90792 CPT Code (2023) | Description, Guidelines, Reimbursement, Modifiers & Examples

The 90792 CPT code can be billed for psychiatric diagnosis. This code includes the:

• reviewing;
• ordering;
• presenting mental condition,;
• diagnostic assessment; and
• follow-up studies performed inpatient psychosocial history require the recommended treatment.

CPT 90792 include direct interaction and interview with family and others. For medical services, psychiatrists have to utilize the CPT codes for evaluation and medical services to get paid.

Providers can use specific strategies for adequate reimbursement for the service provided to the patient.

For example, health providers can analyse how quickly the assessment, psychotherapy, counseling, acute and prolonged illness, complex MDM, and crucial health care are coded. Utilize a pattern with specifications during a patient assessment.

Background Of The 90792 CPT Code

In the preliminary evaluation, CPT 90792 or E&M code can be utilized by providers. But we will analyze the MDM development of the psychiatrist to keep an eye on the assessment of Medicare as an illustration of conclusion. Medicare only pays for the patients who bill for Medicare. 

All other commercial insurances have different billing and processing methods separate from the Medicare billing process. However, the MDM processing and refund methods are almost the same.

Measured and knowledgeable predictions are required to utilize CPT 90792 and E&M codes that established the particulars of the program that solely depend upon the reimbursement.

The main advantage of using CPT 90792 is that it has very little discrimination from CPT 90801, and minimum amendments are required. There must be no duplication of services.

Local Coverage Determination should be of unwavering value to avoid the circumstances of multiple applications of similar procedure codes. 

It is also widely accepted that CPT 90792 can be billed with CPT 90785 other than E&M service. This is specifically significant for psychiatrists of infants and young.

Most of the time, E&M codes are more or less refunded than the 90792 CPT code, which is based upon the complexity of the patient’s contract.

90792 CPT Code Description

As per CMS guidelines, CPT Code 90792 requires:

• Complete medical and psychiatric medical history (including past, family, and social)
• Full scrutiny of mental well-being.
• Proper evaluation for Preliminary diagnosis.
• Efficiency and efficacy of the treatment with the ability of the patient to respond to medication.
• Preliminary strategy of management.
• Described once per day and not on a corresponding day as an E&M service and is performed for the same client by the same provider.
• It was covered once at the start of a sickness.

In the year 2013, substantial variations are witnessed in psychiatric code. This triggered the significant discrepancy between the medical (CPT 90792) and non-medical evaluations (CPT 90791).

The psychotherapy code has been streamlined. Time-based codes are utilized in all sets and comparable to supplementary codes for psychotherapy. 

An add-on interactive complexity has been added that can be consumed with any code in the relevant psychiatry section.

Billing Guidelines

Do not report CPT 90389 and CPT 90840 with the 90792 CPT code. CPT 90389 and 90840 for Crisis Psychotherapy show the total time a physician or other qualified medical professional provides psychotherapy in the event of a crisis, face-to-face with the patient and/or family.

Time spent dates are not consecutive. For a period spent providing psychotherapy in an emergency, a doctor or other qualified medical professional must pay close attention to the patient.

Therefore, another patient during the same period cannot be treated. Patients need to be present at all or some services.

CPT code 90785 for interactive complexity should not be billed with the 90792 CPT code if the patient cannot communicate. 

The 90792 CPT code includes diagnostic psychiatric evaluation. When billing in connection with time-based code, the document should indicate how long it will take to provide the service of interactive complexity.

Psychotherapy is purely dependent upon time and is also called a time-based code. Therefore, it is necessary to document the time when the service is started and the stop time when it is completed.

Along with the evaluation and management service, it is also important to note the service time from start to end or the total time of the service. Total time does not include E&M time. 

Also, note that if psychotherapy is provided in E&M by the same provider or physician, the documentation should specify that these are distinctly recognizable amenities. Psychotherapy time is for direct interaction facility with the patient.

Prolonged services may not be conveyed when psychotherapy services billed with an E&M service are reported.

Extended services may be omitted when reporting psychotherapy services billed as E&M services.

Documentation Requirements

The following documents are required to prevent the denial of the 90792 CPT code. All credentials must be preserved in the patient medical portal and available on demand.

