E/M vs. 90792: Choosing the Right Code for Accurate Reimbursement

It’s a common misconception that E/M codes always yield higher reimbursement than code 90792. However, this is not necessarily true. Different levels of E/M codes correspond to varying degrees of complexity, and their reimbursement rates differ accordingly. 

So, don’t automatically assume you should report an E/M service each time your clinician evaluates a patient. Instead, understand that the level of the E/M code selected directly affects reimbursement, and sometimes CPT code 90792 may be more appropriate depending on the service provided.

Reimbursement Differences Among E/M Codes and Code 90792

A level-three E/M code reimburses less than level-four or level-five encounters within the same code family. For example, code 90792 receives a non-facility Medicare reimbursement of approximately $144.37. This amount is calculated by multiplying 4.03 total non-facility RVUs by the 2014 Medicare conversion rate of 35.8228 (CPT® 2024, American Medical Association. All rights reserved).

Reimbursement Comparison for New Patient E/M Codes

A level-three new patient E/M code (99203) reimburses about $108.18, calculated by multiplying 3.02 total non-facility RVUs by the 2014 Medicare conversion rate of 35.8228. In contrast, higher-level new patient codes pay more than 90792: a level-four new patient code (99204) reimburses approximately $166.22, while a level-five new patient code (99205) pays around $207.06.

When 90792 May Reimburse More Than Established Patient E/M Codes

A level-four established patient E/M code reimburses less than code 90792. It’s essential to base your coding on the services performed and the work involved in the encounter, rather than just potential reimbursement. If the clinical services align better with 90792, you should report that code, even if you initially thought an E/M code would pay more. Always choose the code that accurately reflects the encounter rather than chasing a higher payment.

BillingFreedom: Coding Clarity That Protects Your Revenue

Medical billing isn't just about selecting the highest-paying code; it's about understanding what accurately reflects the work done during a patient encounter. At BillingFreedom, we've built our reputation on doing billing the right way. We don't take shortcuts or rely on assumptions. Instead, we examine closely what actually happened in the room and then use that to inform our coding decisions.

Our team understands how to handle complex codes, especially when there is confusion about whether to bill an E/M or a code like 90792. We ensure that your billing is accurate and free from unnecessary risks.

We don't believe in pushing code to boost numbers in the short term. That kind of approach often leads to denied claims or, worse, audits. Our process keeps your billing clean, compliant, and entirely defensible. You get paid what you're owed without having to look over your shoulder.

At BillingFreedom, we're not just ticking boxes. We look forward to your long-term practice. From reducing rework to ensuring claims are processed correctly the first time, we're committed to providing that every detail is done right. That's what sets us apart, and that's why providers trust us to handle their billing.

For more details about our exceptional mental health billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472. 

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