
CPT Code 90791: The Complete Guide to Psychiatric Diagnostic Evaluation
CPT code 90791 is one of the most commonly used billing codes in behavioral health. Whether you're a mental health provider, practice administrator, or billing specialist, understanding how and when to use 90791 is essential for clean claims and maximum reimbursement.
In this article, we’ll break down:
What CPT code 90791 is
When to use 90791
Documentation requirements
Reimbursement rates
Common billing errors and how to avoid them
What is CPT Code 90791?
CPT 90791 refers to a psychiatric diagnostic evaluation with no medical services. It is typically used for an initial intake or comprehensive evaluation by a licensed mental health professional such as a psychologist, licensed clinical social worker (LCSW), or counselor.
This service includes:
A biopsychosocial assessment
Patient history
Mental status exam
Diagnostic impressions
Treatment planning
Important: 90791 does not include medical services such as prescribing medications or a physical exam. For those, you would typically use 90792 (psychiatric diagnostic evaluation with medical services).
When to Use 90791
Use CPT code 90791 for the first appointment when a provider conducts a full clinical intake. Most payors allow this code to be billed once per provider per patient, though some allow it annually for re-evaluation.
Who Can Bill 90791?
Generally accepted provider types include:
Psychologists (PhD or PsyD)
Licensed Clinical Social Workers (LCSW)
Licensed Professional Counselors (LPC)
Marriage and Family Therapists (LMFT)
Psychiatrists can also use 90791, but if they are performing a medical evaluation, 90792 may be more appropriate.
Documentation Requirements for 90791
To support CPT 90791, documentation should include:
Chief complaint and presenting problem
History of present illness
Past psychiatric, medical, and family history
Social and developmental history
Mental status examination
Diagnostic formulation
Initial treatment plan
Incomplete documentation can lead to claim denials or recoupments. Make sure all required elements are clearly outlined in the note.
Reimbursement Rates for 90791
Medicare and commercial insurance reimbursement varies by geography, provider type, and setting. On average:
Medicare reimburses ~$145–$160 for 90791
Commercial payors may reimburse between $120–$250
It's always best to verify payor-specific rates through your fee schedules or clearinghouse.
Common Billing Pitfalls (And How to Avoid Them)
Mistake | Solution |
---|---|
Billing 90791 multiple times for the same patient | Check payor policy; limit to one per provider unless medically necessary |
Missing required documentation | Use structured templates to ensure all elements are captured |
Using 90791 when medication management is included | Use 90792 if medical services are provided |
Final Takeaway
CPT 90791 is foundational to behavioral health billing, but using it incorrectly can delay payments or trigger audits. Ensure proper documentation, know your payor rules, and train your clinical team to understand the billing implications of intake appointments.
Want to streamline intake compliance or prevent audit risk? Tools like Brellium automatically check 90791 notes for completeness and alignment with payor guidelines.