotherapy?
Yes, however, you cannot report a psychiatric diagnostic procedure (90791 or 90792) on the same day as psychotherapy. Instead, the nurse practitioner’s service could be reported with an E/M code with psychotherapy on the same day (either by the same professional with an add-on code, or separate clinician with principal psychotherapy code).
That said, there are some policy-level decisions by payers (e.g., a few state Medicaid programs), that prohibits billing of multiple visits by separate providers on a single day. You would need to confirm with your payer that you can continue to do this (but if they were OK with it in 2012, it’s not likely they’d be more restrictive in 2013).
* What is “Interactive Complexity”?
Interactive complexity is a new term in CPT for 2013. It refers to specific factors that complicate the delivery of a psychiatric procedure. The code book lists specific circumstances where this might apply, like needing to involve third parties like probation officers, interpreters, other legal guardians, etc.
Interactive complexity is an add-on code and should not be reported as a standalone service; the code is 90785.
Interactive complexity can be used with:
• Initial evaluation codes (90791 and 90792)
• Psychotherapy codes
• Non-family group psychotherapy codes
• E/M codes when used in conjunction with psychotherapy services



Section I: Psychiatric Diagnostic Evaluation (CPT codes 90791, 90792)


Indications

The diagnostic evaluation (CPT code 90791) is a biopsychosocial assessment.

The diagnostic evaluation with medical services (CPT code 90792) is a biopsychosocial and medical assessment.

Both of these evaluations may include discussion with family or other sources in addition to the patient.

The diagnostic interview is indicated for initial or periodic diagnostic evaluation of a patient for suspected or diagnosed psychiatric illness. A second provider seeing the patient for the first time may also use these codes.

An additional diagnostic evaluation service may be considered reasonable and necessary for the same patient if a new episode of illness occurs, an admission or a readmission to inpatient status due to complications of the underlying condition occurs, or when re-evaluation is required to address a new referral question. Certain patients, especially children and geriatric patients may require more than one visit for the completion of the initial diagnostic evaluation. The indication for the assessment should be based on medical necessity and supported in the medical record.

Interactive procedures may be necessary and considered reasonable and necessary for patients whose ability to communicate is impaired by expressive or receptive language impairment from various causes. These may include conductive or sensorineural hearing loss, deaf mutism, aphasia, language barrier, or lack of mental development (childhood).

The Bariatric Surgical Management of Morbid Obesity LCD (L35022) provides specific criteria that support the medical necessity of the psychiatric diagnostic interview. Please refer to LCD L35022 for the specific criteria.

Coverage for the diagnostic interview is limited to physicians (MDs, DOs), Clinical Social Workers (CSWs), Clinical Psychologists (CPs), Clinical Nurse Specialists (CNSs), Physician Assistants (PAs) and Nurse Practitioners (NPs) certified in the state or jurisdiction for psychiatric services.



Section II: Psychological and Neuropsychological Testing


Indications

These diagnostic tests are used when mental illness is suspected, and clarification is essential for the diagnosis and the treatment plan.

Testing conducted when no mental illness/disability is suspected would be considered screening and would not be covered by Medicare. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing.

Examples of problems that might require psychological or neuropsychological testing include:

Assessment of mental functioning for individuals with suspected or known mental disorders for purposes of differential diagnosis or treatment planning.

Assessment of patient strengths and disabilities for use in treatment planning or management when signs or symptoms of a mental disorder are present.

Assessment of patient capacity for decision-making when impairment is suspected that would affect patient care or management.

Differential diagnosis between psychogenic and neurogenic syndromes (e.g., depression versus dementia).

Detection of neurologic disease based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, Acquired Immune Deficiency Syndrome (AIDS) dementia).
Delineation of the neurocognitive effects of central nervous system disorders.

Neurocognitive monitoring of recovery or progression of central nervous system disorders.
When a psychiatric condition or the presence of dementia has already been diagnosed, there is value to the testing only if the information derived from the testing would be expected to have significant impact on the understanding and treatment of the patient. Examples include:

Significant change in the patient’s condition.

