Wiki Unbundling for 99202 and 90791

[laylaykali]

Pattern 23400 Procedure Code 99202 has an unbundle or incidental relationship with Procedure Code 90791 -This is what I am continually receiving as a rejection. I've already tried with modifier 25 and 59 and get basically the same thing. I am billing for the SAME DATE AND PROVIDER but they're being seen for 2 different things. What am I doing wrong?

 

[jkyles]

Hi there, according to the National Correct Coding Initiative, that edit pair cannot be broken with a modifier. Only 90791 will be covered.

 

[laylaykali]

Hi there, according to the National Correct Coding Initiative, that edit pair cannot be broken with a modifier. Only 90791 will be covered.

Sorry still new to all this can you just clarify that if a provider does both I can only bill for 90791?

 

[sls314]

Sorry still new to all this can you just clarify that if a provider does both I can only bill for 90791?

Correct. An E/M visit can't be billed with 97091.

That being said, you may want to consider whether the services being provided would be more accurately represented by 90792 (Psychiatric diagnostic evaluation with medical services).

This is what EncoderPro has for the descriptions of 90791 vs 90792:

A psychiatric diagnostic evaluation is performed, which includes the assessment of the patient's psychosocial history, current mental status, review, and ordering of diagnostic studies followed by appropriate treatment recommendations. In 90792, additional medical services such as physical examination and prescription of pharmaceuticals are provided in addition to the diagnostic evaluation.

Of course, the documentation would have to support that.

 

[jkyles]

Sorry still new to all this can you just clarify that if a provider does both I can only bill for 90791?

That's correct. Some editing pairs do not allow you to unbundle the services with a modifier. For Medicare claims you can use the code edit tool on your Medicare administrative contractor's website.