I could really use some insight to the 90792 . What is considered medical services? I have a provider who references another providers note and does not do their own physical exam. She does the Psych exam including the mental health assessment but the actual physical exam is being referenced. I have a meeting coming up and could use some guidance from someone with experience in this field.
While a provider can take into consideration another provider’s notes and review the records, it cannot be used or replaced for the treating providers medical history, a provider should not be cloning his own notes, let alone other providers notes or using them as his own. This is called cloning and is not considered a part of the treating providers work. When reporting 90792 the provider is stating he has met all requirements for using that code. The provider must do their own exams and history or risk misinformed treatment for the patient, not to mention unfavorable audits, fines, and takebacks.
To report 90791, the treating provider must do a complete psych and medical history, including ordering Labs and other studies. It may also include communication with family or other sources to establish a tentative diagnosis, and the patient’s capacity to benefit from treatment. It is considered a biopsychosocial and medical assessment.
If the provider is simply doing a review of records, there is a CPT code to report that as well.