Wiki 90792

[Pkirsch1]

The 90792 was denied because the provider used it twice within the same year. I let the provider know this, and she told me this person was discharged and came back, so the 90792 is correct. I appealed giving Anthem medical records for the first psych eval 90792, the discharge summary, and the second psych eval re-admission 90792. Anthem still denied. What should I have done to get the claim paid?

 

[sls314]

The 90792 was denied because the provider used it twice within the same year. I let the provider know this, and she told me this person was discharged and came back, so the 90792 is correct. I appealed giving Anthem medical records for the first psych eval 90792, the discharge summary, and the second psych eval re-admission 90792. Anthem still denied. What should I have done to get the claim paid?

Anthem has a hard frequency limit of 1 per 365 days, per member, per provider for patients over the age of 21.

There's nothing you could have done. It doesn't matter if they were discharged and re-admitted.

(Patients under the age of 21 have a limit of 2 per 365 days - if your patient happens to be under 21, I'd make that clear to Anthem.)

Here's the Anthem policy in writing:

https://providernews.anthem.com/ohio/article/reimbursement-policy-update-frequency-editing-professional-4

 

[sls314]

I just realized that my link was specific to Ohio. Here's the link showing the same frequency limit for Connecticut, in case your provider wants to see it:

https://providernews.anthem.com/connecticut/article/reimbursement-policy-update-frequency-editing-professional-6

 

[Pkirsch1]

Thank you so much for your help!