CPT Code 90791: The Definitive Guide [+Reimbursement Rate 2021]

Learn everything about CPT Code 90791, billing for psychiatric diagnostic evaluation, also known as a mental health intake session in common parlance.  We teach you about authorization requirements, pay rate increases, frequency of billing, CPT Code 90791 documentation requirements and coding requirements, and more.

Procedure code 90791, along with 90834 and 90837, is one of the most frequently billed CPT codes for licensed behavioral health providers.

CPT Code 90791 Description

CPT Code 90791 is defined as:

An integrated biopsychosocial assessment, including history, mental status, and recommendations. 

This procedure code is used for diagnostic evaluation of new behavioral health concerns and or illnesses, or upon treatment of a new client.

CPT Code 90791 is typically billed for the initial intake appointment a client will have.  Subsequent sessions will be billed with procedure codes 90834 and 90837, depending on the appointment duration.

It can be billed by Licensed Clinical Social Workers (LCSW), Licensed Professional Counselors (LPC), Licensed Mental Counselors (LMHC), Licensed Marriage Family Therapists (LMFT), clinical psychologists, and psychiatrists.

90791 CPT Code

Does 90791 Require Authorization?

90791 is considered a routine outpatient appointment, so typically no authorization is required.  But like any procedure code, exceptions do exist depending on the plan and insurance company.

Some insurance companies like United Health Care (UHC) will grant one authorization for 90791 and a separate one for 90834 or 90837 EAP sessions.  If authorization is required, when you call and get authorization, make sure that 90791 is covered under it!

To find out if authorization is required, you’ll need to perform an eligibility and benefits verification on the client’s insurance plan.  We provide this service for free as part of our mental health billing service.

Does 90791 Pay More than a Normal Session?

Yes!  90791 almost always pays more per session than 90834 or 90837.

The exact payment depends on the credentialing of the provider rendering services and the insurance plan.  In our experience, 90791 is typically allowed at +35-75% of the 90834 reimbursement rate and +10-50% of the 90837 reimbursement rate.

CPT Code 90791 Time Frame

The Centers for Medicare Services (CMS.gov) requires CPT code 90791 to be 16 minutes in length at minimum and 90 minutes of length at maximum before using an add-on CPT code to designate session time.  (Source)

At TheraThink, we recommend our providers spend at least 60 minutes performing an intake session.  If a provider does need help billing their intake sessions for longer than 90 minutes, we help them by adding the appropriate add-on code to their claim.

If you are not billing your add-on codes for 90+ minute intake sessions, consider hiring us as your mental health insurance billing service to help; we are experts.

90791 Add-on CPT Codes for Time Based Billing

If the diagnostic interview lasts longer than 90 minutes, please use the following CPT codes to designate added time:

  • Add-On CPT Code +99354 — An additional 30-45 minutes of time
    • Use 90791 + 99354 if your session is between 90 and 120 minutes (1.5 to 2 hours)
  • Add-On CPT Code +99355 — An additional 45 minutes of time
    • Use 90791 + 99354 + 99355 if your session between 2-3 hours of time

If you don’t know how to bill add-on codes on your claims, consider reaching out about our mental health billing service.

How Frequently Can 90791 Be Billed for a Client?

This depends on the insurance and the plan and if you’re not sure, call the insurance. Typically Medicare and Medicaid plans allow 90791 once per client per provider per year.

Other plans will allow as frequently as once per 6 months.  Our mental health insurance billing service, TheraThink, calls to verify on your behalf to find out.

90791 vs. 90792

CPT Code 90792 is a very similar code to 90791 but there are some differences.

Like 90791, it is defined as a psychiatric diagnostic evaluation. The only distinction is that 90792 includes medical services done by a physician.

This means that only medically licensed professionals, such as a psychiatrist, can bill 90792.

CPT Code 90791 Reimbursement Rates

The following diagnostic interview reimbursement rates set by the Center for Medicare Services:

90791 reimbursement rate 2021CPT Code 90791 Reimbursement Rate (2021):  $180.75

— Psychiatric diagnostic interview performed by a licensed mental health provider for 20 to 90 minutes in length.

