Wiki 90792 Frequency Exceeded

[consciouscoder]

Hi, fellow coders! New coder here with a question about 90792 for mental/behavioral health:

The practice network I work for is pro-fee billing and our providers treat outpatient at our facilities and sometimes treat inpatient at partnered hospitals. Some of our patients have conditions with severe exacerbation requiring hospitalization multiple times in a one year period. Typically we code the first visit inpatient (*not facility coding*) as 90792 to assess mental status, initiate psychiatric care, and any subsequent inpatient visits are coded as 99233 with psychotherapy when documented. Due to payer frequency we sometimes receive denials for situations like billing frequency met/exceeded when a patient is inpatient multiple times per year. Once 90792 frequency is met for the year, assuming MDM is high for the initial assessment, would:
1. 99223 be an appropriate code in place of 90792?
2. *Or* do you appeal the payer for 90792 based on change in mental status? (Any advice on these appeals would be appreciated)
3. When dx are the same but it's a repeat scenario of severe exacerbation + high risk = is 99223 supported?

Thanks for your input!! (I also posted this in the general coding forum and reposted here at the advice of another member)

 

[alvesey]

If it is less the 6 months from the last 90792and the patient has Medicare or a Medicare MA plan, it should be submitted as a corrected claim for the appropriate level of service of an IP visit. If it has been at least 6 months but not over a year, it should be appealed due to change of mental status, as long as the documentation supports it. A year or more, it shouldn’t be denied, but keep in mind that some payers “count” a 90791 as they do a 90792. Therefore, if the patient is also seeing a therapist that is billing 90791’s as well, you may be out of luck. BCBS used to only allow one (1) 90791 or 90792 per every 365 days, but in the past couple years we’ve billed for some less than that and have gotten paid. All BCBS plans we bill in Iowa go through Wellmark, so I checked and there was no difference for claims on out of state plans vs the in-state Wellmark plans. I looked in the online BCBS provider manual and there was no Blue Inks from last year and could not find any limitations on 90791 and 90792. We don’t get denials from any other payers, but I’ve heard Aetna may start. If you find that you are submitting both 90791 and 90792 against the payer’s allowed schedule, you can also submit 90791’s as the appropriate individual psychotherapy session per the documentation of time, methodology, etc. I hope this helps, but please do your own research to confirm the appropriate payer’s reimbursement policies and restrictions. Thanks!