Mental health evaluations are the basis for good behavioral healthcare. CPT code 90791 is very important for making sure that practitioners get paid for the effort, knowledge, and clinical judgment that goes into initial psychiatric assessments. 90791 is a code that is often used, but it is also one of the most misunderstood and incorrectly billed CPT codes in mental health practice.
This tutorial goes over what CPT 90791 covers, who can bill it, what CMS says you need to do to document it, what to think about when it comes to getting paid, frequent reasons for denial, and the best ways to stay compliant while making the most money.
What Is CPT Code 90791?
CPT code 90791 is used to indicate a psychiatric diagnostic evaluation that doesn’t include medical services. It is a full mental health evaluation that is done when a patient first comes in or when a major diagnostic reassessment is needed.
This evaluation usually involves a full history, a mental state exam, diagnostic impressions, and the creation of a first treatment plan. 90791 is not a code for ongoing treatment like psychotherapy codes are; it is only for diagnosis.
CMS and the AMA say that 90791 is a service that can only be done once per patient each episode of care, unless there is a medical need to do it again.
CPT 90791 as a Diagnostic Medical Service Code
CPT code 90791, also referred to as medical code 90791 or service code 90791, is the standardized billing code used to report a comprehensive psychiatric diagnostic evaluation without medical services. Many providers ask what is code 90791 and how it differs from therapy codes. In simple terms, what is 90791 CPT code? It represents an in-depth clinical assessment designed to establish or reassess a mental health diagnosis. The CPT 90791 description includes gathering patient history, performing a mental status examination, and forming diagnostic impressions that guide treatment planning. Understanding the CPT code 90791 definition is essential for accurate billing, compliance, and reimbursement.
When Is CPT 90791 Used?
Most of the time, CPT 90791 is billed for the first mental health appointment, but it can also be utilized later in treatment if the patient’s condition changes so much that a new diagnostic assessment is needed.
A new patient showing signs of anxiety, despair, or trauma, a patient being examined after being hospitalized for psychiatric reasons, or a reassessment after new symptoms or diagnoses appear are all good examples of when to use it. This code can be used in more than just outpatient settings. It can also be used in office-based practices, community mental health centers, and some facility settings, depending on the regulations of the payer.
Who Can Bill CPT 90791?
Qualified mental health specialists who are legally allowed to diagnose mental health problems within their scope of practice may bill CPT 90791. These people usually include certified professional counselors, marriage and family therapists, psychiatric nurse practitioners, and licensed clinical social workers.
QCMS lets non-physician practitioners bill 90791 on their own as long as the services they perform are within their scope of practice and state laws. But incident-to billing doesn’t work for diagnostic mental health exams. Providers must make sure that their use of CPT 90791 is in line with credentialing, payer enrollment, and scope-of-practice requirements to avoid denials or recoupments.
What Services Are Included in CPT 90791?
During the psychiatric evaluation, CPT 90791 covers a lot of different diagnostic actions. You shouldn’t bill for these services separately; they are all included in one code.
The evaluation usually involves the patient’s current problems, psychiatric history, family and social history, substance use assessment, trauma screening, and a mental status exam. It also includes clinical interpretation, making a diagnosis, and making a first treatment plan.
The service includes time spent analyzing old records, interviewing family members when it makes sense to do so, and writing down what was found.
Time Expectations for CPT 90791
CMS and the AMA have not set a particular time limit for CPT 90791, unlike psychotherapy codes. The service, on the other hand, takes a lot of time, usually between 45 and 90 minutes, depending on how complicated the case is.
Time alone doesn’t determine whether someone can be billed, but the paperwork should show how thorough and complicated the review was. Very short comments may raise red flags during audits, especially if the service often bills 90791.
Documentation Requirements Under CMS Guidelines
For CPT 90791 reimbursement and audit protection, good documentation is very important. CMS expects the record to clearly show that a full psychiatric diagnostic examination is medically necessary.
medically necessary. The paperwork should explain why the evaluation was needed, what information was collected, and how clinical judgments were reached. It should show that the assessment was done for each person, not just based on a template.
A well-documented 90791 encounter usually has a clear main complaint, a full history of the current disease, pertinent psychiatric and medical history, mental status exam results, diagnostic impressions, and a treatment or care plan.