The need to evaluate a patient’s capacity to function in a given situation or environment.

The need to specifically tailor therapeutic and or compensatory techniques to particular aspects of the patient’s pattern of strengths and disabilities.

Adjustment reactions or dysphoria associated with moving to a nursing home do not automatically constitute medical necessity for testing. Testing of every patient upon entry to a nursing home would be considered a routine service and would not be covered by Medicare. However, some individuals enter a nursing home at a time of physical and cognitive decline, and may require psychological testing to arrive at a diagnosis and plan of care. Decisions to test individuals who have recently entered a nursing home need to be made judiciously, on a case-by-case basis. Medical necessity of such evaluations should be documented and maintained in the medical record.

Each test administered must be medically necessary. Standardized batteries of tests are only acceptable if each component test is medically necessary.

Depending on the issues to be assessed, a typical test battery may require 7 to 10 hours to perform, including administration, scoring and interpretation.

CPT code 96105 represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination. If this formal assessment is performed during treatment, it is typically performed only once during treatment and its medical necessity should be documented. If the test is repeated during treatment, the medical necessity of the repeat administration of the test must also be documented.



Rendering Providers

Physical Therapists (PTs), Occupational Therapists (OTs), and Speech Language Pathologists (SLPs) may perform services represented by CPT codes 96105, 96111 and G0451; under the general supervision of a physician or a CP.

Non-physician practitioners (NPPs), such as NPs, CNSs and PAs who personally perform diagnostic psychological and neuropsychological tests are excluded from having to perform these tests under the general supervision of a physician or a CP (Pub. 100-02, Chapter 15, Section 80.2).

Independently Practicing Psychologists (IPPs) may bill for psychological and neuropsychological tests when the tests are ordered by a physician (Pub. 100-02, Chapter 15, Section 80.2).

Limitations 

Routine re-evaluation of chronically disabled patients that is not required for a diagnosis or continued treatment is not medically necessary.

Brief screening measures such as the Folstein Mini-Mental Status Exam or use of other mental status exams in isolation should not be classified separately as psychological or neuropsychological testing, since they are typically part of a more general clinical exam or interview.

Psychological and neuropsychological testing may not be performed on an “incident to” basis (Pub. 100-02, Chapter 15, Section 80.2).

Psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the results of the testing.

Interactive Complexity Add-On 

90785 Interactive Complexity — This add-on code may be used with any of the codes in the Psychiatry section when the encounter is made more complex by the need to involve others along with the patient. It will most frequently be used in the treatment of children. When this add-on is used, documentation must explain what exactly the interactive complexity was (i.e., the need for play equipment with a younger child; the need to manage parents’ anxiety; the involvement of parents with discordant points of view).

Interactive Complexity Services (CPT Code 90785)

Interactive complexity refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients.

The interactive complexity techniques are utilized primarily to evaluate children and/or adults who do not have the ability to interact through ordinary verbal communication. In the aforementioned instances, it involves the use of physical aids and nonverbal communication to overcome barriers to the therapeutic interaction between the clinician and the patient who has not yet developed or has lost either the expressive language communication skills to explain his/her symptoms and response to treatment or the receptive communication skills to understand the clinician if he/she were to use ordinary adult language for communication. An interactive technique may include the use of inanimate objects such as toys and dolls for a child, physical aids, and non-verbal communication to overcome barriers to therapeutic interaction, or an interpreter for a person who is deaf or in situations where the patient does not speak the same language as the provider of care.

If a patient is unable to communicate by any means, the interactive complexity codes should not be billed. This service is used in conjunction with codes for diagnostic psychiatric evaluation (90791, 90792), psychotherapy (90832, 90834, 90837), psychotherapy when performed with an evaluation and management service (90833, 90836, 90838, 99201-99255, 99304-99337, 99341-99350), and group psychotherapy (90853).

Interactive complexity may be reported with psychotherapy when at least one of the following communication factors is present during the visit:

• The need to manage maladaptive communication among participants (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) that complicates delivery of care.

• Caregiver emotions or behaviors that interfere with implementation of the treatment plan.

