The standard for reporting 90801 is 1x per year. Some carriers limit them to one time per year; unless proven medically necessary. Other carriers may allow one interview per hospitalization or significant complications of the underlying condition that warrant another diagnostic interview. I have emailed (and saved) correspondence from the Regulatory Affairs Officer from the APA and her statement was that 90801 can be billed no more than once per year;
typically, unless there were extenuating circumstances that the carrier deemed medically necessary. To answer your question regarding
"does the illness have to be a new illness or a repeat of the old illness coming back"...The "old illness" could be a significant change in progression in the disease. If this is a new illness, carrier guidelines may require reporting an admission code (example only) if the policy benefits for 90801 have been exhausted.
Also...
Q: When and how often is it appropriate to assign code 90801? We have a psych. team who consults in a medical hospital/ER setting and their documentation often meets guidelines for 90801 but someone advised this code can only be submitted 1 x per year? We are also concerned that this code may be meant for outpatient treatment specifically.
A: Here is the definition of the code 90801 from CPT Assistant March 01:
These psychiatric diagnostic interview examinations are most often performed during the initial phase of treatment, as the goal of the examination is to establish a diagnosis and treatment protocol for the patient.
Pre-service work depends on how the patient was referred. At a minimum, the work includes a telephone discussion with the person who initiated the referral (e.g., physician, family, law enforcement agent, employer). May include review of records from referral source and lab or consultation reports.
Intra-service work includes a complete psychiatric history including present illness; past history, family history, complete mental status examination; selected physical examination; arrangements for laboratory tests; establishing a definitive diagnosis or a narrow enough differential diagnosis to warrant a treatment plan; decision making concerning need for degree of supervision (e.g., hospitalization); and counseling the patient regarding diagnosis and options for treatment.
Post-service work includes arranging further studies and further care, a report or discussion with referral source, arranging to obtain additional information and dictating the results of the examination. Frequently, additional communication is required with the patient and/or family after results of studies are known or due to side effects of instituted treatment. A report and consultation with third-party utilization manager are completed to arrange for payment and funding for proposed treatment.
There are no restrictions on the setting for using this code. It can be used in either an outpatient or inpatient setting.
As a foot note regarding billing 90801, you will find that most carriers restrict payment for this code to a once a year allowance. Usage is not based on the discipline of the provider of the service. For example, if the patient had been seen by a psychologist in Feb then saw an MD in August, payment for the second use of 90801 would be denied because the allowance for the year had already been paid. When this code is used for admissions (which it is not a restriction on the use of this code by most payers) payment is based on whether or not the patient has any benefit left for the code. I always recommend to my psychiatric clients that they bill regular hospital admit codes (99221 - 99223) vs. 90801 to avoid this type of problem.
http://health-information.advanceweb.com/Article/Coding-QA-March-15-2005.aspx