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To bill for a 90791 requires a psychiatric diagnostic evaluation be performed, including the assessment of the patient's psychosocial history, current mental status, review, and ordering of diagnostic studies followed by appropriate treatment recommendations. The provider has to actually see the patient in person. Assessment must be provided by an eligible provider such as a psychiatrist, NP, LP, LCSW, CNS-MH, etc., not by the patient.
If the patient completes the assessment in the waiting room and it is then reviewed by any of the people you mention during the visit - does that qualify for a 90791?
If all of the other requirements are met (i.e. review, and ordering of diagnostic studies followed by appropriate treatment recommendations.). By the way, a patient cannot provide an "assessment." They can answer the questions on the form about their psychosocial history, how they feel currently, etc. but only the provider can then "assess" those answers in correlation with their own observations of the patient.
I see that you've requested a new answer. Can you be more specific about what isn't clear to you? What I am inferring from your question is that you wonder if a patient can answer the questions under "asessment" on the form, that the eligible provider can review the answers without seeing the patient. If I've not understood, please help me understand the exact nature of what you're asking.
In ALL cases, the eligible provider must see the patient, not just look over paperwork, in order to bill a 90791.
Thanks for making that clear for me. Yes, the patient can complete the section marked "assessment" in the waiting room. The provider then needs to read over it, not asking each question again :-) but asking the patient only about specific elements that might raise red flags.
In this case, it is no different than having to ask the patient to recite his address, phone number, etc. to the provider after having filled in the paperwork. The provider is the one actually reading the answers and making the assessment of the patient.
Please let me know if you have questions.
Was there anything else you needed to know?
Thank you that is very helpful. Is there a minimum number of assessments required that need to be given or particular areas (depression, anxiety, suicide, etc) that need to be covered?
Since it is a psychological appointment, each area needs to be asked about. That is true just to cover the nature of the patient's problem, not just for billing purposes. Without asking those questions, there would be no way to provide a diagnosis or treatment.
I am asking for the primary care setting. So the patient could be coming in for an annual physical, a sore throat, etc but we are trying to begin screening for behavioral health issues for every patient. So just want make sure I am asking all the right questions so we can bill for a 90791 AND provide the correct service for the patient. Is there anything I am missing in your opinion? Thanks so much for your help!
Primary care is another animal altogether. 90791 is a psychiatric evaluation prior to intake for in-office treatment, referral to a clinic, or inpatient. It isn't simply the little area on a primary care assessment form that asks about depression/anxiety/lifestyle choices (drinking, smoking, drug us). In my opinion this doesn't meet the criteria for a 90791. Some questions you can use to see if you meet the criteria are these: if the patient answers that he is suicidal, are there staff present to treat him? Does your staff do psychotherapy? The code is one I see used in psychology, psychiatry, and ER.
I hate to be the bearer of bad news.
In addition, even if you were contemplating using this code for patients coming in for a physical, you would use 90792 (Psychiatric evaluation with medical services) rather than 90791 (Psychiatric evaluation without medical services).
Also, the Review of Systems in a regular physical exam already includes a psychiatric assessment that asks about depression/anxiety/sleep disorders/etc., and trying to use 90791 or 90792 would be double billing.
Is there anything you didn't understand about my answer, anything that requires further clarification?