• 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.

• 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 has lost expressive or receptive language skills to use or understand typical language.


Psychiatric Diagnostic Evaluation Codes


90791 Psychiatric Diagnostic Evaluation

This code is used for an initial diagnostic interview exam that does not include any medical services. In all likelihood this code will not be used by psychiatrists . 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 order and medical interpretation of laboratory or other diagnostic studies. In the past most insurers would reimburse for one 90791 (then a 90801) per episode of illness. The guidelines now allow for billing this on subsequent days when there is 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 90791 per year for institutionalized patients unless medical necessity can be established for others.

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.

A psychiatric diagnostic evaluation can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient if an extended hiatus in treatment occurs, if the patient requires admission to an inpatient status for a psychiatric illness, or for a significant change in mental status requiring further assessment. An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition. A psychiatric diagnostic evaluation may also be utilized again if the patient has a previously established neurological disorder or dementia and there has been an acute and/or marked mental status change, or a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.

90792 Psychiatric Diagnostic Evaluation with Medical Services

This code 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 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 (see below) 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.

A psychiatric diagnostic evaluation with medical services can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient if an extended hiatus in treatment occurs, if the patient requires admission to an inpatient status for a psychiatric illness, or for a significant change in mental status requiring further assessment. An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition. A psychiatric diagnostic evaluation with medical services may also be utilized again if the patient has a previously established neurological disorder or dementia and there has been an acute and/or marked mental status change, or a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.

Usage Guidelines

Two new codes for Initial Assessment

◦ Without medical services – New code 90791
◦ With medical services – New code 90792

** Medical services include biopsychosocial and medical assessment, including history, mental status, other physical exam elements as indicated and recommendations

* *If medical services are not performed with the initial assessment, the doctor/NPP should use the initial assessment code 90791

* Initial assessment is a face-to-face interaction between a clinician and recipient and/or collaterals

* Time Requirements
◦ 90791 minimum of 45minutes
◦ 90792 minimum of 45 Minutes
◦ Time rounding is not permitted
* No more than three initial assessment services will be reimbursed during an episode of service.

* 90792 may only be used by psychiatrists, physicians or psychiatric nurse practitioners (NPP) who perform an initial assessment with medical services

* 90792 may not be claimed on the same day as an E&M code

* Doctor/NPP modifier (i.e., AF, AG, SA) must be added to the claim (for both 90791 or 90792) in order to receive the additional physician reimbursement add-on

Time and Unit calculation – Medicaid Guidelines

The following time rules apply for converting the duration of the service to the specified number of units:
Less than 8 minutes equals 0 units;
8 minutes through 22 minutes of service equals 1 unit;
23 minutes through 37 minutes of service equals 2 units;
38 minutes through 52 minutes of service equals 3 units;
53 minutes through 67 minutes of service equals 4 units;
68 minutes through 82 minutes of service equals 5 units;
83 minutes through 97 minutes of service equals 6 units;
98 minutes through 112 minutes of service equals 7 units; and
113 minutes through 127 minutes of service equals 8 units, etc.

Psychiatric interviews/evaluations 90791, 90792

90791 includes the assessment of the patient’s psychosocial history, current mental status, review, and ordering of diagnostic studies followed by appropriate treatment recommendations.

90792 is reported if additional medical services such as physical examination and prescription of pharmaceuticals are provided in addition to the diagnostic evaluation. Interviews and communication with family members or other sources are included in these codes.

This procedure is not time defined. The initial evaluation/diagnostic interview session is expected to include face-to-face consumer contact, and encompasses activities critical to the evaluation process, such as communicating with the consumer and the primary care physician and ordering laboratory
tests when clinically appropriate.

Only one initial evaluation/diagnostic interview (90791/90792) may be rendered as part of the initial 12, non-OMS services. A maximum of two diagnostic interviews may be rendered as part of the 150 unit bundle of services for OMS consumers. An additional 90791/90792 may be requested and approved if the additional 90791/90792 is to be provided by a different rendering provider. The different rendering provider may be part of the same OMHC or practice group, or independent of the OMHC or practice group. The primary consideration is that one of the providers is a physician and the other is a non-physician

Interactive complexity code 90785

* Add-on code to the code for a primary psychiatric service.