(Source)

CPT Code 90791 Reimbursement Rate (2020):  $145.44

CPT Code 90792 Reimbursement Rate (2021):  $201.68

— Psychiatric diagnostic interview performed by a psychiatrist for 20 to 90 minutes in length.

(Source)

CPT Code 90792 Reimbursement Rate (2020):  $160.96

CPT Add-On Code +99354 Reimbursement Rate (2021):  $129.10

— Additional time up to 1 hour and 45 minutes for a diagnostic interview

CPT Add-On Code +99354 Reimbursement Rate (2020):  $132.09

CPT Add-On Code +99355 Reimbursement Rate (2021):  $96.31

— Additional time up to three hours for a diagnostic interview (must be used with +99354)

CPT Add-On Code +99355 Reimbursement Rate (2020):  $100.33

(Source)

These 90791 reimbursement rates are set by Medicare and are national rates.  These rates are at the upper level of reimbursement for CPT Code 90791 and because Medicare is picking these rates, they are specifically for LCSWs.

If you have a different license that is not a PhD or MD, you should plan on lower rates than this from commercial insurance policies and Medicaid, in general.

Need help billing these sorts of situations?  Inquire about our mental health insurance billing service.

What License Level is Required to Bill 90791?

90791 license levelBilling for CPT Code 90791 can be performed by the following licensed mental health professionals:

  • Licensed Clinical Social Workers (LCSW)
  • Licensed Professional Counselors (LPC)
  • Licensed Mental Counselors (LMHC)
  • Licensed Marriage Family Therapists (LMFT)
  • Clinical Psychologists (PhD or PsyD)
  • Psychiatrists (MD)

If you have a different license, odds are high you are not eligible to perform a diagnostic evaluation, and as such you are not able to specify a mental health diagnosis for that client.

CPT Code 90791 Coding Requirements

The following services are required, according to Medicare, to complete an initial mental health evaluation for a new client seeking mental health services:

  • 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

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Diagnostic Evaluation Documentation Requirements

Documentation should include:

  • Recording the time
  • Modality of treatment
  • Suggested frequency of treatment
  • Clinical notes that summarize:
    • Diagnosis
    • Symptoms
    • Functional status
    • Focused mental status examination
    • Treatment plan, prognosis, and progress

Documentation for CPT Code 90791 for an diagnostic evaluation must reflect a face to face meeting and this code requires a face to face meeting based on Medicare’s requirements.  (Source).

24 Comments

  1. Karen MacDonald September 17, 2020 at 11:08 am #

    Can you do a 90791 to start couples therapy? Should you?

    (Right now I am using another biller from a prior group practice. But I am keeping your business on file–looks good. Can we have 1-on-1 phone help with your business?)

    Reply

    • Denny September 20, 2020 at 9:09 am #

      Hi Karen, please contact us for questions about our services!

      We recommend conducting 90791 diagnosis evaluation sessions one-on-one with a client or each client.

      Reply

  2. kathleen walton September 26, 2020 at 5:30 am #

    What is the process when the provider does not identify the service as “Psychiatric diagnostic evaluation? A free senior art class was offered in the local newspaper recently. It was not advertised as a “Psychiatric diagnostic evaluation” Low income senior housing requires
    release of all medical records. Psychiatric diagnostic evaluation without an explanation of the specifics implies the class participants sought medical service for psychiatric reasons. What is Medicare policy on this situation?

    Reply

    • Denny September 29, 2020 at 8:08 am #

      This would not be considered a psychiatric evaluation, Kathleen, so best to not code for that. Medicare does not cover art therapy, either.

      Reply

      • Sara December 14, 2020 at 12:41 pm #

        In the case of an initial evaluation and an in-depth medical record chart review (not sure which code can be used) and discussion with a parent. what codes would you recommend?

        Reply

        • Denny January 13, 2021 at 10:30 am #

          We would recommend 90791 for the evaluation and 90846 for the family session without the patient present. Good question Sara!

          Reply

  3. Jeyme S January 15, 2021 at 9:57 am #

    Can you bill 90791 + 99354 together?

