Increase Insurance Reimbursement with These Two Billing Tips
CPT code 90791: Psychiatric diagnostic evaluation
According to Medicare
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. (Center for Medicare & Medicaid Services)
I have confirmed with the American Psychological Association’s Coding & Payment Policy Officer that it would be appropriate to bill for two 90791’s for a child where one parent provides history on the first meeting and the other parent provides additional history on the second meeting. In this case, sessions 1 and 2 can both be billed as diagnostic evaluations (90791).
I recently learned that insurance companies are reimbursing for brief screening instruments such as depression and anxiety inventories as well as ADHD scales. This is the second strategy for increasing insurance reimbursement, which went into effect as of January 1, 2015. Here is a description of the code according to the American Psychological Association’s website.
CPT code 96127: Brief behavioral assessment
Brief emotional/behavioral assessment (for example, depression inventory, attention-deficit/
hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument, is new for 2015. This code should be used to report a brief assessment for ADHD, depression, suicidal risk, anxiety, substance abuse, eating disorders, etc. This code was created in response to the Affordable Care Act’s federal mandate to include mental health services as part of the essential benefits that must be included in all insurance plans offered in individual and small group markets. The mandate covers services such as depression screening for adults and adolescents, alcohol misuse in adults, alcohol and drug use in adolescents, and behavioral assessments in children and adolescents. (American Psychological Association)
In my initial investigation, I have found commercial insurance companies reimbursing similar to Medicare which pays $5.89 for the Philadelphia Metro Area. Keep in mind that this is amount is per instrument, so you could potentially increase your reimbursement by almost $12 by using a BDI and a BAI for example. To do so you would need to bill CPT code 96127 with 2 units or enter two separate charges of the code in your billing program. If you use are entering two or more separate line charges (rather than billing number of units) then use modifier 59 to indicate “distinct procedural service” on each additional 96127. We have just started doing this in my practice so I am anxious to see how it goes.
Lastly, I am not aware of any restrictions on who can bill this code so please leave a comment with your credentials if you are having success or experiencing any difficulties. If you have other reimbursement strategies to share, please leave a comment. Of course, your questions are welcome as well. Take care!