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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6 Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.10 Psychiatric Diagnostic Evaluations : 6.10.2 Psychiatric Diagnostic Evaluation With Medical Services

6.10.2
A psychiatric diagnostic evaluation with medical services (procedure code 90792) may be covered to the extent that it is medically necessary. It includes a history, mental status assessment, and disposition, and may include communication with family members. Procedure code 90792 is a benefit only when services are performed by psychiatrists/physician, clinical nurse specialists, nurse practitioners, or physician assistants.
Examples of medical necessity include, but are not limited to, clients whose ability to communicate is impaired by an expressive or receptive language impairment from various causes, such as conductive or sensorineural hearing loss, deaf mutism, or aphasia.
Medical interpretation of laboratory and other medical diagnostic studies, documentation time, and time spent on medical records are considered part of the diagnostic interview service and are not reimbursed separately.
Psychiatric diagnostic evaluations (procedure code 90791 or 90792) are limited to the following diagnosis codes:
 
An interactive psychiatric diagnostic evaluation (procedure code 90791 or 90792) may be covered to the extent that it is medically necessary. Examples of medical necessity include, but are not limited to, clients whose ability to communicate is impaired by expressive or receptive language impairment from various causes, such as conductive or sensorineural hearing loss, deaf mutism, or aphasia.
Note:
Interactive complexity for psychotherapy services is not reimbursed separately. Interactive complexity add-on procedure code 90875 is informational only and will not be reimbursed separately from the appropriate psychotherapy procedures code.
A psychiatric diagnostic evaluation may be incorporated into an E/M service provided the required elements of the E/M service are fulfilled. An E/M procedure code may be appropriate when the level of decision making is more complex or advanced than that commonly associated with a psychiatric diagnostic evaluation.
Due to the nature of these encounters or visits, the general time frame for such a diagnostic evaluation visit is one hour. A psychiatric diagnostic evaluation counts towards the 12-hour per day, per provider system limitation.

Texas Medicaid & Healthcare Partnership
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