Wiki 90791

Pkirsch1

Networker
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95
Location
Bristol, CT
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Hello,
90791 denied for using twice in 365 days, but it was billed by 2 different Providers/NPI's.

Is it because it's billed under the same facility? Would the dx matter?

Thank you.
 
Usually the rules are payer specific. I know Medicare and our state Medicaid have slightly different frequency guidelines. We even get some denials if there is a 90791 done by a different facility within the allowed time frequency.
 
Pkirsch
They must be on different illness or disease to use separately by differ providers.
i hope this info is helpful
Lady T
 
Pkirsch
They must be on different illness or disease to use separately by differ providers.
i hope this info is helpful
Lady T
Thank you for clarifying Lady T!
Usually the rules are payer specific. I know Medicare and our state Medicaid have slightly different frequency guidelines. We even get some denials if there is a 90791 done by a different facility within the allowed time frequency.
Thank you!
 
According to Medicare policy, when multiple providers are within the same group practice and share the same specialty, they are considered "the same provider" for billing purposes, meaning that services provided by any of them within that group can be treated as if they were provided by a single physician; this is especially relevant when determining if a patient is considered "new" or "established" for billing purposes but can also apply to frequency restrictions. I just did a deep dive on this policy and most payers seem to align with it.
 
According to Medicare policy, when multiple providers are within the same group practice and share the same specialty, they are considered "the same provider" for billing purposes, meaning that services provided by any of them within that group can be treated as if they were provided by a single physician; this is especially relevant when determining if a patient is considered "new" or "established" for billing purposes but can also apply to frequency restrictions. I just did a deep dive on this policy and most payers seem to align with it.
Thank you!
 
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