The Provider’s Secret Weapon: Mastering CPT Code 90791 for Optimal Reimbursement
Mastering CPT code 90791
Medical coding is a crucial component of healthcare reimbursement, and mastering the right codes can make a significant difference in a provider’s bottom line. One of the most important codes to understand is CPT code 90791, which is used for diagnostic evaluations in mental health and substance abuse settings. In this article, we’ll explore the ins and outs of CPT code 90791, including its description, billing guidelines, and reimbursement rates, so that you can optimize your use of this important code. Service code 90791 is used for therapy sessions for non-E/M services.
Understanding CPT code 90791
CPT codes are used to describe medical services and procedures, and they are essential for billing and reimbursement purposes. CPT code 90791 is a diagnostic evaluation code that is used in mental health and substance abuse settings. This code includes an evaluation of the patient’s history, a mental status examination, and a diagnosis, and it is typically used for initial assessments or as part of a treatment plan review.
To bill for CPT code 90791, providers must include certain elements in their documentation, such as the reason for the evaluation, the patient’s history, and the results of the mental status exam. The code can be used in a variety of medical settings, including inpatient care for behavioral health, outpatient care for behavioral health, and telehealth for behavioral health.
The Importance of Psychotherapy Codes
In addition to diagnostic evaluations, psychotherapy codes are crucial for billing mental health services. Common psychotherapy codes include individual psychotherapy (90837), family psychotherapy (90847), and psychotherapy sessions with a health professional (90834).
Billing for Psychotherapy Services
When billing insurance for psychotherapy sessions, it’s essential to document the face-to-face time spent with the patient. Codes for 30-minute (90832) and 45-minute (90834) psychotherapy sessions are available, as well as an additional 30-minute add-on code (90833) for longer sessions. Family psychotherapy sessions can also be listed separately in addition to the primary code (90846), and individual psychotherapy sessions can be billed in 15-minute increments (90832 and 90833).
Insurance Claims and Evaluation and Management
Providers should also be aware that insurance claims may require additional documentation, such as progress notes, to support their billing. Additionally, CPT codes for evaluation and management services, such as 99213 and 99214, can be used in conjunction with psychotherapy codes when appropriate.
Understanding and using these common mental health CPT codes can help counselors optimize their reimbursement for mental health services when billing patients’ healthcare insurance.
Which Providers can use CPT 90791?
Psychiatrists (MD)
Medical doctors (MDs) who specialize in mental health and have completed a residency in psychiatry.
Psychologists (Ph.D. or Psy.D)
Doctoral-level mental health professionals who hold either a Ph.D. (Doctor of Philosophy) or Psy.D (Doctor of Psychology) degree.
Licensed Clinical Social Workers (LCSW)
Master’s-level mental health professionals who have a master’s degree in social work (MSW) and are licensed by their state to provide mental health services.
Licensed Professional Counselors (LPC, LCSW, LMFT)
Master’s-level mental health professionals who have a master’s degree in counseling or a related field and are licensed by their state to provide mental health services.
Nurse Practitioners (NP) and Physician Assistants (PA)
Advanced practice clinicians who have completed a master’s degree or higher in nursing or physician assistant studies, respectively, and are licensed to practice under the supervision of a licensed physician or psychiatrist.
Billing and Reimbursement for CPT code 90791
Optimizing reimbursement is a key goal for providers, and understanding the fee schedule for CPT code 90791 is an important part of that process.
The reimbursement rate for this code can vary depending on the payer and their unique “allowed” rate, with Medicare and Medicaid typically offering lower rates than private insurers:
Aetna (a subsidiary of CVS Health), Beacon Health Options, BCBS, or Blue Cross (Anthem, Inc, Empire BlueCross BlueShield, Carefirst, Health Care Service Corporation, Highmark, Premera, Cambia, Wellmark), Bright Health, Centene Corporation, Cigna or Evernorth Health, Harvard Pilgrim Health CareHealthfirst, Humana, Kaiser Permanente, Meridian Health Services, Molina Healthcare, Oscar Health, Tufts Health Plan, United Healthcare (Optum or UHC), WellCare Health Plans.
To ensure accurate billing and maximize reimbursement, providers should follow specific guidelines when using CPT code 90791. These guidelines include documenting all required elements of the evaluation.
Frequency usage of service code 90791
Generally, behavioral health policies may limit the number of psychiatric diagnostic evaluations that can be performed per patient per year, based on medical necessity and the specific mental health diagnosis. The initial psychiatric diagnostic evaluation may be covered once per episode of care, with additional evaluations covered only when significant changes in the patient’s clinical status have occurred.
It is critical to confirm with each insurance payer for the guidelines and the necessary documentation that is required to use the diagnostic code more than the first occurrence. Please be aware, that each policy within an insurance company may have unique regulations for the usage of CPT 90791.
Length of time for CPT code 90791
According to the American Medical Association (AMA), which publishes the CPT codes, there is no specific time requirement for this code. CPT code 90791 is a psychiatric diagnostic evaluation code used for reporting the initial diagnostic interview examination. There is no specific time requirement for this code, as the duration of the evaluation may vary based on several factors. However, the diagnostic evaluation must be comprehensive and cover a wide range of topics, and it is the responsibility of the clinician to ensure that they have conducted a thorough evaluation that meets the requirements of the code.
