EAP 90801 in Psychiatry Coding and Billing Forum

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EAP 90801

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Hod	EAP 90801	Lead	[-]
Posts: 9 Mar 10 11 9:20 AM Reply Quote More My Recent Posts	Tags : eap, 90801 Need to know if a patient is seen through EAP and all allowed visits used and then they begin using the mental health benefits can the therapist bill another 90801 to the carrier? I don't feel this is correct since the patient is still seeing the same therapist that billed EAP and the patient is not new to them nor has anything significantly changed. Any thoughts?
Doo		#1	[-]
Posts: 6253 Mar 10 11 11:53 AM Reply Quote More My Recent Posts	A 90801 is an evaluation, not a "new patient visit" as it is so often referred as. Continuing treatment generally does not warrant another evaluation. Sharon Moderator Nothing I say shall be construed as legal advice; always check with your own financial or legal advisors for your specific situation.
Hod		#2	[-]
Posts: 9 Mar 10 11 1:11 PM Reply Quote More My Recent Posts	That was my thought too, they argued since it was EAP and no insurance was billed and when they called for authorization they were approved for a 90801. I advised that if the patient had changed carriers ie. Aetna and Anthem we would not bill another 90801 just because they changed carriers. But I wanted to verify there was not something different with EAP since it's been years since I've worked with EAP. Thanks you'e the best!!! Cyndi
Doo		#3	[-]
Posts: 6253 Mar 11 11 12:15 AM Reply Quote More My Recent Posts	You are most certainly correct. Just because you were authorized for something doesn't mean you can do it or bill for it. It still has to be medically necessary. If I get a situation where I'm given, or they offer, a 90801 and I don't need it, I tell them why I don't need it and ask if I can have another 90806 instead. Sharon Moderator Nothing I say shall be construed as legal advice; always check with your own financial or legal advisors for your specific situation.
QuanYin4	Did 90801 get paid under the EAP?	#4	[-]
Posts: 14 Mar 13 11 10:34 AM Reply Quote More My Recent Posts	When a patient uses their EAP benefits prior to managed care and I am unable to bill 90801, then I usually bill the 90801 at the start of managed care visits. My position is that the provider did provide the 90801 service, which just wasn't paid under EAP. I'm not sure how the insurance companies would feel about this, but it meets my ethicacy requirements.
Doo		#5	[-]
Posts: 6253 Mar 13 11 4:08 PM Reply Quote More My Recent Posts	So you bill a 90801 for a date of service for which it was not provided? I would definitely have an ethical problem with that. Also, if the EAP and the regular insurance are two different companies, which they often are, the regular insurance is paying for a service that was not provided when they were responsible for payment. Further, should the provider be audited, they had better be able to show documentation for a full evaluation on the date that you said it was performed, which it does not sound like they can, from your description. Or do you bill the regular insurance for the first visit, a 90801, then use the EAP visits, then go back to the regular insurance? See, the thing is, when you use EAP, you are given a certain number of visits, and the evaluation pays the same as the psychotherapy. So you WERE paid for the 90801 evaluation, you were just paid the same as a regular visit. You cannot bill a service for a date different than it was provided. you can bill 1. 90801EAP 2. 90806EAP 3. 90806EAP 4. 90806 5. 90806 and you can bill 1. 90801 2. 90806EAP 3. 90806EAP 4. 90806EAP 5. 90806 you cannot bill this, as it is fraudulent, unless the provider performed a full evaluation on visit number 4 (since you cannot provide therapy without an evaluation, the provider would have also performed a 90801 on visit number 1). 1. 90806EAP 2. 90806EAP 3. 90806EAP 4. 90801 5. 90806 Sharon Moderator Nothing I say shall be construed as legal advice; always check with your own financial or legal advisors for your specific situation. Last Edited By: Doo Mar 13 11 4:15 PM. Edited 3 times.
Hod		#6	[-]
Posts: 9 Mar 14 11 3:48 AM Reply Quote More My Recent Posts	We have decided we are going to allow it in this situation anyways because, The 12 EAP visits were used and billed as a lump sum (total) and no coding or diagnosis were used per EAP for that particular patient. So when her EAP visits ran out and we started billing her insurance the provider did do a complete psych evaluation (90801) so therefore we are billing the 90801. My understanding after looking further into this is it depends on the EAP program the patient is in. Some of them want total bills some want coding just like you would normal visits. What made this one so difficult and usually the person (therapist/doctor) who sees patient for EAP does not normally see patient for their contiued therapy after EAP visits are used. They are generally referred to someone else but this particular EAP allows the provider to self-refer. Her documentation does support a 90801 that was never the issue. I agree with Sharon on her statement. I tend to be on the conservative side and will not allow a code to be billed unless it is supported and if in question I have researched thoroughly. I ruffle a lot of feathers that way but oh well. Thanks for everyones help! Last Edited By: Hod Mar 14 11 3:56 AM. Edited 1 times.
lchcmm		#7	[-]
Posts: 2 Apr 20 11 12:59 PM Reply Quote More My Recent Posts	My understanding of the 90801 issue is per AMA/APA guidelines is that the 90801 is a allowed once per episode with a gap of 2-3 years between episode. I would caution anyone when determining whether or not to use a code to not base that decision on payment issues. Yes, the reg carrier was not billed a 90801 - only the EAP was. But the question I would ask would be is the 13th visit really a 90801? As I understand it the patient remained with the EAP therapist for sessions after the EAP sessions ended. I would be hard pressed to look at the medical necessity or even reason for doing a 90801 on a patient that has already been seen by the clinician 12 times prior to this appt. Had there been a long gap between the12 and the 13th I would possibly look at it differenly but I am also aware of APA quidelines calling for a lenght of 3 years between episodes/treatment. Obviously it would be different it the patient had gone to a different provider for the 13th session. I always tend to avoid like the plague any coding decision based on whether or not the insurance company would pay for it. The only question that I would ask is whether or not the provider actually did a 90801. One tool I use when making coding decisions is to ask my self is "would I even consider coding it this way if reimbursement was not a factor?" Coding is and should be for the purpose of accurately telling the story of the care rendered for that date of service.
Doo		#8	[-]
Posts: 6253 Apr 21 11 3:23 PM Reply Quote More My Recent Posts	Hod wrote: The 12 EAP visits were used and billed as a lump sum (total) and no coding or diagnosis were used per EAP for that particular patient. I have to say, I have never, in my dozen or so years of working in this field, heard of an EAP that was billed as a lump sum regardless of the number of vsits used, and that no coding or diagnosis occurred. Further, most professional organizations consider it unethical to treat a patient without forming a plan of care and making a diagnosis. Just my two pence. Sharon Moderator Nothing I say shall be construed as legal advice; always check with your own financial or legal advisors for your specific situation.
sporty981		#9	[-]
Posts: 2160 Apr 22 11 4:44 AM Moderator Reply Quote More My Recent Posts	I have seen EAP visits that had to be billed at one time 8 sessions send them in when the 8 sessions are completed generally by fax on their form. However they don't require a code they do require an OTR and the dx etc has to be included along with a plan of care in order to be reimbursed. Karen Habel, CDA, CMBSI, CDBSI Nothing I say shall be construed as legal advice; always check with your own financial or legal advisors for your specific situation.

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