For mental health professionals, the initial intake appointment is a critical juncture. It's where the foundation for a successful therapeutic relationship is laid, and where the administrative and clinical pathways for treatment are established. A key component of this process is the correct application of the CPT code 90791, which is designated for a "psychiatric diagnostic evaluation." Understanding the nuances of this code is not just about getting reimbursed; it's about accurately reflecting the comprehensive work that goes into a new patient's first encounter. This guide will walk you through the essential aspects of the 90791 CPT code, offering clinically sound, evidence-based, and actionable insights to help you master its use.
The 90791 CPT code represents a comprehensive, integrated biopsychosocial assessment. This is not a simple meet-and-greet; it's a deep dive into the patient's world. The American Medical Association (AMA) defines 90791 as a "psychiatric diagnostic evaluation" that includes a history, mental status, and recommendations. Think of it as the clinical equivalent of a comprehensive diagnostic workup. You're not just listening to the presenting problem; you're exploring the biological, psychological, and social factors that contribute to it. This includes a thorough review of the patient's history of present illness, a complete medical and psychiatric history, and a detailed psychosocial assessment. The goal is to formulate a diagnosis and an initial treatment plan. To justify the use of this code, your documentation must reflect a face-to-face meeting and include a detailed record of the evaluation.
A common question on medical forums and in clinician circles is who, exactly, can bill for a 90791. The good news is that it's not limited to psychiatrists. A wide range of licensed mental health professionals can use this code, including:
It's crucial to check your state's specific regulations and the policies of the insurance providers you work with, as there can be variations. For instance, some states may have restrictions on which non-psychiatrist professionals can bill for this code.
This is a frequent point of confusion, and getting it wrong can lead to claim denials. The key distinction lies in the inclusion of medical services. CPT code 90791 is for a "psychiatric diagnostic evaluation without medical services." In contrast, CPT code 90792 is for a "psychiatric diagnostic evaluation with medical services." This means that 90792 can only be billed by a qualified licensed provider who can perform medical services, such as a psychiatrist or a psychiatric nurse practitioner. These medical services might include ordering diagnostic work or prescribing medications. If you are a non-prescribing clinician, 90791 is the appropriate code for your initial intake assessments.
While CPT code 90791 is not strictly time-based, there are guidelines to follow. The typical duration for a comprehensive diagnostic evaluation is between 45 and 60 minutes. However, the Centers for Medicare & Medicaid Services (CMS) have specified a minimum of 16 minutes and a maximum of 90 minutes for a 90791 session before additional coding is required. Many clinicians find that a thorough intake takes at least 60 minutes to complete all the necessary components. If your session extends beyond 90 minutes, you'll need to use add-on codes to be appropriately reimbursed for your time.
Thorough and accurate documentation is the cornerstone of successful billing for 90791. Your notes must justify the use of this code by demonstrating the comprehensive nature of the evaluation. Here are the essential elements to include in your documentation:
To further strengthen your documentation, consider including any diagnostic-specific assessments you used, such as the PHQ-9 for depression or the GAD-7 for anxiety.
A significant motivator for using 90791 correctly is that it typically reimburses at a higher rate than standard psychotherapy sessions. The reimbursement for 90791 is generally 35-75% higher than a 45-minute therapy session (90834) and 10-50% higher than a 60-minute therapy session (90837). The exact reimbursement rate can vary based on your credentials, geographic location, and the specific insurance plan.
Here's a look at the national average Medicare reimbursement rates for 90791 in recent years:
Year
Reimbursement Rate
2024
$169.29
2023
$174.86
2022
$195.46
2021
$180.75
2020
$145.44
It's important to note that these are Medicare rates and may differ from private insurance reimbursement rates.
The frequency of billing for 90791 is limited. Most insurance providers, including Medicare and Medicaid, allow this code to be billed only once per year, per client, per provider. Some private insurance plans may allow it to be billed once every six months. It's essential to verify the specific rules with each insurance provider to avoid claim denials. If a comprehensive reassessment is necessary within the same year due to a new problem or a significant change in the client's condition, you may be able to use 90791 again, but it's always best to check with the payer first.
For initial evaluations that extend beyond the 90-minute mark, you can use add-on codes to bill for the additional time. The primary add-on codes used with 90791 are:
Here's a simple breakdown of how to apply these codes:
Not all insurance plans cover these add-on codes, so it's crucial to verify coverage before using them. Your documentation must also clearly justify the need for the extended session time.
Mistakes in billing can lead to claim denials and delays in reimbursement. Here are some common pitfalls to avoid:
The documentation requirements for 90791 can be time-consuming. This is where technology can be a powerful ally. AI-powered scribe tools, like S10.AI, are designed to streamline the documentation process for mental health professionals. These tools can listen to your sessions and automatically generate robust, insurance-compliant intake notes. They can even provide suggestions for mental health assessments and possible diagnoses. By automating the documentation process, you can save valuable time, reduce administrative burden, and focus on what you do best: providing high-quality care to your clients. Explore how AI scribes can help you create accurate and comprehensive documentation for your 90791 sessions, ensuring you meet all billing requirements with ease.
What specific documentation is required for a 90791 intake to avoid claim denials?
To ensure your 90791 claim is accepted, your documentation must justify the medical necessity of a comprehensive psychiatric diagnostic evaluation. This includes a detailed biopsychosocial assessment, the patient's chief complaint, a history of the present illness, a mental status exam (MSE), a risk assessment, your clinical diagnosis (DSM-5 or ICD-10), and an initial treatment plan with goals. Failing to include these elements is a common reason for audits and denials. Consider implementing tools that streamline this process; for example, explore how an AI scribe with universal EHR integration, like S10.ai, can automatically structure your intake notes to meet these stringent requirements, saving you time and reducing compliance risks.
How often can I bill CPT code 90791 for the same patient?
This is a frequent question on clinician forums. As a general rule, most payers, including Medicare, allow you to bill 90791 only once per patient, per provider, per year. Some commercial insurance plans may allow it every six months. If a client returns after a significant absence (e.g., over a year) with a new presenting issue that requires a full re-evaluation, you can often bill 90791 again. However, it is critical to verify each specific payer's policy before the appointment to avoid reimbursement issues. Learn more about how integrated billing and documentation platforms can help track billing cycles and prevent these common errors.
What is the difference between billing a 90791 psychiatric diagnostic evaluation and a regular 90837 psychotherapy session?
The key difference lies in the service provided. CPT code 90791 is specifically for the initial, comprehensive assessment to diagnose a patient and formulate a treatment plan. It is not time-based but complexity-driven. In contrast, CPT code 90837 is used for subsequent, ongoing 60-minute psychotherapy sessions. Using 90791 for a standard follow-up therapy session is a frequent billing error. Ensuring your clinical note for the initial session clearly reflects a full diagnostic evaluation is crucial to justify the 90791 code. Explore how AI assistants from S10.ai can help you accurately document the unique components of each session type, ensuring your billing accurately reflects the clinical work performed.