Differences Between CPT codes 90791 and 90792
Another important code to understand in mental health and substance abuse settings is CPT code 90792, which is used for psychiatric diagnostic evaluations with medical services. This code includes all the elements of CPT code 90791, as well as additional medical services such as medication management or laboratory testing.
The main difference between the two codes is that CPT code 90792 includes medical services in addition to the diagnostic evaluation, while CPT code 90791 does not. Providers should carefully review the patient’s needs and the services being provided to determine which code is most appropriate.
Tips for Mastering CPT code 90791
To optimize their use of CPT code 90791, providers can follow a few practical tips and strategies. First and foremost, providers should ensure that their staff is trained in proper documentation and billing procedures for the code. Providers can also utilize resources such as online training modules or consulting services to improve their understanding of medical coding and billing.
In addition, providers should regularly review their billing processes and track their reimbursement rates to identify areas for improvement. By taking a proactive approach to medical coding and billing, providers can ensure they are using CPT code 90791 to its fullest potential and maximizing their reimbursement.
CPT code 90791 and telehealth
CPT code 90791 is an important diagnostic code used in psychiatric evaluations, and it is becoming increasingly important in telehealth services. With the COVID-19 pandemic, telehealth has become an essential tool for mental health providers to ensure that their patients can receive the care they need while minimizing the risk of exposure. However, navigating the complexities of telehealth billing can be challenging, and healthcare providers must ensure that they are using the proper coding, including the 90791 CPT code, to avoid billing errors and claim rejections. Providers should ensure they are familiar with the appropriate telehealth CPT codes, service codes, and diagnostic codes for telehealth services to ensure they are billing correctly.
Medical billing services can be incredibly helpful for healthcare providers as they navigate telehealth billing. These services provide end-to-end solutions, including coding, billing, and claim submissions, to ensure that providers are billing accurately and efficiently. Telemedicine companies such as Amwell Telehealth, Aetna Telehealth, and United Healthcare Telehealth offer billing and reimbursement services for telehealth services, helping providers navigate the complexities of telehealth billing. Insurance providers like Cigna Telehealth, Blue Cross Blue Shield Telehealth, and Molina Healthcare offer telehealth services coverage, ensuring that providers can bill for telehealth services and receive proper reimbursement. As telehealth services continue to become more popular, healthcare providers must stay up-to-date with the latest telehealth billing requirements, including the appropriate telehealth CPT codes, service codes, and diagnostic codes, to ensure that they are providing their patients with the best care while being properly reimbursed for their services.
Each insurance company has the requirement to bill telehealth services on the CMS-1500 professional billing form. By the use of a service code, location 2, and/ or with the use of modifier 95 or modifier GT.
Best practice for service code 90791
CPT code 90791 is a powerful tool for providers in mental health and substance abuse settings, and understanding its description, billing guidelines, and reimbursement rates is essential for optimizing its use. By following best practices for medical coding and billing, providers can ensure that they are accurately billing for their services and maximizing their reimbursement.
CPT Codes for Psychology (Non-E/M)
90791 – Psychiatric Diagnostic Examination without medical services
90832 – Individual psychotherapy (time range 16 – 37 minutes)
90834 – Individual psychotherapy (time range 38 -52 minutes)
90837 – Individual psychotherapy (time range 53 – 60 minutes) **
*** There is no code for a 75-minute session *** 1
*** There is no code for a 90-minute session ***
90853 – Group therapy
90846 – Family psychotherapy (without the patient present)
90847 – Family psychotherapy (conjoint psychotherapy) (with patient present).
ADDON CODES
+90785 Interactive complexity
+90839 Patient in crisis
+90840 Patient in crisis (each additional 30 minutes)
* 90837 may require special authorization by the individual insurance payer.
** Family visits can consist of spouses, parents and children, patients, and other family
members.
Essential terms for CPT 90837 and the solo private practice
Credentialed with insurance (paneled with insurance)
Non-credentialed with insurance (non-paneled with insurance)
Billing Service services for Mental Health providers
At MCM South Medical Billing Service, LLC, we understand the importance of ensuring that your medical claims are accurate, complete, and timely submitted. We work with various providers, including psychiatrists, psychologists, clinical therapists, and female therapists with specialties such as LPC, LMFT, LCSW, Ph.D., and Psy.D to ensure that their claims meet the specific payer guidelines.
Services
– Comprehensive medical billing service
– Patient insurance benefits verification (offered as a standalone service)
Know your patient’s benefits
Copayment (co-pay), deductible amount, deductible accumulations, co-insurance, and (OOP) out-of-pocket maximum
Our therapists specialize in various areas, including anxiety, trauma, cognitive-behavioral therapy, child behavior, couples therapy, family therapy, play therapy, sports therapy, ADHD, and psychological testing. By providing comprehensive billing services, we can help providers focus on their areas of expertise while ensuring that their claims are submitted accurately and efficiently.
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