* May be reported, as appropriate, with 90791, 90792, 90832, 90833, 90834, 90836, 90853, 90837, 99201-99255, 99304-99337, and 99341-99350

* One of the following must exist during the session in order to report 90785:

o Maladaptive communication (for example, high anxiety, high reactivity, repeated questions, or disagreement).

o Emotional or behavioral conditions inhibiting implementation of treatment plan.

o Mandated reporting/event exists (for example, abuse or neglect).

o Play equipment, devices, interpreter or translator required due to inadequate language expression or different language spoken between patient and professional.



Section I: Psychiatric Diagnostic Evaluation and Psychiatric Diagnostic Evaluation with Medical Services (CPT codes 90791, 90792)


    A. Psychiatric Diagnostic Evaluation (CPT code 90791)

A psychiatric diagnostic evaluation is an integrated biopsychosocial assessment that includes the elicitation of a complete medical history (to include past, family, and social), psychiatric history, a complete mental status exam, establishment of a tentative diagnosis, and an evaluation of the patient’s ability and willingness to participate in the proposed treatment plan. Information may be obtained from the patient, other physicians, other clinicians or community providers, and/or family members or other sources. There may be overlapping of the medical and psychiatric history depending upon the problem(s).

Although the emphasis, types of details, and style of a psychiatric evaluation differ from the medical evaluation, the purpose is the same: to establish effective communication with interaction of sufficient quality between provider and patient to gather accurate data in order to formulate tentative diagnoses, determine necessity, and as appropriate, initiate an effective and comprehensive treatment plan.

Psychiatric diagnostic evaluations will be considered medically necessary when the patient has a psychiatric illness and /or is demonstrating emotional or behavioral symptoms sufficient to cause inappropriate behavior patterns or maladaptive functioning in personal or social settings, which may be suggestive of a psychiatric illness. This examination may also be medically necessary when baseline functioning is altered by suspected illness or symptoms. It is appropriate for dementia, in patients who experience a sudden and rapid change in behavior.

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.

A psychiatric diagnostic evaluation can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient if an extended hiatus in treatment occurs, if the patient requires admission to an inpatient status for a psychiatric illness, or for a significant change in mental status requiring further assessment. An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition. A psychiatric diagnostic evaluation may also be utilized again if the patient has a previously established neurological disorder or dementia and there has been an acute and/or marked mental status change, or a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.

    B. Psychiatric Diagnostic Evaluation with Medical Services (CPT code 90792)

A psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history (to include past, family, and social), psychiatric history, a complete mental status exam, other physical examination elements as indicated, establishment of a tentative diagnosis, and an evaluation of the patient’s ability and willingness to participate in the proposed treatment plan. The evaluation may include communication with family members or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies.

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.

A psychiatric diagnostic evaluation with medical services can be conducted once, at the onset of an illness or suspected illness. The same provider may repeat it for the same patient if an extended hiatus in treatment occurs, if the patient requires admission to an inpatient status for a psychiatric illness, or for a significant change in mental status requiring further assessment. An extended hiatus is generally defined as approximately 6 months from the last time the patient was seen or treated for their psychiatric condition. A psychiatric diagnostic evaluation with medical services may also be utilized again if the patient has a previously established neurological disorder or dementia and there has been an acute and/or marked mental status change, or a second opinion or diagnostic clarification is necessary to rule out additional psychiatric or neurological processes, which may be treatable.