Patient data regarding the identity (name, DOS) must be recorded on legible paper. This document should have the unmistakable signature of the provider or any other health personnel whore are responsible for patient care.

The billed claim should adequately utilize ICD 10 CM codes, and these codes should be accurate to elaborate the service performed by the provider.

E&M of the psychiatric practice is well thought out a medical necessity if a person is mentally disturbed or demonstrates the ample sensitivity of behavioral symptoms to cause uncertain patterns of illness or initiate the impaired functioning in social surroundings that can be used as an indicator for severity.

For example, this can be true in the case of dementia is Alzheimer’s disease who is experiencing abrupt or impulsive behavioural changes.

Psychiatric evaluations (CPT 90791 and CPT 90792) are completed in numerous sessions on altered days. The claim DOS on which the service concluded is the DOS that needs to be billed. 

Documentation of the 90792 CPT code will confirm that the service was created and settled on another day. If documents are demanded, health records must be provided.

When delivered over various times based on the patient’s ability to provide data, psychiatric testing is billed grounded on the total time involved, as well-defined by the CPT.

Time-Based Calculations

Following are the time-based unit calculations of CPT 90792, as per Medicare guidelines:

Below 8 min = 0 units

From 8 min to 22 min = 1 unit

From 23 min to 37 min = 2 units

From 38 min to 52 min = 3 units

From 53 min to 67 min = 4 units

From 68 min to 82 min = 5 units

From 83 min to 97 min = 6 units

From 98 min to 112 min = 7 units

From 113 min to 127 min = 8 units

If the evaluation and prescription of the provider are given, then the 90792 CPT code can be billed for the additional medical services concerning the diagnostic assessment.

In addition, meetings and statements of family members or other causes are contained within these codes. 

Most insurers would reimburse for one CPT code 90792 per episode of illness. These guidelines now allow claims for the next day of medical necessity for an extended evaluation.

Medicare remunerations only CPT 90792 annually for patients disclosed to the hospital unless it is medically essential for someone else.

Medicare may use this code or the appropriate level of E/M code to designate an initial evaluation or first-day service for an inpatient.

If a social worker is also there and a psychiatrist and both made a complete investigation on a patient, they can bill separate CPT codes. 

A social worker can bill CPT 90791, and a psychiatrist can bill CPT 90792. However, for all clinician associates, it is obligatory to do preliminary scrutiny because the insurance may not compensate for both. 

If the patient is admitted to the inmate psychological medicine service, the specialist will use the initial hospitalization E/M codes (99221-99225), which might cowl both the consult and initial medical specialty evaluation.

Modifiers

If you are approved to bill CPT 90792 synchronized with unconventional licensed mental state clinicians in the same group, please consider using the subsequent 90792 modifiers once cautious writing for your clinicians:

• Modifier AJ used for LCSW (Clinical Social Worker)
• Modifier AF used for trained Psychiatrist (MD)
• Modifier AH used for qualified Clinical Psychologist
• Modifier HP used for Clinical Psychologist (or Doctorate Level Degree)

Reimbursement

Settlements for procedural codes related to Behavioral Health and Evaluation and Management have always been challenging for a coder or biller. 

AMA (American Medical Association) and APA (American Psychiatric Association) have already established submission requirements.

Settlement rates for 20 – 90 min time psychiatric analysis accomplished by a psychiatrist are:

• Reimbursement rate for the 90792 CPT code (Medicare 2020) is: $160.96
• Reimbursement rate for the 90792 CPT code (Medicare 2021) is: $201.68
• Reimbursement rate for the 90792 CPT code (Sample Medicaid in Mississippi) is: $134.42
• Reimbursement rate for the 90792 CPT code (Sample Medicaid in New Jersey) is $325.00

An add-on code may be billed, as appropriate, to the code for the primary psychiatric service (i.e., CPT 90791, CPT 90792, CPT 90832, CPT 90833, CPT 90834, CPT 90836, CPT 90853, CPT 90837).

For submission of CPT 90785, one must document one of these in the health record: for example, continual questions, elevation in reactivity, elevation in anxiety, or disagreement.

CPT code 90792 needs to have a medical valuation performed wholly, and a medical professional should perform it with a valid license.