Wiki Psychiatric Diagnostic Evaluation - 90791 - Dx Issue

JessiePan

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Hello all!

I am new to Billing/Coding Behavioral Health and in my second week a situation has arouse that the company I'm working for has never encountered.

We have a patient who was court appointed to get a Psychiatric Diagnostic Evaluation (90791). During the appointment the patient denied experiencing any depression, anxiety, use of alcohol or substance abuse. At this time my clinician is feeling confused on how to diagnosis in an appropriate way to bill the 90791. I believe the best code to use would be Z65.3 (Problems related to other legal circumstances), but in my experience Z codes shouldn't be used as a primary diagnosis. My clinician thinks F43.2 (Adjustment disorder, unspecified) may be a way around the patients denied symptoms, but I'm unsure if we have enough evidence to support that.

Does anyone out there have any advice or experience in a similar situation?
 
Hello all!

I am new to Billing/Coding Behavioral Health and in my second week a situation has arouse that the company I'm working for has never encountered.

We have a patient who was court appointed to get a Psychiatric Diagnostic Evaluation (90791). During the appointment the patient denied experiencing any depression, anxiety, use of alcohol or substance abuse. At this time my clinician is feeling confused on how to diagnosis in an appropriate way to bill the 90791. I believe the best code to use would be Z65.3 (Problems related to other legal circumstances), but in my experience Z codes shouldn't be used as a primary diagnosis. My clinician thinks F43.2 (Adjustment disorder, unspecified) may be a way around the patients denied symptoms, but I'm unsure if we have enough evidence to support that.

Does anyone out there have any advice or experience in a similar situation?

I wouldn't use F43.2 if there wasn't enough documentation to support it.

What about something like Z04.6 (Encounter for general psychiatric examination, requested by authority)?
 
Also, there's a modifier H9 for court ordered that you may need to use with the CPT 90791. You might want to check on that as well.
 
I wouldn't use F43.2 if there wasn't enough documentation to support it.

What about something like Z04.6 (Encounter for general psychiatric examination, requested by authority)?
Oh! Thank you! I think that might work, but I guess it still falls under using a Z code as a primary Dx... Do you know if that will be an issue being reimbursed?
 
In terms of being reimbursed, you may also need to check the requirements from the patient's insurance policy. The payer may have their own preferences for billing a court ordered examination. Ex- whether they want the H9 modifier, etc.

(Also keep in mind that there's a chance that the patient's policy may exclude coverage for court ordered testing.)

Here's an example of a payer policy for Court Ordered Behavioral Health exams. It's from BCBS Minnesota, and shows how they want it to be billed/coded. I just pulled as a random example because it was the first one I found. :)


Disclaimer: I don't code or bill behavioral health right now. Though I've worked in denials for a large hospital system that included working denials on hospital behavioral health claims and had to learn to search for information to resolve/prevent denials. I can direct you on where to search for information, but I am not an outpatient behavioral health coding expert. :)

Thank you so much!! You really have helped me and so quickly! Thank you! Thank you!


You're welcome!
 
Oh! Thank you! I think that might work, but I guess it still falls under using a Z code as a primary Dx... Do you know if that will be an issue being reimbursed?
Most insurance companies state that they do not cover court ordered services in their benefit plan docs. I would bill the Z code since it seems appropriate and bill the client when it's denied. Without seeing the nite, I doubt there is enough to support an F code.
 
Hello all!

I am new to Billing/Coding Behavioral Health and in my second week a situation has arouse that the company I'm working for has never encountered.

We have a patient who was court appointed to get a Psychiatric Diagnostic Evaluation (90791). During the appointment the patient denied experiencing any depression, anxiety, use of alcohol or substance abuse. At this time my clinician is feeling confused on how to diagnosis in an appropriate way to bill the 90791. I believe the best code to use would be Z65.3 (Problems related to other legal circumstances), but in my experience Z codes shouldn't be used as a primary diagnosis. My clinician thinks F43.2 (Adjustment disorder, unspecified) may be a way around the patients denied symptoms, but I'm unsure if we have enough evidence to support that.

Does anyone out there have any advice or experience in a similar situation?
I agree with msbernards, most (if not all) insurance companies will deny this, and to assign an F code when the documentation doesn't support it would be fraud. We use Z04.6 for "Encounter for general psychiatric examination, requested by authority". We have the client sign an ABN (even non-Medicare) to let the patient know that insurance won't pay for it due to lack of medical necessity. The best practice would be to have your intake staff screen these out and have your organization set up a process with the courts, DHS, or whomever the "authority" is for collecting payment- either from the authority itself, or from the patient. Many courts require that the patient pay for their own evaluations.
 
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