ICD-10 Codes that Support Medical Necessity

F01.51 Vascular dementia with behavioral disturbance
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
F03.90 Unspecified dementia without behavioral disturbance
F03.91 Unspecified dementia with behavioral disturbance
F04 Amnestic disorder due to known physiological condition
F05 Delirium due to known physiological condition
F06.0 Psychotic disorder with hallucinations due to known physiological condition
F06.1 Catatonic disorder due to known physiological condition
F06.30 Mood disorder due to known physiological condition, unspecified
F06.31 Mood disorder due to known physiological condition with depressive features
F06.32 Mood disorder due to known physiological condition with major depressive-like episode
F06.33 Mood disorder due to known physiological condition with manic features
F06.34 Mood disorder due to known physiological condition with mixed features
F06.4 Anxiety disorder due to known physiological condition
F06.8 Other specified mental disorders due to known physiological condition
F07.0 Personality change due to known physiological condition
F07.81 Postconcussional syndrome
F07.89 Other personality and behavioral disorders due to known physiological condition
F07.9 Unspecified personality and behavioral disorder due to known physiological condition
F09 Unspecified mental disorder due to known physiological condition
F10.10 Alcohol abuse, uncomplicated
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.121 Alcohol abuse with intoxication delirium
F10.129 Alcohol abuse with intoxication, unspecified
F10.14 Alcohol abuse with alcohol-induced mood disorder
F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions
F10.151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations
F10.159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified
F10.180 Alcohol abuse with alcohol-induced anxiety disorder
F10.181 Alcohol abuse with alcohol-induced sexual dysfunction
F10.182 Alcohol abuse with alcohol-induced sleep disorder
F10.188 Alcohol abuse with other alcohol-induced disorder
F10.19 Alcohol abuse with unspecified alcohol-induced disorder
F10.20 Alcohol dependence, uncomplicated
F10.21 Alcohol dependence, in remission
F10.220 Alcohol dependence with intoxication, uncomplicated
F10.221 Alcohol dependence with intoxication delirium
F10.229 Alcohol dependence with intoxication, unspecified
F11.10 Opioid abuse, uncomplicated
F11.120 Opioid abuse with intoxication, uncomplicated
F11.129 Opioid abuse with intoxication, unspecified
F11.20 Opioid dependence, uncomplicated
F11.21 Opioid dependence, in remission
F11.220 Opioid dependence with intoxication, uncomplicated
F11.221 Opioid dependence with intoxication delirium
F11.222 Opioid dependence with intoxication with perceptual disturbance
F11.229 Opioid dependence with intoxication, unspecified
F11.23 Opioid dependence with withdrawal
F11.24 Opioid dependence with opioid-induced mood disorder
F11.250 Opioid dependence with opioid-induced psychotic disorder with delusions
F11.251 Opioid dependence with opioid-induced psychotic disorder with hallucinations
F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified
F11.281 Opioid dependence with opioid-induced sexual dysfunction
F11.282 Opioid dependence with opioid-induced sleep disorder
F11.288 Opioid dependence with other opioid-induced disorder
F11.29 Opioid dependence with unspecified opioid-induced disorder
F11.90 Opioid use, unspecified, uncomplicated
F12.10 Cannabis abuse, uncomplicated
F12.20 Cannabis dependence, uncomplicated
F12.21 Cannabis dependence, in remission
F12.220 Cannabis dependence with intoxication, uncomplicated
F12.221 Cannabis dependence with intoxication delirium
F12.222 Cannabis dependence with intoxication with perceptual disturbance
F12.229 Cannabis dependence with intoxication, unspecified
F12.250 Cannabis dependence with psychotic disorder with delusions
F12.251 Cannabis dependence with psychotic disorder with hallucinations
F12.259 Cannabis dependence with psychotic disorder, unspecified
F12.280 Cannabis dependence with cannabis-induced anxiety disorder
F12.288 Cannabis dependence with other cannabis-induced disorder
F12.29 Cannabis dependence with unspecified cannabis-induced disorder
F12.90 Cannabis use, unspecified, uncomplicated
F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated
F13.120 Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated
F13.20 Sedative, hypnotic or anxiolytic dependence, uncomplicated
F13.21 Sedative, hypnotic or anxiolytic dependence, in remission
F13.220 Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated
F13.221 Sedative, hypnotic or anxiolytic dependence with intoxication delirium
F13.229 Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified
F13.230 Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated
