Wiki Code 90791

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HPollock77

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Hello. I am confused on how to use 90791. Can it be used for example 2 days in a row, or two visits a week apart? Or does it have to be billed just as one visit (document the two days on the visit notes) and billed at two units? Please help.
 
If you read the guidelines in your CPT book at the beginning of the section for 90791 it answers. There is more information in the section as well. You can't bill two units of this. Payers also have guidelines on it for per year usage, etc.
"Codes 90791, 90792 may be reported once per day and not on the same day as an evaluation and management service performed by the same individual for the same patient."

I have seen if a provider performs a diagnostic evaluation on a patient multiple times in one day or if the evaluation extends over a period of time that exceeds one day, only one instance of CPT code 90791 should be reported.

Payer examples:

You can also check the MUE search on some of the MAC sites for info: https://www.cgsmedicare.com/medicare_dynamic/j15/mue/mue_tool.aspx
Effective: 1-Jan-23 The MUE for 90791 is 1 The MAI is 3 Date of Service Edit: Clinical MUE Rationale: Code Descriptor / CPT Instruction

90791: Report once per day and may report more than once/year (with separate evaluation)
 
We use 90791 for the initial visit/diagnostic assessment only. Some of the insurances for instance Ohio Medicaid it can only be billed once per calendar year without prior auth. So check with the payer as well as to their guidelines. We just use it for the initial then they use other cpt codes depending on services for example 90832-90837, etc.
 
Most payers will only pay for up to 3 per year of 90791/90792 combined so if you have a clinical assessment and then a medication evaluation there's two already in a short time. We use E/M visits instead for prescribers
 
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