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90792 versus 90791 assigned Medicare RVUs

  1. Default 90792 versus 90791 assigned Medicare RVUs
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    Does anyone know the justification for Medicare pricing 90791 higher than 90792. This is very surprising to me because 90792 includes evaluation with medical services therefore, I would think it would price higher because it includes the E/M. Note: no E/M code can billed with 90791 or 90792.

    I know the work RVU is higher for 90792 but the PE RVU is lower which is causing the 90791 to have a higher Medicare rate but this still doesn't make since since the 90792 includes the medical services.

    90791- Psych diag evaluation (Work RVU 2.80 and NF PE RVU 1.52)= higher Medicare rate then 90792

    90792- Psych diag evaluation with medical services (Work RVU 2.96 and NF PE RVU .58)= lower Medicare rate then 90791

    Thanks in advance!

  2. #2
    Nassau County
    Just noticed that as well - that makes no sense whatsoever.

    My psych providers are still in a huff on just what constitutes "medical services". Does anyone have a fifth grade definition I can give them?
    Ken Ferguson, CPC, CPCO
    Long Island, NY

  3. #3
    Q: In looking at the 2013 Medicare Physician Fee Schedule, I noticed that Medicare is paying more for CPT code 90791, the code for the psychiatric diagnostic evaluation without medical services, than it is for 90792, the same code with medical services. How could this be?

    A: These two codes were created to distinguish the work done by psychiatrists from that done by nonphysicians. They replace 90801, which was used by all mental health providers even though its descriptor included medical services that many of them were not qualified to perform. Unfortunately, and completely contrary to the usual procedure for newly created CPT codes, the Centers for Medicare and Medicaid service (CMS) chose to implement the new CPT coding structure for psychiatry without finalizing new values (RVUs) , as is normally the case. Instead, CMS created interim values for the new codes based on the 2012 code values and applied them to the 2013 coding structure. In order to maintain budget neutrality for 2013, CMS reduced the practice expense component for codes billed exclusively by medical professionals even though other changes to the code values were not made, while letting the practice expense value remain the same for nonphysician codes. The rationale given by CMS for this was that those providers now able to bill evaluation and management (E/M) services would benefit from higher practice expense payments any time they billed an E/M code. Oddly, CMS chose to apply this rationale not only to the values for the psychotherapy add-on codes that are used with E/M codes, but also to apply it to the initial diagnostic evaluation (90792) that includes medical services – a service that cannot be billed with an E/M code. As a result of this formula, the total payment for the 90792 is less (by about $25) than that for the 90791 even though the work is greater, the malpractice liability is greater, and the practice expense values are certainly no less than that for all mental health clinicians. Once the values are finalized and the practice expense is calculated equally, 90792 will pay more than 90791. Regardless of this, APA has made it clear to CMS that it is unacceptable for this current inequity to be in place even on an interim basis.

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