Procedure code 90791, along with 90834 and 90837, is one of the most frequently billed CPT codes for licensed behavioral health providers. In this article, we answered one of the most asked questions about CPT Code 90791 i.e. ‘How Often Can You Bill 90791?’. We also provided detailed information on accurately using CPT Code 90791 which will help you to avoid denials and rejections related to 90791.
CPT Code 90791 is typically billed for the initial intake appointment a client will have. Subsequent sessions will be billed with CPT Code 90834 and CPT Code 90837, depending on the appointment duration. It can be billed by Licensed Clinical Social Workers (LCSW), Licensed Professional Counselors (LPC), Licensed Mental Counselors (LMHC), Licensed Marriage Family Therapists (LMFT), clinical psychologists, and psychiatrists. CPT Code 90791 is used for psychiatric diagnostic evaluation and is defined as:
An integrated biopsychosocial assessment, including history, mental status, and recommendations.
How Often Can You Bill 90791?
This depends on the insurance and the plan and if you’re not sure, call the insurance. Typically Medicare and Medicaid plans allow 90791 once per client per provider per year. Other plans will allow as frequently as once per 6 months.
These 90791 reimbursement rates are set by Medicare and are national rates. These rates are at the upper level of reimbursement for CPT Code 90791 and because Medicare is picking these rates, they are specifically for LCSWs. The following diagnostic interview reimbursement rates set by the Center for Medicare Services:
- CPT Code 90791 (Year 2020): $145.44
- CPT Code 90792 (Year 2020): $160.96
- CPT Code +99354 (Year 2020): $132.09
- CPT Code +99355 (Year 2020): $100.33
90791 is considered a routine outpatient appointment, so typically no authorization is required. But like any procedure code, exceptions do exist depending on the plan and the insurance company. Some insurance companies like United Health Care (UHC) will grant one authorization for 90791 and a separate one for 90834 or 90837 EAP sessions. If authorization is required, when you call and get authorization, make sure that 90791 is covered under it! To find out if authorization is required, you’ll need to perform an eligibility and benefits verification on the client’s insurance plan.
The Centers for Medicare Services (CMS.gov) requires CPT code 90791 to be 16 minutes in length at a minimum and 90 minutes of length at maximum before using an add-on CPT code to designate session time.
90791 Add-on CPT Codes
If the diagnostic interview lasts longer than 90 minutes, please use the following CPT codes to designate added time:
- Add-On CPT Code +99354 — An additional 30-45 minutes of time
- Use 90791 + 99354 if your session is between 90 and 120 minutes (1.5 to 2 hours)
- Add-On CPT Code +99355 — An additional 45 minutes of time
- Use 90791 + 99354 + 99355 if your session between 2-3 hours of time
CPT Code 90791 vs. CPT Code 90792
CPT Code 90792 is a very similar to CPT Code 90791 but there are some differences. Like 90791, it is defined as a psychiatric diagnostic evaluation. The only distinction is that 90792 includes medical services done by a physician. This means that only medically licensed professionals, such as a psychiatrist, can bill 90792.
Mental Health Professionals
Billing for CPT Code 90791 can be performed by the following licensed mental health professionals:
- Licensed Clinical Social Workers (LCSW)
- Licensed Professional Counselors (LPC)
- Licensed Mental Counselors (LMHC)
- Licensed Marriage Family Therapists (LMFT)
- Clinical Psychologists (PhD or PsyD)
- Psychiatrists (MD)
Documentation for CPT Code 90791 for an diagnostic evaluation must reflect a face to face meeting and this code requires a face to face meeting based on Medicare’s requirements. Documentation should include:
- Recording the time
- Modality of treatment
- Suggested frequency of treatment
- Clinical notes that summarize:
- Functional status
- Focused mental status examination
- Treatment plan, prognosis, and progress
We tried to provide in detail answers on ‘How Often Can You Bill 90791?’ and other details on accurately billing CPT Code 90791. For accurate Mental/Behavioral Health medical billing, knowing your CPT codes is the most important thing. In our blog series of ‘Know Your Codes’ or ‘KYC,’ we discussed the most common CPT codes in detail and when to use them. E2E Medical Billing Services is known for it’s accurate Mental/Behavioral Health medical billing and coding. To know more about our services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com