Medical Necessity and Diagnostic Justification
The most important thing to remember when invoicing for CPT 90791 is medical necessity The assessment must be rational and essential for diagnosing or excluding a mental health disorder and informing treatment choices.
CMS and private payers want doctors to establish that the patient’s symptoms, functional impairment, or risk factors make a full diagnostic assessment necessary. If you use 90791 on a regular basis or over and over again without a clinical reason, you may be denied or audited.
Clearly writing down how bad the symptoms are, how long they last, how they affect function, and how unsure the diagnosis is will help prove that medical care is necessary.
Can CPT 90791 Be Billed With Psychotherapy Codes?
You can’t usually bill CPT 90791 on the same day with psychotherapy treatments like 90832, 90834, or 90837. CMS sees the diagnostic evaluation as a separate service that should happen at a different time than continuous therapy.
Some commercial payers may let you bill the same day in certain situations, but this is not the norm. Before trying to bill the same day, providers should always check the policies of each payer.
One reason claims are denied is because psychotherapy is billed incorrectly with 90791.
Telehealth Billing for CPT 90791
When done through interactive audio-video communication, Medicare and most commercial payers will pay for CPT 90791 through telehealth.
The paperwork must show that the service was given through telehealth, including the patient’s consent, and show that the provider followed state licensing and payer telehealth rules. Telehealth evaluations must follow the same rules as in-person evaluations when it comes to paperwork.
Telehealth has made it more easier for people to get mental examinations, but billing accuracy is still very important.
Reimbursement for CPT 90791
Depending on the payer, where the service is provided, and the kind of provider, the reimbursement rates for CPT 90791 are different. Compared to psychotherapy codes, Medicare reimbursement is usually moderate to high, which shows how complicated the service is.
Depending on the terms of the contract, commercial payers may pay more or less. Medicaid payments are often different from state to state, and they typically need extra paperwork or permission. Payers are more likely to look at 90791 because it is a high-value code.
Common Reasons CPT 90791 Claims Are Denied
A lot of 90791 denials happen not because the service wasn’t right, but because the paperwork or billing information was missing or wrong. Some common causes for refusal are not having a medical need, not having enough paperwork, charging the code several times without a good explanation, billing for psychotherapy on the same day, or employing the wrong type of provider.
Payers may also decline claims if the examination seems to be a duplicate or if the diagnosis doesn’t reflect the level of assessment that was invoiced.
Audit Risk and Compliance Considerations
Auditors often look at CPT 90791 because it is a diagnostic code and pays more. CMS and private payers keep a close eye on how often providers bill 90791, especially when they do it a lot or in a short amount of time.
To lower the possibility of an audit, providers should make sure that their documentation is always of high quality, stay away from copy-pasting notes, and make it clear why a fresh diagnostic examination was needed when billing 90791 more than once. Mental health practices should do internal chart audits and billing checks on a regular basis.
Best Practices for Billing CPT 90791
To bill CPT 90791 successfully, clinical care, paperwork, and code must all be correct. Providers should see the diagnostic evaluation as a separate and complete service, not just a formality for intake. Clear narratives, personalized evaluations, correct diagnosis selection, and compliance with payer regulations substantially enhance reimbursement results. Working with skilled medical billing professionals can help lower the chances of denials and compliance issues even further.
How A2Z Billing Support Improves 90791 Reimbursement
Even if the clinical paperwork is correct, you could still lose money if you code or file a claim wrong. A2Z mental health billing services make sure that CPT 90791 is billed accurately, backed up properly, and followed up on if it is turned down. Billing specialists verify documentation to make sure it follows the rules, make sure the rules for each payer are valid, handle modifiers and telehealth indicators, and deal with appeals when claims are denied or down-coded.
This help enables therapists to focus more on their patients while keeping their money in order.
Make An Appintment With A2ZFrequently Asked Questions (FAQs)
Yes, CPT 90791 can be billed again if there is evident medical need, such as a major change in the patient’s condition or the need for a new diagnostic examination. It is important to explicitly write out the explanation.
CPT 90791 doesn't have a set time limit, however the evaluation should be thorough. Very brief meetings could make the audit risk go up.
No, most of the time. CMS usually doesn't let you bill CPT 90791 on the same day as psychotherapy treatments. Some business payers might make exclusions.