CPT Code 90791: Psychiatric diagnostic evaluation

Learn more about CPT code 90791, its requirements, and guidelines for more accurate coding and billing.

What is CPT code 90791?

CPT code 90791 is a code used for the initial intake appointment and psychiatric evaluation, without medical services. It involves a comprehensive mental health assessment of a patient in need of mental health services for any new behavioral health concerns.

The service performed is most often an integrated biopsychosocial assessment, in which the healthcare professional assesses the patient's mental status, takes a history, evaluates a mental health diagnosis, and plans treatment.

Typically, the healthcare professionals who use this code are those who are providing psychotherapy services, like licensed behavioral health providers, licensed mental health providers, and licensed mental health professionals. More specific examples of these professionals are:

Psychiatrists
Clinical psychologists
Licensed professional counselors
Licensed marriage family therapists
Licensed clinical social workers
Licensed mental counselors

CPT code 90791 documentation requirements

During the session and prior to billing, healthcare providers must ensure that they follow the requirements for documentation. As a guide, here's a list of what must be documented:

Detailed clinic notes
Comprehensive mental health history
Evaluation of the patient's ability to respond to treatment
Mental status exam
Risk assessment
Treatment recommendations

CPT code 90791 billing guidelines

Once documentation is finished, to guarantee that the healthcare provider receives reimbursement for their services, it's best that they review whether they've used the proper code, by using the list of billing guidelines below as a reference:

The code is only used for initial evaluations
The client's insurance plan should be able to cover any add-on CPT codes
The visit should typically last 60 minutes, even if there is no time limit specified
The code cannot be billed with other psychotherapy codes on the same day
There must be a medical necessity justification if the payers require such proof

Frequently asked questions

Since the code is more often used in a routine outpatient appointment, it typically doesn't require prior authorization. However, that still depends on the insurance provider's rules and the patient's specific plan.

In a year, according to Medicare and Medicade, the code can only be billed once per client per provider.

Yes, the 90791 CPT code can be billed for telehealth.