F13.231 Sedative, hypnotic or anxiolytic dependence with withdrawal delirium
F13.232 Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbance
F13.239 Sedative, hypnotic or anxiolytic dependence with withdrawal, unspecified
F13.24 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood disorder
F13.250 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions
F13.251 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations
F13.259 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified
F13.26 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder
F13.27 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia
F13.280 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorder
F13.281 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual dysfunction
F13.282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
F13.288 Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorder
F13.29 Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic-induced disorder
F13.90 Sedative, hypnotic, or anxiolytic use, unspecified, uncomplicated
F14.10 Cocaine abuse, uncomplicated
F14.120 Cocaine abuse with intoxication, uncomplicated
F14.20 Cocaine dependence, uncomplicated
F14.21 Cocaine dependence, in remission
F14.220 Cocaine dependence with intoxication, uncomplicated
F14.221 Cocaine dependence with intoxication delirium
F14.222 Cocaine dependence with intoxication with perceptual disturbance
F14.229 Cocaine dependence with intoxication, unspecified
F14.23 Cocaine dependence with withdrawal
F14.24 Cocaine dependence with cocaine-induced mood disorder
F14.250 Cocaine dependence with cocaine-induced psychotic disorder with delusions
F14.251 Cocaine dependence with cocaine-induced psychotic disorder with hallucinations
F14.259 Cocaine dependence with cocaine-induced psychotic disorder, unspecified
F14.280 Cocaine dependence with cocaine-induced anxiety disorder
F14.281 Cocaine dependence with cocaine-induced sexual dysfunction
F14.282 Cocaine dependence with cocaine-induced sleep disorder
F14.288 Cocaine dependence with other cocaine-induced disorder
F14.29 Cocaine dependence with unspecified cocaine-induced disorder
F14.90 Cocaine use, unspecified, uncomplicated
F15.10 Other stimulant abuse, uncomplicated
F15.120 Other stimulant abuse with intoxication, uncomplicated
F15.20 Other stimulant dependence, uncomplicated
F15.21 Other stimulant dependence, in remission
F15.220 Other stimulant dependence with intoxication, uncomplicated
F15.221 Other stimulant dependence with intoxication delirium
F15.222 Other stimulant dependence with intoxication with perceptual disturbance
F15.229 Other stimulant dependence with intoxication, unspecified
F15.23 Other stimulant dependence with withdrawal
F15.24 Other stimulant dependence with stimulant-induced mood disorder
F15.250 Other stimulant dependence with stimulant-induced psychotic disorder with delusions
F15.251 Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations
F15.259 Other stimulant dependence with stimulant-induced psychotic disorder, unspecified
F15.280 Other stimulant dependence with stimulant-induced anxiety disorder
F15.281 Other stimulant dependence with stimulant-induced sexual dysfunction
F15.282 Other stimulant dependence with stimulant-induced sleep disorder
F15.288 Other stimulant dependence with other stimulant-induced disorder
F15.29 Other stimulant dependence with unspecified stimulant-induced disorder
F15.90 Other stimulant use, unspecified, uncomplicated
F16.10 Hallucinogen abuse, uncomplicated
F16.120 Hallucinogen abuse with intoxication, uncomplicated
F16.20 Hallucinogen dependence, uncomplicated
F16.21 Hallucinogen dependence, in remission
F16.220 Hallucinogen dependence with intoxication, uncomplicated
F16.221 Hallucinogen dependence with intoxication with delirium
F16.229 Hallucinogen dependence with intoxication, unspecified
F16.24 Hallucinogen dependence with hallucinogen-induced mood disorder
F16.250 Hallucinogen dependence with hallucinogen-induced psychotic disorder with delusions
F16.251 Hallucinogen dependence with hallucinogen-induced psychotic disorder with hallucinations
F16.259 Hallucinogen dependence with hallucinogen-induced psychotic disorder, unspecified
F16.280 Hallucinogen dependence with hallucinogen-induced anxiety disorder
F16.283 Hallucinogen dependence with hallucinogen persisting perception disorder (flashbacks)
F16.288 Hallucinogen dependence with other hallucinogen-induced disorder
F16.29 Hallucinogen dependence with unspecified hallucinogen-induced disorder
F16.90 Hallucinogen use, unspecified, uncomplicated
F17.200 Nicotine dependence, unspecified, uncomplicated
F17.201 Nicotine dependence, unspecified, in remission
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.211 Nicotine dependence, cigarettes, in remission
