CPT Code 90792: Psychiatric Diagnostic Evaluation with Medical Services

What is psychiatric diagnostic evaluation with medical services (CPT 90792)?

A psychiatric diagnostic evaluation is a first appointment where a licensed mental health provider takes time to understand what a person is going through emotionally and mentally. It’s usually done when someone is starting therapy, noticing new symptoms, or just wants to figure out what’s really going on. The goal is to get a clear picture of the person’s mental health history, current struggles, and what kind of support might help.

For many mental health clients, this evaluation is the foundation for creating a treatment plan that actually fits their needs. Sometimes, though, it goes beyond as it might include a medical evaluation. That’s when a medical professional checks the physical health and medication history or even runs lab tests to make sure nothing medical is contributing to the issue.

When that happens, licensed medical professionals use CPT code 90792. This code is for a psychiatric diagnostic evaluation with medical services, which means it includes both the psychological and medical sides. It’s different from CPT 90791, which is used when no medical services are involved. Knowing the difference matters for both care planning and insurance billing.

CPT code 90792 documentation requirements

If you’re documenting a CPT 90792 session, here’s what you’ll need to cover:

• Complete medical and psychiatric history (past medical and psychiatric history, family history, social history)
• Complete mental status examination
• Establishment of initial diagnosis evaluation
• Other physical exam component as indicated
• Evaluation of the patient’s ability and willingness to participate in the proposed treatment plan
• Communication with family members or other sources (if necessary)
• Prescription of medications (if appropriate)
• Review and ordering of laboratory or other diagnostic studies (if necessary)

Following these steps during mental and medical assessment makes sure your 90792 evaluation is thorough, meaningful, and compliant with documentation standards.

CPT code 90792 billing guidelines

Billing for CPT 90792 has its own rules, and using the right codes at the right time makes all the difference. Here’s what you need to know when billing 90792:

• CPT 90792 can be conducted once at the onset of an illness or suspected illness
• The same provider may repeat 90792 if:
  • There is an extended break in treatment (approximately 6 months)
  • The patient is admitted to inpatient status for psychiatric illness
  • There is a significant change in the patient's mental status requiring reassessment
• 90792 may also be used again if the patient has a neurological disorder or dementia with an acute and/or marked mental status change
• Second opinions or diagnostic clarification may justify a repeat 90792
• An evaluation and management services code can be used for an initial interview instead if all  documentation requirements are met. Remember that evaluation and management services performed do not include psychotherapy.

Adhering to these helps ensure your billing stays accurate and compliant.