90791
Psychiatric Diagnostic Evaluation
Code Description
CPT code 90791 is used to report a psychiatric diagnostic evaluation without medical services. The evaluation includes an integrated biopsychosocial assessment, patient history, mental status examination, and development of treatment recommendations. It is typically performed at the beginning of a course of behavioral health treatment to establish a diagnosis and treatment plan.
Unlike CPT 90792, this code does not include medical services such as prescribing medications or performing a physical examination.
When to Use 90791
Common examples include:
Initial mental health evaluation
Depression assessment
Anxiety evaluation
Behavioral health intake
Psychological assessment
Initial counseling evaluation
Documentation Requirements
Documentation should include:
Presenting concerns
Comprehensive psychosocial history
Mental status examination
Clinical assessment
Diagnosis or diagnostic impression
Treatment recommendations and plan
Common Billing Mistakes
Common billing mistakes include:
Reporting 90791 for psychotherapy sessions
Billing 90791 repeatedly without medical necessity
Confusing 90791 with 90792
Insufficient documentation of the diagnostic evaluation
Reporting psychotherapy instead of a diagnostic assessment
Related CPT Codes
90792
Psychiatric Diagnostic Evaluation With Medical Services
90834
Psychotherapy, 45 Minutes
90837
Psychotherapy, 60 Minutes
FAQ
What does CPT code 90791 cover?
CPT code 90791 reports a psychiatric diagnostic evaluation without medical services. It includes a biopsychosocial assessment, history, mental status examination, and treatment recommendations.
What is the difference between CPT 90791 and 90792?
CPT 90791 is used for psychiatric diagnostic evaluations without medical services, while CPT 90792 includes medical services such as medication evaluation or physical examination.
Is CPT 90791 used for psychotherapy?
No. CPT 90791 is a diagnostic evaluation code. Ongoing psychotherapy sessions are reported with psychotherapy CPT codes such as 90834 or 90837.
Who can report CPT 90791?
Depending on state law and payer policy, CPT 90791 may be reported by qualified behavioral health professionals such as psychologists, licensed clinical social workers, licensed professional counselors, marriage and family therapists, and other eligible mental health providers.
Procedure Type
Psychiatric Evaluation
Specialty
Service Includes
Behavioral Health
Diagnostic Evaluation Without Medical Services