    Reply

  4. Lisa Brown February 4, 2021 at 9:44 am #

    90791 completed.
    Client goes into hospital and then physical rehab.
    Returns home
    Should client have been discharged?
    Can a new 90791 assessment be completed?

    Reply

    • Denny February 22, 2021 at 8:53 am #

      Utilizing 90791 multiple times depends on the insurance company and plan of the client. It may be appropriate to render services with 90791 coding depending on the context of treatment. Whether insurance will cover multiple CPT Code 90791 sessions is a different issue, though.

      Reply

  5. Sheryl February 28, 2021 at 5:35 am #

    For an intake dept for a behavioral health hosp-inpt php iop we do what we call level of care assessment. Could this be coded as 90791?

    Reply

    • Denny March 29, 2021 at 12:49 pm #

      I cannot speak specifically to what the level of care assessment entails but it sounds like it fits. The main thing here is to ensure your clinician’s license levels are appropriate for coding 90791 as well.

      Reply

  6. Brian March 23, 2021 at 6:25 am #

    New patient. 30 minutes of Initial evaluation completed and then she has to leave unexpectedly. Presenting concern and background completed. Symptoms assessed. Mental Status Evaluation completed. I have enough for a preliminary diag but need some aspects of patient history. I have a follow-up session scheduled and can get the remaining info then. Do I bill 90791 for that first session and then 90832/4/7 for the next? Any thoughts are greatly appreciated.

    Reply

    • Denny March 29, 2021 at 12:51 pm #

      Yes, the diagnostic interview is not time specific so use it when conducting your first sessions where the client’s Dx is being determined, regardless of length. And then individual therapy codes thereafter.

      Reply

      • debra patterson April 12, 2021 at 11:58 am #

        Good afternoon. Brian’s question peaked my interest. would you recommend submitting for the 90791, even though required elements were not completed in that first session?

        Reply

        • Denny April 21, 2021 at 7:30 am #

          No definitely not, we recommend always using the appropriate code for your sessions and choosing the appropriate code involves completing the requirements for services for that code.

          Reply

  7. Laura Ness April 12, 2021 at 4:31 pm #

    For Medicare if initial eval was done for psychotherapy at an agency, and then the therapist moved to independent practice but continued to see the same clients, would a new 90791 eval be required by Medicare? Is the initial psych eval good enough or should it be renewed if place of service moves even if therapist is the same? Thanks ahead for any help.

    Reply

    • Denny April 21, 2021 at 7:31 am #

      It’s not required but if you’re a new rendering provider and you feel the need to perform a new eval, you can do so in this case. But not required, no!

      Reply

  8. Nicole April 14, 2021 at 12:35 pm #

    Do you have to bill a 90791? What if you gather information over several sessions and bill a 90832/90834 for each?

    Reply

    • Denny April 21, 2021 at 7:31 am #

      This approach is fine if you’re not performing a diagnostic evaluation. You do not have to bill 90791.

      Reply

      • Darshania L Strait June 9, 2021 at 9:13 am #

        Hi Denny,

        Certain patients, especially children and geriatric patients may require more than one visit for the completion of the initial diagnostic evaluation. If the service is being performed by a non-physician (90791) who can not bill an E/M service how do we bill for the visits that are not completed?

        Reply

        • Denny June 10, 2021 at 10:54 am #

          If warranted due to medical necessity, simply bill 90791 on a second date of service or for a second session that day with the appropriate same day modifier. Whether an insurance company will cover this treatment is up to their policy and we’d encourage you or your team to make a call about this scenario before conducting services as part of routine billing best practices.

          Reply

  9. Dana Bowling May 28, 2021 at 8:57 am #

    Social work did a 90791 initially along with 4 other 90837 sessions through client’s EAP provider. Now that is exhausted and client is moving on to her commercial UHC insurance. Is it ethical or necessary to perform another 90791 session?

    Reply

    • Denny June 7, 2021 at 1:49 pm #

      Evaluations are typically done at the outset of treatment. We would recommend against doing so.

      Reply

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