What is CPT Code 90791?

What is 90791 CPT Code?

The CPT Code 90791 is used for psychiatric diagnostic evaluations without medical services. It was created in 2013, along with 90792, to replace the former psychiatric diagnostic evaluation codes 90801 and 90802. This code is flexible in that it can be used by clinical psychologists, licensed professional counselors, licensed marriage and family therapists, and licensed clinical social workers, in addition to psychiatrists. CPT Code 90791 represents “integrated biopsychosocial assessment, including history, mental status, and recommendations.”

Code 90792 was created at the same time as code 90701, and these two codes are often the source of confusion for many practitioners. The only real difference between the two codes is that code 90792 includes medical services such as writing a prescription. For this reason, only psychiatrists and other medical professionals can use code 90792.

This code has multiple benefits, this code can be used to reimburses more than other common mental health CPT service codes like 90834 (individual psychotherapy, 45 minutes) and 90837 (individual psychotherapy, 60 minutes). And typically, no preauthorization is required (although some plans do require preauthorization, so be sure to check individual payer guidelines).

Is 90791 covered by Medicare?

Medicare will pay for only one 90791 per year for institutionalized patients unless medical necessity can be established for others. when a patient is referred with an organic diagnosis and a mental health diagnosis is established, the mental health diagnosis should be billed.

Requirements to Use Code 90791

CPT code 90791 covers such a broad array of assessments, it’s quite flexible and is a popular choice. However, there are some rules that limit its use, and you can encounter problems getting reimbursed if you don’t know these requirements.

First, although some payers allow providers to bill this code every six month, most will only reimburse the code once per year per client. This is why code 90791 is typically used for initial assessments and yearly progress evaluations.

Part of the regulations governing the use of code 90791 are related to what the session must include. According to Medicare, each session billed with code 90791 must include the following (or have the following characteristics):

  • Elicitation of a complete medical and psychiatric history
  • Mental status examination
  • Evaluation of the patient’s ability and capacity to respond to treatment
  • Initial plan of treatment
  • Reported once per day
  • Not reported say day as E/M service performed by the same provider
  • Covered at the outset

Most private payers follow the same requirements as Medicare. Each payer is unique, however, so it’s a good idea to check with each client’s insurer to see what their requirements are before you plan to use this code.

Required Documentation for Code 90791

Medicare also has specific documentation rules associated with code 90791, and again, most payers share these requirements. Here’s what your documentation should include.

  • Exact time record
  • Modalities and frequency
  • Clinical notes that summarize:
    • Diagnosis
    • Symptoms
    • Functional status
    • Focused mental status examination
    • Treatment plan, prognosis, and progress
    • Name, signature, and credentials of the person providing the service

A therapy practice needs several things in order to be healthy and sustainable. While billing isn’t typically considered an exciting topic, it’s one of the most important elements of building a strong foundation for your practice. And knowing your CPT codes is an essential part of getting reimbursed accurately for the services you provide. Code 90791 is an important code that you’ll want to use when applicable due to its benefits.

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