Bariatric Pre-Surgery Psychological Assessment/Evaluation


Local Chapter Officer
Portland Metro Oregon
Best answers
HELP!! My clinic is using a psychologist to evaluate patients wanting to go through with bariatric surgery for weight loss. I keep reading how all the charges should be dropped on the return visit when the patient comes in to receive feedback from all the tests completed during the first visit. My question is how should the first visit be coded? Regular office visit E/M? Or something else?

Here's how it works:

Patient presents to clinic for evaluation with psychologist to prepare for bariatric surgery. At least 60 min is used completing MMPI, PHQ9, MBMD, AUDIT, DAST, GAD7 and a few other tests.
This same patient then returns to clinic (the next day/week/month) to review results and receive feedback from the psychologist in preparation for the surgery.

I'm thinking the first visit should be coded with one of the following:
1. Regular E/M visit
- OR -
2. 96136 - Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes
3. 96137 - each additional 30 min as documentation supports

Then for the follow up visit to review and receive feedback I think the coding should be as follows:
1. 96130 - Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour
2. 96131 - each additional hour as documentation supports

It turns out when the psychologists use the 90791 (psychiatric diagnostic evaluation) their numbers are being tracked in the wrong department, which is a problem and the reason for my confusion.