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.221 Nicotine dependence, chewing tobacco, in remission
F17.290 Nicotine dependence, other tobacco product, uncomplicated
F17.291 Nicotine dependence, other tobacco product, in remission
F18.10 Inhalant abuse, uncomplicated
F18.120 Inhalant abuse with intoxication, uncomplicated
F18.20 Inhalant dependence, uncomplicated
F18.21 Inhalant dependence, in remission
F18.220 Inhalant dependence with intoxication, uncomplicated
F18.221 Inhalant dependence with intoxication delirium
F18.229 Inhalant dependence with intoxication, unspecified
F18.24 Inhalant dependence with inhalant-induced mood disorder
F18.250 Inhalant dependence with inhalant-induced psychotic disorder with delusions
F18.251 Inhalant dependence with inhalant-induced psychotic disorder with hallucinations
F18.259 Inhalant dependence with inhalant-induced psychotic disorder, unspecified
F18.27 Inhalant dependence with inhalant-induced dementia
F18.280 Inhalant dependence with inhalant-induced anxiety disorder
F18.288 Inhalant dependence with other inhalant-induced disorder
F18.29 Inhalant dependence with unspecified inhalant-induced disorder
F18.90 Inhalant use, unspecified, uncomplicated
F19.10 Other psychoactive substance abuse, uncomplicated
F19.120 Other psychoactive substance abuse with intoxication, uncomplicated
F19.20 Other psychoactive substance dependence, uncomplicated
F19.21 Other psychoactive substance dependence, in remission
F19.220 Other psychoactive substance dependence with intoxication, uncomplicated
F19.221 Other psychoactive substance dependence with intoxication delirium
F19.222 Other psychoactive substance dependence with intoxication with perceptual disturbance
F19.229 Other psychoactive substance dependence with intoxication, unspecified
F19.230 Other psychoactive substance dependence with withdrawal, uncomplicated
F19.231 Other psychoactive substance dependence with withdrawal delirium
F19.232 Other psychoactive substance dependence with withdrawal with perceptual disturbance
F19.239 Other psychoactive substance dependence with withdrawal, unspecified
F19.24 Other psychoactive substance dependence with psychoactive substance-induced mood disorder
F19.250 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions
F19.251 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations
F19.259 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder, unspecified
F19.26 Other psychoactive substance dependence with psychoactive substance-induced persisting amnestic disorder
F19.27 Other psychoactive substance dependence with psychoactive substance-induced persisting dementia
F19.280 Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder
F19.281 Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction
F19.282 Other psychoactive substance dependence with psychoactive substance-induced sleep disorder
F19.288 Other psychoactive substance dependence with other psychoactive substance-induced disorder
F19.29 Other psychoactive substance dependence with unspecified psychoactive substance-induced disorder
F19.90 Other psychoactive substance use, unspecified, uncomplicated
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.5 Residual schizophrenia
F20.81 Schizophreniform disorder
F20.89 Other schizophrenia


Covered Services and Limitation

Items and services that can be included as part of the structured, multimodal active treatment program, include:
Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, clinical nurse specialists, certified alcohol and drug counselors);
Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if required, must be a component of the physicians treatment plan for the individual;
Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients;
Drugs and biologicals that cannot be self administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29);
Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals;
Family counseling services for which the primary purpose is the treatment of the patient’s condition;
Patient training and education, to the extent the training and educational activities are closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition; and
Medically necessary diagnostic services related to mental health treatment.

Limitations

Noncovered Services-Benefit category Denials
Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;
Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or
Patients who are otherwise psychiatrically stable or require medication management only.
Noncovered Services-Coverage Denials
Services to hospital inpatients;
Meals, self-administered medications, transportation; and
Vocational training.
Noncovered-Reasonable and Necessary Denials
Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of a PHP; or
Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization.
CPT codes 90875 and 90876